title: Outcomes of direct and indirect medical intensive care unit admissions from the emergency department of an acute care hospital: a retrospective cohort study.
abstract: OBJECTIVE
  This study aimed to determine if the risk of adverse outcomes (in-hospital and 60-day mortality, intensive care unit (ICU) and total hospital length of stay (LOS)) was greater for medical ICU (MICU) or high dependency unit (HDU) patients indirectly admitted from the emergency department (ED) than for directly admitted patients.
  
  
  METHODS
  This study was conducted at a large public acute care hospital in Singapore.
  
  
  METHODS
  In this retrospective cohort study, hospital records of patients who were admitted directly from the ED, or initially admitted to the general wards from the ED and subsequently transferred to the MICU/HDU within 24 h, were reviewed. Patients were included if they were: (A) discharged from the MICU/HDU in 2009 and were admitted from the ED and (B) transferred to the MICU/HDU within 24 h of presentation at the ED. Data from 706 patients were analysed; 58.4% were men with a median age of 61 years.
  
  
  METHODS
  The following outcomes were compared: in-hospital mortality, 60-day mortality, LOS at the MICU/HDU, as well as total hospital LOS.
  
  
  RESULTS
  Of the 706 patients, 491 (69.5%) were directly admitted to the MICU/HDU. After adjusting for demographics, comorbidities, interventions at the ED and clinical parameters at the ED (heart rate, respiration, oxygen saturation, mean arterial pressure), as well as the Apache II score on arrival at the MICU/HDU, indirectly admitted patients had a higher risk of in-hospital mortality (OR=3.07, 95% CI 1.39 to 6.80), death within 60 days (OR=3.09, 95% CI 1.40 to 6.83) and risk of staying >1 day at the MICU/HDU (OR=2.54, 95% CI 1.48 to 4.36). There was no significant difference in total in-hospital LOS.
  
  
  CONCLUSIONS
  Indirectly admitted MICU/HDU patients had generally poorer outcomes. As the magnitude of effect may vary across settings, context-specific studies may be useful for improving outcomes.
authors.affiliation: Health Services & Outcomes Research, National Healthcare Group, Singapore, Singapore.
authors.forename: Joseph Antonio D
authors.identifier: http://orcid.org/0000-0003-2960-7861
authors.initials: JA
authors.lastname: Molina
authors.affiliation: Emergency Department, Tan Tock Seng Hospital, Singapore, Singapore.
authors.forename: Eillyne
authors.initials: E
authors.lastname: Seow
authors.affiliation: Health Services & Outcomes Research, National Healthcare Group, Singapore, Singapore.
authors.forename: Bee Hoon
authors.initials: BH
authors.lastname: Heng
authors.affiliation: Health Services & Outcomes Research, National Healthcare Group, Singapore, Singapore.
authors.forename: Wai Fung
authors.initials: WF
authors.lastname: Chong
authors.affiliation: Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore, Singapore.
authors.forename: Benjamin
authors.initials: B
authors.lastname: Ho
mesh_terms: D015331:Cohort Studies; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data*; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care / Q000379:methods / Q000706:statistics & numerical data*; D010343:Patient Admission / Q000706:statistics & numerical data*; D010351:Patient Discharge / Q000706:statistics & numerical data; D010360:Patient Transfer / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D012846:Singapore
keywords: ACCIDENT & EMERGENCY MEDICINE