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Yılmaz A, Sevil H, Can S, Ararat E, Güvenç E, Diker S. Assessment of Hospital Medical Emergency Team Operations in a Tertiary Care Center in Turkey. Niger J Clin Pract 2024; 27:1095-1101. [PMID: 39348330 DOI: 10.4103/njcp.njcp_150_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 08/12/2024] [Indexed: 10/02/2024]
Abstract
BACKGROUND Rapid Response Teams, strategically devised to mitigate mortality and morbidity stemming from unforeseen deteriorations and cardiac arrests within healthcare facilities, are ubiquitously implemented on a global scale. AIM The aim of the study is to compare emergency physicians (EPs) and non-EPs on management protocols of Hospital Medical Emergency Teams (HoMET). METHODS This was a retrospective cross-sectional study. The hospital archive underwent a retrospective scanning process, and patient records were meticulously examined. The assessment encompassed various facets, including demographic characteristics, activation locations, and response and intervention times of HoMET teams, composed of both EPs and other healthcare professionals. Data analysis was conducted using SPSS software version 20.0. RESULTS A total of 1056 calls were included, with 52% (n = 549) involving male patients. The average age was 67.15 ± 19.45 years. EPs served as the team leader in 53% of the calls. Cardiac arrest was considered in 93.6% of the cases. The EPs group exhibited a higher average patient age, longer intervention times, and shorter arrival times (P < 0.001, P = 0.027, P < 0.001, respectively). A significant difference was observed in the locations of the calls and the groups of calls considering cardiac arrest (P < 0.001, P < 0.001, respectively). CONCLUSION The optimization of intervention teams is imperative given the persistently high incidence and mortality rates associated with in-hospital cardiac arrests. Leveraging the expertise of EPs in the management of arrests and critical patients can potentially enhance the effectiveness of these teams. Nonetheless, further research is warranted to comprehensively explore and validate this aspect.
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Affiliation(s)
- A Yılmaz
- Department of Emergency Medicine, Uşak Research and Training Hospital, Uşak, Turkey
| | - H Sevil
- Department of Emergency Medicine, Uşak Research and Training Hospital, Uşak, Turkey
| | - S Can
- Department of Emergency Medicine, Uşak Research and Training Hospital, Uşak, Turkey
| | - E Ararat
- Department of Emergency Medicine, Antalya Kepez State Hospital, Antalya, Turkey
| | - E Güvenç
- Department of Emergency Medicine, Buca Seyfi Demirsoy Research and Training Hospital, İzmir, Turkey
| | - S Diker
- Department of Internal Medicine, Uşak Research and Training Hospital, Uşak, Turkey
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Dünser MW, Noitz M, Tschoellitsch T, Bruckner M, Brunner M, Eichler B, Erblich R, Kalb S, Knöll M, Szasz J, Behringer W, Meier J. Emergency critical care: closing the gap between onset of critical illness and intensive care unit admission. Wien Klin Wochenschr 2024:10.1007/s00508-024-02374-w. [PMID: 38755419 DOI: 10.1007/s00508-024-02374-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 04/20/2024] [Indexed: 05/18/2024]
Abstract
Critical illness is an exquisitely time-sensitive condition and follows a disease continuum, which always starts before admission to the intensive care unit (ICU), in the majority of cases even before hospital admission. Reflecting the common practice in many healthcare systems that critical care is mainly provided in the confined areas of an ICU, any delay in ICU admission of critically ill patients is associated with increased morbidity and mortality. However, if appropriate critical care interventions are provided before ICU admission, this association is not observed. Emergency critical care refers to critical care provided outside of the ICU. It encompasses the delivery of critical care interventions to and monitoring of patients at the place and time closest to the onset of critical illness as well as during transfer to the ICU. Thus, emergency critical care covers the most time-sensitive phase of critical illness and constitutes one missing link in the chain of survival of the critically ill patient. Emergency critical care is delivered whenever and wherever critical illness occurs such as in the pre-hospital setting, before and during inter-hospital transfers of critically ill patients, in the emergency department, in the operating theatres, and on hospital wards. By closing the management gap between onset of critical illness and ICU admission, emergency critical care improves patient safety and can avoid early deaths, reverse mild-to-moderate critical illness, avoid ICU admission, attenuate the severity of organ dysfunction, shorten ICU length of stay, and reduce short- and long-term mortality of critically ill patients. Future research is needed to identify effective models to implement emergency critical care systems in different healthcare systems.
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Affiliation(s)
- Martin W Dünser
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria.
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, Krankenhausstraße 9, 4020, Linz, Austria.
| | - Matthias Noitz
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| | - Thomas Tschoellitsch
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| | - Markus Bruckner
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| | - Markus Brunner
- Ambulance and Disaster Relief Services, Oberösterreichisches Rotes Kreuz, 4020, Linz, Austria
| | - Bernhard Eichler
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| | - Romana Erblich
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| | - Stephan Kalb
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| | - Marius Knöll
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
| | | | - Wilhelm Behringer
- Department of Emergency Medicine, Vienna General Hospital, 1090, Vienna, Austria
| | - Jens Meier
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital and Johannes Kepler University, 4020, Linz, Austria
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Drumheller BC, Tam J, Schatz KW, Doshi AA. Use of resuscitative endovascular balloon occlusion of the aorta (REBOA) and ultrasound-guided left stellate ganglion block to rescue out of hospital cardiac arrest due to refractory ventricular fibrillation: A case report. Resusc Plus 2024; 17:100524. [PMID: 38162991 PMCID: PMC10755478 DOI: 10.1016/j.resplu.2023.100524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 11/20/2023] [Accepted: 11/23/2023] [Indexed: 01/03/2024] Open
Abstract
Out of hospital cardiac arrest from shockable rhythms that is refractory to standard treatment is a unique challenge. Such patients can achieve neurological recovery even with long low-flow times if perfusion can somehow be restored to the heart and brain. Extracorporeal cardiopulmonary resuscitation is an effective treatment for refractory cardiac arrest if applied early and accurately, but often cannot be directly implemented by frontline providers and has strict inclusion/exclusion criteria. We present the case of a novel treatment strategy for out of hospital cardiac arrest due to refractory ventricular fibrillation utilizing Resuscitative Endovascular Balloon Occlusion of the Aorta-assisted cardiopulmonary resuscitation and intra-arrest left stellate ganglion blockade to achieve return of spontaneous circulation and eventual good neurological outcome after 101 minutes of downtime.
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Affiliation(s)
- Byron C. Drumheller
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jonathan Tam
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Kimberly W. Schatz
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Ankur A. Doshi
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Bracey A, Tichauer MB, Wu GP, Barnicle RN, Lu CJ, Tanzi MV, Pellet AC, Pauzé DR, Weingart SD, Duncan LJ, Wright BJ. Blueprint for the development of resuscitation and emergency critical care fellowships. AEM EDUCATION AND TRAINING 2023; 7:e10905. [PMID: 37720309 PMCID: PMC10502636 DOI: 10.1002/aet2.10905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 08/11/2023] [Accepted: 08/11/2023] [Indexed: 09/19/2023]
Abstract
The volume of critically ill patients presenting to the emergency department (ED) is increasing rapidly. Continued growth will likely further stress an already strained U.S. health care system. Numerous studies have demonstrated an association with worsened outcomes for critically ill patients boarding in the ED. To address the increasing volume and complexity of critically ill patients presenting to EDs nationwide, resuscitation and emergency critical care (RECC) fellowships were developed. RECC programs teach a general approach to the management of the undifferentiated critically ill patient, advanced management of critically ill patients by disease presentation, and ongoing supportive care of the critically ill patient boarding in the ED. The result is critical care training beyond that of a typical emergency medicine (EM) residency with a focus on the unique features and challenges of caring for critically ill patients in the ED not normally found in critical care fellowships. Graduates from RECC fellowships are well suited to practicing in any ED practice model and may be especially well prepared for EDs that distinguish acuity between zones (e.g., resuscitative care units, ED-based intensive care units). In addition to further developing clinical acumen, RECC fellowships provide graduates with a niche in EM education, research, and administration. In this article, we describe the philosophical principles and practical components necessary for the creation of future RECC fellowships.
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Affiliation(s)
- Alexander Bracey
- Department of Emergency MedicineAlbany Medical Center HospitalAlbanyNew YorkUSA
| | - Matthew B. Tichauer
- Department of Emergency MedicineHartford Hospital/University of ConnecticutHartfordConnecticutUSA
- Department of Critical CareHartford Hospital/University of ConnecticutHartfordConnecticutUSA
| | - Gregory P. Wu
- Department of Emergency MedicineAlbany Medical Center HospitalAlbanyNew YorkUSA
- Department of MedicineAlbany Medical Center HospitalAlbanyNew YorkUSA
| | - Ryan N. Barnicle
- Department of Emergency MedicineWarren Alpert Medical School of Brown UniversityProvidenceRhode IslandUSA
| | - Christina J. Lu
- Department of Emergency MedicineHartford Hospital/University of ConnecticutHartfordConnecticutUSA
| | - Matthew V. Tanzi
- Department of Emergency MedicineStony Brook University HospitalStony BrookNew YorkUSA
| | - Andrew C. Pellet
- Department of Emergency MedicineAlbany Medical Center HospitalAlbanyNew YorkUSA
- Department of SurgeryAlbany Medical Center HospitalAlbanyNew YorkUSA
| | - Denis R. Pauzé
- Department of Emergency MedicineAlbany Medical Center HospitalAlbanyNew YorkUSA
| | - Scott D. Weingart
- Department of Emergency MedicineNassau University Medical CenterEast MeadowNew YorkUSA
| | - Luke J. Duncan
- Department of Emergency MedicineAlbany Medical Center HospitalAlbanyNew YorkUSA
- Department of SurgeryAlbany Medical Center HospitalAlbanyNew YorkUSA
| | - Brian J. Wright
- Department of Emergency MedicineStony Brook University HospitalStony BrookNew YorkUSA
- Department of NeurosurgeryStony Brook University HospitalStony BrookNew YorkUSA
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5
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Utilizing an emergency medicine stabilization team to provide critical care in a rural health system. Am J Emerg Med 2023; 63:113-119. [PMID: 36356488 DOI: 10.1016/j.ajem.2022.10.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 09/23/2022] [Accepted: 10/21/2022] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Over the past decade, Emergency Department (ED) patient volumes have increased more than available hospital ICU capacity. This has led to increased boarding and crowding in EDs, requiring new methods of providing intensive care. Many hospitals nationwide have developed ICU boarding mitigation strategies at the hospital and ED level or implemented ED-based resuscitative care units to improve patient care and disposition. However, these have been described in the setting of larger medical centers without broader application to rural, community ED environments. The authors herein have created an ED model utilizing a physician and nurse on-call team to provide improved care to critically ill patients requiring resuscitation when an ICU bed is not immediately available. GOALS The goal of this paper is to describe a novel approach to providing critical care in a rural health system. A community health system-based resuscitation team named Emergency Medicine Stabilization Team, or EMSTAT, was developed as a mobile team consisting of one emergency physician and one emergency or critical care nurse. The authors present data from the first 12 months of the program including diagnoses, procedures, temporal trends, and lengths of stay. RESULTS Over the course of twelve months, EMSTAT was contacted for 195 patients and ultimately traveled to bedside for 131 cases. The three most common diagnoses seen were sepsis, respiratory failure, and diabetic emergencies. 99 documented procedures were performed; the most common were central venous catheters, arterial lines, and intubations. 104 patients were admitted to the intensive care unit, while the other 27 were either downgraded to a lower level of care, discharged, transitioned to palliative care, or died. DISCUSSION Over a twelve-month period, the authors describe a novel rural community-based mobile critical care team. This team demonstrated the ability to quickly arrive at bedside, continue resuscitation, acquire a disposition, and provide individualized critical are. This model serves as a roadmap for developing similar community based-resuscitation programs.
