23: Prolonged Emergency Department Length of Stay Is Not Associated With Worse Neurologic Outcomes In Patients With Intracerebral Hemorrhage

Abstract

Study ObjectivesSpontaneous intracerebral hemorrhage (ICH) is the most devastating form of acute stroke, with a mortality rate of 30-50%. Specialized care in neurologic intensive care units (ICUs) reduces mortality and improves outcome. Unfortunately, transfer to these ICUs is frequently delayed, resulting in prolonged emergency department (ED) lengths of stay (EDLOS). We hypothesized that prolonged EDLOS would be associated with worse neurologic outcomes.MethodsWe performed a retrospective review of a prospectively collected registry of consecutive patients with spontaneous ICH presenting to a single urban academic ED from February 2005 to October 2009. Patients were excluded from analysis if their goals of care were made comfort measures only (CMO) in the ED or they were not admitted to the ICU. The primary outcome was modified Rankin Scale (mRS) on hospital discharge. Secondary outcomes were hospital and ICU length of stay and hematoma expansion at 24 hours. We analyzed the relationship between EDLOS and discharge mRS using a non-parametric mixed model. Potential covariates were identified a priori for their clinical relevance, but excluded from the model if the p value of the Spearman correlation coefficient for their relationship either to EDLOS or to mRS were ≥ 0.20. Covariates included in the final model were: Glasgow Coma Scale (GCS) on presentation, initial hematoma volume and need for endotracheal intubation.ResultsDuring the study period, 616 subjects presented with spontaneous ICH. Of these, 34 were excluded for use of CMO orders, 4 were not admitted to an ICU, and 4 presented twice for recurrent ICH in this time frame (only the first presentation was used), leaving 574 for analysis. The median age was 75 years (IQR 63-82 years), and 49.6% were female. The median EDLOS was 5.1h (IQR 3.7-7.1h), and 18.5% had an EDLOS greater than 8 hours. The median discharge mRS was 4 (IQR 3-6) with an overall mortality of 30%. In the bivariate analysis, longer EDLOS was associated with better neurologic outcome (Spearman's r = −0.25, p<0.0001). EDLOS was inversely correlated with disease severity on presentation, as measured by initial GCS score (r = 0.22, p<0.0001), initial hematoma volume (r = −0.20, p<0.0001), and intubation status (median EDLOS if intubated 4.1h versus 5.7h if not intubated, p<0.0001). In the controlled multivariate analysis, EDLOS was not associated with discharge mRS (p>0.05).ConclusionIn this analysis, EDLOS was not associated with worse neurologic outcomes. Simple correlations suggested improved outcomes among patients with longer EDLOS, contradicting our initial hypothesis. However, multivariate analysis identified no such association, highlighting the importance of appropriate control of confounding. Patients with more severe disease appear to be transferred more rapidly to the ICU and our multivariate model may have been unable to fully overcome the confounding by this effect. Alternately, collaboration between neurologic specialists and emergency physicians may be sufficient to ensure that all necessary care is provided to these patients while they remain in the ED. Study ObjectivesSpontaneous intracerebral hemorrhage (ICH) is the most devastating form of acute stroke, with a mortality rate of 30-50%. Specialized care in neurologic intensive care units (ICUs) reduces mortality and improves outcome. Unfortunately, transfer to these ICUs is frequently delayed, resulting in prolonged emergency department (ED) lengths of stay (EDLOS). We hypothesized that prolonged EDLOS would be associated with worse neurologic outcomes. Spontaneous intracerebral hemorrhage (ICH) is the most devastating form of acute stroke, with a mortality rate of 30-50%. Specialized care in neurologic intensive care units (ICUs) reduces mortality and improves outcome. Unfortunately, transfer to these ICUs is frequently delayed, resulting in prolonged emergency department (ED) lengths of stay (EDLOS). We hypothesized that prolonged EDLOS would be associated with worse neurologic outcomes. MethodsWe performed a retrospective review of a prospectively collected registry of consecutive patients with spontaneous ICH presenting to a single urban academic ED from February 2005 to October 2009. Patients were excluded from analysis if their goals of care were made comfort measures only (CMO) in the ED or they were not admitted to the ICU. The primary outcome was modified Rankin Scale (mRS) on hospital discharge. Secondary outcomes were hospital and ICU length of stay and hematoma expansion at 24 hours. We analyzed the relationship between EDLOS and discharge