RESEARCH ARTICLE
Rate of Preventable Early Unplanned Intensive Care Unit Transfer for Direct Admissions and Emergency Department Admissions AUTHORS Jennifer Reese, MD,a Sara J. Deakyne, MPH,b Ashley Blanchard, MD,c Lalit Bajaj, MD, MPHd a
Sections of Hospital Medicine and d Emergency Medicine, Department of Pediatrics, University of Colorado, Children’s Hospital Colorado, Aurora, Colorado; b Research Informatics, Children’s Hospital Colorado, Aurora, Colorado; and c New York–Presbyterian Morgan Stanley Children’s Hospital, Columbia University Medical Center, New York, New York KEY WORDS transfers, direct admission, ICU, quality improvement ABBREVIATIONS ACM: admitting case manager ED: emergency department NOC: Network of Care OR: operating room ORRQIP: Organizational Research Risk and Quality Improvement Panel PDR: Patient Disposition Review PEWS: Pediatric Early Warning Score www.hospitalpediatrics.org doi:10.1542/hpeds.2013-0102 These data were presented in a platform presentation at the Pediatric Academic Society; May 1, 2012; Boston, MA. Address correspondence to Jennifer Reese, MD, Section of Hospital Medicine, Children’s Hospital Colorado, Box B302, 13123 E 16th Ave, Aurora, CO 80045. E-mail: jennifer.reese@ childrenscolorado.org
abstract BACKGROUND AND OBJECTIVE: Appropriate patient placement at the time of admission to avoid unplanned transfers to the ICU and codes outside of the ICU is an important safety goal for many institutions. The objective of this study was to determine if the overall rate of unplanned ICU transfers within 12 hours of admission to the inpatient medical/surgical unit was higher for direct admissions compared with emergency department (ED) admissions. METHODS: This was a retrospective cohort study of all unplanned ICU transfers within 12 hours of admission to an inpatient unit at a tertiary care children’s hospital from January 2010 to December 2012. Proportions of preventable unplanned transfers from the ED and from direct admission were calculated and compared. RESULTS: Over the study period, there were a total of 46 998 admissions; 279 unplanned ICU transfers occurred during the study period of which 101 (36%) were preventable. Preventable unplanned transfers from each portal of entry were calculated and compared with the total number of admissions from those portals. The portals of entry evaluated included admissions from our internal ED versus all outside facility transfers. The rates of early unplanned transfer (per 1000 admissions) by portal of entry were 3.50 for direct admissions and 3.18 for ED. There was no difference between direct admissions and ED admissions resulting in preventable unplanned transfers to the ICU (P = .64). CONCLUSIONS: Rates of unplanned ICU transfers within 12 hours of admission to an inpatient unit are not higher for direct admissions compared with ED admissions. Further studies are required to determine clinical risk factors associated with unplanned ICU transfer after admission, thus allowing for more accurate initial patient placement.
HOSPITAL PEDIATRICS (ISSN Numbers: Print, 2154 - 1663; Online, 2154 - 1671). Copyright © 2015 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
Triaging patients to the appropriate level of care and escalating treatment of patients with evolving critical illness are key components to hospital medicine. In the pediatric setting, it has been shown that ward admissions to the ICU have higher odds of mortality than ICU admissions from the emergency department (ED).1 Additionally, within the pediatric population, patients admitted to an ICU from a referring hospital were more ill than patients admitted from within the institution.2 Unplanned ICU transfers have been used as a patient safety measure and quality indicator by many organizations3 and also represent a substantial increase in resource utilization.4
Downloaded from http://hosppeds.aappublications.org/ at UCSF Library & CKM on January 17, 2015
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HOSPITAL Pediatrics®
AN OFFICIAL JOURNAL OF THE AMERICAN ACADEMY OF PEDIATRICS
The goal in evaluating unplanned transfers is to identify potentially preventable cases, to develop interventions to help reduce adverse outcomes, such as increased hospital length of stay and increased mortality rates. A recent study in the pediatric literature aimed to describe the clinical characteristics of children who require ICU transfer by a retrospective review of unplanned early ICU transfer at 1 institution. Clinical characteristics that accounted for a large proportion of early unplanned ICU transfer include age