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Bassin BS, Haas NL, Sefa N, Medlin R, Peterson TA, Gunnerson K, Maxwell S, Cranford JA, Laurinec S, Olis C, Havey R, Loof R, Dunn P, Burrum D, Gegenheimer-Holmes J, Neumar RW. Cost-effectiveness of an Emergency Department-Based Intensive Care Unit. JAMA Netw Open 2022; 5:e2233649. [PMID: 36169958 PMCID: PMC9520346 DOI: 10.1001/jamanetworkopen.2022.33649] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Value in health care is quality per unit cost (V = Q/C), and an emergency department-based intensive care unit (ED-ICU) model has been associated with improved quality. To assess the value of this care delivery model, it is essential to determine the incremental direct cost of care. OBJECTIVE To determine the association of an ED-ICU with inflation-adjusted change in mean direct cost of care, net revenue, and direct margin per ED patient encounter. DESIGN, SETTING, AND PARTICIPANTS This retrospective economic analysis evaluated the cost of care delivery to patients in the ED before and after deployment of the Joyce and Don Massey Family Foundation Emergency Critical Care Center, an ED-ICU, on February 16, 2015, at a large academic medical center in the US with approximately 75 000 adult ED visits per year. The pre-ED-ICU cohort was defined as all documented ED visits by patients 18 years or older with a complete financial record from September 8, 2012, through June 30, 2014 (660 days); the post-ED-ICU cohort, all visits from July 1, 2015, through April 21, 2017 (660 days). Fiscal year 2015 was excluded from analysis to phase in the new care model. Statistical analysis was performed March 1 through December 30, 2021. EXPOSURES Implementation of an ED-ICU. MAIN OUTCOMES AND MEASURES Inflation-adjusted direct cost of care, net revenue, and direct margin per patient encounter in the ED. RESULTS A total of 234 884 ED visits during the study period were analyzed, with 115 052 patients (54.7% women) in the pre-ED-ICU cohort and 119 832 patients (54.5% women) in the post-ED-ICU cohort. The post-ED-ICU cohort was older (mean [SD] age, 49.1 [19.9] vs 47.8 [19.6] years; P < .001), required more intensive respiratory support (2.2% vs 1.1%; P < .001) and more vasopressor use (0.5% vs 0.2%; P < .001), and had a higher overall case mix index (mean [SD], 1.7 [2.0] vs 1.5 [1.7]; P < .001). Implementation of the ED-ICU was associated with similar inflation-adjusted total direct cost per ED encounter (pre-ED-ICU, mean [SD], $4875 [$15 175]; post-ED-ICU, $4877 [$17 400]; P = .98). Inflation-adjusted net revenue per encounter increased by 7.0% (95% CI, 3.4%-10.6%; P < .001), and inflation-adjusted direct margin per encounter increased by 46.6% (95% CI, 32.1%-61.2%; P < .001). CONCLUSIONS AND RELEVANCE Implementation of an ED-ICU was associated with no significant change in inflation-adjusted total direct cost per ED encounter. Holding delivery costs constant while improving quality demonstrates improved value via the ED-ICU model of care.
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Affiliation(s)
- Benjamin S. Bassin
- Division of Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor
- Max Harry Weil Institute for Critical Care Research and Innovation, Ann Arbor, Michigan
| | - Nathan L. Haas
- Division of Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor
- Max Harry Weil Institute for Critical Care Research and Innovation, Ann Arbor, Michigan
| | - Nana Sefa
- Division of Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor
- Department of Critical Care, Medstar Washington Hospital Center, Washington, DC
| | - Richard Medlin
- Department of Emergency Medicine and Learning Health Sciences, University of Michigan, Ann Arbor
| | | | - Kyle Gunnerson
- Division of Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor
- Max Harry Weil Institute for Critical Care Research and Innovation, Ann Arbor, Michigan
| | - Steve Maxwell
- Department of Emergency Medicine, University of Michigan, Ann Arbor
| | | | - Stephanie Laurinec
- Division of Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor
- Max Harry Weil Institute for Critical Care Research and Innovation, Ann Arbor, Michigan
| | - Christine Olis
- Clinical Financial Planning & Analysis, University of Michigan, Ann Arbor
| | - Renee Havey
- Department of Emergency Medicine, University of Michigan, Ann Arbor
| | - Robert Loof
- Department of Emergency Medicine, University of Michigan, Ann Arbor
| | - Patrick Dunn
- Clinical Financial Planning & Analysis, University of Michigan, Ann Arbor
| | - Debra Burrum
- Department of Emergency Medicine, University of Michigan, Ann Arbor
| | | | - Robert W. Neumar
- Division of Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor
- Max Harry Weil Institute for Critical Care Research and Innovation, Ann Arbor, Michigan
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Delayed Admission to the Intensive Care Unit and Mortality of Critically Ill Adults: Systematic Review and Meta-analysis. BIOMED RESEARCH INTERNATIONAL 2022; 2022:4083494. [PMID: 35146022 PMCID: PMC8822318 DOI: 10.1155/2022/4083494] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 01/27/2022] [Indexed: 01/09/2023]
Abstract
Delayed admission of patients to the intensive care unit (ICU) is increasing worldwide and can be followed by adverse outcomes when critical care treatment is not provided timely. This systematic review and meta-analysis appraised and synthesized the published literature about the association between delayed ICU admission and mortality of adult patients. Articles published from inception up to August 2021 in English-language, peer-reviewed journals indexed in CINAHL, PubMed, Scopus, Cochrane Library, and Web of Science were searched by using key terms. Delayed ICU admission constituted the intervention, while mortality for any predefined time period was the outcome. Risk for bias was evaluated with the Newcastle-Ottawa Scale and additional criteria. Study findings were synthesized qualitatively, while the odds ratios (ORs) for mortality with 95% confidence intervals (CIs) were combined quantitatively. Thirty-four observational studies met inclusion criteria. Risk for bias was low in most studies. Unadjusted mortality was reported in 33 studies and was significantly higher in the delayed ICU admission group in 23 studies. Adjusted mortality was reported in 18 studies, and delayed ICU admission was independently associated with significantly higher mortality in 13 studies. Overall, pooled OR for mortality in case of delayed ICU admission was 1.61 (95% CI 1.44-1.81). Interstudy heterogeneity was high (I2 = 66.96%). According to subgroup analysis, OR for mortality was remarkably higher in postoperative patients (OR, 2.44, 95% CI 1.49-4.01). These findings indicate that delayed ICU admission is significantly associated with mortality of critically ill adults and highlight the importance of providing timely critical care in non-ICU settings.
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Singh M, Maharaj R, Allorto N, Wise R. Profile of referrals to an intensive care unit from a regional hospital emergency centre in KwaZulu-Natal. Afr J Emerg Med 2021; 11:471-476. [PMID: 34804783 PMCID: PMC8581501 DOI: 10.1016/j.afjem.2021.07.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 07/06/2021] [Accepted: 07/19/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction The objective was to describe the clinical characteristics, disease profile and outcome of patients referred from a regional hospital Emergency Centre (EC) to the Intensive Care Unit (ICU). Methods A retrospective review was performed using data extracted from the Integrated Critical Care Electronic Database (iCED). Data were extracted from the database with respect to patient characteristics, Society of Critical Care Medicine (SCCM) grading, and outcome of the ICU referral. Modified early warning scores (MEWS) were calculated from EC referral data. Results There were a total of 2187 referrals. Of these, 56.3% (1231/2187) were male. The mean age of referrals was 36 years. Of the referred patients, 41.5% (907/2187) were initially accepted for admission. A further 378 patients were accepted for admission after a follow up ICU review. Medical conditions accounted for the majority of patient referrals, followed by general surgery and trauma. Most patients initially accepted to ICU were classified as SCCM I and II and had a mean MEWS of 4. Almost half of the patients experienced a delay in admission, most commonly due to a lack of ICU bed availability. ICU mortality was 13.6% for patients admitted from the EC. Discussion The EC population referred to the ICU was young with a high burden of medical and trauma conditions. Decisions to accept patients to ICU are limited by available resources, and there was a need to apply ICU triage criteria. Delays in the transfer of ICU patients from the EC increase the workload and contribute to EC crowding.
