The Emergency Critical Care Center (EC3) is an emergency department-based intensive care unit (ED-ICU) designed to improve timely access to critical care for ED patients. ED patients requiring intensive care are initially evaluated and managed in the main ED prior to transfer to a separate group of ED-ICU clinicians. The timing of patient transfers to the ED-ICU may decrease the number of handoffs between main ED teams and have an impact on both patient outcomes and optimal provider staffing models, but has not previously been studied. We aimed to analyze patterns of transfer to the ED-ICU and the relationship with shift turnover times in the main ED. We hypothesized that the number of transfers to the ED-ICU increases near main ED shift turnover times. Methods: An electronic health record search identified all patients managed in the ED and ED-ICU in 2016 and 2017. We analyzed the number of ED arrivals per hour, the number of ED-ICU consults per hour, the time interval from ED arrival to ED-ICU consult, the distribution throughout the day, and the relationship with shift turnover times in the main ED. Results: A total of 160,198 ED visits were queried, of which 5308 (3.3%) were managed in the ED-ICU. ED shift turnover times were 7 am, 3 pm, and 11 pm. The mean number of ED-ICU consults placed per hour was 221 (85 standard deviation), with relative maximums occurring near ED turnover times: 10:31 pm-11:30 pm (372) and 2:31 pm-3:30 pm (365). The minimum was placed between 7:31 am-8:30 am (88), shortly after the morning ED turnover time. The median interval from ED arrival time to ED-ICU consult order was 161 minutes (range 6-1,434; interquartile range 144-174). Relative minimums were observed for patients arriving shortly prior to ED turnover times: 4:31 am-5:30 am (120 minutes [min]), 12:31 pm-1:30 pm (145 min), and 9:31 pm-10:30 pm (135 min). Relative maximums were observed for patients arriving shortly after ED turnover times: 7:31 am-8:30 am (177 min), 4:31 pm-5:30 pm (218 min), and 11:31 pm-12:30 am (179 min). Conclusion: ED-ICU utilization was highest near ED shift turnover times, and utilization was dissimilar to overall ED arrival patterns. Patients arriving immediately prior to ED shift turnover received earlier consults to the ED-ICU, suggesting these patients may have been preferentially transferred to the ED-ICU rather than signed out to the next team of emergency clinicians. These findings may guide operational planning, staffing models, and timing of shift turnover for other institutions implementing ED-ICUs. Future studies could investigate whether an ED-ICU model improves critically ill patients' outcomes by minimizing ED provider handoffs. [
department (ED). Where there were previously clear-cut boundaries that separated peripheral and central access, ultrasound allows access to veins that were once too deep for direct visualization and too small for blind exploration. Traditional length catheters (3-5cm) are prone to dislodgement and failure when accessing deep vessels, however longer midline catheters (10-25cm) allow for deep peripheral vein cannulation with sufficient length to remain adequately seated and stabilized in deep vessels. Midline catheters are available in a variety of lengths and lumens, and can readily be placed under ultrasound guidance using a modified Seldinger technique into the cephalic, basilic, or brachial veins. Recent studies have demonstrated successful placement by residents in a surgical ICU setting, with potential cost saving associated with decreased central venous access. The purpose of our study was to evaluate the feasibility and safety of midline catheter placement in the emergency department, and the potential complications of placement.Methods: This is a retrospective review of data prospectively collected from all patients with a midline catheter placed in the emergency department at Stony Brook University Hospital. SBUH is a 603-bed tertiary care referral center with an annual ED volume that exceeds 100,000 patients (adult and pediatric). Two separate midline kits were available for use: the single lumen 10cm 20 gauge Bard PowerGlide Catheter, and the dual lumen 5 french 20cm trimmable MedComp Midline Catheter. Each midline placed was associated with a separate procedure note and the following data points were recorded: indication, technique, location, catheter type, and immediate complications. A review of medication administration record was queried for any vasoactive medications administered, and nursing documentation recorded days the catheter remained in place along with any long term complications including infection, development of DVT, extravasation, and port patency.Results: Data were extracted from the first 200 midline catheters placed. Ninety-seven percent (194/200) were placed using ultrasound guidance and modified Seldinger technique, 3% were placed using a sterile over-wire-exchange of an existing peripheral catheter. Thirty-eight percent were single lumen and the remaining 62% were dual lumen. Ninety-eight percent were uncomplicated insertions. There were 2 failed procedures (inability to place), 1 hematoma development, and there was 1 recognized arterial cannulation which did not require intervention other than holding sustained manual pressure. The average duration of midline in place was 6.7 days, with a minimum of 1 day and a maximum of 48 days. Long term complications included inability to aspirate (10%), leakage from insertion site (5%), edema (1.5%), erythema without subsequent infection (1%), infiltration (1%). Vasopressors were used in 28% of midlines.Conclusions: Midlines can be safely placed in the ED by emergency physicians with few complications.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.
hi@scite.ai
10624 S. Eastern Ave., Ste. A-614
Henderson, NV 89052, USA
Copyright © 2024 scite LLC. All rights reserved.
Made with 💙 for researchers
Part of the Research Solutions Family.