Cost-effectiveness of an Emergency Department–Based Intensive Care Unit

Bassin, Benjamin S.; Haas, Nathan L.; Sefa, Nana; Medlin, Richard; Peterson, Timothy A.; Gunnerson, Kyle J.; Maxwell, Steve; Cranford, James A.; Laurinec, Stephanie; Olis, Christine; Havey, Renee; Loof, Robert; Dunn, Patrick; Burrum, Debra; Gegenheimer-Holmes, Jennifer; Neumar, Robert W.

doi:10.1001/jamanetworkopen.2022.33649

Cited by 13 publications

(12 citation statements)

References 41 publications

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“…As boarding of non‐ICU/general care patients in the ED may continue to be a widespread issue, recognition of decompensation and developing pathways to deliver timely, high‐quality care to these patients is paramount. An ED‐ICU model can deliver early coordinated critical care and likely mitigate preventable complications of disease progression 14 . Future work can evaluate the impact of ED‐ICUs on outcomes at other institutions, including additional methods of caring for decompensating boarding patients.…”

Section: Discussionmentioning

confidence: 99%

Impact of emergency department‐based intensive care unit on outcomes of decompensating boarding emergency department patients

Doan,

Perez,

Bassin

et al. 2023

JACEP Open

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ObjectivesEmergency department (ED) boarding, or remaining in the ED after admission before transfer to an inpatient bed, is prevalent. Boarding patients may decompensate before inpatient transfer, necessitating escalation to the intensive care unit (ICU). We evaluated the impact of an ED‐ICU on decompensating boarding ED patients.MethodsThis is a retrospective single‐center observational study. We identified decompensated boarding ED patients necessitating critical care before departure from the ED from October 2012 to December 2021. An automated query and manual chart review extracted data. Three cohorts were defined: pre‐ED‐ICU implementation (Group 1), post‐ED‐ICU implementation with ED‐ICU care (Group 2), and post‐ED‐ICU implementation with inpatient ICU admission without ED‐ICU care (Group 3). Primary outcome was ICU length of stay (LOS). Secondary outcomes included hospital LOS, in‐hospital mortality, and ICU admissions with ICU LOS <24 hours. Between‐groups comparisons used multiple regression analysis for continuous variables, χ2 tests and multivariable logistic regression analysis for binary variables, and follow‐up contrasts for statistically significant omnibus tests.ResultsA total of 1123 visits met inclusion criteria: 225 in Group 1, 780 in Group 2, and 118 in Group 3. Mean ICU LOS was shorter for Group 2 than Group 1 or 3 (47.4 vs 92.3 vs 103.9 hours, P < 0.001). Mean hospital LOS was shorter for Group 2 than Group 1 or 3 (185.1 vs 246.8 vs 257.3 hours, P < 0.01). In‐hospital mortality was similar between groups. The proportion of ICU LOS <24 hours was lower for Group 2 than Group 1 or 3 (16.5 vs 27.1 vs 32.2%, P < 0.01).ConclusionFor decompensating boarding ED patients, ED‐ICU care was associated with decreased ICU and hospital LOS, similar mortality, and fewer short‐stay ICU admissions, suggesting ED‐ICU care is associated with downstream resource preservation.

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Section: Discussionmentioning

confidence: 99%

Impact of emergency department‐based intensive care unit on outcomes of decompensating boarding emergency department patients

Doan,

Perez,

Bassin

et al. 2023

JACEP Open

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“…Best practice consideration to develop step-down units, long-term care units, and tele-ICUs comes with an emphasis on ensuring appropriate sta ng, adequate resources, and robust governance process. On the other hand, previously published literature is equivocal with regards to endorsing other speciality ICUs (e.g., surgical intermediate care units, emergency department-based ICU) manned by non-ICU teams, despite the availability of positive studies [5,30,43]. This hesitancy may be due to concerns regarding quality of care being provided by non-ICU teams and highlights the need to ensure standardization irrespective of clinical team involved.…”

Section: Discussionmentioning

confidence: 99%

“…2. Infrastructure fundamentals: Implementing evidence-based care, information technology best practices, e cient care delivery, and the sustainable use of resources [30][31][32][33]. 3.…”