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Affiliation(s)
- Mika Singh
- Division of Emergency Medicine, College of Health Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- Corresponding author.
| | - Roshen Maharaj
- Division of Emergency Medicine, College of Health Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- Department of Emergency Medicine, Livingstone Tertiary Hospital, Port Elizabeth, South Africa
| | - Nikki Allorto
- Pietermaritzburg Burn Service, Pietermaritzburg Metropolitan Department of Surgery, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, South Africa
| | - Robert Wise
- Discipline of Anaesthesia and Critical Care, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
- Adult Intensive Care Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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Mermiri M, Mavrovounis G, Chatzis D, Mpoutsikos I, Tsaroucha A, Dova M, Angelopoulou Z, Ragias D, Chalkias A, Pantazopoulos I. Critical emergency medicine and the resuscitative care unit. Acute Crit Care 2021; 36:22-28. [PMID: 33508185 PMCID: PMC7940106 DOI: 10.4266/acc.2020.00521] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 11/21/2020] [Accepted: 11/23/2020] [Indexed: 01/08/2023] Open
Abstract
Critical emergency medicine is the medical field concerned with management of critically ill patients in the emergency department (ED). Increased ED stay due to intensive care unit (ICU) overcrowding has a negative impact on patient care and outcome. It has been proposed that implementation of critical care services in the ED can negate this effect. Two main Critical Emergency Medicine models have been proposed, the "resource intensivist" and "ED-ICU" models. The resource intensivist model is based on constant presence of an intensivist in the traditional ED setting, while the ED-ICU model encompasses the notion of a separate ED-based unit, with monitoring and therapeutic capabilities similar to those of an ICU. Critical emergency medicine has the potential to improve patient care and outcome; however, establishment of evidence-based protocols and a multidisciplinary approach in patient management are of major importance.
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Affiliation(s)
- Maria Mermiri
- Department of Emergency Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Georgios Mavrovounis
- Department of Emergency Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | | | | | | | - Maria Dova
- Medical School, European University of Cyprus, Nicosia, Cyprus
| | - Zacharoula Angelopoulou
- Department of Anesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Dimitrios Ragias
- Department of Anesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Athanasios Chalkias
- Department of Anesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Ioannis Pantazopoulos
- Department of Emergency Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
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Hickey S, Mathews KS, Siller J, Sueker J, Thakore M, Ravikumar D, Olmedo RE, McGreevy J, Kohli-Seth R, Carr B, Leibner ES. Rapid deployment of an emergency department-intensive care unit for the COVID-19 pandemic. Clin Exp Emerg Med 2020; 7:319-325. [PMID: 33440110 PMCID: PMC7808837 DOI: 10.15441/ceem.20.102] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 10/03/2020] [Indexed: 02/07/2023] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic mandated rapid, flexible solutions to meet the anticipated surge in both patient acuity and volume. This paper describes one institution’s emergency department (ED) innovation at the center of the COVID-19 crisis, including the creation of a temporary ED–intensive care unit (ICU) and development of interdisciplinary COVID-19–specific care delivery models to care for critically ill patients. Mount Sinai Hospital, an urban quaternary academic medical center, had an existing five-bed resuscitation area insufficiently rescue due to its size and lack of negative pressure rooms. Within 1 week, the ED-based observation unit, which has four negative pressure rooms, was quickly converted into a COVID-19–specific unit, split between a 14-bed stepdown unit and a 13-bed ED-ICU unit. An increase in staffing for physicians, physician assistants, nurses, respiratory therapists, and medical technicians, as well as training in critical care protocols and procedures, was needed to ensure appropriate patient care. The transition of the ED to a COVID-19–specific unit with the inclusion of a temporary expanded ED-ICU at the beginning of the COVID-19 pandemic was a proactive solution to the growing challenges of surging patients, complexity, and extended boarding of critically ill patients in the ED. This pandemic underscores the importance of ED design innovation with flexible spacing, interdisciplinary collaborations on structure and services, and NP ventilation systems which will remain important moving forward.
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Affiliation(s)
- Sean Hickey
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kusum S Mathews
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jennifer Siller
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Judah Sueker
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mitali Thakore
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Deepa Ravikumar
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ruben E Olmedo
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jolion McGreevy
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Roopa Kohli-Seth
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Brendan Carr
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Evan S Leibner
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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11
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Drumheller BC, Mareiniss DP, Overberger RC, Sabolick EE. Design and implementation of a temporary emergency department-intensive care unit patient care model during the COVID-19 pandemic surge. J Am Coll Emerg Physicians Open 2020; 1:1255-1260. [PMID: 33363286 PMCID: PMC7753833 DOI: 10.1002/emp2.12323] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 10/13/2020] [Accepted: 10/27/2020] [Indexed: 12/23/2022] Open
Abstract
The ongoing pandemic of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has resulted in rapid surges of critically ill patients infected with coronavirus disease 2019 (COVID-19) pneumonia presenting to the emergency department (ED) and requiring ICU admission nationwide. Despite adaptations in critical care personnel staffing, bed availability and supply provision, many inpatient ICUs have become acutely crowded, leading to boarding of critically ill patients with COVID-19 and other diseases in the ED. To address this scenario at our urban, safety net, tertiary care institution in the spring of 2020, we designed and implemented a temporary "emergency department-intensive care unit" (ED-ICU) patient care service. Critical care-trained emergency physicians took call and came into the hospital overnight/on weekends to provide bedside treatment to admitted ICU patients boarding for prolonged periods in our ED. In this manuscript, we describe the creation and execution of the ED-ICU service and the characteristics and management of the patients who received care under this model.
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Affiliation(s)
- Byron C Drumheller
- Department of Emergency Medicine Einstein Healthcare Network Einstein Medical Center Philadelphia Philadelphia Pennsylvania USA
| | - Darren P Mareiniss
- Department of Emergency Medicine Einstein Healthcare Network Einstein Medical Center Philadelphia Philadelphia Pennsylvania USA
| | - Ryan C Overberger
- Department of Emergency Medicine Einstein Healthcare Network Einstein Medical Center Philadelphia Philadelphia Pennsylvania USA
| | - Erin E Sabolick
- Department of Emergency Medicine Einstein Healthcare Network Einstein Medical Center Philadelphia Philadelphia Pennsylvania USA
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12
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Strickler SS, Choi DJ, Singer DJ, Oropello JM. Emergency physicians in critical care: where are we now? J Am Coll Emerg Physicians Open 2020; 1:1062-1070. [PMID: 33145559 PMCID: PMC7593427 DOI: 10.1002/emp2.12105] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 04/25/2020] [Accepted: 04/28/2020] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE Prior to 2011, emergency physicians who completed critical care (CC) fellowship were unable to obtain board certification in the United States. Three pathways for CC board certification have since been established. This study explores the training, practice, and perceived challenges of emergency medicine/critical care fellows and emergency medicine/critical care physicians in the United States. METHODS Anonymous institutional review board-approved survey distributed via email through an online survey engine from April to December 2016. Participants were recruited through national organizations and independent interest groups. Emergency physicians who were in CC fellowship or had completed a CC fellowship and were in practice in the United States participated voluntarily. RESULTS Of the 162 respondents, 152 were included (92 physicians, 60 fellows). Eighty-nine percent ranged from 31-50 years old. Among fellows, 90% desired a dual discipline practice. Among physicians, 63% split their time between the emergency department and ICU. Seventy-one percent of physicians reported working in academic institutions. Among physicians engaged in a dual practice, mean full-time equivalent (±SD) devoted to the ED was 0.37 (±0.22), mean full-time equivalent for ICU was 0.47 (±0.22), and mean full-time equivalent for protected academic time was 0.28 (±0.19). Emergency medicine/critical care fellows and emergency medicine/critical care physicians identified numerous challenges associated with duality. CONCLUSIONS Since the advent of critical care board certification for emergency physicians in the United States, there has been an increasing number of emergency physicians pursuing CC fellowships and achieving CC board certification. Emergency medicine/critical care physicians are venturing into a variety of practice models, demonstrating that the employment landscape remains plastic. Not unexpectedly, emergency medicine/critical care fellows and emergency medicine/critical care physicians are encountering challenges intrinsic to their duality.
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Affiliation(s)
- Samantha S. Strickler
- Department of Emergency Medicine and Department of AnesthesiaDivision of Critical Care MedicineEmory UniversityAtlantaGeorgiaUSA
| | - Daisi J. Choi
- Department of Emergency Medicine, Weill Cornell Medical CollegeCornell UniversityNew YorkNew YorkUSA
| | - Daniel J. Singer
- Department of Emergency MedicineLincoln Medical CenterBronxNew YorkUSA
| | - John M. Oropello
- Department of SurgeryIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
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13
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The critical care literature 2019. Am J Emerg Med 2020; 39:197-206. [PMID: 33036856 DOI: 10.1016/j.ajem.2020.09.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 09/20/2020] [Accepted: 09/22/2020] [Indexed: 11/23/2022] Open
Abstract
An emergency physician (EP) is often the first health care provider to evaluate, resuscitate, and manage a critically ill patient. In recent years, the annual hours of critical care delivered in emergency departments across the United States has steadily increased. From 2006 to 2014, emergency department (ED) visits for critically ill patients increased approximately 80%. In addition to seeing more critically ill patients, EPs are often tasked with providing critical care long beyond the initial resuscitation period. In fact, more than 50% of ED patients that require admission to the ICU remain in the ED for more than 6 h. Prolonged ED wait times for critically ill patients to be transferred to the ICU is associated with increased hospital, 30-day, and 90-day mortality. It is during these early hours of critical illness, while the patient is in the ED, where lives can be saved or lost. Therefore, it is important for the EP to be knowledgeable about recent developments in resuscitation and critical care medicine. This review summarizes important articles published in 2019 pertaining to the resuscitation and care of select critically ill patients. We chose these articles based on our opinion of the importance of the study findings and their application to emergency medicine. The following topics are covered: sepsis, rapid sequence intubation, mechanical ventilation, neurocritical care, post-cardiac arrest care, and ED-based ICUs.
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14
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Jayaprakash N, Pflaum-Carlson J, Gardner-Gray J, Hurst G, Coba V, Kinni H, Deledda J. Critical Care Delivery Solutions in the Emergency Department: Evolving Models in Caring for ICU Boarders. Ann Emerg Med 2020; 76:709-716. [PMID: 32653331 DOI: 10.1016/j.annemergmed.2020.05.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Revised: 03/21/2020] [Accepted: 05/01/2020] [Indexed: 10/23/2022]
Abstract
The National Academy of Medicine has identified emergency department (ED) crowding as a health care delivery problem. Because the ED is a portal of entry to the hospital, 25% of all ED encounters are related to critical illness. Crowding at both an ED and hospital level can thus lead to boarding of a number of critically ill patients in the ED. EDs are required to not only deliver immediate resuscitative and stabilizing care to critically ill patients on presentation but also provide longitudinal care while boarding for the ICU. Crowding and boarding are multifactorial and complex issues, for which different models for delivery of critical care in the ED have been described. Herein, we provide a narrative review of different models of delivery of critical care reported in the literature and highlight aspects for consideration for successful local implementation.
