TY - JOUR
T1 - Predictors of Delayed Recognition of Critical Illness in Emergency Department Patients and Its Effect on Morbidity and Mortality
AU - Goel, Neha N.
AU - Durst, Matthew S.
AU - Vargas-Torres, Carmen
AU - Richardson, Lynne D.
AU - Mathews, Kusum S.
N1 - Funding Information:
The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article. NNG has received study support from the NIH National Heart, Lung, and Blood Institute (Award: DHHS-1T32 HL129974-PI: Richardson). KSM has received study support from the NIH National Heart, Lung, and Blood Institute (Award: 1K23HL130648-PI: Mathews). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Heart, Lung, and Blood Institute and the National Institutes of Health. [NNG] reports no additional conflict of interest other than the above funding sources, and contributed to this work through data analysis, and manuscript preparation. [MSD] reports no conflict of interest, and contributed to this work through conceptual design and data collection. [CVT] reports no conflict of interest, and contributed to this work through data analysis. [LDR] reports no conflict of interest, and contributed to this work through conceptual design. [KSM] reports no additional conflict of interest other than the above funding sources, and contributed to this work through conceptual design, data collection, analysis, and manuscript preparation.
Funding Information:
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported in part through the Mount Sinai Data Warehouse (MSDW) resources and staff expertise provided by Scientific Computing at the Icahn School of Medicine at Mount Sinai.
Funding Information:
We would also like to acknowledge Ioannis Konstantinidis, MD, and Marie Lauzon, MS, for their contribution to our work. The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported in part through the Mount Sinai Data Warehouse (MSDW) resources and staff expertise provided by Scientific Computing at the Icahn School of Medicine at Mount Sinai.
Publisher Copyright:
© The Author(s) 2020.
PY - 2022/1
Y1 - 2022/1
N2 - Purpose: Timely recognition of critical illness is associated with improved outcomes, but is dependent on accurate triage, which is affected by system factors such as workload and staffing. We sought to first study the effect of delayed recognition on patient outcomes after controlling for system factors and then to identify potential predictors of delayed recognition. Methods: We conducted a retrospective cohort study of Emergency Department (ED) patients admitted to the Intensive Care Unit (ICU) directly from the ED or within 48 hours of ED departure. Cohort characteristics were obtained through electronic and standardized chart abstraction. Operational metrics to estimate ED workload and volume using census data were matched to patients’ ED stays. Delayed recognition of critical illness was defined as an absence of an ICU consult in the ED or declination of ICU admission by the ICU team. We employed entropy-balanced multivariate models to examine the association between delayed recognition and development of persistent organ dysfunction and/or death by hospitalization day 28 (POD+D), and multivariable regression modeling to identify factors associated with delayed recognition. Results: Increased POD+D was seen for those with delayed recognition (OR 1.82, 95% CI 1.13-2.92). When the delayed recognition was by the ICU team, the patient was 2.61 times more likely to experience POD+D compared to those for whom an ICU consult was requested and were accepted for admission. Lower initial severity of illness score (OR 0.26, 95% CI 0.12-0.53) was predictive of delayed recognition. The odds for delayed recognition decreased when ED workload is higher (OR 0.45, 95% CI 0.23-0.89) compared to times with lower ED workload. Conclusions: Increased POD+D is associated with delayed recognition. Patient and system factors such as severity of illness and ED workload influence the odds of delayed recognition of critical illness and need further exploration.
AB - Purpose: Timely recognition of critical illness is associated with improved outcomes, but is dependent on accurate triage, which is affected by system factors such as workload and staffing. We sought to first study the effect of delayed recognition on patient outcomes after controlling for system factors and then to identify potential predictors of delayed recognition. Methods: We conducted a retrospective cohort study of Emergency Department (ED) patients admitted to the Intensive Care Unit (ICU) directly from the ED or within 48 hours of ED departure. Cohort characteristics were obtained through electronic and standardized chart abstraction. Operational metrics to estimate ED workload and volume using census data were matched to patients’ ED stays. Delayed recognition of critical illness was defined as an absence of an ICU consult in the ED or declination of ICU admission by the ICU team. We employed entropy-balanced multivariate models to examine the association between delayed recognition and development of persistent organ dysfunction and/or death by hospitalization day 28 (POD+D), and multivariable regression modeling to identify factors associated with delayed recognition. Results: Increased POD+D was seen for those with delayed recognition (OR 1.82, 95% CI 1.13-2.92). When the delayed recognition was by the ICU team, the patient was 2.61 times more likely to experience POD+D compared to those for whom an ICU consult was requested and were accepted for admission. Lower initial severity of illness score (OR 0.26, 95% CI 0.12-0.53) was predictive of delayed recognition. The odds for delayed recognition decreased when ED workload is higher (OR 0.45, 95% CI 0.23-0.89) compared to times with lower ED workload. Conclusions: Increased POD+D is associated with delayed recognition. Patient and system factors such as severity of illness and ED workload influence the odds of delayed recognition of critical illness and need further exploration.
KW - ED boarding
KW - ED crowding
KW - critically ill
KW - emergency department (ED)
KW - time-to-treatment
UR - http://www.scopus.com/inward/record.url?scp=85094666155&partnerID=8YFLogxK
U2 - 10.1177/0885066620967901
DO - 10.1177/0885066620967901
M3 - Article
C2 - 33118840
AN - SCOPUS:85094666155
SN - 0885-0666
VL - 37
SP - 52
EP - 59
JO - Journal of Intensive Care Medicine
JF - Journal of Intensive Care Medicine
IS - 1
ER -