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Emergency department length of stay for critical care admissions: a population-based study

Rose L, Scales DC, Atzema C, Burns KE, Gray S, Doing C, Kiss A, Rubenfeld G, Lee JS. Ann Am Thorac Soc. 2016; 13(8):1324-32. Epub 2016 Apr 25.

Rationale — Emergency department (ED) crowding is common; results in prolonged ED length of stay (LOS), and may worsen outcomes for critically ill patients.

Objectives — To describe patient, institutional and ED level variables associated with prolonged ED LOS for patients admitted from ED to the intensive care unit (ICU).

Methods — Population-based cohort study in Ontario, Canada of adults admitted to ICU from ED, excluding inter-hospital transfers and scheduled visits. Regression modelling examined associations between patient/centre-level variables and ED LOS >6 hours and on 90-day mortality.

Measurements and Main Results — From April 2007 to March 2012, 261,274 adults presented to 118 EDs with 314,836 ICU admissions, representing 4.1% of all adult ED visits (incidence 1,374 ICU admissions/100,000 ED visits). Median (IQR) ED LOS was 7 (4-13) hours. Less than half (41.4%, 95%CI 41.2-41.5) had ED LOS ≤6 hours; 10.5% (95%CI 10.4-10.6) stayed ≥24 hours. Centre level variables associated with ED LOS >6 hours included shift-level ED crowding (mean LOS of patients of similar acuity registering in same 8 hours) (OR 1.19/hour, 95%CI 1.19-1.19), ED annual volume (OR 1.01/1000 patients, 95%CI 1.01-1.01), ED presentation 00:00-07:59 (OR 1.41, 95%CI 1.38-1.45), and ICU functioning at >20% above average annual census (OR 1.10, 95%CI 1.08-1.12). ED LOS >6 hours was not associated with 90-day mortality after adjustment (OR 0.99, 95%CI 0.97-1.02).

Conclusions — Less than half of ICU patients had an ED LOS ≤6 hours, an internationally recognized performance indicator for ED care quality. ED and ICU strain generated by time-varying demand on capacity were important determinants of ED LOS.

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Keywords: Intensive/critical care Emergency department visits Quality indicators Health care evaluation