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Affiliation(s)
- Namita Jayaprakash
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI; Division of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, MI.
| | - Jacqueline Pflaum-Carlson
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI; Division of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, MI
| | - Jayna Gardner-Gray
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI; Division of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, MI
| | - Gina Hurst
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI; Division of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, MI
| | - Victor Coba
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI; Surgical Critical Care, Henry Ford Hospital, Detroit, MI
| | - Harish Kinni
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI; Division of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, MI
| | - John Deledda
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI
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15
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Haas NL, Puls HA, Adan AJ, Hatton C, Joseph JR, Hebert C, Hackenson D, Gunnerson KJ, Bassin BS. Emergency Department-based Intensive Care Unit Use Peaks Near Emergency Department Shift Turnover. West J Emerg Med 2020; 21:866-870. [PMID: 32726257 PMCID: PMC7390565 DOI: 10.5811/westjem.2020.4.46000] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 04/13/2020] [Indexed: 11/23/2022] Open
Abstract
Introduction The Emergency Critical Care Center (EC3) is an emergency department-based intensive care unit (ED-ICU) designed to improve timely access to critical care for ED patients. ED patients requiring intensive care are initially evaluated and managed in the main ED prior to transfer to a separate group of ED-ICU clinicians. The timing of patient transfers to the ED-ICU may decrease the number of handoffs between main ED teams and have an impact on both patient outcomes and optimal provider staffing models, but has not previously been studied. We aimed to analyze patterns of transfer to the ED-ICU and the relationship with shift turnover times in the main ED. We hypothesized that the number of transfers to the ED-ICU increases near main ED shift turnover times. Methods An electronic health record search identified all patients managed in the ED and ED-ICU in 2016 and 2017. We analyzed the number of ED arrivals per hour, the number of ED-ICU consults per hour, the time interval from ED arrival to ED-ICU consult, the distribution throughout the day, and the relationship with shift turnover times in the main ED. Results A total of 160,198 ED visits were queried, of which 5308 (3.3%) were managed in the ED-ICU. ED shift turnover times were 7 am, 3 pm, and 11 pm. The mean number of ED-ICU consults placed per hour was 221 (85 standard deviation), with relative maximums occurring near ED turnover times: 10:31 pm–11:30 pm (372) and 2:31 pm–3:30 pm (365). The minimum was placed between 7:31 am – 8:30 am (88), shortly after the morning ED turnover time. The median interval from ED arrival time to ED-ICU consult order was 161 minutes (range 6–1,434; interquartile range 144–174). Relative minimums were observed for patients arriving shortly prior to ED turnover times: 4:31 am – 5:30 am (120 minutes [min]), 12:31 pm – 1:30 pm (145 min), and 9:31 pm – 10:30 pm (135 min). Relative maximums were observed for patients arriving shortly after ED turnover times: 7:31 am – 8:30 am (177 min), 4:31 pm – 5:30 pm (218 min), and 11:31 pm – 12:30 am (179 min). Conclusion ED-ICU utilization was highest near ED shift turnover times, and utilization was dissimilar to overall ED arrival patterns. Patients arriving immediately prior to ED shift turnover received earlier consults to the ED-ICU, suggesting these patients may have been preferentially transferred to the ED-ICU rather than signed out to the next team of emergency clinicians. These findings may guide operational planning, staffing models, and timing of shift turnover for other institutions implementing ED-ICUs. Future studies could investigate whether an ED-ICU model improves critically ill patients’ outcomes by minimizing ED provider handoffs.
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Affiliation(s)
- Nathan L Haas
- Michigan Medicine, Department of Emergency Medicine, Ann Arbor, Michigan.,Michigan Medicine, Division of Emergency Critical Care, Ann Arbor, Michigan
| | - Henrique A Puls
- Michigan Medicine, Department of Emergency Medicine, Ann Arbor, Michigan
| | - Andrew J Adan
- University of Cincinnati, Department of Emergency Medicine, Cincinnati, Ohio
| | - Colman Hatton
- Michigan Medicine, Department of Emergency Medicine, Ann Arbor, Michigan
| | - John R Joseph
- Michigan Medicine, Department of Emergency Medicine, Ann Arbor, Michigan
| | - Christopher Hebert
- University of Washington, Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Seattle, Washington
| | - David Hackenson
- Michigan Medicine, Department of Emergency Medicine, Ann Arbor, Michigan.,Michigan Medicine, Division of Emergency Critical Care, Ann Arbor, Michigan
| | - Kyle J Gunnerson
- Michigan Medicine, Department of Emergency Medicine, Ann Arbor, Michigan.,Michigan Medicine, Division of Emergency Critical Care, Ann Arbor, Michigan.,Michigan Medicine, Department of Internal Medicine, Ann Arbor, Michigan.,Michigan Medicine, Department of Anesthesiology/Critical Care, Ann Arbor, Michigan
| | - Benjamin S Bassin
- Michigan Medicine, Department of Emergency Medicine, Ann Arbor, Michigan.,Michigan Medicine, Division of Emergency Critical Care, Ann Arbor, Michigan
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16
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Cheung Y, Ko S, Wong OF, Lam HSB, Ma HM, Lit CHA. Clinical experience in management of bloodstream infection in emergency medical ward: A preliminary report. HONG KONG J EMERG ME 2019. [DOI: 10.1177/1024907919890495] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
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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Affiliation(s)
- Ying Cheung
- Accident and Emergency Department, Princess Margaret Hospital, Kwai Chung, Hong Kong
| | - Shing Ko
- Accident and Emergency Department, North Lantau Hospital, Tung Chun, Hong Kong
| | - Oi Fung Wong
- Accident and Emergency Department, North Lantau Hospital, Tung Chun, Hong Kong
| | - Hoi Shiu Bosco Lam
- Department of Pathology, Princess Margaret Hospital, Kwai Chung, Hong Kong
| | - Hing Man Ma
- Accident and Emergency Department, North Lantau Hospital, Tung Chun, Hong Kong
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17
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Jeong H, Jung YS, Suh GJ, Kwon WY, Kim KS, Kim T, Shin SM, Kang MW, Lee MS. Emergency physician-based intensive care unit for critically ill patients visiting emergency department. Am J Emerg Med 2019; 38:2277-2282. [PMID: 31785978 DOI: 10.1016/j.ajem.2019.09.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 08/11/2019] [Accepted: 09/17/2019] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND To provide a prompt and optimal intensive care to critically ill patients visiting our emergency department (ED), we set up and ran a specific type of emergency intensive care unit (EICU) managed by emergency physician (EP) intensivists. We investigated whether this EICU reduced the time interval from ED arrival to ICU transfer (ED-ICU interval) without altering mortality. METHODS This was a retrospective study conducted in a tertiary referral hospital. We collected data from ED patients who were admitted to the EICU (EICU group) and other ICUs including medical, surgical, and cardiopulmonary ICUs (other ICUs group), from August 2014 to July 2017. We compared these two groups with respect to demographic findings, including the Acute Physiology and Chronic Health Evaluation II (APACHE II) score, ED-ICU interval, ICU mortality, and hospital mortality. RESULTS Among the 3440 critically ill patients who visited ED, 1815 (52.8%) were admitted to the EICU during the study period. The ED-ICU interval for the EICU group was significantly shorter than that for the other ICUs group by 27.5% (5.0 ± 4.9 vs. 6.9 ± 5.4 h, p < 0.001). In multivariable analysis, the ICU mortality (odds ratio = 1.062, 95% confidence interval 0.862-1.308, p = 0.571) and hospital mortality (odds ratio = 1.093, 95% confidence interval 0.892-1.338, p = 0.391) of the EICU group were not inferior to those of the other ICUs group. CONCLUSIONS The EICU run by EP intensivists reduced the time interval from ED arrival to ICU transfer without altering hospital mortality.
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Affiliation(s)
- Hwain Jeong
- Division of Critical Care Medicine, Department of Emergency Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea.
| | - Yoon Sun Jung
- Division of Critical Care Medicine, Department of Emergency Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea.
| | - Gil Joon Suh
- Division of Critical Care Medicine, Department of Emergency Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea; Department of Emergency Medicine, Seoul National University College of Medicine, Seoul 03080, Republic of Korea.
| | - Woon Yong Kwon
- Division of Critical Care Medicine, Department of Emergency Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea; Department of Emergency Medicine, Seoul National University College of Medicine, Seoul 03080, Republic of Korea.
| | - Kyung Su Kim
- Division of Critical Care Medicine, Department of Emergency Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Taegyun Kim
- Division of Critical Care Medicine, Department of Emergency Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - So Mi Shin
- Division of Critical Care Medicine, Department of Emergency Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea.
| | - Min Woo Kang
- Department of Emergency Medicine, CHA Bundang Medical Center, Gyeonggi-do 13496, Republic of Korea
| | - Min Sung Lee
- Division of Critical Care Medicine, Department of Emergency Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea
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18
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Maezawa S, Kudo D, Miyagawa N, Yamanouchi S, Kushimoto S. Association of Body Weight Change and Fluid Balance With Extubation Failure in Intensive Care Unit Patients: A Single-Center Observational Study. J Intensive Care Med 2019; 36:175-181. [PMID: 31726914 DOI: 10.1177/0885066619887694] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
PURPOSE To elucidate whether fluid balance and body weight change are associated with failed planned extubation. MATERIALS AND METHODS Patients who received invasive mechanical ventilation for over 24 hours were enrolled and divided into extubation success and extubation failure groups. Fluid balance and body weight fluctuation within 24 and 48 hours before extubation and from admission to planned extubation were calculated. The primary outcome was extubation failure (ie, all-cause reintubation within 72 hours). The association of extubation failure with fluid balance and body weight change was assessed via logistic regression analysis. RESULTS Extubation failure occurred in 12(7.4%)/161 patients. The extubation success group had a significantly lower fluid balance within 24 hours before extubation than did the extubation failure group (-276 mL [-1111 to 456] vs 1217 mL [503 to 1875], P = .002). However, fluid balance within 48 hours before extubation, cumulative fluid balance, and body weight change were not significantly different between the 2 groups. The sensitivity and specificity of water balance +1000 mL within 24 hours before extubation for the extubation failure group were 0.54 and 0.84, respectively, based on the receiver operating characteristic curve. Logistic regression analysis showed that fluid balance within 24 hours before extubation was associated with extubation failure (odds ratio: 22.9, 95% confidence interval: 4.1-128.4). CONCLUSIONS A larger fluid balance within 24 hours before extubation is associated with extubation failure. Thus, fluid balance may be a good indicator of extubation outcome.
