An Emergency Department–Based Intensive Care Unit is Associated with Decreased Hospital and Intensive Care Unit Utilization for Diabetic Ketoacidosis

Haas, Nathan L.; Whitmore, Sage P.; Cranford, James A.; Tsuchida, Ryan E.; Nicholson, Adam; Boyd, Christina L.; Gunnerson, Kyle J.; Gianchandani, Roma; Bassin, Benjamin S.

doi:10.1016/j.jemermed.2019.10.005

Cited by 21 publications

(15 citation statements)

References 14 publications

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“…Preventing short-stay ICU admissions is one strategy to optimize ICU bed allocation for patients decompensating on wards, ICU-to-Western Journal of Emergency Medicine ICU transfers, and patients with more prolonged critical care needs. 8,[14][15][16] In our study, only 7.4% of the observed patient population required an inpatient ICU admission after receiving care in the ED-ICU, and 43.6% did not require hospitalization.…”

Section: Discussionmentioning

confidence: 48%

Descriptive Analysis of Extubations Performed in an Emergency Department-based Intensive Care Unit

Haas

Larabell

Schaeffer

et al. 2020

WestJEM

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Extubation of appropriate patients in the emergency department (ED) may be a strategy to avoid preventable or short-stay intensive care unit (ICU) admissions, and could allow for increased ventilator and ICU bed availability when demand outweighs supply. Extubation is infrequently performed in the ED, and a paucity of outcome data exists. Our objective was to descriptively analyze characteristics and outcomes of patients extubated in an ED-ICU setting. Methods: We conducted a retrospective observational study at an academic medical center in the United States. Adult ED patients extubated in the ED-ICU from 2015-2019 were retrospectively included and analyzed. Results: We identified 202 patients extubated in the ED-ICU; 42% were female and median age was 60.86 years. Locations of endotracheal intubation included the ED (68.3%), outside hospital ED (23.8%), and emergency medical services/prehospital (7.9%). Intubations were performed for airway protection (30.2%), esophagogastroduodenoscopy (27.7%), intoxication/ingestion (17.3%), respiratory failure (13.9%), seizure (7.4%), and other (3.5%). The median interval from ED arrival to extubation was 9.0 hours (interquartile range 6.2-13.6). One patient (0.5%) required unplanned re-intubation within 24 hours of extubation. The attending emergency physician (EP) at the time of extubation was not critical care fellowship trained in the majority (55.9%) of cases. Sixty patients (29.7%) were extubated compassionately; 80% of these died in the ED-ICU, 18.3% were admitted to medical-surgical units, and 1.7% were admitted to intensive care. Of the remaining patients extubated in the ED-ICU (n = 142, 70.3%), zero died in the ED-ICU, 61.3% were admitted to medical-surgical units, 9.9% were admitted to intensive care, and 28.2% were discharged home from the ED-ICU. Conclusion: Select ED patients were safely extubated in an ED-ICU by EPs. Only 7.4% required ICU admission, whereas if ED extubation had not been pursued most or all patients would have required ICU admission. Extubation by EPs of appropriately screened patients may help decrease ICU utilization, including when demand for ventilators or ICU beds is greater than supply. Future research is needed to prospectively study patients appropriate for ED extubation.

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Section: Discussionmentioning

confidence: 48%

Descriptive Analysis of Extubations Performed in an Emergency Department-based Intensive Care Unit

Haas

Larabell

Schaeffer

et al. 2020

WestJEM

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“…Multiple recent studies have demonstrated benefits of ED‐ICUs, including observed reduction in mortality, reduction in rates of ICU admission or hospitalization, and reductions in hospital LOS. 18 , 19 , 26 , 27 , 28 , 29 , 30 Centers with high rates of ED boarding of patients who are critically ill and those considering implementing an ED‐ICU can consider these findings in the context of their individual practice environments to best mitigate detrimental effects of ED boarding of patients who are critically ill on the local scale. With increasing numbers of ED‐ICUs and more centers considering implementing similar units, continued assessment of outcomes (including prospective research) to guide further development is essential.…”

