ED boarding of critical care patients may increase ICU length of stay, ventilator days

NASHVILLE, Tenn. — Each additional minute patients spent boarded in the ED led to a 0.026% increase in ICU length of stay and a 0.023% increase in ventilator days, according to a study presented at CHEST Annual Meeting.

A task force created by the Society of Critical Care Medicine and the American College of Emergency Physicians defined ED boarding of critical care medicine (CCM) patients as the time spent in the ED after deciding the patient should be admitted to the ICU or after 6 hours in the ED.

ED-CCM boarding has been an area that has generated a lot of concern during the COVID-19 pandemic due to surge conditions, Palak Rath, MD, resident physician of internal medicine at Cleveland Clinic Akron General, said during her presentation.

“We wanted to explore the impact of ED-CCM boarding during the COVID-19 pandemic in our hospital,” Rath said. “We also wanted to foster some discussion about avenues for improvement and innovations or new models of care."

“Most of the literature we have focuses on large hospitals and referral centers, so the impact of boarding at rural and community hospitals is poorly understood, and that is one of the major reasons why we decided to go ahead with our project,” she added.

Rath and colleagues conducted a retrospective chart review of 445 patients (median age, 62.8 years ± 16.9; 55.5% men) admitted to the medical ICU (MICU) between Oct. 1, 2020, and Jan. 1, 2022, 145 of whom had COVID-19 and respiratory failure.

Overall, the mean ED boarding time — defined as the interval between when an ED provider placed a MICU consult order and when the patient was transported to the MICU — was 462 minutes (± 1,108 minutes; median, 205 minutes). Median MICU length of stay was 2.1 days (interquartile range [IQR], 1-4.8) and median days on ventilator was 5 (IQR, 2-10).

Results of a linear regression analysis adjusted for APACHE III score showed a significant relationship between boarding time and ICU length of stay (parameter estimate, 0.026% change; P = .0073) and ventilator days (parameter estimate, 0.023% change; P = .0375) for the whole cohort. These data indicate that for each additional minute of boarding time, length of stay increased by 0.026% and ventilator days increased by 0.023%, Rath said.

Thus, based on an average boarding time of 205 minutes, the average patient would experience a 5.33% increase in ICU length of stay and a 4.72% increase in ventilator days due to boarding, she added.

However, logistical regression analysis showed boarding time was not significantly associated with 30-day mortality (OR = 1; 95% CI, 0.999-1) for the full patient population.

When looking at the COVID-19 subgroup, researchers did not find significant associations between boarding time and MICU length of stay, ventilator days or 30-day mortality, although this subgroup may have been insufficiently powered to detect differences, Rath said.

Researchers also did not find a significant association between illness severity based on APACHE III score and boarding time.

“This actually refutes our initial hypothesis that the sickest patients would be the first to be transported to MICU,” Rath said.

Researchers are planning future research to address additional covariates such as nurse-to-patient ratio and total ICU patient census, Rath added.

Reference:

Rath P, et al. Chest. 2022;doi:10.1016/j.chest.2022.08.883.