Abstract
IntroductionDue to hospital crowding, mechanically ventilated patients are increasingly spending hours boarding in emergency departments (ED) before intensive care unit (ICU) admission. This study aims to evaluate the association between time ventilated in the ED and in-hospital mortality, duration of mechanical ventilation, ICU and hospital length of stay (LOS).MethodsThis was a multi-center, prospective, observational study of patients ventilated in the ED, conducted at three academic Level I Trauma Centers from July 2011 to March 2013. All consecutive adult patients on invasive mechanical ventilation were eligible for enrollment. We performed a Cox regression to assess for a mortality effect for mechanically ventilated patients with each hour of increasing LOS in the ED and multivariable regression analyses to assess for independently significant contributors to in-hospital mortality. Our primary outcome was in-hospital mortality, with secondary outcomes of ventilator days, ICU LOS and hospital LOS. We further commented on use of lung protective ventilation and frequency of ventilator changes made in this cohort.ResultsWe enrolled 535 patients, of whom 525 met all inclusion criteria. Altered mental status without respiratory pathology was the most common reason for intubation, followed by trauma and respiratory failure. Using iterated Cox regression, a mortality effect occurred at ED time of mechanical ventilation > 7 hours, and the longer ED stay was also associated with a longer total duration of intubation. However, adjusted multivariable regression analysis demonstrated only older age and admission to the neurosciences ICU as independently associated with increased mortality. Of interest, only 23.8% of patients ventilated in the ED for over seven hours had changes made to their ventilator.ConclusionIn a prospective observational study of patients mechanically ventilated in the ED, there was a significant mortality benefit to expedited transfer of patients into an appropriate ICU setting.
Highlights
Due to hospital crowding, mechanically ventilated patients are increasingly spending hours boarding in emergency departments (ED) before intensive care unit (ICU) admission
Using iterated Cox regression, a mortality effect occurred at ED time of mechanical ventilation > 7 hours, and the longer ED stay was associated with a longer total duration of intubation
In a prospective observational study of patients mechanically ventilated in the ED, there was a significant mortality benefit to expedited transfer of patients into an appropriate ICU setting. [West J Emerg Med. 2017;18(5)972-979.]
Summary
Mechanically ventilated patients are increasingly spending hours boarding in emergency departments (ED) before intensive care unit (ICU) admission. Hospital crowding, leading to boarding patients in the emergency department (ED), is a common problem nationwide with crowding reported in 90% of EDs, 40% of which report crowding on a daily basis.[1] Boarding is a particular problem for patients awaiting intensive care unit (ICU) beds; the American Hospital Association (AHA) reports an average ED boarding time of six hours for critically ill patients in crowded EDs.[2] Multiple studies worldwide have illuminated the detrimental effect of ED crowding on patient outcomes and mortality.[2,3,4,5,6,7,8] Delay in transfer of mechanically ventilated patients from the ED to the ICU has been associated with higher in-patient mortality and longer hospital length of stay (LOS).[2,8,9]. The population of patients needing prolonged acute mechanical ventilation (defined as >96 hours) is projected to grow at a rate of 5.5% per year. 12
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