Association of an Emergency Department–Based Intensive Care Unit With Survival and Inpatient Intensive Care Unit Admissions

Gunnerson, Kyle J.; Bassin, Benjamin S.; Havey, Renee; Haas, Nathan L.; Sozener, Cemal B.; Medlin, Richard; Gegenheimer-Holmes, Jennifer; Laurinec, Stephanie; Boyd, Christina L.; Cranford, James A.; Whitmore, Sage P.; Hsu, Cindy H.; Khan, Reham; Vazirani, Neha Naresh; Maxwell, Steve; Neumar, Robert W.

doi:10.1001/jamanetworkopen.2019.7584

Cited by 79 publications

(106 citation statements)

References 24 publications

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“…ICU admissions from the ED fell by 12.9%, and short‐stay ICU admissions (ICU length of stay < 24 hr) were 37.1% lower. Time to ICU‐level care was reduced by 1.9 hours, and more patients received ICU‐level care within 6 hours (77.6% vs 58.3%) 64 . Similar comparative data have not been published in other RCU models, but the role of the RCU will be clarified through more detailed studies in other practice settings.…”

Section: Resultsmentioning

confidence: 56%

Boarding of critically Ill patients in the emergency department

et al. 2020

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Objectives Emergency department boarding is the practice of caring for admitted patients in the emergency department after hospital admission, and boarding has been a growing problem in the United States. Boarding of the critically ill has achieved specific attention because of its association with poor clinical outcomes. Accordingly, the Society of Critical Care Medicine and the American College of Emergency Physicians convened a Task Force to understand the implications of emergency department boarding of the critically ill. The objective of this article is to review the U.S. literature on (1) the frequency of emergency department boarding among the critically ill, (2) the outcomes associated with critical care patient boarding, and (3) local strategies developed to mitigate the impact of emergency department critical care boarding on patient outcomes. Data sources and study selection Review article. Data extraction and data synthesis Emergency department–based boarding of the critically ill patient is common, but no nationally representative frequency estimates has been reported. Boarding literature is limited by variation in the definitions used for boarding and variation in the facilities studied (boarding ranges from 2% to 88% of ICU admissions). Prolonged boarding in the emergency department has been associated with longer duration of mechanical ventilation, longer ICU and hospital length of stay, and higher mortality. Health systems have developed multiple mitigation strategies to address emergency department boarding of critically ill patients, including emergency department‐based interventions, hospital‐based interventions, and emergency department–based resuscitation care units. Conclusions Emergency department boarding of critically ill patients was common and was associated with worse clinical outcomes. Health systems have generated a number of strategies to mitigate these effects. A definition for emergency department boarding is proposed. Future work should establish formal criteria for analysis and benchmarking of emergency department–based boarding overall, with subsequent efforts focused on developing and reporting innovative strategies that improve clinical outcomes of critically ill patients boarded in the emergency department.

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Section: Resultsmentioning

confidence: 56%

Boarding of critically Ill patients in the emergency department

et al. 2020

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“…Structural changes for critical care in the ED, such as the CCSU described in this manuscript, have been reported infrequently, although none involve step‐down critical care provided by advanced practice providers. The University of Michigan Medical Center opened a 9‐bed intensive care unit adjacent to its adult ED in 2015 with a medical staff consisting of emergency medicine physicians and residents, critical care fellows and physician assistants 10 . Study authors reported a decrease in risk‐adjusted 30‐day mortality among all ED patients.…”

Section: Discussionmentioning

confidence: 99%

Evaluation of an advanced practice provider emergency department critical care step‐down unit

