Pre- and Post-Implementation of One-Hour Rule for the Boarding of Referral of Critically Ill Patients in the Emergency Department

In 2017, the Taiwan Ministry of Health and Welfare established a regional electronic referral system in Central Taiwan to streamline transfers of critically ill patients from the intensive care unit (ICU) of a regional hospital to a medical hospital center. Moreover, in 2018, a one-hour rule for the boarding of referral of critically ill patients from emergency department (ED) to ICU was implemented. This pre- and post-implementation study enrolled consecutive critically ill referral patients from a single academic medical center hospital from January 1, 2017 to December 31, 2018. After implementation of the one-hour rule, two interventions, namely, active bed management before patient arrival and no requirement for laboratory test results to be completed before ICU admissions, were used to improve patient flow in the ED. After implementation of one-hour rule, the proportion of patients transferred to the ICU within 1 hour increased from 3.1% to 65.9% (p < 0.001). Median ED length of stay (LOS) reduced from 129.5 minutes to 52.0 minutes (p < 0.001). The overall mortality rate decreased from 34.4% to 26.8%, without a significant difference. In conclusion, the implementation of the one-hour rule for the boarding of referral of critically ill patients in the ED is safe and possible. Achieving the target significantly reduced ED LOS by 77.5 minutes without an increase in patient mortality rate.