The effect of emergency department crowding on lung-protective ventilation utilization for critically ill patients

J Crit Care. 2019 Aug:52:40-47. doi: 10.1016/j.jcrc.2019.03.008. Epub 2019 Mar 23.

Abstract

Objective: To measure effects of ED crowding on lung-protective ventilation (LPV) utilization in critically ill ED patients.

Methods: This is a retrospective cohort study of adult mechanically ventilated ED patients admitted to the medical intensive care unit (MICU), over a 3.5-year period at a single academic tertiary care hospital. Clinical data, including reason for intubation, severity of illness (MPM0-III), acute respiratory distress syndrome (ARDS) risk score (EDLIPS), and ventilator settings were extracted via electronic query of electronic health record and standardized chart abstraction. Crowding metrics were obtained at 5-min intervals and averaged over the ED stay, stratified by acuity and disposition. Multivariate logistic regression was used to predict likelihood of LPV prior to ED departure.

Results: Mechanical ventilation was used in 446 patients for a median ED duration of 3.7 h (interquartile ratio, IQR, 2.3, 5.6). Mean MPM0-III score was 32.5 ± 22.7, with high risk for ARDS (EDLIPS ≥5) seen in 373 (82%) patients. Initial and final ED ventilator settings differed in 134 (30.0%) patients, of which only 47 (35.1%) involved tidal volume changes. Higher percentages of active ED patients (workup in-progress) and those requiring eventual admission were associated with lower odds of LPV utilization by ED departure (OR 0.97, 95%CI 0.94-1.00; OR 0.97, 95%CI 0.94-1.00, respectively). In periods of high volume, ventilator adjustments to settings other than the tidal volume were associated with higher odds of LPV utilization. Reason for intubation, MPM0-III, and EDLIPS were not associated with LPV utilization, with no interactions detected in times of crowding.

Conclusions: ED patients remain on suboptimal tidal volume settings with infrequent ventilator adjustments during the ED stay. Hospitals should focus on both systemic factors and bedside physician and/or respiratory therapist interventions to increase LPV utilization in times of ED boarding and crowding for all patients.

Publication types

  • Observational Study
  • Research Support, N.I.H., Extramural

MeSH terms

  • Academic Medical Centers
  • Adult
  • Aged
  • Continuity of Patient Care
  • Critical Illness*
  • Crowding*
  • Dyspnea / etiology
  • Electronic Health Records
  • Emergency Service, Hospital*
  • Female
  • Guideline Adherence
  • Humans
  • Intensive Care Units*
  • Length of Stay
  • Logistic Models
  • Male
  • Middle Aged
  • Respiration, Artificial / adverse effects*
  • Respiratory Distress Syndrome / etiology
  • Respiratory Distress Syndrome / prevention & control*
  • Retrospective Studies
  • Tertiary Care Centers
  • Tidal Volume
  • Ventilators, Mechanical