Section: Expert Panelmentioning

confidence: 99%

Interventions to promote cost-effectiveness in adult Intensive care units: consensus statement and considerations for best practice from a multidisciplinary and multinational eDelphi study

Kansal,

Latour,

See

et al. 2023

Preprint

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Background There is limited evidence to guide interventions that promote cost-effectiveness in adult intensive care units (ICU). The aim of this consensus statement is to identify globally applicable interventions for best ICU practice and provide guidance for judicious use of resources. Methods A three-round modified online Delphi process, using a web-based platform sought consensus from 61 multidisciplinary ICU experts (physicians, nurses, allied health, administrators) from 21 countries. Round 1 was qualitative to ascertain opinions on cost-effectiveness criteria based on four key domains of high-value healthcare (foundational elements; infrastructure fundamentals; care delivery priorities; reliability and feedback). Round 2 was qualitative and quantitative, while round 3 was quantitative to reiterate and establish criteria. Both rounds 2 and 3 utilised a five-point Likert scale for voting. Consensus was considered when > 70% of the experts voted for a proposed intervention. Thereafter, the steering group endorsed interventions that were identified as ‘critical’ by more than 50% of steering group members. These interventions and experts’ comments were summarized as final considerations for best practice. Results At the conclusion of round 3, consensus was obtained on 50 best practice considerations for cost-effectiveness in adult ICU. Finally, the steering group endorsed 9 ‘critical’ best practice considerations. This included adoption of a multidisciplinary ICU model of care, focus on staff training and competency assessment, ongoing quality audits, thus ensuring high quality of critical care services whether within or outside the four walls of ICUs, implementation of a dynamic staff roster, multidisciplinary approach to implementing end-of-life care, early mobilization and promoting international consensus efforts on the Green ICU concept. Conclusions This Delphi study with international experts resulted in 9 consensus statements and best practice considerations promoting cost-effectiveness in adult ICUs. Stakeholders (government bodies, professional societies) must lead the efforts to identify locally applicable specifics while working within these best practice considerations with the available resources.

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“…patients after major elective surgery or those deteriorating on hospital wards). An economic analysis revealed that critical care delivery in the ED is cost-effective [ 18 ], a finding that is of particular importance in healthcare systems with payment-per-diagnosis reimbursement.…”

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confidence: 99%

Care of the critically ill begins in the emergency medicine settings

2024

European Journal of Emergency Medicine

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The most sophisticated intensive care often becomes unnecessarily expensive terminal care where the pre-ICU system is uncoordinated or undeveloped ' -Peter Safar, 1974 Critical illness refers to life-threatening conditions resulting from an acute disease, injury, adverse environmental influence, poisoning, surgery, or decompensation of a chronic disease. It is an exquisitely time-sensitive condition, and early identification, support, and treatment significantly impact outcome. Pathologies which have the potential to become life-threatening often originate before the patient presents to the hospital, which explains the prevalence of evolving or established critical illness seen in the emergency departments (EDs). The common maxim where 'prevention is better than cure' implies that the earlier the treatment the better the outcome in other words, 'the earlier the better'. It is obvious and advantageous that evidence-based critical care should not be limited to the ICU but rather initiated as early as possible and regardless of the geographical location, whether in the prehospital setting or ED. Peter Safar was the first to indicate that efforts to enhance the chances of survival and organ recovery from critical illness must not only focus on patient management in the ICU, but address the entire patient pathway from the prehospital scene, the ED to the ICU, further including the operating room and general wards [1]. He referred to critical care as the continuum of care the critically ill or injured patient requires to recover.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

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Cost-effectiveness of an Emergency Department–Based Intensive Care Unit

Cited by 13 publications

References 41 publications

Impact of emergency department‐based intensive care unit on outcomes of decompensating boarding emergency department patients

Impact of emergency department‐based intensive care unit on outcomes of decompensating boarding emergency department patients

Interventions to promote cost-effectiveness in adult Intensive care units: consensus statement and considerations for best practice from a multidisciplinary and multinational eDelphi study

Care of the critically ill begins in the emergency medicine settings

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