Emergency Department Length of stay is considered a key measure of emergency department throughput, and it is perceived as a measure of healthcare service quality, especially for those who need ICU care . The society of critical care medicine (SOCCM) 2016, suggests the transfer time of critically ill patients from the ED to the ICU should be minimized or < 6 h. So, the aim of this study was to identify factors that affect ICU admission of critically ill patients and their length of stay in the ED. The result of the current study revealed that 86 (84.3%) of the critically ill patients had been delayed for ICU admission, while only the rest patients, 16 (15.7%), were transferred to the ICU in less than 6 h of ED stay. This was comparable to the same study done in Pakistan in which 67.7% of them stayed in the ED for more than 6 h before transferred to the ICU . The results were also relatively comparable with a study conducted in Ethiopia among 431 critically ill patients who need ICU admission; the results reported that around 67.5% of the patients had delayed ICU admission , This number discrepancy might occurred due to that, this previous study conducted in Ethiopia was included the pediatric ED patients, besides sociodemographic characteristics of patients might also change over time. This shows that critical care service in Ethiopia still needs an improvement.
In contrast to these studies, a study conducted in Finland shows EDLOS of critically ill patients was short and from the total critically ill patients, 79.3% admitted to the ICU within 3 h of ED admission , the possible reason for this study finding gap was due to difference between low income and high-income countries healthcare access. Additionally, this study shows that the median time of EDLOS was 13.5 h, and this demonstrates still there is a prolonged emergency department length of stay of critically ill patients as the emergency time target was < 6 h. This study was relatively consistent with the study conducted in Pakistan which reveals, the median emergency department LOS of critically ill patients who need ICU care was 10.5 h , and a similar study conducted in Ontario, Canada showed the median EDLOS for all ICU admissions from ED was 7 (4–13) hours . In contrast to these studies, a study conducted in Ethiopia in 2016 showed that the median EDLOS was 48 h . These result discrepancies may be the result of some improvement in the health sector; few governmental and nongovernmental health facilities were launched.
High EDLOS may lead to increased ED overcrowding and may have an impact on the critically ill patient outcome, whereas certain organizational resource allocation and critical care service improvement may have a positive effect on it. Interdisciplinary methods can be utilized to investigate factors causing prolonged EDLOS and contribute a better understanding of them.
Based on the data presented in this study, an acute respiratory failure that requires ventilator support 34(33.3%), was the common reason for the need for ICU admission and septic shock was the second 30(29.4%), followed by Life-threatening dysrhythmias 7.8%, but a study was done in Ontario Canada and Pakistan showed cardiovascular disease is the most common cause of ICU admission (36 and 47.6% respectively) [17, 26], this discrepancy may be because cardiovascular disease is the leading cause of mortality especially in the developed countries. In the previous study done in Ethiopia and also in Finland trauma was the common reason for ICU admission (11.6 and 21.1% respectively) [15, 21], which was not comparable to the current study. This may be due to trauma centers being launched in the city after the studies were conducted.
There are many major contributing factors for delayed ICU admission and in this study, nearly half 56 (54.9%) of critically ill patients had delayed for ICU admission due to lack of ICU bed 56 (65.1%) followed by delays in radiological investigation results 13(15.1%) and poor prognosis, delayed laboratory investigation results, and delayed in therapeutic procedures that can be done in the ED was the reasons (8(9.3%), 6 (7.0%), and 3 (3.5%)) respectively. This study goes in line with a previous study done in Ethiopia which revealed lack of ICU beds is the main reason for the prolonged ED stay . While studies conducted in Finland and Pakistan showed diagnostic and therapeutic procedures that can be done in the ED and diagnostic group was the main reason for those who have delayed ICU admission [17, 21], it shows their ICU bed capacity was better than ours.
This study indicates that critical care service is limited in the study hospital and other facilities like radiological service and laboratory service need improvement. Patients who had malignancy and those who had severe illness spent prolonged ED stay due to their poor prognosis and scarcity of critical care units the physician prioritizes other patients.
The present study reveals critically ill patients who had co-morbidity have delayed ICU admission, but in multivariate analysis, it doesn’t show any significant association. This finding was consistent with study conducted in Madrid, Spain which reveals that patients with co-morbidly was the risk factor associated to prolongation of ED length of stay . Male critically ill patients were less likely to transfer to the ICU within 6 h of ED stay by 82% than females (AOR =0.175(0.044, 0.693)). This was consistent with a retrospective study conducted in Finland that reveals gender of study participants had association with prolonged ICU admission (P = 0.004) . This study is not comparable with the study done in Ontario, Canada, which shows no significant difference was found between male and female critically ill patients regarding delayed ICU admission . This may be possibly due to co-morbidity diseases like cancer having a higher prevalence in males than females.
This study reveals that lack of ICU bed (AOR = 0.022, 95% CI: (0.002,0.201)) has a significant association with delayed ICU admission and it shows that critically ill patients were less likely to transfer with less than 6 h by 97% when there is lack of ICU bed. This study was consistent with a study conducted in Turkey which shows, lack of space in the intensive care unit had a significant association for delayed ICU admission . Furthermore, this study was supported with another study conducted in Ethiopia, which shows shortage of ICU beds were significant association with delayed ICU admission(AOR = 8.7, 95%CI:(3.2–23.2)) .
This contradicts a study done in Finland, which shows a performed radiological investigation was scored significantly higher than the other factors that cause delayed ICU admissions . These observations could be explained by the fact that even though the scarcity of ICU beds were a common worldwide problem, this issue was the extreme problem in developing countries, which contributes for delayed ICU admission for critically ill patients that had negative effect on patient outcomes as our study shows that, among patients who had been delayed for ICU admission, 30(34.9%) of them died while waiting for ICU admission.
To improve timely ICU admission of critically ill patients the organization should have to more IICU beds, train the ED doctors about prioritizing transfer over radiology exams, and transfer the investigation results of critically ill patients to ED timely.
Strengths and limitations of the study
The limitations of the study were, as the study was based on a single institution, generalization as a whole might be not considered. Besides, a cross-sectional study by its nature cannot establish a definitive cause and effect relationship to identify the risk factors. Additionally, even though the finding of the study was interesting, due to small sample size generalization of outcome patients who had prolonged ICU admission was difficult.
The strengths of this study were that variables were categorized and used based on ICU admission guidelines. The study data added the outcomes of delayed ICU admission and the reason for prolonged ICU admission from ED of critically ill patients which can be a source especially for low income countries. .