title: "Deterioration to Door Time": An Exploratory Analysis of Delays in Escalation of Care for Hospitalized Patients.
abstract: Timely escalation of care for patients experiencing clinical deterioration in the inpatient setting is challenging. Deterioration on a general floor has been associated with an increased risk of death, and the early period of deterioration may represent a time during which admission to the intensive care unit (ICU) improves survival. Previous studies examining the association between delay from onset of clinical deterioration to ICU transfer and mortality are few in number and were conducted more than 10 years ago.
  
  
  
  We aimed to evaluate the impact of delays in the escalation of care among clinically deteriorating patients in the current era of inpatient medicine.
  
  
  
  This was a retrospective cohort study that analyzed data from 793 patients transferred from non-intensive care unit (ICU) inpatient floors to the medical intensive care unit (MICU), from 2011 to 2013 at an urban, tertiary, academic medical center.
  
  
  
  "Deterioration to door time (DTDT)" was defined as the time between onset of clinical deterioration (as evidenced by the presence of one or more vital sign indicators including respiratory rate, systolic blood pressure, and heart rate) and arrival in the MICU.
  
  
  
  In our sample, 64.6 % had delays in care escalation, defined as greater than 4 h based on previous studies. Mortality was significantly increased beginning at a DTDT of 12.1 h after adjusting for age, gender, and severity of illness.
  
  
  
  Delays in the escalation of care for clinically deteriorating hospitalized patients remain frequent in the current era of inpatient medicine, and are associated with increased in-hospital mortality. Development of performance measures for the care of clinically deteriorating inpatients remains essential, and timeliness of care escalation deserves further consideration.
authors.affiliation: Section of General Medicine, Department of Internal Medicine, Yale University School of Medicine, Harkness Hall A, Room 306, 367 Cedar St., New Haven, CT, 06510, USA. christopher.sankey@yale.edu.|Yale-New Haven Hospital, New Haven, CT, USA. christopher.sankey@yale.edu.
authors.forename: Christopher B
authors.initials: CB
authors.lastname: Sankey
authors.affiliation: Section of Geriatric Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA.
authors.forename: Gail
authors.initials: G
authors.lastname: McAvay
authors.affiliation: Section of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA.
authors.forename: Jonathan M
authors.initials: JM
authors.lastname: Siner
authors.affiliation: Patient Safety and Quality, Hackensack University Medical Center, Hackensack, NJ, USA.
authors.forename: Carol L
authors.initials: CL
authors.lastname: Barsky
authors.affiliation: Section of General Medicine, Department of Internal Medicine, Yale University School of Medicine, Harkness Hall A, Room 306, 367 Cedar St., New Haven, CT, 06510, USA.|Yale-New Haven Hospital, New Haven, CT, USA.
authors.forename: Sarwat I
authors.initials: SI
authors.lastname: Chaudhry
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000075902:Clinical Deterioration; D057286:Electronic Health Records / Q000639:trends; D004636:Emergency Service, Hospital / Q000639:trends; D005260:Female; D006760:Hospitalization / Q000639:trends*; D006801:Humans; D007362:Intensive Care Units / Q000639:trends*; D007902:Length of Stay / Q000639:trends; D008297:Male; D008875:Middle Aged; D010360:Patient Transfer / Q000379:methods / Q000639:trends*; D012189:Retrospective Studies; D061665:Time-to-Treatment / Q000639:trends*; D055815:Young Adult
keywords: care escalation; care transitions; delays; inpatient clinical deterioration; timeliness