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Affiliation(s)
- Shota Maezawa
- Department of Emergency and Critical Care, Tohoku University Hospital, Aoba-ku, Sendai, Japan.,Department of Emergency and Critical Care, 73692Osaki Citizen Hospital, Osaki, Japan
| | - Daisuke Kudo
- Department of Emergency and Critical Care, Tohoku University Hospital, Aoba-ku, Sendai, Japan.,Division of Emergency and Critical Care Medicine, Graduate School of Medicine, Tohoku University, Aoba-ku, Sendai, Japan
| | - Noriko Miyagawa
- Department of Emergency and Critical Care, Tohoku University Hospital, Aoba-ku, Sendai, Japan
| | - Satoshi Yamanouchi
- Department of Emergency and Critical Care, 73692Osaki Citizen Hospital, Osaki, Japan.,Division of Emergency and Critical Care Medicine, Graduate School of Medicine, Tohoku University, Aoba-ku, Sendai, Japan
| | - Shigeki Kushimoto
- Department of Emergency and Critical Care, Tohoku University Hospital, Aoba-ku, Sendai, Japan.,Division of Emergency and Critical Care Medicine, Graduate School of Medicine, Tohoku University, Aoba-ku, Sendai, Japan
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19
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Gunnerson KJ, Bassin BS, Havey RA, Haas NL, Sozener CB, Medlin RP, Gegenheimer-Holmes JA, Laurinec SL, Boyd C, Cranford JA, Whitmore SP, Hsu CH, Khan R, Vazirani NN, Maxwell SG, Neumar RW. Association of an Emergency Department-Based Intensive Care Unit With Survival and Inpatient Intensive Care Unit Admissions. JAMA Netw Open 2019; 2:e197584. [PMID: 31339545 PMCID: PMC6659143 DOI: 10.1001/jamanetworkopen.2019.7584] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
IMPORTANCE Increased patient acuity, decreased intensive care unit (ICU) bed availability, and a shortage of intensivist physicians have led to strained ICU capacity. The resulting increase in emergency department (ED) boarding time for patients requiring ICU-level care has been associated with worse outcomes. OBJECTIVE To determine the association of a novel ED-based ICU, the Emergency Critical Care Center (EC3), with 30-day mortality and inpatient ICU admission. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used electronic health records of all ED visits between September 1, 2012, and July 31, 2017, with a documented clinician encounter at a large academic medical center in the United States with approximately 75 000 adult ED visits per year. The pre-EC3 cohort included ED patients from September 2, 2012, to February 15, 2015, when the EC3 opened, and the post-EC3 cohort included ED patients from February 16, 2015, to July 31, 2017. Data analyses were conducted from March 2, 2018, to May 28, 2019. EXPOSURES Implementation of EC3, an ED-based ICU designed to provide rapid initiation of ICU-level care in the ED setting and seamless transition to inpatient ICUs. MAIN OUTCOMES AND MEASURES The main outcomes were 30-day mortality among ED patients and rate of ED to ICU admission. RESULTS A total of 349 310 visits from a consecutive sample of ED patients (mean [SD] age, 48.5 [19.7] years; 189 709 [54.3%] women) were examined; the pre-EC3 cohort included 168 877 visits and the post-EC3 cohort included 180 433 visits. Implementation of EC3 was associated with a statistically significant reduction in risk-adjusted 30-day mortality among all ED patients (pre-EC3, 2.13%; post-EC3, 1.83%; adjusted odds ratio, 0.85; 95% CI, 0.80-0.90; number needed to treat, 333 patient encounters; 95% CI, 256-476). The risk-adjusted rate of ED admission to ICU decreased with implementation of EC3 (pre-EC3, 3.2%; post-EC3, 2.7%; adjusted odds ratio, 0.80; 95% CI, 0.76-0.83; number needed to treat, 179 patient encounters; 95% CI, 149-217). CONCLUSIONS AND RELEVANCE Implementation of a novel ED-based ICU was associated with improved 30-day survival and reduced inpatient ICU admission. Additional research is warranted to further explore the value of this novel care delivery model in various health care systems.
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Affiliation(s)
- Kyle J. Gunnerson
- Department of Anesthesiology, Michigan Medicine, University of Michigan, Ann Arbor
- Department of Emergency Medicine, Michigan Medicine, University of Michigan, Ann Arbor
- Division of Emergency Critical Care, Michigan Medicine, University of Michigan, Ann Arbor
- Michigan Center for Integrative Research in Critical Care, Ann Arbor
- Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor
| | - Benjamin S. Bassin
- Department of Emergency Medicine, Michigan Medicine, University of Michigan, Ann Arbor
- Division of Emergency Critical Care, Michigan Medicine, University of Michigan, Ann Arbor
- Michigan Center for Integrative Research in Critical Care, Ann Arbor
| | - Renee A. Havey
- Department of Emergency Medicine, Michigan Medicine, University of Michigan, Ann Arbor
- Division of Emergency Critical Care, Michigan Medicine, University of Michigan, Ann Arbor
| | - Nathan L. Haas
- Department of Emergency Medicine, Michigan Medicine, University of Michigan, Ann Arbor
- Division of Emergency Critical Care, Michigan Medicine, University of Michigan, Ann Arbor
| | - Cemal B. Sozener
- Department of Emergency Medicine, Michigan Medicine, University of Michigan, Ann Arbor
- Division of Emergency Critical Care, Michigan Medicine, University of Michigan, Ann Arbor
| | - Richard P. Medlin
- Department of Emergency Medicine, Michigan Medicine, University of Michigan, Ann Arbor
| | | | - Stephanie L. Laurinec
- Department of Emergency Medicine, Michigan Medicine, University of Michigan, Ann Arbor
- Division of Emergency Critical Care, Michigan Medicine, University of Michigan, Ann Arbor
- Michigan Center for Integrative Research in Critical Care, Ann Arbor
| | - Caryn Boyd
- Department of Emergency Medicine, Michigan Medicine, University of Michigan, Ann Arbor
| | - James A. Cranford
- Department of Emergency Medicine, Michigan Medicine, University of Michigan, Ann Arbor
| | - Sage P. Whitmore
- Department of Emergency Medicine, Michigan Medicine, University of Michigan, Ann Arbor
- Division of Emergency Critical Care, Michigan Medicine, University of Michigan, Ann Arbor
- Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor
| | - Cindy H. Hsu
- Department of Emergency Medicine, Michigan Medicine, University of Michigan, Ann Arbor
- Division of Emergency Critical Care, Michigan Medicine, University of Michigan, Ann Arbor
- Michigan Center for Integrative Research in Critical Care, Ann Arbor
- Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor
| | - Reham Khan
- Department of Emergency Medicine, Michigan Medicine, University of Michigan, Ann Arbor
| | - Neha N. Vazirani
- Department of Emergency Medicine, Michigan Medicine, University of Michigan, Ann Arbor
- Division of Emergency Critical Care, Michigan Medicine, University of Michigan, Ann Arbor
- School of Dentistry, University of Michigan, Ann Arbor
| | - Stephen G. Maxwell
- Department of Emergency Medicine, Michigan Medicine, University of Michigan, Ann Arbor
| | - Robert W. Neumar
- Department of Emergency Medicine, Michigan Medicine, University of Michigan, Ann Arbor
- Division of Emergency Critical Care, Michigan Medicine, University of Michigan, Ann Arbor
- Michigan Center for Integrative Research in Critical Care, Ann Arbor
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20
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Leibner E, Spiegel R, Hsu CH, Wright B, Bassin BS, Gunnerson K, O’Connor J, Stein D, Weingart S, Greenwood JC, Rubinson L, Menaker J, Scalea TM. Anatomy of resuscitative care unit: expanding the borders of traditional intensive care units. Emerg Med J 2019; 36:364-368. [PMID: 30940715 PMCID: PMC6568315 DOI: 10.1136/emermed-2019-208455] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 03/17/2019] [Accepted: 03/21/2019] [Indexed: 11/03/2022]
Abstract
Resuscitation lacks a place in the hospital to call its own. Specialised intensive care units, though excellent at providing longitudinal critical care, often lack the flexibility to adapt to fluctuating critical care needs. We offer the resuscitative care unit as a potential solution to ensure that patients receive appropriate care during the most critical hours of their illnesses. These units offer an infrastructure for resuscitation and can meet the changing needs of their institutions.
