Critical care medicine as a subspecialty of emergency medicine

Melanson, Patrick R.P.

doi:10.1017/s1481803500007296

Cited by 4 publications

(5 citation statements)

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“…More than half of the ACU patients received extensive workups (admission processing, acute management). While we have not detailed these extensive diagnostic evaluations and management requirements, the practice described in this report further supports the philosophy of extending the definition of emergency practice, 16,17 and taking on the responsibility of patient care at the transition boundary between immediate evaluation and stabilization and longer-term inpatient management. In our case, initially this was less a philosophic orientation than a solution to the necessity of further controlling the care of our patients as a means to better control overall ED operations.…”

Section: Discussionmentioning

confidence: 52%

Effect of an Emergency Department (ED) Managed Acute Care Unit on ED Overcrowding and Emergency Medical Services Diversion

Kelen

Scheulen

Hill

2001

Academic Emergency Medicine

102

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Abstract. Objective: To determine the impact of an inpatient, emergency department (ED)-managed acute care unit (ACU) on ED overcrowding and use of ambulance diversion. Methods: Descriptive observational study with prospectively collected data from a 14-bed ACU recently opened remote from the main ED. Rates of patients who left without being seen (LWBS) and ambulance diversion frequency and duration were adjusted for ED patient volumes and compared with those for the period immediately before the ACU was opened and with those for a matching time period during the previous year. Results: There were 1,589 patients seen in the ACU during the first ten weeks of operation, representing about 14.5% of the ED volume (10,871). About 33% could be classified as post-ED management, 20% as admission processing, and the rest as primary evaluation. The number of patients who LWBS decreased from 10.1% of the ED census two weeks prior to opening of the ACU, and from 9.4% during the previous year, to 5.0% (range 4.2%-6.2%) during the ensuing ten weeks post opening. Ambulance diversion was a mean of 6.7 hours per 100 patients before the unit opened and 5.6 hours per 100 patients during the same time in the previous year, and decreased to 2.8 hours per 100 patients after the unit opened (p < 0.05, respectively). A six-month pre-and two-month post-examination revealed that the mean monthly hours of ambulance diversion for the ED decreased by 40% (202 hours vs 123 hours) (p < 0.05) in contrast to a mean increase of 44% (186 hours vs 266 hours) (p < 0.05) experienced by four proximate hospitals. Conclusions: An ED-managed ACU can have significant impact on ED overcrowding and ambulance diversion, and it need not be located proximate to the ED. Key words: emergency; emergency department overcrowding; observation medicine; ambulance diversion; emergency department operations. ACADEMIC EMERGENCY MEDICINE 2001; 8:1095-1100 Chest pain, observation, rapid diagnostic, and short stay units have in- creasingly become part of emergency practice and were created to solve a variety of problems. Many of these relate to admission avoidance. While the literature regarding the value of such units is also increasing, most reports to date describe the impact of such units on single disease or presentation management, such as chest pain or asthma. A Medline search failed to return any reports on the effect of emergency department (ED) overcrowding or emergency medical services (EMS) diversion as a result of the creation of such units, although a recent abstract suggests increased inpatient capacity would result from admission avoidance for patients with certain diagnosis-related groups (DRGs). 1 We did find one study of an internal medicine controlled shortstay admission unit, which suggested its creation resulted in decreased ED patient length of stay at least for some patients, although other proxies of ED overcrowding were not reported.2 In order to address issues of ED overcrowding, we developed a 14-bed inpatient-based emergency acute care unit (...

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Section: Discussionmentioning

confidence: 52%

Effect of an Emergency Department (ED) Managed Acute Care Unit on ED Overcrowding and Emergency Medical Services Diversion

Kelen

Scheulen

Hill

2001

Academic Emergency Medicine

102

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“…En respuesta a todo lo expuesto anteriormente, en algunos países donde la medicina de urgencia ya está desarrollada, han literalmente llevado la UCI a la Urgencia, brindado "Cuidados Críticos de Urgencia" con los más altos estándares requeridos, hasta el momento en que los pacientes puedan ser finalmente dispuestos en las unidades manejadas por los especialistas en cuidados críticos 30 .…”

Section: Impacto De La Saturación De Los Servicios De Urgencia En Losunclassified

