ED to ICU Transfer Project
Improve ICU mortality rate: This particular project was brought about after two ICU mortality cases were analyzed. It was found that delays between the ED and transfer to the ICU were the primary cause of death. This conclusion was also supported by medical literature, which closely correlates mortality of ICU patients with length of stay in the ED.
The baseline time for a patient to get to the ICU once admitted in the ED was 6 h on average. I distinctly remember one of our first meetings when the discussion turned to our goal. We had discussed cutting it in half, then to 2 h. Finally, I mentioned that we really already had a process of getting patients requiring the ICU out of the ED in less than 60 min. Everyone stared. The Door to Balloon time for acute MI patients presenting to the ED was rapidly approaching the 60-min mark. Whether someone is septic or having an acute myocardial infarction, their transfer time should be no different. So, 60 min was determined to be the benchmark we would shoot for.
Our team was the following: ICU representative, ED representative, Bed assignment, Hospitalist representative, Administrative representative.
Our team determined we would need 6 months to complete the project.
The project was limited to a single process transferring from ED to ICU—no scaling needed to be considered.
With a plan in mind, our team first set out to determine what the current process was for identifying and then transferring an ICU patient from the ED. It was extremely complex. We found that depending on the time of day, there were different phone calls to make, and that, further complicating things, there were different people responsible for determining whether the patient should go to the ICU. We also found that perceptions had developed that the ED was placing patients in the ICU just to get them out of the ED. Also, there was no electronic method to track data. We mapped out the whole convoluted process and quickly the whole team understood that we needed a streamlined process, with only one phone call to make and a mechanism to track progress.
The concept of using an identified ICU nurse as the focal point of communication was developed. This person had two primary responsibilities:
- (1) Initiate the cascade of events that needed to occur when called for with a patient requiring ICU care
- (2) Always have an ICU bed available for the next ICU patient
This person would also fill out the hand log to track the patients and metrics.
The new process was implemented but not without problems. Everyday follow-up phone calls would be made to providers involved with any ICU patient whose transfer process exceeded our benchmark. Weeks went by and slowly we got consistently below the 2-h mark. Then months later, we gradually began to achieve the 60-min mark. This is a critical point in projects. Too often, hospitals achieve results and then move on to other things. The project was handed over to the hospitalist group. We watched as the numbers started getting right back to baseline. The team looked at what was happening and concluded that the provider follow-up was no longer there. We had learned that it was integral to the process.
The project was then handed to the physician director of the ICU who truly took ownership. They got the project back on track and to this day, it remains a significant success.
Two interesting downstream effects came out of this project. Raw mortality for ICU patients dropped an astonishing 15% and the length of stay of ICU patients dropped by almost a day. In hospital capacity management, these are the kinds of projects and successes you live for. Some of us still celebrate the success to this day.