Gardner Kevin, Gordon Alexandra June, Shannon Bryant, Nesbitt Jason, Wilson Jennifer G, Mitarai Tsuyoshi, Kohn Michael A
Department of Emergency Medicine Stanford Medical School Palo Alto California USA.
J Am Coll Emerg Physicians Open. 2022 Jan 27;3(1):e12667. doi: 10.1002/emp2.12667. eCollection 2022 Feb.
Studies have found that prolonged boarding time for intensive care unit (ICU) patients in the emergency department (ED) is associated with higher in-hospital mortality. However, these studies introduced selection bias by excluding patients with ICU admission orders who were downgraded and never arrived in the ICU. Consequently, they may overestimate mortality in prolonged ED boarders.
This was a retrospective cohort study at a single center covering the period from August 14, 2015 to August 13, 2019. Adult ED patients with medical ICU admission orders and at least 6 hours of subsequent critical care in either the ED or the ICU were included. Patients were classified as having either prolonged (>6 hours) or non-prolonged (≤6 hours) ED boarding. Downgraded patients were identified, and mortality was compared, both including and excluding downgraded patients.
Of 1862 patients, 612 (32.9%) had prolonged boarding; at 6 hours after ICU admission order entry, they were still in the ED. The remaining 1250 (67.1%) had non-prolonged boarding; at 6 hours after the ICU admission order entry, they were already in the ICU. In-hospital mortality in the non-prolonged boarding group was 18.9%. In the prolonged boarding group, 296 (48.4%) patients were downgraded in the ED and never arrived in the ICU. Including these ED downgrades, the mortality in the prolonged boarding group was 13.4% (risk difference -5.5%, 95% confidence interval [CI] -8.9% to -2.0%, = 0.0031). When we excluded downgrades, the mortality in the prolonged boarding group increased to 17.4% (risk difference -1.5%, 95% CI -6.2% to 3.2%, = 0.5720). The lower mortality in the prolonged group was attributable to lower severity of illness (mean emergency critical care SOFA [eccSOFA] difference: -0.8, 95% CI -1.1 to -0.4, < 0.0001).
Excluding critical care patients who were downgraded in the ED leads to selection bias and overestimation of mortality among prolonged ED boarders.
研究发现，急诊科（ED）中重症监护病房（ICU）患者的长时间候诊与较高的院内死亡率相关。然而，这些研究通过排除那些被降级且从未进入ICU的有ICU入院医嘱的患者引入了选择偏倚。因此，它们可能高估了长时间在急诊科候诊患者的死亡率。
这是一项在单一中心进行的回顾性队列研究，涵盖2015年8月14日至2019年8月13日期间。纳入有医学ICU入院医嘱且在ED或ICU中随后接受至少6小时重症监护的成年ED患者。患者被分类为有长时间（>6小时）或非长时间（≤6小时）的ED候诊。识别出被降级的患者，并比较包括和排除被降级患者的死亡率。
在1862例患者中，612例（32.9%）有长时间候诊；在ICU入院医嘱录入后6小时，他们仍在ED。其余1250例（67.1%）有非长时间候诊；在ICU入院医嘱录入后6小时，他们已在ICU。非长时间候诊组的院内死亡率为18.9%。在长时间候诊组中，296例（48.4%）患者在ED被降级且从未进入ICU。包括这些ED降级患者，长时间候诊组的死亡率为13.4%（风险差异-5.5%，95%置信区间[CI]-8.9%至-2.0%，P = 0.0031）。当我们排除降级患者时，长时间候诊组的死亡率增至17.4%（风险差异-1.5%，95%CI-6.2%至3.2%，P = 0.5720）。长时间候诊组较低的死亡率归因于较低的疾病严重程度（平均急诊重症监护序贯器官衰竭评估[eccSOFA]差异：-0.8，95%CI-1.1至-0.4，P < 0.0001）。
排除在ED被降级的重症监护患者会导致选择偏倚，并高估长时间在ED候诊患者的死亡率。
