Risk factors for unplanned transfer to the intensive care unit after emergency department admission

Published:March 12, 2017DOI:



      Unplanned Intensive Care Unit (ICU) admission has been used as a surrogate marker of adverse events, and is used by the Australian Council of Healthcare Accreditation as a reportable quality indicator. If we can identify independent variables predicting deterioration which require ICU transfer within 24 h after emergency department (ED) admission, direct ICU admission should be considered. This may improve patient safety and reduce adverse events by appropriate disposition of patients presenting to the ED.


      The aim of this study was to identify independent variables predicting deterioration which require ICU transfer within 24 h after ED admission.


      A case control study was performed to examine characteristics of patients who underwent an unplanned transfer to the ICU within 24 h after ED admission.


      There were significantly more hypercapnia patients in the ICU admission group (n = 17) compared to the non-ICU group (n = 5) (p = 0.028). There were significantly greater rates of tachypnea in septic patients (p = 0.022) and low oxygen saturation for patients with pneumonia (p = 0.045). The level of documentation of respiratory rate was poor.


      In patients presenting to the ED, hypercapnia was a predictor for deterioration which requires ICU transfer within 24 h after ED admission. Additional predicting factors in patients with sepsis or pneumonia were respectively tachypnea and low oxygen saturation. For these patient groups direct ICU admission should be considered to prevent unplanned ICU admission. This data emphasizes the importance of measuring the vital signs, particularly the respiratory rate.


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        • Shiloh A.L.
        • Eisen L.A.
        • Savel R.H.
        The unplanned intensive care unit admission.
        J Crit Care. 2015; 30: 419-420
        • Goldhill D.R.
        • Sumner A.
        Outcome of intensive care patients in a group of British intensive care units.
        Crit Care Med. 1998; 26: 1337-1345
        • Lundberg J.S.
        • Perl T.M.
        • Wiblin T.
        • Costigan M.D.
        • Dawson J.
        • Nettleman M.D.
        • et al.
        Septic shock: an analysis of outcomes for patients with onset on hospital wards versus intensive care units.
        Crit Care Med. 1998; 26: 1020-1024
        • Tam V.
        • Frost S.A.
        • Hillman K.M.
        • Salamonson Y.
        Using administrative data to develop a nomogram for individualizing risk of unplanned admission to intensive care.
        Resuscitation. 2008; 79: 241-248
        • Kennedy M.
        • Joyce N.
        • Howell M.D.
        • Lawrence Mottley J.
        • Shapiro N.I.
        Identifying infected ED patients admitted to the Hospital Ward at risk of clinical deterioration and ICU transfer.
        Acad Emerg Med. 2010; 17: 1080-1085
        • Tsai J.C.
        • Weng S.J.
        • Huang C.Y.
        • Yen D.H.
        • Chen H.L.
        Feasibility of using the predisposition, insult/infection, physiological response, and organ dysfunction concept of sepsis to predict the risk of deterioration and unplanned intensive care unit transfer after emergency department admission.
        J Chin Med Assoc. 2014; 77: 133-141
        • Osborn T.M.
        • Nguyen H.B.
        • Rivers E.P.
        Emergency medicine and the surviving sepsis campaign: an international approach to an aging severe sepsis and septic shock.
        Ann Emerg Med. 2005; 46: 228-231
        • Subbe C.P.
        • Kruger M.
        • Rutherford P.
        • Gemmel L.
        Validation of a modified early warning score in medical admissions.
        Q J Med. 2001; 94: 521-526
        • Cretikos M.A.
        • Bellomo R.
        • Hillman K.
        • Chen J.
        • Finfer S.
        • Flabouris A.
        Respiratory rate: the neglected vital sign.
        MJA. 2008; 188
        • Subbe C.P.
        • Davies R.G.
        • Williams E.
        • Rutherford P.
        • Gemmell L.
        Effect of introducing the modified early warning score on clinical outcomes, cardio-pulmonary arrests and intensive care utilisation in acute medical admissions.
        Anaesthesia. 2003; 58: 797-802
        • Kellett J.
        • Murray A.
        • Woodworth S.
        • Huang W.
        Trends in weighted vital signs and the clinical course of 44,531 acutely ill medical patients while in hospital.
        Acupunct Med. 2015; 14: 3-9
        • Lovett P.B.
        • Buchwald J.M.
        • Stürmann K.
        • Bijur P.
        The vexatious vital: neither clinical measurements by nurses nor an electronic monitor provides accurate measurements of respiratory rate in triage.
        Ann Emerg Med. 2005; 45: 68-76
        • Lim W.S.
        • van der Eerden M.M.
        • Laing R.
        • Boersma W.G.
        • Karalus N.
        • Town G.I.
        • et al.
        Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study.
        Thorax. 2003; 58: 377-382
        • Fine M.J.
        • Auble T.E.
        • Yealy D.M.
        • Hanusa B.H.
        • Weissfeld L.A.
        • Singer D.E.
        • et al.
        A prediction rule to identify low-risk patients with community-acquired pneumonia.
        N Engl J Med. 1997; 336: 243-250
        • Marhong J.
        • Fan E.
        Carbon dioxide in the critically ill: too much or too little of a good thing?.
        Respir Care. 2014; 59