Outcomes in Acute Care Journal Club Arrowe Park Hospital Valluru ST4 Emergency Medicine 27/09/13.

Outcomes in Acute Care

Journal Club Arrowe Park Hospital

Valluru ST4 Emergency Medicine27/09/13

Association between EDLOS (emergency department length of stay) and outcome

of patients admitted either to a ward, intensive care or high dependency unit

Emergency Medicine Australia 2013

Glossary

• EDLOS emergency department length of stay• ED emergency department• LOS length of stay• ICU intensive care unit• SDU step down unit• Access block is EDLOS greater than 8 hours,

patients waiting an inpatient bed in the ED resulting in overcrowding

• Short stay ward is observation ward

Known so far

• EDLOS and ICU outcome has mixed results• EDLOS is an independent predictor of ICU

mortality in sepsis• No studies to compare and contrast EDLOS

and outcome for patients admitted to ward, ICU or SDU in the same health setting

Objectives

• To compare and contrast the association between EDLOS and hospital outcome

• Of patients admitted from the ED directly • To a ward, an ICU or SDU• Using EDLOS as a continuous measure • At the predefined cut-off value of 4 hours and

up to 8 hours• Outcome measures-Hospital outcome and

hospital LOS

Methods

• Retrospective cohort study done at• The Royal Adelaide Hospital Australia• Over 4 years from Jan 2004 to Dec 2007• Human Research Ethics committee approved• 43778 patients met the criteria• 43484 patients for final data analysis (99.3%)• 294 patients (0.7%) were omitted

Inclusion criteria

Patients with all of the following were included • Age > 15 years• Admitted from the ED directly to a ward, the ICU

or SDU• EDLOS less than 24 hPatients were divided into the following categories,

based on discharge location from the ED• Ward (direct admission from the ED to a ward)• ICU (direct admission from the ED to the ICU)• SDU (direct admission from the ED to the SDU)

Exclusion Criteria

Patients with any of the following:• Death while in the ED• Admitted from the ED directly to the operating theatre, coronary care unit, burns unit• Admission to the ED short stay ward, including

those subsequently admitted to a ward, ICU or SDU

• ED source of admission was another hospital• Patients sent home from ED

Statistics• Statistical analysis involved comparison of medians using two-sample Kolmogorov–Smirnov and

permutation tests• Logistic regression analysis was used to examine the

various ED and demographic factors affecting mortality

• In-hospital outcome was assessed using EDLOS with the cut-off of 8 hr

• Analyses were carried out using the R statistical language (R Foundation for Statistical Computing, Vienna, Austria,2011)

% Patients remaining in the ED

All patients Ward ICU SDU

At 4 hours 85.9% 87.7% 27.7% 67.9%

At 8 hours 41.1% 42.3% 6.8% 20.5%

Median EDLOS

ICU SDU Ward

> 4 hours 19.4% 52.1% 77.9%

> 8 hours 5.2% 15.5% 32.6%

Footer For Table 1 & 2

Median EDLOS & Mortality

All patients Ward ICU SDU

Median EDLOS

7.12 h 7.19 h 2.36 h 5.07 h

Alive 7.12 h 7.18 h 2.41 h 5.04 h

Dead 7.10 h 7.44 h 2.26 h 5.46 h

p- Value 0.65 <0.01 <0.08 <0.07

% Patients whose hospital outcome is death and EDLOS

All patients Ward ICU SDU

<4 hours 19.5% 10.1% 73.1% 24.6%

<8 hours 60.1% 53.9% 93.1% 72.5%

Median EDLOS and death as hospital outcome

ICU SDU Ward

> 4 hours 18.3% 66.7% 81.8%

> 8 hours 5.3% 24.6% 46.1%

Hospital Mortality of patients with & without EDLOS >8 h

All patients Ward ICU SDU

EDLOS < 8h 4.1% 3.2% 23.6% 7.2%

EDLOS > 8h 3.9% 3.7% 23.9% 10.6%

p- value 0.16 <0.01 0.52 0.09

Median LOS in correlation with EDLOS

All patients Ward ICU SDU

Hospital LOS in days

4.0 3.9 7.4 6.8

ICU/SDU in days

1.6 0.9

EDLOS – mortality predictor

Single regression model

Key points EDLOS

• Patients admitted to ICU had shortest EDLOS• EDLOS for patients admitted to ICU or SDU

was not significant among survivors and those who died

• Majority of ED patients were ward patients with lower urgency and longest EDLOS- more critical care beds and ICU patients prioritised

EDLOS & mortality• EDLOS is a continuous variable cut-off set at 8h• Longer EDLOS among those who died in the

patients admitted from the ED to ward• Shorter EDLOS among those who died in the

patients admitted from the ED to ICU• EDLOS was a significant independent predictor for

mortality for patients admitted from the ED to SDU• EDLOS was not a significant predictor of hospital

mortality• EDLOS potentially modifiable factor

Golden 4 hour rule

• Important time based harm minimisation • Performance measure set for patients • Admitted from the ED• Rapidly adopted• Pros and cons• Less relevant for ICU patients

Strengths of this study

• Examined EDLOS across groups of patients admitted from a single acute hospital ED

• Explored the association of EDLOS and outcome of patients from the ED to a ward, ICU or SDU

• First study for specifically differentiate for SDU patients

Weaknesses of this study

• Single centre study• Diverse ED population not covered• Different country • Difficult to generalise the findings• Staffing, funding, bed situation issues

Take home message

• EDLOS is not a significant predictor of mortality

• EDLOS is modifiable

Discussion