mRS using a non-parametric mixed model. Potential covariates were identified a priori for their clinical relevance, but excluded from the model if the p value of the Spearman correlation coefficient for their relationship either to EDLOS or to mRS were ≥ 0.20. Covariates included in the final model were: Glasgow Coma Scale (GCS) on presentation, initial hematoma volume and need for endotracheal intubation. We performed a retrospective review of a prospectively collected registry of consecutive patients with spontaneous ICH presenting to a single urban academic ED from February 2005 to October 2009. Patients were excluded from analysis if their goals of care were made comfort measures only (CMO) in the ED or they were not admitted to the ICU. The primary outcome was modified Rankin Scale (mRS) on hospital discharge. Secondary outcomes were hospital and ICU length of stay and hematoma expansion at 24 hours. We analyzed the relationship between EDLOS and discharge mRS using a non-parametric mixed model. Potential covariates were identified a priori for their clinical relevance, but excluded from the model if the p value of the Spearman correlation coefficient for their relationship either to EDLOS or to mRS were ≥ 0.20. Covariates included in the final model were: Glasgow Coma Scale (GCS) on presentation, initial hematoma volume and need for endotracheal intubation. ResultsDuring the study period, 616 subjects presented with spontaneous ICH. Of these, 34 were excluded for use of CMO orders, 4 were not admitted to an ICU, and 4 presented twice for recurrent ICH in this time frame (only the first presentation was used), leaving 574 for analysis. The median age was 75 years (IQR 63-82 years), and 49.6% were female. The median EDLOS was 5.1h (IQR 3.7-7.1h), and 18.5% had an EDLOS greater than 8 hours. The median discharge mRS was 4 (IQR 3-6) with an overall mortality of 30%. In the bivariate analysis, longer EDLOS was associated with better neurologic outcome (Spearman's r = −0.25, p<0.0001). EDLOS was inversely correlated with disease severity on presentation, as measured by initial GCS score (r = 0.22, p<0.0001), initial hematoma volume (r = −0.20, p<0.0001), and intubation status (median EDLOS if intubated 4.1h versus 5.7h if not intubated, p<0.0001). In the controlled multivariate analysis, EDLOS was not associated with discharge mRS (p>0.05). During the study period, 616 subjects presented with spontaneous ICH. Of these, 34 were excluded for use of CMO orders, 4 were not admitted to an ICU, and 4 presented twice for recurrent ICH in this time frame (only the first presentation was used), leaving 574 for analysis. The median age was 75 years (IQR 63-82 years), and 49.6% were female. The median EDLOS was 5.1h (IQR 3.7-7.1h), and 18.5% had an EDLOS greater than 8 hours. The median discharge mRS was 4 (IQR 3-6) with an overall mortality of 30%. In the bivariate analysis, longer EDLOS was associated with better neurologic outcome (Spearman's r = −0.25, p<0.0001). EDLOS was inversely correlated with disease severity on presentation, as measured by initial GCS score (r = 0.22, p<0.0001), initial hematoma volume (r = −0.20, p<0.0001), and intubation status (median EDLOS if intubated 4.1h versus 5.7h if not intubated, p<0.0001). In the controlled multivariate analysis, EDLOS was not associated with discharge mRS (p>0.05). ConclusionIn this analysis, EDLOS was not associated with worse neurologic outcomes. Simple correlations suggested improved outcomes among patients with longer EDLOS, contradicting our initial hypothesis. However, multivariate analysis identified no such association, highlighting the importance of appropriate control of confounding. Patients with more severe disease appear to be transferred more rapidly to the ICU and our multivariate model may have been unable to fully overcome the confounding by this effect. Alternately, collaboration between neurologic specialists and emergency physicians may be sufficient to ensure that all necessary care is provided to these patients while they remain in the ED. In this analysis, EDLOS was not associated with worse neurologic outcomes. Simple correlations suggested improved outcomes among patients with longer EDLOS, contradicting our initial hypothesis. However, multivariate analysis identified no such association, highlighting the importance of appropriate control of confounding. Patients with more severe disease appear to be transferred more rapidly to the ICU and our multivariate model may have been unable to fully overcome the confounding by this effect. Alternately, collaboration between neurologic specialists and emergency physicians may be sufficient to ensure that all necessary care is provided to these patients while they remain in the ED.