This study showed that applying a lean approach to the laps of admission to ICU and the introduction of a novel quality indicator effectively reduced the time to admission to ICU.
There is an association between delayed ICU admission and higher mortality5. It was shown that patients meeting ICU admission criteria but treated out of the ICU have higher mortality10. An admission delay from the emergency department of four hours 11,12 and as short as one hour13 was shown to increase the mortality of mechanically ventilated patients. Mortality increase was also seen in non-ventilated patients with community-acquired pneumonia14. Septic patients managed at the emergency department for more than 12 hours showed a significantly increased risk of death compared with patients transferred to the ICU in less than six hours15.
In a recent meta-analysis, delayed admission was associated with significantly higher mortality, with an overall quantitative synthesis of findings indicating an increase in the odds for mortality by 61%16. However, if the referral department is of high complexity, no association was found 17.
A significant association was found between the number of ICU beds available and ICU admission within two hours18. However, in this study, hospital mortality was similar between groups.
To have enough ICU beds and staff availability is an undoubted and undisputed vision for every hospital and society, although not always real because of the high cost and the scarcity of medical and nursing professionals.
Our study found that the emergency department was the most frequent referral (54%), followed by the combined surgical department and the operating room (25%), then the combined six internal medicine departments of the hospital (21%).
Both the surgical and medical departments referred most of their patients during the morning shift and less during the night shift. The evening shift was the busiest for patients transferred from the emergency department and the operating room, being the night shift the less transfer-burdened from all the departments. Despite the morning round admitting fewer patients and being better staffed than the evening shift, longer admission time was revealed, followed by the night shift and the shorter time noted at the evening shift (Table 2). It is to note that the morning shift is usually the busiest time at the unit. Although better staffed, our findings point to a possible disproportion between the amount of work expected to be done and the number of staff doing the work.
The evening shift also showed a shorter delay to transfer of a patient from ICU to other departments when zero ICU beds were available and a shorter time to arrange the bed for new admission. The arrangement of the space for admission requires special cleaning. This activity is done by a team that is not organic to the unit and takes longer to recruit at night.
As expected, significantly longer time-to-admission was recorded when no ICU bed was available (Table 3). As shown, a significant difference was noted up to the 4th lap, as no significant difference was seen from then to the patient admission.
Surprising interactions between lapses were found. If some lap was longer, all the laps were longer despite not being dependent on each other, as seen by the Pearson correlation (Table 4). We can only hypothesize that similar factors influenced each lapse correlated in time, situation, and referral department.
Finally, our study showed a significant shortening in time to admission before and after the intervention (Table 5), as the total mean time to admission was shortened by 14 minutes, from 92.4 minutes to a mean of 78.6 minutes.
The limitations of the present study must, however, be acknowledged. Manually registering each time can be subjected to manipulation. Though that was periodically supervised, and neither the supervisor nor the staff doing the registration wasn't aware of the intention of registering the data. Referral departments were not aware of the study at any of their phases. It is also to note that the initial registers were not used until consistent annotation was achieved. Being a single-site study, our conclusions cannot be directly extrapolated and are only supposed to be the same at other institutions. Nonetheless, our hospital is a secondary trauma level university institution periodically supervised by the Joint Commission for Quality in Hospital Care Accreditation and Certification. Other similar institutions are then supposed to have to cope with comparable situations.
We didn't compare other variables such as patient's severity, length of stay in the unit, or mortality, but this was beyond the goals of the study and the intervention, anyhow, shortening time to ICU admission and fastening interventions to improve the level of care are believed to be significant corners to professional care.
Many variables cannot be modified by the ICU staff. The time demanded the transfer of a stable patient from the ICU to another department depends on the availability of a free bed in the receiving ward. The early hours of the morning shift, before discharges started at the different hospital departments, were puzzling because the admitting ward was also at full capacity. Finally, the time required by the referral department to transfer the patient after the ICU approval can also be barely changed by the ICU team.
One of the main amendable reasons for the delay was identified in our study as the lapse required from the decision to admit a patient to the ICU until the authorization given by the ICU to the referral department to transfer the patient. As we learned that the referral department needs an average of 44.5 minutes to move the patient to the ICU, another door for intervention was open as we started to superpose actions that were done in sequence in the past. This data is being acquired now, and we hope to furtherly shorten the time to admission to our ICU.