This is a short audit which was done to see what factors delay admission of a patient from ER to ICU and how can these be prevented.

1. Time between decision to admit and ICU arrival of patients
from emergency department
Authors
A. Al-Harthy, A.F. Mady, M. A. Rana, W. Al-Etreby, O. A. Ramadan, K. T. Rahman
Department of Intensive Care Medicine,
King Saud Medical City, Riyadh, Kingdom of Saudi Arabia
Corresponding Author
Waleed Tharwat Hashim Al-Etreby
Kingdom of Saudi Arabia, Riyadh, P.O. Box 331140 ZIP code 11373 Al-Shemaisi
Anesth_71@yahoo.com
Lead Consultant
Abdul Rahman Mishal Al-Harthy
King Saud Medical City, Critical Care Department
Riyadh, Kingdom of Saudi Arabia
The Online Journal of Clinical Audits. 2014; Vol 6(4).
Published November 2014
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Abstract
One of the most important quality measures is process, which includes access to care and timeliness as
key dimensions. Reduction of the time taken to transfer admitted patients to ICU from ED helps enhance
process greatly. In addition, early admission to ICU of critical patients, not only helps to solve the
problem of ED overcrowding, it was also shown by studies to improve patients’ outcome.
Aims
To measure the median time between the decision to admit a patient from ED, and actual arrival to ICU,
at King Saud Medical City, Riyadh, KSA.
Methods
Median time (in minutes) between decision to admit a patient from ED and arrival to ICU, during April
2014
Results
The median time between decision to admit and ICU arrival during April 2014 was 100 minutes, which is
below our delay deadline of 240 minutes, however, 13 patients were delayed, out of which 7 delays were
justified medically, but 6 cases were delayed due to non-medical reasons.
Conclusions
Despite having a median time between decision to admit and ICU arrival of 100 minutes, we had a delay
of admission in about 15% of all of our admissions from ED, about half of those delays were not due to
medical reasons, and may have resulted from shortage of staff or poor interdepartmental communication.
`
Introduction
Process is one of the clinical quality measures identified in the specifications manual for
national hospital inpatient quality measures, by the Centres for Medicare and Medicaid
services (CMS), and The Joint Commission 1
. Two of the important key dimensions of
quality performance (that involve process) are availability or access to care and
timeliness 2
.
Reduction of the time patients remain in the emergency department (ED) and arrive to
the intensive care unit (ICU), can significantly improve access to care and allow for
provision of additional treatment specific to each patient’s condition in a timely fashion3
.
It also helps in solving the problem of ED overcrowding, that is becoming a
phenomenon, involving not only large urban teaching hospitals, but also involves
suburban and rural healthcare facilities 3,4
.
As for the outcome of the patients themselves, studies were able to show an
independent association between delayed admission and higher mortality, even if the
patient is eventually admitted to the ICU, and that each hour of delay is associated with
increased mortality 5
. The same conclusion of increased mortality associated with
delayed ICU admission was reached by other authors as well 6-8
.
Aims
• To measure the median time between the decision to admit a patient from ED,
and actual arrival to ICU, at King Saud Medical City, Riyadh, KSA.
• To identify delayed admissions, as defined by our policy 9
as: 240 minutes or
more.

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Audit Standards
All patients admitted to ICU directly from ED.
Methods
• Inclusion: Any patient admitted to ICU from ED.
• Exclusion: ward, or post-operative admissions.
• Time frame: 1/4/2014 to 30/4/2014
• Source of data: patient’s medical record:
o Computerized admission form from ED.
o ICU admission notes.
• Scoring: Median time.
• The median time of each day’s admissions is calculated to generate a line
graph.
Results
In the month of April, 2014. A total of 144 patients were admitted to the ICU at King
Saud Medical City, Riyadh, Saudi Arabia. Patients that were admitted directly from
ED were 87 (60.4%), divided over the days of the month, only 13 cases (14.9%)
were delayed (240 minutes or more), (table 1) (figure 1).
Table 1: ICU admissions, April/2014
Admitted from Number (%)
Emergency Department 87 (60.4%)
Post-operative 22 (15.3%)
Inpatient wards 30 (20.8%)
Fax from other peripheral hospitals 5 (3.5%)
Total 144