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Affiliation(s)
- Evan Leibner
- Institute of Critical Care Medicine, Mount Sinai Hospital, New York, New York, USA
- Department of Surgery, Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Emergency Medicine, Mount Sinai Hospital, New York, New York
| | - Rory Spiegel
- Department of Emergency Medicine, The University of Maryland Medical Center, Baltimore, New York, USA
- Department of Pulmonary Critical Care, The University of Maryland Medical Center, Baltimore, New York, USA
| | - Cindy H Hsu
- Department of Emergency Medicine, Division of Emergency Critical Care, University of Michigan, Ann Arbor, Michigan, USA
- Department of Surgery, Division of Acute Care Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Brian Wright
- Departments of Neurosurgery, Stony Brook University School of Medicine, New York, USA
- Department of Emergency Medicine, Stony Brook University School of Medicine, New York, USA
| | - Benjamin S Bassin
- Department of Emergency Medicine, Division of Emergency Critical Care, University of Michigan, Ann Arbor, Michigan, USA
| | - Kyle Gunnerson
- Department of Emergency Medicine, Division of Emergency Critical Care, University of Michigan, Ann Arbor, Michigan, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Department of Anesthesiology/Critical Care, University of Michigan, Ann Arbor, Michigan, USA
| | - James O’Connor
- Department of Surgery, Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Deborah Stein
- Department of Surgery, Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Scott Weingart
- Department of Emergency Medicine, Stony Brook University School of Medicine, New York, USA
| | - John C Greenwood
- Department of Emergency Medicine, Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology & Critical Care, Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lewis Rubinson
- Department of Surgery, Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jay Menaker
- Department of Surgery, Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Thomas M Scalea
- Department of Surgery, Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Stohl S, Sprung CL, Lippert A, Pirracchio R, Artigas A, Iapichino G, Harris S, Pezzi A, Schlesinger M. Impact of triage-to-admission time on patient outcome in European intensive care units: A prospective, multi-national study. J Crit Care 2019; 53:11-17. [PMID: 31174171 DOI: 10.1016/j.jcrc.2019.05.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 04/10/2019] [Accepted: 05/27/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Ubiquitous bed shortages lead to delays in intensive care unit (ICU) admissions worldwide. Assessing the impact of delayed admission must account for illness severity. This study examined both the relationship between triage-to-admission time and 28-day mortality and the impact of controlling for Simplified Acute Physiology Score (SAPS) II scores on that relationship. METHODS Prospective cross-sectional analysis of referrals to eleven ICUs in seven European countries between 2003 and 2005. Outcomes among patients admitted within versus after 4 h were compared using a Chi-square test. Triage-to-admission time was also analyzed as a continuous variable; outcomes were assessed using a non-parametric Kruskal-Wallis test. RESULTS Among 3175 patients analyzed, triage-to-admission time was 2.1 ± 3.9 h. Patients admitted within 4 h had higher SAPS II scores (33.6 versus 30.6, Pearson correlation coefficient -0.07, p < 0.0001). 28-day mortality was surprisingly higher among patients admitted earlier (29.6 vs 25.2%, OR 1.25, 95% CI 0.99-1.58, p = 0.06). Even after adjusting for SAPS II scores, delayed admission was not associated with higher mortality (OR 1.08, CI 0.83-1.41, p = 0.58). CONCLUSIONS Even after accounting for quantifiable parameters of illness severity, delayed admission did not negatively impact outcome. Triage practices likely influence outcomes. Severity scores may not fully reflect illness acuity or trajectory.
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Affiliation(s)
- Sheldon Stohl
- Department of Anesthesiology and Critical Care Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, Faculty of Medicine, Jerusalem, Israel.
| | - Charles L Sprung
- Department of Anesthesiology and Critical Care Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, Faculty of Medicine, Jerusalem, Israel
| | - Anne Lippert
- Head of Unit, CHPE, Center for HR, Capital Region of Denmark, Copenhagen Academy for Medical Education and Simulation, Herlev University Hospital, Herlev, Denmark
| | - Romain Pirracchio
- Department of Anesthesia and Perioperative Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California San Francisco, San Francisco, California, USA
| | - Antonio Artigas
- Critical Care Department, CIBERes, Corporación Sanitaria Universitaria Parc Tauli, Autonomous University of Barcelona, University Hospitals Sagrado Corazón-General de Cataluña, IDC Quiron, Barcelona, Spain
| | | | - Steve Harris
- Anaesthesia and Critical Care, University College London Hospital, London, UK
| | - Angelo Pezzi
- Ospedale San Paolo, Polo Universitario, Milan, Italy
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Mosadeghrad AM, Gebru AA, Sari AA, Getu MIA. Emergency medical services in Ethiopia: Drivers, challenges and opportunities. Hum Antibodies 2019; 27:33-41. [PMID: 30958339 DOI: 10.3233/hab-190368] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Ethiopia has a well established health care system but lacks significant improvements on emergency medical services and suffers a shortage of equally initiative among all regional states and city administration of Ethiopia. This study aimed to examine the drivers, challenges, and opportunities of Emergency Medical Services (EMS) and to identify new evidence for future policy making in Ethiopia. METHOD A narrative review of the literature related to EMS was undertaken to describe the drivers, challenges, and opportunities for EMS in Ethiopia from July, 2000 to September, 2018. The search was done from four relevant electronic databases: MEDLINE, Science Directs, Scopus and PubMed by using Google Scholar and Google with key search words used mainly as "Emergency Medical services in Ethiopia". The inclusion criteria were an original study or review studies involving Emergency Medical Services in Ethiopia. Among the available papers, the relevant articles were selected while the irrelevant ones were excluded. RESULTS There was lack of trained emergency medical providers and misdistribution of trained professionals, immaturity of the program, lack of partnership and stakeholders and lack of motivation towards Emergency medical services. Emergency medical services hamper significant problems similar to other African countries that required being addressed in Ethiopia context for achieving the program and in order to obtain intended outcomes for the country. CONCLUSION A long-term discussion is needed to further improve the services system in various health care facilities. An Emergency Medical services policy making and analysis framework is needed to make quality emergency medical care at Emergency department in hospitals and outside the hospitals.
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Affiliation(s)
- Ali Mohammad Mosadeghrad
- Department of Health Management and Economics, School of Public Health, Health Information Management Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Addis Adera Gebru
- Department of Health Management and Economics, School of Public Health, International Campus, Tehran University of Medical Sciences, Tehran, Iran.,Department of Nursing, Faculty of Health Sciences, Woldia University, Woldia, Ethiopia
| | - Ali Akbari Sari
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - MIkiyas Amare Getu
- Department of Nursing, Faculty of Health Sciences, Woldia University, Woldia, Ethiopia
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Bayram B, Şancı E. Invasive mechanical ventilation in the emergency department. Turk J Emerg Med 2019; 19:43-52. [PMID: 31065603 PMCID: PMC6495062 DOI: 10.1016/j.tjem.2019.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 03/13/2019] [Indexed: 10/29/2022] Open
Abstract
Emergency department (ED) lenght of stay of the patients requiring admission to the intensive care units has increased gradually in recent years. Mechanical ventilation is an integral part of critical care and mechanically ventilated patients have to be managed and monitored by emergency physicians for longer than expected in EDs. This early period of care has significant impact on the outcomes of these patients. Therefore, emergency physicians should have comprehensive knowledge of mechanical ventilation. This review will summarize the current literature of the basic concepts, appropriate clinical applications, monitoring parameters, components and mechanisms of mechanical ventilation in the ED.
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Affiliation(s)
- Başak Bayram
- Dokuz Eylul University, School of Medicine, Department of Emergency Medicine, Izmir, Turkey
| | - Emre Şancı
- Darıca Farabi Education and Research Hospital, Department of Emergency Medicine, Kocaeli, Turkey
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Hoffman JMW, Mayer K. Destination Critical Care: A Roadmap for Academic Clinicians, Educators, and Mentors. AEM EDUCATION AND TRAINING 2019; 3:74-78. [PMID: 30680349 PMCID: PMC6339554 DOI: 10.1002/aet2.10308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 10/20/2018] [Accepted: 10/22/2018] [Indexed: 06/09/2023]
Abstract
The purpose of this article is to provide a framework for academic clinicians, educators, and mentors to advise the emergency medicine (EM) resident with an interest in the field of critical care medicine. Prior articles have detailed the prerequisites and specific training curricula of the distinct critical care pathways, but an approach for the advising faculty member in this climate of increased interest in critical care training has yet to be disseminated. In this article, we assume a starting point of EM residency and focus on pivotal training and decision points that occur along the path to matriculation into a critical care fellowship program. These decision points are described in stepwise fashion with aligned questions to help the EM resident evaluate individual strengths and desires that may help the decision-making process. We also describe considerations of the postfellowship job market, as this also plays a role in the fellowship decision-making process.
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Affiliation(s)
- Jean M. W. Hoffman
- Department of Emergency Medicine and AnesthesiaUniversity of Colorado School of MedicineAuroraCO
| | - Katherine Mayer
- Department of Emergency Medicine and Internal MedicineUniversity of Colorado School of MedicineAuroraCO
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Sultan M, Mengistu G, Debebe F, Azazh A, Trehan I. The burden on emergency centres to provide care for critically ill patients in Addis Ababa, Ethiopia. Afr J Emerg Med 2018; 8:150-154. [PMID: 30534519 PMCID: PMC6277535 DOI: 10.1016/j.afjem.2018.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 07/04/2018] [Accepted: 07/17/2018] [Indexed: 11/18/2022] Open
Abstract
Introduction Given the scarcity of critical care hospital beds in Africa, emergency centres (ECs) are increasingly charged with caring for critically ill patients for extended periods of time. The objective of this study was to improve the understanding of the nature and outcomes of critically ill patients with prolonged treatment times of more than six hours in two ECs in Addis Ababa, Ethiopia. Methods This study was conducted over three months in two ECs of urban tertiary care hospitals in Addis Ababa. Structured questionnaires were completed by six emergency and critical care nurses. EC patients were included if they met the Society for Critical Care Medicine (SCCM) intensive care unit (ICU) admission criteria and stayed in the EC for more than 6 h. We collected initial demographic and clinical information, data about the patients’ clinical course in the EC, and data regarding the patients’ disposition. We used descriptive statistics for analysis. Results A total of 291 patients, over the course of three months, had an EC stay that exceeded six hours. The median length of stay for these patients was 48 h (interquartile range: 25–72 h). The most common categories of illness were neurological disease in 87 patients (30%) and cardiovascular disease in 61 patients (21%). The most frequent aetiologies of critical illness were severe head trauma and severe sepsis with multi-organ failure (26 patients, 9% each). A total of 94 patients (32%) died in the EC, while 86 (30%) were discharged directly from the EC without hospital admission. Discussion ECs in Addis Ababa face a heavy burden in caring for a large number of critically ill patients over a long period of time, with relatively high mortality rates. These findings should promote supporting emergency centres to strengthen and expand ICU capacity to provide appropriate critical care services.
