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FACP. Colegio de médicos de Tarragona Nº 4305520 / fgcapriles@gmail.com




Monday, May 9, 2016

ED floor admit - ICU care

emDocs - March 2, 2016 - Author: Long B -  Edited by: Koyfman A and Alerhand S
First, appropriate disposition is important, as decompensation on the floor is associated with worse outcomes. Goldhill found transferred patients (floor to ICU) experienced a mortality rate of 53% compared to 30% of direct admissions to an ICU from the ED. Clinical deterioration on the hospital floor is an independent predictor of mortality. Patients admitted to the ICU directly have lower mortality and shorter length of stay when compared with patients with unplanned transfer from the floor/ward to the ICU. In patients with septic shock diagnosed in the ward versus ICU, patients on the ward had higher mortality, greater time to receipt of IV fluid, and greater time to vasopressor administration.
floor to ICU 1
What can emergency providers do?
Is there a way to decrease this risk of unplanned ICU transfer? The most important factor is knowing what risk factors are associated with decompensation and need for transfer. Emergency physicians provide great care, and patients will often improve with your resuscitation measures in the ED. The patient who was initially on the cusp of intubation or death may turn around quickly with measures including IV fluids, antibiotics, pain treatment, and/or noninvasive positive pressure ventilation. You might be thinking that because the patient looks so good now, they will look just as good several hours later.
If admitting the patient to a normal floor or ward, be sure to re-evaluate the patient’s vital signs and clinical appearance. Go through the laboratory and imaging results and look for those risk factors discussed above. If something is bothering you about the patient, speak with the admitting physician about your concerns. Closely look at the vital signs to ensure they truly are normal. Be wary of the patient who experienced a transient drop in blood pressure but then returns to normal, which is associated with increased risk of death. A recent 2015 study evaluated patients presenting with non-traumatic hypotension, and this study showed an in-hospital mortality of 12% for hypotension in the ED and an in-hospital mortality of 33-52% for pre-hospital shock!"