Critical Care: Critical Care - ICU Management |

Intermediate Care to Intensive Care Triage: A Quality Improvement Project FREE TO VIEW

Pranav Chandrashekar, MBBS; Ali Abdel-Halim; David Hager, MD
Author and Funding Information

Johns Hopkins Hospital, Baltimore, MD

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):213A. doi:10.1016/j.chest.2016.08.226
Text Size: A A A
Published online

SESSION TITLE: Critical Care - ICU Management

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 26, 2016 at 01:30 PM - 02:30 PM

PURPOSE: Intermediate care units (IMCUs) were created to accommodate patients whose care needs exceed what is feasible on a general ward, but do not require intensive care. However, some patients triaged to intermediate care may deteriorate and require intensive care. Like many teaching hospitals, the decision to escalate care at Johns Hopkins Hospital is often made by resident physicians (PGY2 or PGY3). This responsibility can cause stress due to uncertainty and can lead to delays in Intensive Care Unit (ICU) admission. Discussion of triage decisions, and sharing this responsibility with supervising physicians is encouraged, but does not always take place. We conducted a quality improvement (QI) project to (1) facilitate communication between resident and supervising physicians, and (2) expedite transfer of appropriate patients from our medical IMCU to the medical ICU.

METHODS: A “4Es” structure (engage, educate, execute, evaluate) was used conduct this QI project. An ICU resident triage card was developed and deployed in April 2013. The card required the ICU triage resident to sign their name, document each ICU consult, and the name of the supervising physician with whom they discussed the case. Though a card was to be completed for all consults, this study only reports data from patients transferred from the IMCU to the ICU during baseline (July-December 2012) and intervention (July-December 2013) phases. Data were collected retrospectively from the electronic health record including routine demographic data, ICU admitting diagnosis, severity of illness on arrival to the ICU (Acute Physiology and Chronic Health Evaluation version 2 -APACHE II & Simplified Acute Physiology score version 2 -SAPS II), comorbidity (Charlson Comorbidity Index-CCI), hospital mortality, and length of stay (LOS).

RESULTS: During the baseline and intervention phases, 83 and 95 unique patients, respectively, were transferred from the IMCU to the ICU with similar mean ages (58.4 vs. 58.3 years; NS). A similar proportion of patients were female in each group. Each group had similar admitting diagnoses, with the exception of cardiac diseases being less common during the intervention phase (24% vs. 9%, p = 0.01). A trend towards decreased mortality was appreciated during the intervention phase (34% vs. 22%; p = 0.08), despite similar APACHE II, SAPS II, and CCI scores. Length of stay among survivors (median days [IQR];p-value) decreased when comparing the baseline and intervention phase, including pre-ICU (3.0[1.6-8.8] vs. 1.3[0.6-6.6];p<0.01), ICU (4[3-6] vs. 3[1-5];p=0.08), post-ICU (8[4 - 19] vs. 4.5[2-11];p<0.01), and hospital LOS (21[10-37] vs. 12[6-20];p<0.001).

CONCLUSIONS: Use of shared decision making during the triage of IMCU patients to the ICU may decrease inpatient mortality without changing severity of illness on arrival to the ICU, and decreases pre-ICU, ICU, post-ICU, and hospital LOS.

CLINICAL IMPLICATIONS: Low cost interventions that facilitate communication between resident and supervising physicians may improve patient outcomes and are likely to decrease the cost of care among critically ill medical patients.

DISCLOSURE: The following authors have nothing to disclose: Pranav Chandrashekar, Ali Abdel-Halim, David Hager

No Product/Research Disclosure Information




Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
CHEST Journal Articles
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543