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Why some Emergency Department patients with admission orders do not get quickly transferred to the inpatients?

The admitted Emergency Department (ED) patients should be disposed to an appropriate clinical inpatient bed based on validated clinical criteria. The patients should not be held unnecessarily in ED once the decision to admit has been made. The mortality of these admitted patients increases proportionately with the length of stay in ED. Patient movement from ED should be based on accredited criteria based on Hospital resources. Lack of use of validated criteria can lead to unnecessary delay and ED patient boarding. Admitted patients from the ED who are denied access to inpatient units may continue to have abnormal vital signs for several days. *Correspondence to: Taimur S. Butt, Chairman, Department of Emergency Medicine, King Faisal Specialist Hospital & Research CentreMadinah, KSA, E-mail: tbutt@kfshrc.edu.sa Received: May 21, 2020; Accepted: June 15, 2020; Published: June 18, 2020 Introduction The disposition of admitted patients in the Emergency Department (ED) should happen without any significant delay. Once the initial resuscitation and stabilization has occurred, admitted patients should be transferred to an appropriate clinical setting [1]. A delay in transferring these patients causes ED boarding, which stacks up clinical risk [2]. The boarded patients’ mortality increases significantly with every hour of stay in ED, including those patients who need admission to intensive care [3]. Most hospitals will use a standardized criterion to transfer patients out of the ED to an appropriate unit. Our institution uses measures adopted from the hospitals’ “Rapid Response Team” (RRT) activation criteria (Figure 1) which are intended for hospital inpatients. RRT has been successfully used to identify inpatients who require urgent interventions to prevent clinical deterioration [1-3]. These “advanced RRT criteria” (ARRT) comprises of patients’ vitals, clinical presentations, laboratory parameters and health care worker clinical gestalt. The reliability of RRT activation and early intervention with management of admitted patients in the hospital has been clearly documented with reduction in mortality [2]. However, the use of these criteria to determine the suitability of admitted ED patients for inpatient ward transfer is not a common practice. Our institution uses the ARRT criteria to determine the suitability of ED boarded patients for inpatient ward, intensive care unit (ICU) or coronary care unit (CCU) transfers. The patients who do not fit under these criteria are considered unfit and remain in the ED as boarded patients. We wanted to find the common reason for an ED patient with admission orders to continue to stay in the ED and being unfit for transfer to inpatient bed. Methods & statistical analysis The cohort of ED patients with admission orders who were not considered fit for transfer to the inpatients were studied over a period of three months. Patients who were fit to be transferred but were boarded in ED due to the lack of availability of an appropriate inpatient bed were excluded. List of ED patient with admission orders was obtained daily from the hospital electronic system (ICIS). The ED charge nurses’ list of admitted patients who were considered unfit for inpatient transfer was also obtained daily during the study period. Each patients’ electronic medical record was reviewed in detail to corroborate the unfit reasons mentioned in the manual list. We collected the data of our selected patients including reason for being unfit for ward transfer, demographics, code status, admitting service, reason for admission, duration of ED boarding due to being unfit and disposition. Descriptive statistics for the continuous variables were reported as mean ± standard deviation and categorical variables were interpreted as frequencies and percentages. The categorical variables were compared by Chi-square test and the continuous variables were compared by Student’s t-test or ANOVA. Univariate and multivariate logistic regression was used to identify the independent variables that contribute significantly to major outcomes of this study. The level of statistical significance is set at p < 0.05. Butt T (2020) Why some Emergency Department patients with admission orders do not get quickly transferred to the inpatients? Volume 5: 2-4 Trauma Emerg Care, 2020 doi: 10.15761/TEC.1000198 97 (81%) of the ED boarded unfit patients were eventually sent to the inpatient ward. 17 (14%) were sent to an intensive care or coronary care unit while 5 (4%) patients were discharged home. Discussion Timely transfer of admitted ED patients to a clinical area appropriate to the needed level of care i.e., intensive care, coronary care, operating room, or med-surgical floor will decrease patient risk and improve quality of care (Figure 2). Inpatient level of care is determinted by the treating physician expertise, available resources, total nursing hours and nursing skill mix [4]. RRT activation criteria have been used by hospitals for several years as an aid for recognizing clinical deterioration of inpatients. Our institution has a well-established inpatient RRT that operated 24/7. This was developed following the recommendations from the Institute of Healthcare Improvement Campaign to manage inpatients [5]. The RRT criteria are validated for early intervention during inpatient deterioration. Patients identity was protected, and consent was not required as this was an observational study without any interventions.