(361) Common ICU Diagnoses Associated With Early ED Downgrade by a Novel Emergency Critical Care Program

Introduction: The implementation of the Stanford Emergency Critical Care Program (ECCP) was associated with a mortality benefit. We aimed to identify common critical care diagnoses associated with an increase in early Emergency Department (ED) downgrades by ECCP.

Methods: This single center, retrospective cohort analysis included adult ED patients with an admission order to the Medical Intensive Care Unit (MICU) or ECCP service within 12 hours of ED arrival. The primary outcome was the proportion of patients downgraded to non-ICU status while in the ED within 6 hours of ICU admission order (ED downgrade < 6h), adjusted by severity of illness. For the 10 most frequent diagnoses, a difference-in-differences (DiD) analysis compared the change in outcomes for patients who received critical care admission orders during ECCP hours vs. non-ECCP hours. Secondary outcomes included the proportion of patients who never occupied an ICU bed, length of stay, and mortality.

Results: 1882 patients were included. The top ten critical care diagnoses were respiratory failure, sepsis/septic shock, diabetic ketoacidosis (DKA), altered mental status, gastrointestinal bleed, cardiac arrest, other forms of shock, hyponatremia, airway monitoring, and renal failure/hyperkalemia. Admission during ECCP hours was associated with a severity-adjusted increase in ED downgrade < 6h (DiD 19% [CI: 13% - 25%]), as well as an increase in patients who never occupied an ICU bed (DiD 13% [5.9% - 21%]). A significant increase in ED downgrade < 6h was observed among patients with respiratory failure and sepsis/septic shock (DiD 25.9%, [13.9% - 37.9%], and DiD 13.0%, [1.9% - 25%], respectively). An increase in the proportion of patients who never occupied an ICU bed was observed among the respiratory failure and DKA groups (DiD 18.8%, [2.7% - 35%] and DiD 48.0%, [17% - 78%], respectively). There was no statistically significant difference in outcomes for other diagnoses.

Conclusions: Admission during ECCP hours was associated with an increase in early ED downgrade for patients with respiratory failure and sepsis/septic shock, and an increase in proportion of patients who never occupied an ICU bed for respiratory failure and DKA. This work highlights a target population for ED-based interventions focused on ICU resource optimization.