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

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 patients met the criteria 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 h Patients 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 patientsWardICUSDU At 4 hours85.9%87.7%27.7%67.9% At 8 hours41.1%42.3%6.8%20.5%

Median EDLOS ICUSDUWard > 4 hours19.4%52.1%77.9% > 8 hours5.2%15.5%32.6%

Footer For Table 1 & 2

Median EDLOS & Mortality All patientsWardICUSDU Median EDLOS 7.12 h7.19 h2.36 h5.07 h Alive7.12 h7.18 h2.41 h5.04 h Dead7.10 h7.44 h2.26 h5.46 h p- Value0.65<0.01<0.08<0.07

% Patients whose hospital outcome is death and EDLOS All patientsWardICUSDU <4 hours19.5%10.1%73.1%24.6% <8 hours60.1%53.9%93.1%72.5%

Median EDLOS and death as hospital outcome ICUSDUWard > 4 hours18.3%66.7%81.8% > 8 hours5.3%24.6%46.1%

Hospital Mortality of patients with & without EDLOS >8 h All patientsWardICUSDU EDLOS < 8h4.1%3.2%23.6%7.2% EDLOS > 8h3.9%3.7%23.9%10.6% p- value0.16<

Median LOS in correlation with EDLOS All patientsWardICUSDU Hospital LOS in days ICU/SDU in days

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