Section: Discussionmentioning

confidence: 99%

Emergency department length of stay and outcomes of emergency department–based intensive care unit patients

et al. 2022

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Objective Emergency department (ED) boarding of patients who are critically ill is associated with poor outcomes. ED‐based intensive care units (ED‐ICUs) may mitigate the risks of ED boarding. We sought to analyze the impact of ED length of stay (LOS) before transfer to an ED‐ICU on patient outcomes. Methods We retrospectively analyzed adult ED patients managed in the ED‐ICU at a US medical center. Bivariate and multivariable linear regressions tested ED LOS as a predictor of inpatient ICU and hospital LOS, and separate bivariate and multivariable logistic regressions tested ED LOS as a predictor of inpatient ICU admission, 48‐hour mortality, and hospital mortality. Multivariable analyses’ covariates were age, sex, Charlson Comorbidity Index (CCI), Emergency Severity Index, and eSimplified Acute Physiology Score (eSAPS3). Results We included 5859 ED visits with subsequent care in the ED‐ICU. Median age, CCI, eSAPS3, ED LOS, and ED‐ICU LOS were 62 years (interquartile range [IQR], 48–73 years), 5 (IQR, 2–8), 46 (IQR, 36–56), 3.6 hours (IQR, 2.5–5.3 hours), and 8.5 hours (IQR, 5.3–13.4 hours), respectively, and 46.3% were women. Bivariate analyses showed negative associations of ED LOS with hospital LOS (β = −3.4; 95% confidence interval [CI], −5.9 to −1.0), inpatient ICU admission (odds ratio [OR], 0.86, 95% CI, 0.84–0.88), 48‐hour mortality (OR, 0.89; 95% CI, 0.82–0.98), and hospital mortality (OR, 0.89; 95% CI, 0.85–0.92), but no association with inpatient ICU LOS. Multivariable analyses showed a negative association of ED LOS with inpatient ICU admission (OR, 0.91; 95% CI, 0.88–0.93), but no associations with other outcomes. Conclusions We observed no significant associations between ED LOS before ED‐ICU transfer and worsened outcomes, suggesting an ED‐ICU may mitigate the risks of ED boarding of patients who are critically ill.

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“…More broadly, as focus is shifting from proving the benefit of LPV to proving it can be implemented and adhered to, an ED-ICU is one strategy to increase LPV adherence (39). Additionally, these findings add to the robust patient and resource utilization outcomes in other common disease states associated with an ED-ICU (26)(27)(28)(29)(30)(31). Health systems may consider these results when determining the feasibility of ED-ICU implementation and future work should examine outcomes associated with ED-ICUs at other institutions.…”

Section: Discussionmentioning

confidence: 99%

Initiation of a Lung Protective Ventilation Strategy in the Emergency Department: Does an Emergency Department-Based ICU Make a Difference?

Harvey

Haas²,

Chen

et al. 2022

Critical Care Explorations

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BACKGROUND: Lung protective ventilation (LPV) is a key component in the management of acute respiratory distress syndrome and other acute respiratory pathology. Initiation of LPV in the emergency department (ED) is associated with improved patient-centered and system outcomes, but adherence to LPV among ED patients is low. The impact of an ED-based ICU (ED-ICU) on LPV adherence is not known. METHODS: This single-center, retrospective, cohort study analyzed rates of adherence to a multifaceted LPV strategy pre- and post-implementation of an ED-ICU. LPV strategy components included low tidal volume ventilation, avoidance of severe hyperoxia and high plateau pressures, and positive end-expiratory pressure settings in alignment with best-evidence recommendations. The primary outcome was adherence to the LPV strategy at time of ED departure. RESULTS AND CONCLUSIONS: A total of 561 ED visits were included in the analysis, of which 60.0% received some portion of their emergency care in the ED-ICU. Adherence to the LPV strategy was statistically significantly higher in the ED-ICU cohort compared with the pre-ED-ICU cohort (65.8% vs 41.4%; p < 0.001) and non-ED-ICU cohort (65.8% vs 43.1%; p < 0.001). Among the ED-ICU cohort, 92.8% of patients received low tidal volume ventilation. Care in the ED-ICU was also associated with shorter ICU and hospital length of stay. These findings suggest improved patient and resource utilization outcomes for mechanically ventilated ED patients receiving care in an ED-ICU.

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An Emergency Department–Based Intensive Care Unit is Associated with Decreased Hospital and Intensive Care Unit Utilization for Diabetic Ketoacidosis

Cited by 21 publications

References 14 publications

Descriptive Analysis of Extubations Performed in an Emergency Department-based Intensive Care Unit

Descriptive Analysis of Extubations Performed in an Emergency Department-based Intensive Care Unit

Emergency department length of stay and outcomes of emergency department–based intensive care unit patients

Initiation of a Lung Protective Ventilation Strategy in the Emergency Department: Does an Emergency Department-Based ICU Make a Difference?

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