We have found that critically ill patients in our study were managed in the ED for 4.9 hours prior to transfer to an ICU. In addition, although the majority of emergent airway management is provided in the ED and pre-hospital setting, other invasive procedures such as central venous catheterization and arterial cannualtion were more commonly preformed after transfer to an ICU setting.
The management of critical illness in the emergency department occurs at a crucial phase in a patient's care, when intervention may significantly improve outcome and survival. [4, 5, 13] Early and aggressive care for critically ill patients is believed to optimize patient outcomes, as the stabilization of physiological derangements reduces the progression of multi-organ dysfunction. [13–15] However, the ED may not be the optimal location for prolonged or ongoing provision of critical care, as physicians and other health care members have divided priorities in the management of other ED patients. ED physicians and nurses may not possess the skill sets to allow for the provision of optimal care beyond the acute resuscitation. In addition, some ED's may not have the resources available to provide ongoing or prolonged care for critically ill patients, and therefore the rapid transport of patient to an ICU environment is desirable.
The median LOS of patients in our study are similar to previous reports, which range from 4.4-6.2 hours.[1, 3, 6, 7, 12] Little data is available for countries other than the USA, and therefore this study highlights a potential global issue. Emergency Department LOS of critically ill patients is likely multifactorial and may include time required for ED diagnosis, resuscitation and necessary investigations. However, other factors such as ED overcrowding, ICU resource availability and local practice patterns may affect ED LOS. Further work focusing on modifiable factors contributing to prolonged ED LOS of critically ill patients would further clarify this issue.
This study has also demonstrated that some invasive procedures are performed frequently in the ED while others are not completed until after admission to the ICU. It is interesting that the majority of airway interventions occurred in the ED prior to ICU admission (94.4%), however relatively few patients underwent invasive procedures such as CVC or AC insertion in the ED. In addition, invasive procedures not performed in the ED were often performed early in the ICU admission. Other studies have reported variable procedure completion rates in the ED, as EETI rates have ranged from 13.3-30.8% [8, 10, 11, 13], CVC rates 3.9-26%; and arterial catheter rates 0.0-14.8% [8, 10, 11] It is possible that some procedures may have been delayed until transfer, which may indicate that life saving therapy was delayed.
Our study highlights several important issues, namely the prolonged length of stay of critically ill patients in the ED and an apparent disparity in invasive procedures employed in the ED. Current evidence suggests that aggressive resuscitation and interpretation of physiologic data in critically ill patients is beneficial in patient outcomes, and may result in a reduction in ICU admissions. [4, 13, 15] It is unclear if the management provided for patents in this study was optimal, or if a reduction in the LOS or additional invasive procedures performed in the ED would have impacted on patient outcomes. Further investigation is warranted.