title: A critical analysis of unplanned ICU transfer within 48 hours from ED admission as a quality measure.
abstract: OBJECTIVE
  Unplanned intensive care unit (ICU) transfer (UIT) within 48 hours of emergency department (ED) admission increases morbidity and mortality. We hypothesized that a majority of UITs do not have critical interventions (CrIs) and that CrI is associated with worse outcomes.
  
  
  OBJECTIVE
  The objective of the study is to characterize all UITs (including patients who died before ICU transfer), the proportion with CrI, and the effect of having CrI on mortality.
  
  
  METHODS
  This is a single-center, retrospective cohort study of UITs within 48 hours from 2008 to 2013 at an urban academic medical center and included patients 18 years or older without advanced directives (ADs). Critical intervention was defined by modified Delphi process. Data included demographics, comorbidities, reasons for UIT, length of stay, CrIs, and mortality. We calculated descriptive statistics with 95% confidence intervals (CIs).
  
  
  RESULTS
  A total of 837 (0.76%) of 108 732 floor admissions from the ED had a UIT within 48 hours; 86 admitted patients died before ICU. We excluded 23 ADs, 117 postoperative transfers, 177 planned ICU transfers, and 4 with missing data. Of the 516 remaining, 65% (95% CI, 61%-69%) received a CrI. Unplanned ICU transfer reasons are as follows: 33 medical errors, 90 disease processes not present on arrival, and 393 clinical deteriorations. Mortality was 10.5% (95% CI, 8%-14%), and mean length of stay was 258 hours (95% CI, 233-283) for those with CrI, whereas the mortality was 2.8% (95% CI, 1%-6%) and mean length of stay was 177 hours (95% CI, 157-197) for those without CrI.
  
  
  CONCLUSIONS
  Unplanned ICU transfer is rare, and only 65% had a CrI. Those with CrI had increased morbidity and mortality.
authors.affiliation: Boston Medical Center, Emergency Medicine, Boston, MA, USA.
authors.forename: Cassidy M
authors.initials: CM
authors.lastname: Dahn
authors.affiliation: Boston Medical Center, Emergency Medicine, Boston, MA, USA.
authors.forename: A Travis
authors.initials: AT
authors.lastname: Manasco
authors.affiliation: Boston Medical Center, Emergency Medicine, Boston, MA, USA.
authors.forename: Alan H
authors.initials: AH
authors.lastname: Breaud
authors.affiliation: Boston Medical Center, Emergency Medicine, Boston, MA, USA.
authors.forename: Samuel
authors.initials: S
authors.lastname: Kim
authors.affiliation: Boston Medical Center, Emergency Medicine, Boston, MA, USA.
authors.forename: Natalia
authors.initials: N
authors.lastname: Rumas
authors.affiliation: Boston Medical Center, Emergency Medicine, Boston, MA, USA.
authors.forename: Omer
authors.initials: O
authors.lastname: Moin
authors.affiliation: Boston Medical Center, Emergency Medicine, Boston, MA, USA; Boston University School of Medicine, Boston, MA, USA.
authors.forename: Patricia M
authors.initials: PM
authors.lastname: Mitchell
authors.affiliation: Boston University School of Public Health, Boston, MA, USA.
authors.forename: Kerrie P
authors.initials: KP
authors.lastname: Nelson
authors.affiliation: Boston Medical Center, Emergency Medicine, Boston, MA, USA; Boston University School of Medicine, Boston, MA, USA.
authors.forename: William
authors.initials: W
authors.lastname: Baker
authors.affiliation: Boston Medical Center, Emergency Medicine, Boston, MA, USA; Boston University School of Medicine, Boston, MA, USA.
authors.forename: James A
authors.initials: JA
authors.lastname: Feldman
mesh_terms: D000368:Aged; D004630:Emergencies; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data*; D007902:Length of Stay / Q000639:trends; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D010343:Patient Admission / Q000706:statistics & numerical data*; D010360:Patient Transfer / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D013997:Time Factors