Emergency Department ICUs Add Value

Critical Care Delivery in the Emergency Department: Bringing the Intensive Care Unit to the Patient

Boarding of critically ill patients in the Emergency Department (ED) has increased over the past 20 years, leading hospital systems to explore ED-focused models of critical care delivery. ED-critical care delivery models vary between health systems due to differences in hospital resources and the needs of the critically ill patients boarding in the ED. Three published systems include an ED critical care intensivist consultation model, a hybrid model, and an ED-intensive care unit model. Paraphrasing the Greek philosopher, Plato, "necessity is the mother of invention." This proverb rings true as EDs are facing an increasing challenge of caring for boarding patients, especially those who are critically ill.

Rearranging the furniture: A blueprint for reappropriating fixed resources to create an emergency department resuscitative care unit

Emergency department (ED) care teams face challenges in providing timely, high-quality care to critically ill patients because of competing patient care priorities and a multitude of system strains, including patient boarding. Patients who are boarding in the ED experience increased morbidity and mortality, and this is particularly true for those who are critically ill. Geography-based models for critical care delivery in the ED range from resuscitation bays to full-fledged ED intensive care units. Studies have shown that such models can improve patient survival without affecting cost. Here, we describe how we reappropriated limited fixed resources to create a critical care resuscitation unit in a busy, urban, academic ED. Our objective is to provide a blueprint for similar models, paying particular attention to operations, clinical care, education, and financial stability.

A study protocol for a multicentre, prospective, before-and-after trial evaluating the feasibility of implementing targeted SEDation after initiation of mechanical ventilation in the emergency department (The ED-SED Pilot Trial)

INTRODUCTION

Sedation is a cornerstone therapy in the management of patients receiving mechanical ventilation and is highly influential on outcome. Early sedation depth appears especially influential, as early deep sedation is associated with worse outcome when compared with light sedation. Our research group has shown that patients receiving mechanical ventilation in the emergency department (ED) are exposed to deep sedation commonly, and ED sedation depth is impactful on intensive care unit (ICU) care and clinical outcomes. While extensive investigation has occurred for patients in the ICU, comparatively little data exist from the ED. Given the influence that ED sedation seems to carry, as well as a lack of ED-based sedation trials, there is significant rationale to investigate ED-based sedation as a means to improve outcome.

METHODS AND ANALYSIS

This is a multicentre (n=3) prospective, before-and-after pilot trial examining the feasibility of implementing targeted sedation in the immediate postintubation period in the ED. A cohort of 344 patients receiving mechanical ventilation in ED will be included. Feasibility outcomes include: (1) participant recruitment; (2) proportion of Richmond Agitation-Sedation Scale (RASS) scores in the deep sedation range; (3) reliability (agreement) of RASS measurements performed by bedside ED nurses; and (4) adverse events. The proportion of deep sedation measurements before and after the intervention will be compared using the χ² test. Logistic regression will be used to compare before-and-after differences, adjusting for potential confounders. The inter-rater correlation coefficient will be used to assess paired observations between a study team member and bedside ED nurses, and to describe reliability of RASS measurements.

ETHICS AND DISSEMINATION

The Human Research Protection Office at Washington University in St. Louis School of Medicine has approved the study. The publication of peer-reviewed manuscripts and the presentation of abstracts at scientific meetings will be used to disseminate the work.

REGISTRATION

ClinicalTrials.gov identifier NCT04410783; Pre-results.