Rate of Preventable Early Unplanned Intensive Care Unit Transfer for Direct Admissions and Emergency Department Admissions AUTHORS Jennifer Reese, MD,a Sara J. Deakyne, MPH,b Ashley Blanchard, MD,c Lalit Bajaj, MD, MPHd a
Sections of Hospital Medicine and d Emergency Medicine, Department of Pediatrics, University of Colorado, Children’s Hospital Colorado, Aurora, Colorado; b Research Informatics, Children’s Hospital Colorado, Aurora, Colorado; and c New York–Presbyterian Morgan Stanley Children’s Hospital, Columbia University Medical Center, New York, New York KEY WORDS transfers, direct admission, ICU, quality improvement ABBREVIATIONS ACM: admitting case manager ED: emergency department NOC: Network of Care OR: operating room ORRQIP: Organizational Research Risk and Quality Improvement Panel PDR: Patient Disposition Review PEWS: Pediatric Early Warning Score www.hospitalpediatrics.org doi:10.1542/hpeds.2013-0102 These data were presented in a platform presentation at the Pediatric Academic Society; May 1, 2012; Boston, MA. Address correspondence to Jennifer Reese, MD, Section of Hospital Medicine, Children’s Hospital Colorado, Box B302, 13123 E 16th Ave, Aurora, CO 80045. E-mail: jennifer.reese@ childrenscolorado.org
abstract BACKGROUND AND OBJECTIVE: Appropriate patient placement at the time of admission to avoid unplanned transfers to the ICU and codes outside of the ICU is an important safety goal for many institutions. The objective of this study was to determine if the overall rate of unplanned ICU transfers within 12 hours of admission to the inpatient medical/surgical unit was higher for direct admissions compared with emergency department (ED) admissions. METHODS: This was a retrospective cohort study of all unplanned ICU transfers within 12 hours of admission to an inpatient unit at a tertiary care children’s hospital from January 2010 to December 2012. Proportions of preventable unplanned transfers from the ED and from direct admission were calculated and compared. RESULTS: Over the study period, there were a total of 46 998 admissions; 279 unplanned ICU transfers occurred during the study period of which 101 (36%) were preventable. Preventable unplanned transfers from each portal of entry were calculated and compared with the total number of admissions from those portals. The portals of entry evaluated included admissions from our internal ED versus all outside facility transfers. The rates of early unplanned transfer (per 1000 admissions) by portal of entry were 3.50 for direct admissions and 3.18 for ED. There was no difference between direct admissions and ED admissions resulting in preventable unplanned transfers to the ICU (P = .64). CONCLUSIONS: Rates of unplanned ICU transfers within 12 hours of admission to an inpatient unit are not higher for direct admissions compared with ED admissions. Further studies are required to determine clinical risk factors associated with unplanned ICU transfer after admission, thus allowing for more accurate initial patient placement.
HOSPITAL PEDIATRICS (ISSN Numbers: Print, 2154 - 1663; Online, 2154 - 1671). Copyright © 2015 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
Triaging patients to the appropriate level of care and escalating treatment of patients with evolving critical illness are key components to hospital medicine. In the pediatric setting, it has been shown that ward admissions to the ICU have higher odds of mortality than ICU admissions from the emergency department (ED).1 Additionally, within the pediatric population, patients admitted to an ICU from a referring hospital were more ill than patients admitted from within the institution.2 Unplanned ICU transfers have been used as a patient safety measure and quality indicator by many organizations3 and also represent a substantial increase in resource utilization.4
Downloaded from http://hosppeds.aappublications.org/ at UCSF Library & CKM on January 17, 2015
| 27
HOSPITAL Pediatrics®
AN OFFICIAL JOURNAL OF THE AMERICAN ACADEMY OF PEDIATRICS
The goal in evaluating unplanned transfers is to identify potentially preventable cases, to develop interventions to help reduce adverse outcomes, such as increased hospital length of stay and increased mortality rates. A recent study in the pediatric literature aimed to describe the clinical characteristics of children who require ICU transfer by a retrospective review of unplanned early ICU transfer at 1 institution. Clinical characteristics that accounted for a large proportion of early unplanned ICU transfer include age
