Critical Care Medicine Training and Certification for Emergency Physicians

Huang, David T.; Osborn, Tiffany M.; Gunnerson, Kyle J.; Gunn, Scott R.; Trzeciak, Stephen; Kimball, Edward J.; Fink, Mitchell P.; Angus, Derek C.; Dellinger, R. Phillip; Rivers, Emanuel P.

doi:10.1016/j.annemergmed.2005.04.011

Cited by 23 publications

(15 citation statements)

References 41 publications

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“…Demand for critical care services is increasing even as a shortage of intensivists exists, 1 and interest in critical care fellowship training among trainees is low 2–4 . In 2005, a consensus paper endorsed by the Society of Critical Care Medicine (SCCM) and multiple emergency medicine (EM) societies called for establishing access to formal critical care medicine (CCM) training and certification for emergency physicians (EPs) and noted that dual‐trained EM‐CCM physicians would not only help address the intensivist shortage, but also strengthen critical care delivery in the emergency department (ED) and facilitate coordination between EDs and intensive care units (ICUs) 5 …”

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confidence: 99%

Current Practice, Demographics, and Trends of Critical Care Trained Emergency Physicians in the United States

Mayglothling

Gunnerson

Huang

2010

Academic Emergency Medicine

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Objectives: Critical care medicine (CCM) is of growing interest among emergency physicians (EPs), but the number of CCM-trained EPs and their postfellowship practice is unknown. This study's purpose was to conduct a descriptive census survey of EPs who have completed or are currently in a CCM fellowship. Methods:The authors created a Web-based survey, and requests to participate were sent to EPs who have completed or are currently in a CCM fellowship. Responses were collected over a 12-month period. Physicians were located via multiple whom electronic mailing lists, including the Emergency Medicine Section of the Society of Critical Care Medicine, Critical Care Section of the American College of Emergency Physicians, and the Emergency Medicine Residents' Association. The authors also contacted CCM fellowship coordinators and used informal networking. Data were collected on emergency medicine (EM) and other residency training; discipline, duration, and year of CCM fellowship; current practice setting; and board certification status, including the European Diploma in Intensive Care (EDIC).Results: A total of 104 physicians completed the survey (97% response rate), of whom 73 had completed fellowship at the time of participation, and 31 of whom were in fellowship training. Of those who completed fellowship, 36 ⁄ 73 (49%) practice both EM and CCM, and 45 ⁄ 73 (62%) practice in academic institutions. Multiple disciplines of fellowship were represented: multidisciplinary (39), surgical (28), internal medicine (16), anesthesia (14), and other (4). Together, the CCM fellowships at the University of

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confidence: 99%

Current Practice, Demographics, and Trends of Critical Care Trained Emergency Physicians in the United States

Mayglothling

Gunnerson

Huang

2010

Academic Emergency Medicine

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“…The emerging role of the ED in severe sepsis and septic shock is a much needed and evolving part of the landscape of critical care medicine [18]. Although the merits of EGDT and frequency of eligible patients are minimized by Ho and coworkers and followed by a call for a multicenter trial, the Society of Critical Care Medicine and Surviving Sepsis Campaign has opted not to wait but to adopt the same rational approach of subspecialists such as surgeons, cardio-logists, and neurologists in applying 'right care, right now'.…”

