Critical care provided in an urban emergency department

Nelson, Malcolm; Waldrop, Ron D.; Jones, John; Randall, Z

doi:10.1016/s0735-6757(98)90066-3

Cited by 53 publications

(37 citation statements)

References 8 publications

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“…Previous studies have acknowledged that long delays do occur before patients are physically admitted to the ICU. [1][2][3][4] The assumption that the patient's physiologic status on admission to an ICU is representative of the initial phase of critical illness is often incorrect because these variables are often much worse and frequently corrected prior to ICU arrival. 37 This period prior to ICU arrival is called lead time bias in physiologic scoring systems.…”

Section: Discussionmentioning

confidence: 99%

“…In some hospitals, up to 8% of all patients presenting to the ED and more than 25% of those admitted to the hospital are critically ill patients 1 with a duration of stay ranging from 2.5 to 18 hours. [1][2][3][4] Furthermore, there has been a 152% increase in the number of patients with ED length of stay greater than six hours from 1988 to 1997. 5 This reality necessitates provision of critical care in the ED prior to ICU admission.…”

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confidence: 99%

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Critical Care in the Emergency Department A Physiologic Assessment and Outcome Evaluation

Nguyen

Rivers

Havstad

et al. 2000

Academic Emergency Medicine

151

102

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Abstract. Objectives:The changing landscape of health care in this country has seen an increase in the delivery of care to critically ill patients in the emergency department (ED). However, methodologies to assess care and outcomes similar to those used in the intensive care unit (ICU) are currently lacking in this setting. This study examined the impact of ED intervention on morbidity and mortality using the Acute Physiology and Chronic Health Evaluation (APACHE II), the Simplified Acute Physiology Score (SAPS II), and the Multiple Organ Dysfunction Score (MODS). Methods: This was a prospective, observational cohort study over a three-month period. Critically ill adult patients presenting to a large urban ED and requiring ICU admission were enrolled. APACHE II, SAPS II, and MODS scores and predicted mortality were obtained at ED admission, ED discharge, and 24, 48, and 72 hours in the ICU. In-hospital mortality was recorded. Results: Eighty-one patients aged 64 Ϯ 18 years were enrolled during the study period, with a 30.9% in-hospital mortality. The ED length of stay was 5.9 Ϯ 2.7 hours and the hospital length of stay was 12.2 Ϯ 16.6 days. Nine (11.1%) patients initially accepted for ICU admission were later admitted to the general ward after ED intervention. Septic shock was the predominant admitting diagnosis. At ED admission, there was a significantly higher APACHE II score in nonsurvivors (23.0 Ϯ 6.0) vs survivors (19.8 Ϯ 6.5, p = 0.04), while there was no significant difference in SAPS II or MODS scores. The APACHE II, SAPS II, and MODS scores were significantly lower in survivors than nonsurvivors throughout the hospital stay (p Յ 0.001). The hourly rates of change (decreases) in APACHE II, SAPS II, and MODS scores were significantly greater during the ED stay (Ϫ0.55 Ϯ 0.64, Ϫ1.02 Ϯ 1.10, and Ϫ0.16 Ϯ 0.43, respectively) than subsequent periods of hospitalization in survivors (p < 0.05). There was a significant decrease in APACHE II and SAPS II predicted mortality during the ED stay (Ϫ8.0 Ϯ 14.0% and Ϫ6.0 Ϯ 14.0%, respectively, p < 0.001) and equally at 24 hours in the ICU (Ϫ7.0 Ϯ 13.0% and Ϫ4.0 Ϯ 16.0%, respectively, p Յ 0.02). The APACHE II and SAPS II predicted mortality approached actual in-hospital mortality at approximately 12 hours and 36 hours after ED admission (in the ICU), respectively. Conclusions: The care provided during the ED stay for critically ill patients significantly impacts the progression of organ failure and mortality. Although this period is brief compared with the total length of hospitalization, physiologic determinants of outcome may be established before ICU admission. This study emphasizes the importance of ED intervention. It also suggests that unique physiologic assessment methodologies should be developed to examine the quality of patient care, improve the accuracy of prognostic decisions, and objectively measure the impact of clinical interventions and pathways in the ED setting.

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

Critical Care in the Emergency Department A Physiologic Assessment and Outcome Evaluation

Nguyen

Rivers

Havstad

et al. 2000

Academic Emergency Medicine

151

102

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“…2,3 Initiation of mechanical ventilation in the ED is common, and because of the long ED length of stays (LOSs) for critically ill patients, mechanical ventilation hours provided have also increased. [4][5][6][7][8][9][10][11][12][13] Despite these trends, there remain relatively few data on ED-based mechanical ventilation practices. 14 ARDS exacts a signifi cant toll on patients who are mechanically ventilated in terms of mortality, long-term survivor morbidity, and health-care use.…”

mentioning

confidence: 99%

Mechanical Ventilation and ARDS in the ED

Fuller

Mohr

Miller

et al. 2015

Chest

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“…11 Although most ED visits are non-emergent, EDs deliver a substantial amount of critical care. In low-acuity departments, critically ill patients account for approximately 1% of visits, 12 but in urban teaching hospitals, this figure rises as high as 8.5%. 13,14 EPs frequently perform critical care procedures, and the ED procedural spectrum is similar to that of the intensive care unit (ICU).…”

Section: Critical Care In the Ed: The Presentmentioning

confidence: 99%

Critical care medicine as a subspecialty of emergency medicine

Melanson

2000

CJEM

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IntroductionL'exercice de la médecine d'urgence a changé de façon dramatique au cours des vingt dernières années. Elle continue toujours d'évoluer et le rythme des changements s'accélère. Il y a vingt-cinq ans, les patients qui visitaient un départe-ment d'urgence avaient peu de chances d'être traités par un médecin qui possédait plus que les connaissances minimales sur la façon d'identifier, stabiliser et réanimer les malades dont la vie était en danger.1 La spécialité de mé-decine d'urgence a vu le jour en raison d'une frustration face aux piètres normes pour les soins d'urgence et parce que des médecins dévoués s'inquiétaient du manque de pré-paration reçue à l'université pour affronter la réalité au dé-partement d'urgence.1,2 Avec le temps, plusieurs surspécialités ont évolué, notamment les soins pré-hospitaliers, la toxicologie et la médecine du sport. La médecine des soins critiques est également devenue une sur-spécialité de la médecine d'urgence, ce qui n'est pas surprenant puisque les urgentologues administrent un pourcentage substantiel des soins critiques.

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Critical care provided in an urban emergency department

Cited by 53 publications

References 8 publications

Critical Care in the Emergency Department A Physiologic Assessment and Outcome Evaluation

Critical Care in the Emergency Department A Physiologic Assessment and Outcome Evaluation

Mechanical Ventilation and ARDS in the ED

Critical care medicine as a subspecialty of emergency medicine

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