title: Reduced Hospital Duration of Stay Associated with Revised Emergency Department-Intensive Care Unit Admission Policy: A before and after Study.
abstract: BACKGROUND
  Emergency department (ED) and hospital crowding adversely impacts patient care. Although reduction methods for duration of stay in the ED have been explored, few focus on medical intensive care unit (MICU) patients.
  
  
  OBJECTIVE
  To quantify duration of stay or mortality changes associated with a policy intervention that changed the role of an MICU resident to "screen" and write MICU admission orders in the ED to instead meet the patient and write orders in the MICU if there was an available bed. The intervention moved "screening" bed management-appropriateness discussions to the MICU attending or fellow level.
  
  
  METHODS
  We performed a retrospective before and after study at an urban, level 1 trauma center of adults admitted to the MICU from the ED during the first 6 months in 2009 before, and the corresponding 6 months in 2010, after the intervention. We collected demographics, ED, MICU, and hospital duration of stay, duration of mechanical ventilation, Acute Physiology and Chronic Health Evaluation (APACHE) scores, and mortality from electronic medical records. Linear models compared duration of stay differences; logistic regression compared in-hospital mortality. T-tests assessed APACHE score changes before and after the policy change. Analyses were adjusted for age and sex.
  
  
  RESULTS
  We included 498 patients, average age 66 years (±18), 52% male. Hospital duration of stay decreased 18% from 6.8 to 5.6 days (unadjusted p = 0.029). MICU duration of stay decreased from 3.5 to 3.3 days (unadjusted p = 0.34) and ED duration of stay from arrival to physical transfer decreased 40 min (375 to 324 min; unadjusted p = 0.006). Mortality and APACHE scores were unchanged.
  
  
  CONCLUSIONS
  A streamlined admission intervention from the ED to the MICU was associated with decreased ED and hospital duration of stay without altering mortality.
authors.affiliation: Department of Emergency Medicine, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey.
authors.forename: Jonathan V
authors.initials: JV
authors.lastname: McCoy
authors.affiliation: Department of Emergency Medicine, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey.
authors.forename: Alexa R
authors.initials: AR
authors.lastname: Gale
authors.affiliation: Division of Pulmonary and Critical Care Medicine, Director Medical Intensive Care Unit, Department of Medicine, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey.
authors.forename: Jag
authors.initials: J
authors.lastname: Sunderram
authors.affiliation: Department of Biostatistics, Rutgers-School of Public Health, New Brunswick, New Jersey.
authors.forename: Pamela A
authors.initials: PA
authors.lastname: Ohman-Strickland
authors.affiliation: Department of Emergency Medicine, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey.
authors.forename: Robert M
authors.initials: RM
authors.lastname: Eisenstein
mesh_terms: D018806:APACHE; D000368:Aged; D003441:Crowding; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units / Q000458:organization & administration*; D007902:Length of Stay / Q000706:statistics & numerical data*; D008297:Male; D016134:Organizational Policy; D010343:Patient Admission / Q000706:statistics & numerical data*; D012121:Respiration, Artificial / Q000706:statistics & numerical data; D012189:Retrospective Studies; D014193:Trauma Centers
keywords: ED; ICU; critical care; duration of stay; utilization; workflow