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Zhou VL, Shofer FS, Desai NG, Lorincz IS, Mull NK, Adler DH, Greenwood JC. Predictors of Short Intensive Care Unit Stay for Patients with Diabetic Ketoacidosis Using a Novel Emergency Department-Based Resuscitation and Critical Care Unit. J Emerg Med 2018; 56:127-134. [PMID: 30401511 DOI: 10.1016/j.jemermed.2018.09.048] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 09/16/2018] [Accepted: 09/22/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND The resuscitation and critical care unit is a novel emergency department-intensive care unit designed to provide early critical care to emergency department patients for ≤24 h. OBJECTIVES This study sought to identify clinical variables associated with short intensive care unit (ICU) stays in patients with diabetic ketoacidosis (DKA), who commonly require ICU-level care. METHODS We conducted a retrospective, single-center, cross-sectional study of DKA patients ≥18 years of age who presented to an academic, urban hospital emergency department over 16 months. Patient demographics and clinical variables extracted from medical records were compared between prolonged ICU stay patients of ≥24 h versus short ICU stay patients (SSPs) of <24 h. ICU care was defined as treatment in the resuscitation and critical care unit or inpatient ICU. RESULTS One hundred sixty-eight emergency department visits with a primary diagnosis of DKA were analyzed. There were 53 prolonged ICU stay patients, 58 SSPs, and 57 patients required no ICU time. SSPs had significantly higher initial serum bicarbonate (13.0 vs. 9.0 mEq/L, p = 0.01) and shorter anion gap closure time (9.8 vs. 14.4 hours, p = 0.003). Medication nonadherence was a significantly more frequent precipitant in SSPs (67.2% vs. 47.2%, p = 0.03). Initial anion gap, glucose, beta-hydroxybutyrate, and severity of illness scores were not significantly different between groups. After multivariate logistic regression adjusting for variables significant from univariate analysis, higher initial bicarbonate (p = 0.04) and medication nonadherence (p = 0.03) remained significantly associated with SSPs. CONCLUSIONS Patients with DKA with short ICU stays have higher initial bicarbonate levels and are more likely to have medication nonadherence than patients requiring prolonged critical care. These variables may identify patients with DKA who are best treated in an emergency department-intensive care unit to potentially reduce inpatient ICU use.
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Affiliation(s)
- Victoria L Zhou
- School of Medicine and Dentistry, University of Rochester, Rochester, New York
| | - Frances S Shofer
- Department of Emergency Medicine, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nikita G Desai
- Department of Emergency Medicine, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ilona S Lorincz
- Department of Endocrinology, Diabetes, and Metabolism, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nikhil K Mull
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David H Adler
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York
| | - John C Greenwood
- Department of Emergency Medicine, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania
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Sahadeo A, McDowald K, Direktor S, Hynes EA, Rogers ME. Effectiveness of collaboration between emergency department and intensive care unit teams on mortality rates of patients presenting with critical illness: a quantitative systematic review protocol. ACTA ACUST UNITED AC 2018; 15:66-75. [PMID: 28085728 DOI: 10.11124/jbisrir-2016-003003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
REVIEW OBJECTIVE The objective of this review is to identify the effectiveness of collaboration between emergency department (ED) and intensive care unit teams on mortality rates of critically ill adult patients in the ED.
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Affiliation(s)
- Anna Sahadeo
- 1College of Health Professions, Pace University, New York, New York, USA 2The Northeast Institute for Evidence Synthesis and Translation (NEST): a Joanna Briggs Institute Center of Excellence
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Mathews KS, Durst M, Vargas-Torres C, Olson AD, Mazumdar M, Richardson LD. Effect of Emergency Department and ICU Occupancy on Admission Decisions and Outcomes for Critically Ill Patients. Crit Care Med 2018; 46:720-727. [PMID: 29384780 PMCID: PMC5899025 DOI: 10.1097/ccm.0000000000002993] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES ICU admission delays can negatively affect patient outcomes, but emergency department volume and boarding times may also affect these decisions and associated patient outcomes. We sought to investigate the effect of emergency department and ICU capacity strain on ICU admission decisions and to examine the effect of emergency department boarding time of critically ill patients on in-hospital mortality. DESIGN A retrospective cohort study. SETTING Single academic tertiary care hospital. PATIENTS Adult critically ill emergency department patients for whom a consult for medical ICU admission was requested, over a 21-month period. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patient data, including severity of illness (Mortality Probability Model III on Admission), outcomes of mortality and persistent organ dysfunction, and hourly census reports for the emergency department, for all ICUs and all adult wards were compiled. A total of 854 emergency department requests for ICU admission were logged, with 455 (53.3%) as "accept" and 399 (46.7%) as "deny" cases, with median emergency department boarding times 4.2 hours (interquartile range, 2.8-6.3 hr) and 11.7 hours (3.2-20.3 hr) and similar rates of persistent organ dysfunction and/or death 41.5% and 44.6%, respectively. Those accepted were younger (mean ± SD, 61 ± 17 vs 65 ± 18 yr) and more severely ill (median Mortality Probability Model III on Admission score, 15.3% [7.0-29.5%] vs 13.4% [6.3-25.2%]) than those denied admission. In the multivariable model, a full medical ICU was the only hospital-level factor significantly associated with a lower probability of ICU acceptance (odds ratio, 0.55 [95% CI, 0.37-0.81]). Using propensity score analysis to account for imbalances in baseline characteristics between those accepted or denied for ICU admission, longer emergency department boarding time after consult was associated with higher odds of mortality and persistent organ dysfunction (odds ratio, 1.77 [1.07-2.95]/log10 hour increase). CONCLUSIONS ICU admission decisions for critically ill emergency department patients are affected by medical ICU bed availability, though higher emergency department volume and other ICU occupancy did not play a role. Prolonged emergency department boarding times were associated with worse patient outcomes, suggesting a need for improved throughput and targeted care for patients awaiting ICU admission.
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Affiliation(s)
- Kusum S. Mathews
- Division of Pulmonary, Critical Care, & Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai
| | - Matthew Durst
- Division of Pulmonary, Critical Care, & Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai
| | | | - Ashley D. Olson
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai
| | - Madhu Mazumdar
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai
| | - Lynne D. Richardson
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai
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Criterion validity and inter-rater reliability of a palliative care screening tool for patients admitted to an emergency department intensive care unit. Palliat Support Care 2017; 16:685-691. [PMID: 29277163 DOI: 10.1017/s1478951517001080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The use of palliative care (PC) screening criteria to trigger PC consultations may optimize the utilization of PC services, improve patient comfort, and reduce invasive and futile end-of-life care. The aim of the present study was to assess the criterion validity and inter-rater reliability of a PC screening tool for patients admitted to an emergency department intensive care unit (ED-ICU). METHOD Observational retrospective study evaluating PC screening criteria based on the presence of advanced diagnosis and the use of two "surprise questions" (traditional and modified). Patients were classified at ED-ICU admission in four categories according to the proposed algorithm.ResultA total of 510 patients were included in the analysis. From these, 337 (66.1%) were category 1, 0 (0.0%) category 2, 63 (12.4%) category 3, and 110 (21.6%) category 4. Severity of illness (Simplified Acute Physiology Score III score and mechanical ventilation), mortality (ED-ICU and intrahospital), and PC-related measures (order for a PC consultation, time between admission and PC consultation, and transfer to a PC bed) were significantly different across groups, more evidently between categories 4 and 1. Category 3 patients presented similar outcomes to patients in category 1 for severity of illness and mortality. However, category 3 patients had a PC consultation ordered more frequently than did category 1 patients. The screening criteria were assessed by two independent raters (n = 100), and a substantial interrater reliability was found, with 80% of agreement and a kappa coefficient of 0.75 (95% confidence interval = 0.62, 0.88).Significance of resultsThis study is the first step toward the implementation of a PC screening tool in the ED-ICU. The tool was able to discriminate three groups of patients within a spectrum of increasing severity of illness, risk of death, and PC needs, presenting substantial inter-rater reliability. Future research should investigate the implementation of these screening criteria into routine practice of an ED-ICU.
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Khan S, England P, Lee J, Shah K. The Successes and Challenges of Integrating Emergency Medicine With Critical Care Medicine. Ann Emerg Med 2017; 71:632-635. [PMID: 29174832 DOI: 10.1016/j.annemergmed.2017.10.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Indexed: 11/26/2022]
Affiliation(s)
- Sharaf Khan
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Peter England
- Department of Anesthesia Critical Care, University of Michigan, Ann Arbor, MI
| | - Jarone Lee
- Department of Emergency Medicine and Surgery, Massachusetts General Hospital, Boston, MA
| | - Kaushal Shah
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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Gunnerson KJ. The Emergency Department's Impact on Inpatient Critical Care Resources. Acad Emerg Med 2017; 24:1283-1285. [PMID: 28772343 DOI: 10.1111/acem.13268] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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McDowald K, Direktor S, Hynes EA, Sahadeo A, Rogers ME. Effectiveness of collaboration between emergency department and intensive care unit teams on mortality rates of patients presenting with critical illness: a systematic review. JBI DATABASE OF SYSTEMATIC REVIEWS AND IMPLEMENTATION REPORTS 2017; 15:2365-2389. [PMID: 28902700 DOI: 10.11124/jbisrir-2017-003365] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
BACKGROUND The increasing volume of adult patients with critical illness entering emergency departments (EDs) burdens the resources of EDs worldwide. This subpopulation faces a high risk of mortality because they require specialized care which many EDs are not yet poised to deliver. An element crucial to delivering care and decreasing the mortality of critically ill patients in the ED is expert collaborative practice across disciplines. Several ED and intensive care unit (ICU) collaborative models exist including: emergency department intensive care units (EDICU) and medical emergency teams (MET). OBJECTIVES To evaluate the effectiveness of collaboration between the ED and ICUs on the mortality rates of critically ill adult ED patients. INCLUSION CRITERIA TYPES OF PARTICIPANTS Adult ED patients, 18 years and over, with non-surgical critical illness meeting the criteria for ICU admission. TYPES OF INTERVENTION(S) Collaboration between the ED and ICU in the management of critically ill patients in the ED. TYPES OF STUDIES Observational and descriptive studies. TYPE OF OUTCOME All-cause mortality, including 30-day mortality and in-hospital mortality rates at any time period. SEARCH STRATEGY The comprehensive literature search included published and unpublished studies in English from the beginning of each database through November 30, 2016. Databases searched included: PubMed, CINAHL, Embase and Cochrane Central Register of Controlled Trials (CENTRAL). A search for gray literature and electronic hand searching of relevant journals was also performed. METHODOLOGICAL QUALITY Studies were assessed for methodological quality by four independent reviewers using standardized appraisal tools from the Joanna Briggs Institute (JBI). DATA EXTRACTION Data related to the methods, participants, interventions and findings were extracted using a standardized data extraction tool from JBI. DATA SYNTHESIS Statistical pooling into a meta-analysis was not possible due to the clinical and methodological heterogeneity in the interventions and outcome measures of the included studies. Results are presented in a narrative form. RESULTS Three collaborative models (EDICU, Direct Provider-Provider Collaboration and MET) were identified across five studies. Findings from these studies showed conflicting results. The reviewers were unable to synthesize the evidence to state conclusively the effectiveness of collaborative models on mortality rates of critically ill patients. CONCLUSIONS There is limited and conflicting evidence related to the effectiveness of EDICU collaborative models on the mortality rates of critically ill patients preventing the development of practice recommendations. This review underscores the need for more research into the benefits of collaborative models between the ED and ICU.