“…Como solución al problema de espera de camas críticas en situaciones de saturación y demora en el traslado de paciente a la unidad de cuidados críticos -que no involucran a las otras estrategias mencionadas anteriormente a nivel institucionalse han planteado protocolos de alianza o coordinación entre unidades de cuidados intensivos y el SU. Reconociendo que los servicios de urgencia se hacen cargo de un gran volumen de pacientes críticos, en Estados Unidos de Norteamérica (y probablemente a medida que la medicina de urgencia se establezca como especialidad médica en nuestro país) se ha propuesto la necesidad de formar sub-especialistas de urgencia en cuidados críticos 30 .…”

Section: Propuesta De Alianza Entre Los Servicios De Urgencia Y Las Uunclassified

Medicina de urgencia y unidades de cuidados intensivos: Una alianza necesaria en busca de la mejoría de la atención de pacientes críticos

et al. 2016

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The need for critical care services is increasing in Chile. Critical care beds and specialists in this area are scarce. In this article we discuss some aspects that hamper the care of critically ill patients from their arrival to the emergency department to their transfer to the ICU. Special emphasis is given to system saturation and its multiple causes. The benefits of an integrative approach between emergency medicine and critical care specialists are highlighted and some solutions are proposed to strengthen this partnership.

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“…Should these concepts be extended to EDs as well, above and beyond existing early intervention models for stroke, myocardial infarction, and trauma? How should the ED and ICU be more closely operationally aligned, as suggested by recent papers from the UK [41,42], Canada [43], the USA [44] and Australia [45]? Also, what is the best way to spend the 'critical care budget'?…”

Section: Implications For Controlling the Cost Of Critical Carementioning

confidence: 99%

Untitled

Huang

2004

Crit Care

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498 ED = emergency department; EGDT = early goal-directed therapy; ICU = intensive care unit; LOS = length of stay; NIPPV = noninvasive positive pressure ventilation. Critical Care December 2004 Vol 8 No 6 Huang IntroductionThe cost of critical care is widely recognized as both expensive and increasing [1,2]. Government and private organizations have devoted considerable effort to devising cost control strategies for intensive care units (ICUs) [3,4]. One under-explored area of potential cost saving is how critically ill patients are managed in the emergency department (ED). Specifically, what impact does initial ED care of critically ill patients have on downstream ICU costs? There are surprisingly few data with which to address this question, but we examine what is available. Critical care delivery in the emergency departmentIt is first important to recognize that a significant amount of critical care is already performed in the ED. In the 2001 US National Hospital Ambulatory Medical Care Survey [5], 19.2% of all ED patients were classified as emergent (patients who should be seen within 15 min), and over 992,000 patients were admitted to an ICU through an ED. The average ICU bed wait time in this survey was slightly over 4 hours. Furthermore, there is evidence that the amount of critical illness in EDs is increasing. Lambe and coworkers [6] reported that, in Californian EDs, critical visits increased by 59% between 1990 and 1999, whereas nonurgent visits actually decreased by 8%. Several US single-center studies have also documented the extent of critical care delivery in EDs. Fromm and coworkers [7] reported that, during a 1-year study period in a teaching hospital, 154 patient-days of ED critical care were provided, with ED length of stays (LOSs) for these patients of up to nearly 11 hours. Nguyen and colleagues [8] estimated that an even greater amount of critical care, 464.4 patient-days, was provided annually in their large urban teaching hospital. Similarly, Nelson and coworkers [9] examined the amount of critical care provided in their urban hospital's ED and ICUs during a 3-month study, and found that 15% of all critical care was performed in the ED. Finally, Varon and coworkers [10] and Svenson and colleagues [11] reported that critically ill patients spent several hours in the ED before transfer to an ICU, and that critical care procedures were commonly performed in the ED. AbstractCritical care is both expensive and increasing. Emergency department (ED) management of critically ill patients before intensive care unit (ICU) admission is an under-explored area of potential cost saving in the ICU. Although limited, current data suggest that ED care has a significant impact on ICU costs both positive and negative. ICU practices can also affect the ED, with a lack of ICU beds being the primary reason for ED overcrowding and ambulance diversion in the USA. Earlier application in the ED of intensive therapies such as goal-directed therapy and noninvasive ventilation may reduce ICU costs by decreasing len...

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Critical care medicine as a subspecialty of emergency medicine

Cited by 4 publications

References 44 publications

Effect of an Emergency Department (ED) Managed Acute Care Unit on ED Overcrowding and Emergency Medical Services Diversion

Effect of an Emergency Department (ED) Managed Acute Care Unit on ED Overcrowding and Emergency Medical Services Diversion

Medicina de urgencia y unidades de cuidados intensivos: Una alianza necesaria en busca de la mejoría de la atención de pacientes críticos

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