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Figure 1: Time between decision to admit and ICU arrival, for patients admitted from
ED, April/2014
The median time between decision to admit and ICU arrival for those 87 patients
was 100 minutes. The median time between decision to admit and ICU arrival for
any single day was more than 240 minutes in two occasions.
(figure 2)
Figure 2: Line graph of the median time of daily admissions from ED.
Discussion
Out of 144 patients admitted to our ICU during the month of April/ 2014. 87 patients
came directly from the ED, 31 cases(35.6%) were medical and 56 cases (64.4%)
were surgical or trauma patients, among the 87 patients 66 (75.9%) were intubated
and mechanically ventilated.
Minutes
Days
Delay deadline (240 minutes)
Minutes
Days
Delay deadline (240 minutes)

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The median time between decision to admit and ICU arrival was 100 minutes for all
87 patients, the maximum median time of any single day was 274 minutes
(28/April), while the minimum median time for any single day was 69.5 minutes
(12/April).
Out of the 87 cases admitted from ED, 13 cases were delayed (more than 240
minutes). The longest duration taken by a delayed case to arrive to ICU was 780
minutes, whereas the shortest duration taken by a delayed case to arrive to the ICU
was 245 minutes.
We were able to medically justify the delay in 7 cases, whom were delayed due to:
Ø Haemodynamic instability and high inotropic support (3)
Ø High ventilatory settings: high FiO2, high PEEP (2)
Ø Ongoing dialysis (1)
Ø Requested radiological investigation prior to ICU transfer (1)
However, in 6 other delayed cases we could not justify the delay medically, and the
identified reasons of their delay were:
Ø A very busy primary team physician, who couldn’t accompany the patient to the
ICU.
Ø A single respiratory therapist covering ER alone, and can’t transfer the patient to
the ICU within the time limit.
Ø Bed in ICU is not ready, because the patient already occupying it is not
discharged yet.
Conclusions
On one hand the median time between decision to admit and arrival to ICU is less
than the delay deadline of 240 minutes, on the other hand, we do have a
percentage of about 15% of delayed cases admitted from ED, and almost have of
those cases are delayed because of non-medical reasons, that involve either the
lack of personnel, or poor communication and arrangement between inpatient units
and the bed management.
Recommendations
Staffing:
• Inadequate staffing clearly contributes to delay of admission.
• It is recommended that a designee physician be available in each shift, to
transfer patients to ICU.
• Respiratory therapist assigned for transfer of patients only, is also
recommended.
Vacant beds:
• The hospital should have an effective process to identify vacant beds, and
communicate their availability between in-patient units.
• More cooperation from bed management, to evacuate beds in ICU in timely
fashion.
• Availability of social workers 24/7 to solve problems of patients for transfer from
ICU, to make beds available for new admissions.

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Monitoring:
• Re-audit the same measure after implementation of the recommendations.
• We recommend collecting data and continuous monitoring throughout the year,
or over several years, so that the results are more representative of the actual
situation.
References
1. Specifications Manual for National Inpatient Hospital Quality Measures , Discharge Dates 01-01-
14 (1Q14) through 12-31-14 (4Q14) v4.3b
2. Janet A Brown. The Healthcare Quality Handbook: A Professional Resource and Study Guide. ,
25
th
ed; 2011.
3. Derlet RW, Richards JR. Emergency department overcrowding in Floride, New York, and
Texas. South Med. J 2002; 95(8): 846-9.
4. National Quality measures clearinghouse, measure summary NQMC- 8828, Jan 2013
5. Lucienne TQ Cardoso, Cintia MC Grion*, Tiemi Matsuo, Elza HT Anami, Ivanil AM Kauss,
Ludmila Seko, Ana M Bonametti. Impact of delayed admission to intensive care units on
mortality of critically ill patients: a cohort study. Critical Care 2011; 15: R28.
6. Marcos I. Restrepo, MD, MSc, FCCP; Eric M. Mortensen, MD, MSc; Jordi Rello, MD, PhD;
Jennifer Brody , MD; and Antonio Anzueto, MD. Late Admission to the ICU in Patients With
Community-Acquired Pneumonia Is Associated With Higher Mortality. Chest 2010; 137(3): 552–
557.
7. Bing-Hua YU. Delayed admission to intensive care unit for critically surgical patients is
associated with increased mortality.American J Surg 2014; 208(2): 268-74.
8. Renaud B, Brun-Buisson C, Santin A, Coma E, Noyez C, Fine MJ, Yealy DM, Labarère J..
Outcomes of early, late, and no admission to the intensive care unit for patients hospitalized with
community-acquired pneumonia.. Acad Emerg Med 2012; 19(3): 294-303.
9. King Saud Medical City, Riyadh, Kingdom of Saudi Arabia. Administrative Policy and Procedure:
Admission of Inpatients. APP-KSMC-017 (v4). 13/May/2014.