LO51: Increased mortality and costs in emergency department sepsis patients with delayed intensive care unit admission

Abstract

Introduction: Sepsis remains a major cause of mortality. In the Emergency Department (ED), rapid identification and management of sepsis have been associated with improved outcomes. Following ED assessment, patients with infection may be directly admitted to the Intensive Care Unit (ICU), or alternatively admitted to hospital wards or sent home, with risk of future deterioration necessitating ICU admission. Little is known regarding outcomes and costs of ICU sepsis patients who are initially admitted to a ward or discharged home (delayed ICU admission), as compared to those with direct ICU admission from the ED. Methods: We analyzed a prospectively collected registry (2011-2014) of patients admitted to the ICU with a diagnosis of sepsis at two academic hospitals. We included all adult patients with an index ED visit within 72 hours of ICU admission. Patients were categorized into 3 groups: 1) Admitted directly to ICU; 2) Admitted to wards, with ICU admission within 72 hours; and 3) Sent home, with ICU admission within 72 hours. ICU length of stay (LOS) and total costs (both direct and indirect) were recorded. The primary outcome, in-hospital mortality, was analyzed using a multivariable logistic regression model, controlling for confounding variables (including patient sex, comorbidities, and illness severity). Results: 657 ICU patients were included. Of these, 338 (51.4%) were admitted directly from ED to ICU, 246 (37.4%) were initially admitted to the wards, and 73 (11.1%) were initially sent home. In-hospital mortality was lowest amongst patients admitted directly to the ICU (29.5%), as compared to patients admitted to ICU from wards (42.7%), or home (61.6%). Delayed ICU admission was associated with increased odds of mortality (adjusted odds ratio 1.85 [1.24-2.76], P<0.01) and increased median ICU LOS (11 days vs. 4 days, P<0.001). Median total costs were lowest among patients directly admitted to the ICU ($19,924, [Interquartile range [IQR], 10,333-32,387]), as compared to those admitted from wards ($72,155 [IQR, $42,771-122,749]) and those initially sent home ($45,121 [IQR, $19,930-86,843]). Conclusion: Only half of ED sepsis patients ultimately requiring ICU admission within 72 hours of ED arrival are directly admitted to the ICU. Delayed ICU admission is associated with higher mortality, LOS, and costs.