et al. 2020

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Objective In response to concerns about patient care and safety, our urban, tertiary care, Level 1 trauma center adult emergency department (ED) created an advanced practice provider‐staffed critical care step‐down unit (CCSU). We conducted a comprehensive evaluation of the CCSU's impact on patient care, safety, and ED operations. Methods We compared ED length of stay, return visits to the ED within 72 hours, billing code assignments (current procedural terminology evaluation and management [CPT E&M] codes), and quality of electronic health record documentation per QNOTE for the 2 years after the CCSU was initiated (CCSU period) versus before its initiation (pre‐CCSU period). Results There were 31,418 critical care ED patient visits in the pre‐CCSU period and 33,396 in the CCSU period. Median ED length of stay did not change overall between the CCSU versus pre‐CCSU period (∆1 [95% confidence interval (CI) = −2.4, 4.4] minutes), but decreased for patients who remained in the critical care suites (∆‐4 [95% CI = −7.8, −0.2] minutes). 72‐hour return ED visits also did not change overall (∆0% [95% CI = −0.1, 0]), but decreased for patients who remained in the critical care suites (∆0.4% [95% CI = −0.05, −0.4]). CPT E&M billing increased for highest‐level visits (99,291: ∆1.3% [95% CI= 0.5, 2.0]). Quality of electronic health record documentation as measured by QNOTE also improved (∆11.5% [95% CI = 4.9, 18.1]). Conclusion This ED's CCSU performance metrics indicate at least moderate improvement in ED length of stay, 72‐hour return visits, critical care patient billing, and electronic health record documentation. EDs elsewhere can consider implementation of this advanced practice provider‐staffed solution to improvement in critical care in ED.

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“…11 These alternative care models, while highly variable in structure, provide more specialized opportunities for the critical care medicine-trained EP and support for both the EM and ICU inpatient teams and potentially improved outcomes for critically ill ED boarding patients. 12…”

Section: Discussionmentioning

confidence: 99%

Triage and Ongoing Care for Critically Ill Patients in the Emergency Department: Results from a National Survey of Emergency Physicians

Mathews

Rodríguez

Nelson

et al. 2020

WestJEM

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Introduction: We conducted a cross-sectional study at the Icahn School of Medicine at Mount Sinai to elicit emergency physician (EP) perceptions regarding intensive care unit (ICU) triage decisions and ongoing management for boarding of ICU patients in the emergency department (ED). We assessed factors influencing the disposition decision for critically ill patients in the ED to characterize EPs' perceptions about ongoing critical care delivery in the ED while awaiting ICU admission. Methods: Through content expert review and pilot testing, we iteratively developed a 25-item written survey targeted to EPs, eliciting current ICU triage structure, opinions on factors influencing ICU admission decisions, and views on caring for critically ill patients "boarding" in the ED for >4-6 hours. Results: We approached 732 EPs at a large, national emergency medicine conference, achieving 93.6% response and completion rate, with 54% academic and 46% community participants. One-fifth reported having formal ICU admission criteria, although only 36.6% reported adherence. Common factors influencing EPs' ICU triage decisions were illness severity (91.1%), ICU interventions needed (87.6%), and diagnosis (68.2%), while ICU bed availability (13.5%) and presence of other critically ill patients in ED (10.2%) were less or not important. While 72.1% reported frequently caring for ICU boarders, respondents identified high patient volume (61.3%) and inadequate support staffing (48.6%) as the most common challenges in caring for boarding ICU patients. Conclusion: Patient factors (eg, diagnosis, illness severity) were seen as more important than system factors (eg, bed availability) in triaging ED patients to the ICU. Boarding ICU patients is a common challenge for more than two-thirds of EPs, exacerbated by ED volume and staffing constraints. [West J Emerg Med. 2020;21(1)330-335.] specific factors (e.g., co-morbidities, severity of illness, likelihood to benefit), as well as system factors (e.g., ICU bed availability, other waiting patients, availability of intermediate

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Association of an Emergency Department–Based Intensive Care Unit With Survival and Inpatient Intensive Care Unit Admissions

Abstract: This cohort study compares 30-day mortality and inpatient intensive care unit (ICU) admissions before and after the implementation of a novel emergency department–based ICU.

Cited by 79 publications

References 24 publications

Boarding of critically Ill patients in the emergency department

Boarding of critically Ill patients in the emergency department

Evaluation of an advanced practice provider emergency department critical care step‐down unit

Triage and Ongoing Care for Critically Ill Patients in the Emergency Department: Results from a National Survey of Emergency Physicians

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