Section: Resultsmentioning

confidence: 99%

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Rivers

2006

Crit Care

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Although multiple studies of acute myocardial infarction, trauma, and stroke have been translated into improved outcomes by applying diagnosis and therapy at the most proximal stage of hospital presentation (before intensive care unit arrival), this approach to the sepsis patient has been lacking. In response to this, a trial comparing early goal-directed therapy (EGDT) versus standard care was performed using internally and externally validated criteria for early identification of high risk patients, established definitions, and a consensus-derived protocol to reverse the hemodynamic perturbations of hypovolemia, vasoregulation, myocardial suppression and increased metabolic demands. That trial of EGDT resulted in significant reductions in morbidity, mortality, vasopressor use, and health care resource consumption. The end-points used in the protocol and the outcome results were subsequently externally validated, revealing similar or better mortality benefit. This commentary examines the rational and validation for the use of early markers of illness severity. Current evidence support the endpoints in the EGDT protocol, external validity in regards to outcome benefit and the universal need to improve the quality of care for early sepsis.A recent retrospective, observational study by Ho and coworkers [1] measured the incidence and outcome of septic patients presenting at an Australian emergency department (ED) with criteria for early goal-directed therapy (EGDT) and found significantly fewer EGDT candidates than previous studies [2]. A number of initiatives aiming to reduce worldwide mortality associated with sepsis, such as the Surviving Sepsis Campaign, have previously noted the importance of the tenets of early hemodynamic optimization to try and overcome this devastating disease. In patients with severe sepsis or septic shock, clinicians must be aware that a considerable proportion of those with significant lactic acidosis can have near normal serum bicarbonate or normal calculated anion gap values, which may lead to underestimated disease severity [3][4][5]. In the EGDT study [2], of the patients enrolled with a lactate level greater than 4 mmol/l, more than 30% had a bicarbonate level greater than 22 and an anion gap of less than or equal to 15 mEq/l. Other studies have shown that even if an anion gap is present, the mortality rate is significantly higher for lactic acidosis (56%) than for strong ion gap acidosis (39%) and hyperchloremic acidosis (29%) [6]. Despite mentioning lactate as a criterion in the study, Ho and coworkers did not report data regarding the levels or number of measurements found. Thus, it is possible that they underestimated the prevalence of high-risk patients in need of early hemodynamic optimization. This may explain why they strikingly found only 50 patients over 3.5 years (14.2 per year) meeting criteria for severe sepsis and septic shock in a large teaching hospital emergency department (ED) that sees 40,000 patients each year with a 30% admission rate.The lactate level ...

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“…Formal dual-fellowship training in critical care medicine for emergency physicians has been developed and formally approved in the United States in 2011. [24][25][26] Emergency Department Intensive Care Units (EDICUs) have also been established in some of the ED in the United States. The EDICU serves a designated area in the ED providing comparable care for the critically ill as standard ICUs.…”

Section: Discussionmentioning

confidence: 99%

Clinical experience in management of bloodstream infection in emergency medical ward: A preliminary report

Cheung

Ko²,

Wong³

et al. 2021

Hong Kong j. emerg. med.

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Background: Bloodstream infection is a life-threatening clinical condition posing significant morbidities and mortalities. An “Emergency Critical Care Management Program” has been implemented in the Emergency Medicine Ward at North Lantau Hospital as a pilot critical care service model in the local emergency medicine wards. Patients with blood stream infection are recruited in the program and managed under pre-defined guideline. Objectives: We report our experience in managing patients with blood stream infection in the Emergency Medicine Ward and analyzed their clinical outcomes. Methods: This was a retrospective cohort study including a total of 64 patients with blood stream infection admitted to the Emergency Medicine Ward from 1 March 2015 and 31 March 2018. Patients’ characteristics, microbiology, and risk factors associated with adverse outcomes including in-hospital mortality were analyzed. Results: The most common organism isolated from blood cultures was Escherichia coli (56%). Eight patients were transferred to the tertiary hospital. The overall in-hospital mortality was 7.8% (5/64). From the univariate analysis, advanced age (p < 0.001), higher Sequential Organ Failure Assessment score and quick Sequential Organ Failure Assessment score (p < 0.001), higher Charlson Comorbidity Index (p = 0.003), more organ dysfunction (p < 0.001), pre-existing medical history of chronic liver disease (p = 0.001), dysfunction in respiratory system (p = 0.032), cardiovascular system (p = 0.044) and the central nervous system (p < 0.001), presence of septic shock (p = 0.004), and need for higher level of organ support from the use of inotropes (p < 0.001) and mechanical ventilation (p = 0.024) were associated with in-hospital mortality. In the subgroup analysis, the in-hospital mortality rate for the patients with Sequential Organ Failure Assessment score less than 6 was 1.56% (1/64). Among the five in-hospital mortality cases, four of them were managed in the Emergency Medicine Ward under the End-of-Life Care Program. Decision for withholding and withdrawing life-sustaining therapy was made with the patients’ families. Conclusion: This preliminary report demonstrated that with careful patient selection, adoption of guidelines, and availability of expertise, critical care service can be safely implemented in the emergency medicine ward.

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Critical Care Medicine Training and Certification for Emergency Physicians

Cited by 23 publications

References 41 publications

Current Practice, Demographics, and Trends of Critical Care Trained Emergency Physicians in the United States

Current Practice, Demographics, and Trends of Critical Care Trained Emergency Physicians in the United States

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Clinical experience in management of bloodstream infection in emergency medical ward: A preliminary report

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