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Affiliation(s)
- Kerchelle McDowald
- 1Pace University, College of Health Professions, New York, USA 2The Northeast Institute for Evidence Synthesis and Translation (NEST): a Joanna Briggs Institute Center of Excellence
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Johnson NJ, Maher PJ, Badulak J, Luks AM. The Transition From Emergency Medicine Resident to Critical Care Fellow: A Road Map. AEM EDUCATION AND TRAINING 2017; 1:116-123. [PMID: 30051020 PMCID: PMC6001715 DOI: 10.1002/aet2.10023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 12/21/2016] [Accepted: 01/12/2017] [Indexed: 06/08/2023]
Abstract
Emergency medicine (EM) residents now have a number of opportunities for fellowship training in critical care medicine (CCM). The aim of this review is to help EM residents navigate the application process, transition to fellowship, and start planning their careers beyond fellowship. Pathways to advanced training in CCM available for EM residents include internal medicine-CCM, anesthesiology-CCM, surgical critical care, and neurocritical care. Each has unique prerequisites, application timelines, and training requirements. EM residency graduates generally already have well-developed crisis management and team leadership skills and excel with procedures such as airway management, vascular access, and bedside ultrasound. Potential areas for growth for EM trainees include critical care physiology, end-of-life care, longitudinal inpatient care, and perioperative medicine. Career opportunities for physicians trained in EM and CCM are diverse and include options in community or academic settings. Some choose EM or CCM exclusively or engage in a mix of both. Academic positions with joint opportunities in EM and CCM are desirable, but can be challenging to negotiate. Many EM-CCM physicians serve as topic experts in their respective groups for clinical care, quality improvement, education, or research involving the interface between the ED and intensive care unit. As career paths in critical care continue to grow in popularity, EM residents, as well as CCM faculty and program directors, should be aware of the available fellowship options, as well as training and career development needs specific to EM residents.
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Affiliation(s)
- Nicholas J. Johnson
- Division of Emergency MedicineUniversity of Washington/Harborview Medical CenterSeattleWA
- Division of Pulmonary and Critical Care MedicineUniversity of Washington/Harborview Medical CenterSeattleWA
| | - Patrick J. Maher
- Division of Pulmonary and Critical Care MedicineUniversity of Washington/Harborview Medical CenterSeattleWA
| | - Jenelle Badulak
- Division of Pulmonary and Critical Care MedicineUniversity of Washington/Harborview Medical CenterSeattleWA
| | - Andrew M. Luks
- Division of Pulmonary and Critical Care MedicineUniversity of Washington/Harborview Medical CenterSeattleWA
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Wong OF, Ko S, Cheung WH, Wong WY, Ma HM, Lit ACH. Emergency Critical Care Service in Emergency Medicine Ward: The Experience in North Lantau Hospital. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490791702400104] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
With the increased demand of critical care, emergency physicians often provide a significant proportion of critical care for the critically ill patients apart from their primary roles in resuscitation and initial stabilisation. The dual training pathway of emergency medicine and intensive care medicine enables the Accident and Emergency Departments (AEDs) to be staffed with emergency intensivist to provide care of critically ill patients in the AEDs beyond the initial resuscitation. North Lantau Hospital is a community hospital located in central Tung Chung of Lantau Island. Transporting critically ill patients to the nearest tertiary hospital requires a significant amount of time which poses high risk to them. An “Emergency Critical Care Management” pilot program was created under these circumstances. In this pilot program, up to 2 beds in the Emergency Medicine Ward (EMW) are used for managing critically ill patients. The experience and preliminary outcomes of implementing critical care service in the EMW are shared in this article.
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Affiliation(s)
- OF Wong
- North Lantau Hospital, Accident and Emergency Department, 8 Chung Yan Road, Tung Chun, Lantau, Hong Kong
| | - S Ko
- North Lantau Hospital, Accident and Emergency Department, 8 Chung Yan Road, Tung Chun, Lantau, Hong Kong
| | - WH Cheung
- North Lantau Hospital, Accident and Emergency Department, 8 Chung Yan Road, Tung Chun, Lantau, Hong Kong
| | - WY Wong
- North Lantau Hospital, Accident and Emergency Department, 8 Chung Yan Road, Tung Chun, Lantau, Hong Kong
| | - HM Ma
- North Lantau Hospital, Accident and Emergency Department, 8 Chung Yan Road, Tung Chun, Lantau, Hong Kong
| | - ACH Lit
- North Lantau Hospital, Accident and Emergency Department, 8 Chung Yan Road, Tung Chun, Lantau, Hong Kong
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Buskop C, Berve PO, Sabel MA. [The debate about emergency medicine in Norway]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2016; 136:296-7. [PMID: 26905840 DOI: 10.4045/tidsskr.15.1223] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Mosier JM, Marcolini E. An alternative perspective regarding the "myth of the workforce crisis". Am J Respir Crit Care Med 2015; 191:717-8. [PMID: 25767928 DOI: 10.1164/rccm.201412-2297le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Emergency department intensive care units—Does the evidence support this model of care? J Crit Care 2015; 30:643. [PMID: 25824202 DOI: 10.1016/j.jcrc.2015.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Tseng JC, Li CH, Chen KF, Chan YL, Chang SS, Wang FL, Chiu TF, Chen JC. Outcomes of an emergency department intensive care unit in a tertiary medical center in Taiwan: An observational study. J Crit Care 2015; 30:444-8. [PMID: 25660907 DOI: 10.1016/j.jcrc.2015.01.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Revised: 01/01/2015] [Accepted: 01/11/2015] [Indexed: 11/25/2022]
Abstract
PURPOSE The boarding of critically ill patients in the emergency department (ED) could reduce quality of care and increase mortality. An ED intensive care unit (ICU) was set up in a 3715-bed medical center to facilitate timely delivery of critical care. This study reports comparative outcomes of EDICU patients with specialty ICU patients. MATERIALS AND METHODS Medical records of adult nontrauma ED patients admitted to nonsurgical ICUs (EDICU, medical, cardiac, alimentary, and neurological units) between January 2007 and July 2011 were retrospectively reviewed. The respective number of admissions, bed turnover rate, and length of stay were compared. Cox regression models were also applied to compare inhospital mortality risks among these patients. RESULTS With only 13% (14/108) of all ICU beds, EDICU admitted 36% (3711/10449) of patients. Emergency department ICU patients had an unfavorable adjusted hazard ratio for inhospital mortality compared with medical ICU and cardiac ICU patients, but after excluding patients with an ICU length of stay of 2 days or less, the difference in hazard ratio became nonsignificant. CONCLUSIONS Emergency department ICU has admitted a disproportionately higher proportion of patients without sacrificing quality of care. Specialty care could be secured through direct communication between EDICU and specialty physicians and forming close collaboration between departments and ICUs.
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Affiliation(s)
- Jo-Chi Tseng
- Department of Emergency Medicine, Chang Gung Memorial Hospital Linkou, Kweishan, Taoyuan 33305, Taiwan.
| | - Chih-Huang Li
- Department of Emergency Medicine, Chang Gung Memorial Hospital Linkou, Kweishan, Taoyuan 33305, Taiwan.
| | - Kuan-Fu Chen
- Department of Emergency Medicine, Chang Gung Memorial Hospital Keelung, Keelung 20401, Taiwan; Clinical Informatics and Medical Statistics Research Center, Chang Gung University, Kweishan, Taoyuan 33302, Taiwan.
| | - Yi-Ling Chan
- Department of Emergency Medicine, Chang Gung Memorial Hospital Linkou, Kweishan, Taoyuan 33305, Taiwan.
| | - Shy-Shin Chang
- Department of Emergency Medicine, Chang Gung Memorial Hospital Linkou, Kweishan, Taoyuan 33305, Taiwan.
| | - Feng-Lin Wang
- Department of Emergency Medicine, Chang Gung Memorial Hospital Linkou, Kweishan, Taoyuan 33305, Taiwan.
| | - Te-Fa Chiu
- Department of Emergency Medicine, Chang Gung Memorial Hospital Linkou, Kweishan, Taoyuan 33305, Taiwan.
| | - Jih-Chang Chen
- Department of Emergency Medicine, Chang Gung Memorial Hospital Linkou, Kweishan, Taoyuan 33305, Taiwan.
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Aslaner MA, Akkaş M, Eroğlu S, Aksu NM, Özmen MM. Admissions of critically ill patients to the ED intensive care unit. Am J Emerg Med 2014; 33:501-5. [PMID: 25737412 DOI: 10.1016/j.ajem.2014.12.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 11/27/2014] [Accepted: 12/09/2014] [Indexed: 10/24/2022] Open
Abstract
INTRODUCTION Many emergency departments (EDs) have established units capable of providing critical care because of increasing need for critical care, called as ED intensive care unit (EDICU). However, prolonged critical care leads to crowding, resulting in poor quality of care and high mortality rates. We aimed to determine which type of critically ill patients play a main role for crowding in the EDICU, and how to manage these patients. METHOD Patients aged older than 18 years who presented to the ED and presented for consultation to the ICU were eligible for inclusion in this study. Patients were classified into 4 priority groups by the Society of Critical Care Medicine. RESULT Four hundred medical patients were enrolled in the study. Sixty-one patients were not admitted to hospital (15.2% of all patients) and were treated in the EDICU. These patients were older (mean age, 66.6 years) and had a higher percentage belonging to the priority 3 group (82.0%-unstable with reduced likelihood of recovery due to chronic illness) in comparison with other ICUs patients (mean age, 60.4 years and 11.9%, respectively) (P < .05). In priority 3 patients, the length of stay was median 120 hours, and also, length of invasive mechanical ventilations duration was median 19 hours in the EDICU. CONCLUSIONS Emergency department intensive care unit occupancy appears driven by categorized as "reduced benefit" patients, and these units tend to become alternative dumping grounds for palliative care services. Hospitals and health care administrators should take special care to develop policies for improving the management of these patients.
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Affiliation(s)
- Mehmet Ali Aslaner
- Emergency Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey.
| | - Meltem Akkaş
- Emergency Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Sercan Eroğlu
- Emergency Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Nalan M Aksu
- Emergency Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Mehmet Mahir Özmen
- Emergency Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
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