Risk factors for unplanned ICU admission after emergency department holding orders

Emergency department (ED) holding orders are used in an effort to streamline patient flow. Little research exists on the safety of this practice. Here, we report on prevalence and risk factors for upgrade of medical admissions to ICU for whom holding orders were written.

Retrospective review of holding order admissions through our ED for years 2013-2018. Pregnancy, prisoner, pediatric, surgical, and ICU admissions were excluded, as were transfers from other hospitals. Risk factors of interest included vital signs, physiologic data, laboratory markers, sequential organ failure assessment (SOFA), Quick SOFA (qSOFA), modified early warning (MEWS) scores, and Charlson Comorbidity Index (CCI). Primary outcome was ICU transfer within 24 hours of admission. Analysis was completed using multivariable logistic regression.

Between 2013 and 2018, the ED had 203,374 visits. Approximately 20% (N = 54,915) were admitted, 23% of whom had holding orders (N = 12,680). A minority of those with a holding order were transferred to the ICU within 24 hours (N = 79; 0.62%). Those transferred to ICU had increased heart and respiratory rate, P/F ratio, and increased oxygen need. They also had higher MEWS, quick SOFA (qSOFA), and SOFA scores. Multivariable logistic regression demonstrated a significant association between ICU admission and FiO2 (odds ratio [OR] 1.47; 95% confidence interval [CI] 1.25-1.74), MEWS (OR 1.31; 95% CI 1.14-1.52), SOFA Score (OR 1.19; 95% CI 1.05-1.35), and gastrointestinal (OR 3.25; 95% CI: 1.50-7.03) or other combined diagnosis (OR 2.19; CI: 1.07-4.48) (P = 0.0017).

Holding orders are used for >20% of all admissions and <1% of those admissions required transfer to ICU within 24 hours.