Effect of emergency critical care nurses and emergency department boarding time on in-hospital mortality in critically ill patients

Nesbitt, Jason; Mitarai, Tsuyoshi; Chan, Garrett K.; Wilson, Jennifer G.; Niknam, Kian; Nudelman, Matthew; Cinkowski, Cristopher; Kohn, Michael A.

doi:10.1016/j.ajem.2020.12.067

Cited by 3 publications

(5 citation statements)

References 21 publications

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“…Few studies have reported the clinical impact of alternative models to deliver early longitudinal critical care for patients from or in the ED. Implementation of a 24-hour ECC nursing program ( 20 ) or an MICU alert team consisting of a dedicated ICU nurse and physician assistant ( 21 ) was not associated with improved mortality for critically ill patients in the ED. Neither program involved dedicated physicians to provide ongoing bedside care in the ED.…”

Section: Discussionmentioning

confidence: 99%

“…The score was calculated using data collected at the time of the initial ED order for hospital admission. As in prior studies that used the eccSOFA score ( 20 , 25 ), patients were categorized into three prespecified illness severity categories based on eccSOFA score: low (0–3), intermediate (4–7), and high (≥ 8). To allow for within-stratum differences in severity, the eccSOFA score was modeled using linear splines with knots at 4, 8, and 12.…”

Section: Methodsmentioning

confidence: 99%

“…Various alternative care models have been developed to address these issues (12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22). However, evidence of benefit on patient-centered outcomes is limited to a few programs that require a dedicated space within the ED or elsewhere in the hospital (16,17,23,24).…”

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confidence: 99%

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Association of an Emergency Critical Care Program With Survival and Early Downgrade Among Critically Ill Medical Patients in the Emergency Department*

Mitarai

Gordon

Nudelman

et al. 2023

Critical Care Medicine

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Association of an Emergency Critical Care Program With Survival and Early Downgrade Among Critically Ill Medical Patients in the Emergency Department* OBJECTIVES: To determine whether implementation of an Emergency Critical Care Program (ECCP) is associated with improved survival and early downgrade of critically ill medical patients in the emergency department (ED). DESIGN: Single-center, retrospective cohort study using ED-visit data between 2015 and 2019. SETTING: Tertiary academic medical center. PATIENTS: Adult medical patients presenting to the ED with a critical care admission order within 12 hours of arrival. INTERVENTIONS: Dedicated bedside critical care for medical ICU patients by an ED-based intensivist following initial resuscitation by the ED team. MEASUREMENTS AND MAIN RESULTS:Primary outcomes were inhospital mortality and the proportion of patients downgraded to non-ICU status while in the ED within 6 hours of the critical care admission order (ED downgrade <6 hr). A difference-in-differences (DiD) analysis compared the change in outcomes for patients arriving during ECCP hours (2 pm to midnight, weekdays) between the preintervention period (2015-2017) and the intervention period (2017-2019) to the change in outcomes for patients arriving during non-ECCP hours (all other hours). Adjustment for severity of illness was performed using the emergency critical care Sequential Organ Failure Assessment (eccSOFA) score. The primary cohort included 2,250 patients. The DiDs for the eccSOFA-adjusted inhospital mortality decreased by 6.0% (95% CI, -11.9 to -0.1) with largest difference in the intermediate illness severity group (DiD, -12.2%; 95% CI, -23.1 to -1.3). The increase in ED downgrade less than 6 hours was not statistically significant (DiD, 4.8%; 95% CI, -0.7 to 10.3%) except in the intermediate group (DiD, 8.8%; 95% CI, 0.2-17.4). CONCLUSIONS:The implementation of a novel ECCP was associated with a significant decrease in inhospital mortality among critically ill medical ED patients, with the greatest decrease observed in patients with intermediate severity of illness. Early ED downgrades also increased, but the difference was statistically significant only in the intermediate illness severity group. KEY WORDS: critical care medicine; emergency department critical care; emergency medicine; health care delivery models; intensive care unit triage C ritical care delivery in U.S. emergency departments (EDs) is increasing, particularly in urban hospitals (1, 2). Between 2006 and 2014, ED visits for critically ill patients increased by 80% with minimal accompanying growth in available ED capacity and ICU beds (3). The ED is not designed for longitudinal care of the critically ill; previous studies on ED boarding of

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Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

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Association of an Emergency Critical Care Program With Survival and Early Downgrade Among Critically Ill Medical Patients in the Emergency Department*

Mitarai

Gordon

Nudelman

et al. 2023

Critical Care Medicine

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“…[4][5][6][7][8] In our hospital, however, ICU patients with prolonged ED boarding times have significantly lower illness severity and consequently have lower rather than higher in-hospital mortality. 9 Additionally, a substantial proportion of admitted ICU patients who board in our ED for >6 hours are downgraded to non-ICU care and never reach the ICU, but these pre-ICU downgrades were excluded from previous studies. [5][6][7] This creates a selection bias in the prolonged boarding group by including only the patients who were too severely ill to be downgraded in the ED even after a prolonged period.…”

Section: Importancementioning

confidence: 99%

“…During the entire study period, a dual trained critical care medicine/emergency medicine (CCM/EM) nurse was available to assist ED nurses with boarding ICU patients. 9 From August 14, 2017 to August 13, 2019, a dual trained CCM/EM physician was available from 2 pm to midnight on weekdays to assist with management. 11…”

Section: Patientsmentioning

confidence: 99%

Selection bias in estimating the relationship between prolonged ED boarding and mortality in emergency critical care patients

et al. 2022

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Emergency critical care—overview of the literature and current concepts

Reindl,

Rovas,

Köhnke

et al. 2024

Notfall Rettungsmed

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ZusammenfassungBis zu 10 % aller Notfallpatienten sind intensiv- oder überwachungspflichtig – Tendenz steigend. Im klinischen Alltag können jedoch nur wenige dieser Fälle unmittelbar auf eine Intensiv- oder Überwachungsstation verlegt werden. Aus diesem Grund besteht mitunter die Notwendigkeit einer verlängerten notfallmedizinischen Versorgung kritisch kranker Patient:innen in der Notaufnahme. Unter dem Motto „upstairs care, downstairs“ haben große Notaufnahmen im angloamerikanischen Raum hierfür die „emergency critical care units“ (ECCU) entwickelt. Dieses Konzept steht für eine frühe hochintensive Versorgung kritisch kranker Patient:innen innerhalb von Notaufnahmen mit dem Ziel einer bestmöglichen Stabilisierung und Allokation im Krankenhaus. Im Rahmen dieser Übersichtsarbeit sollen die bisherigen Daten zu ECCU genauer analysiert und auf die Situation in deutschen Notaufnahmen übertragen werden.

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Effect of emergency critical care nurses and emergency department boarding time on in-hospital mortality in critically ill patients

Cited by 3 publications

References 21 publications

Association of an Emergency Critical Care Program With Survival and Early Downgrade Among Critically Ill Medical Patients in the Emergency Department*

Association of an Emergency Critical Care Program With Survival and Early Downgrade Among Critically Ill Medical Patients in the Emergency Department*

Selection bias in estimating the relationship between prolonged ED boarding and mortality in emergency critical care patients

Emergency critical care—overview of the literature and current concepts

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