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Sell J, Haas NL, Korley FK, Cranford JA, Bassin BS. Euglycemic Diabetic Ketoacidosis: Experience with 44 Patients and Comparison to Hyperglycemic Diabetic Ketoacidosis. West J Emerg Med 2023; 24:1049-1055. [PMID: 38165186 PMCID: PMC10754195 DOI: 10.5811/westjem.60361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 07/12/2023] [Accepted: 07/18/2023] [Indexed: 01/03/2024] Open
Abstract
Introduction Euglycemic diabetic ketoacidosis (DKA) (glucose <250 milligrams per deciliter (mg/dL) has increased in recognition since introduction of sodium-glucose co-transporter 2 (SGLT2) inhibitors but remains challenging to diagnose and manage without the hyperglycemia that is otherwise central to diagnosing DKA, and with increased risk for hypoglycemia with insulin use. Our objective was to compare key resource utilization and safety outcomes between patients with euglycemic and hyperglycemic DKA from the same period. Methods This is a retrospective review of adult emergency department patients in DKA at an academic medical center. Patients were included if they were >18 years old, met criteria for DKA on initial laboratories (pH ≤7.30, serum bicarbonate ≤18 millimoles per liter [mmol/L], anion gap ≥10), and were managed via a standardized DKA order set. Patients were divided into euglycemic (<250 milligrams per deciliter [mg/dL]) vs hyperglycemic (≥250 mg/dL) cohorts by presenting glucose. We extracted and analyzed patient demographics, resource utilization, and safety outcomes. Etiologies of euglycemia were obtained by manual chart review. For comparisons between groups we used independent-group t-tests for continuous variables and chi-squared tests for binary variables, with alpha 0.05. Results We identified 629 patients with DKA: 44 euglycemic and 585 hyperglycemic. Euglycemic patients had milder DKA on presentation (higher pH and bicarbonate, lower anion gap; P < 0.05) and lower initial glucose (195 vs 561 mg/dL, P < 0.001) and potassium (4.3 vs 5.3 mmol/L, P < 0.001). Etiologies of euglycemia were insulin use prior to arrival (57%), poor oral intake with baseline insulin use (29%), and SGLT2 inhibitor use (14%). Mean time on insulin infusion was shorter for those with euglycemic DKA: 13.5 vs 19.4 hours, P = 0.003. Mean times to first bicarbonate >18 mmol/L and first long-acting insulin were similar. Incidence of hypoglycemia (<70 mg/dL) while on insulin infusion was significantly higher for those with euglycemic DKA (18.2 vs 4.8%, P = 0.02); incidence of hypokalemia (<3.3 mmol/L) was 27.3 vs 19.1% (P = 0.23). Conclusion Compared to hyperglycemic DKA patients managed in the same protocolized fashion, euglycemic DKA patients were on insulin infusions 5.9 hours less, yet experienced hypoglycemia over three times more frequently. Future work can investigate treatment strategies for euglycemic DKA to minimize adverse events, especially iatrogenic hypoglycemia.
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Affiliation(s)
- Jordan Sell
- University of Michigan, Department of Emergency Medicine, Ann Arbor, Michigan
| | - Nathan L. Haas
- University of Michigan, Department of Emergency Medicine, Ann Arbor, Michigan
- University of Michigan, Department of Emergency Medicine, Division of Critical Care, Ann Arbor, Michigan
- The Max Harry Weil Institute for Critical Care Research and Innovation, Ann Arbor, Michigan
| | - Frederick K. Korley
- University of Michigan, Department of Emergency Medicine, Ann Arbor, Michigan
- The Max Harry Weil Institute for Critical Care Research and Innovation, Ann Arbor, Michigan
| | - James A. Cranford
- University of Michigan, Department of Emergency Medicine, Ann Arbor, Michigan
| | - Benjamin S. Bassin
- University of Michigan, Department of Emergency Medicine, Ann Arbor, Michigan
- University of Michigan, Department of Emergency Medicine, Division of Critical Care, Ann Arbor, Michigan
- The Max Harry Weil Institute for Critical Care Research and Innovation, Ann Arbor, Michigan
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Doan J, Perez S, Bassin BS, England P, Chen C, Cranford JA, Gottula AL, Hartley S, Haas NL. Impact of emergency department-based intensive care unit on outcomes of decompensating boarding emergency department patients. J Am Coll Emerg Physicians Open 2023; 4:e13036. [PMID: 37692194 PMCID: PMC10484072 DOI: 10.1002/emp2.13036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 08/10/2023] [Accepted: 08/18/2023] [Indexed: 09/12/2023] Open
Abstract
Objectives Emergency department (ED) boarding, or remaining in the ED after admission before transfer to an inpatient bed, is prevalent. Boarding patients may decompensate before inpatient transfer, necessitating escalation to the intensive care unit (ICU). We evaluated the impact of an ED-ICU on decompensating boarding ED patients. Methods This is a retrospective single-center observational study. We identified decompensated boarding ED patients necessitating critical care before departure from the ED from October 2012 to December 2021. An automated query and manual chart review extracted data. Three cohorts were defined: pre-ED-ICU implementation (Group 1), post-ED-ICU implementation with ED-ICU care (Group 2), and post-ED-ICU implementation with inpatient ICU admission without ED-ICU care (Group 3). Primary outcome was ICU length of stay (LOS). Secondary outcomes included hospital LOS, in-hospital mortality, and ICU admissions with ICU LOS <24 hours. Between-groups comparisons used multiple regression analysis for continuous variables, χ2 tests and multivariable logistic regression analysis for binary variables, and follow-up contrasts for statistically significant omnibus tests. Results A total of 1123 visits met inclusion criteria: 225 in Group 1, 780 in Group 2, and 118 in Group 3. Mean ICU LOS was shorter for Group 2 than Group 1 or 3 (47.4 vs 92.3 vs 103.9 hours, P < 0.001). Mean hospital LOS was shorter for Group 2 than Group 1 or 3 (185.1 vs 246.8 vs 257.3 hours, P < 0.01). In-hospital mortality was similar between groups. The proportion of ICU LOS <24 hours was lower for Group 2 than Group 1 or 3 (16.5 vs 27.1 vs 32.2%, P < 0.01). Conclusion For decompensating boarding ED patients, ED-ICU care was associated with decreased ICU and hospital LOS, similar mortality, and fewer short-stay ICU admissions, suggesting ED-ICU care is associated with downstream resource preservation.
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Benson B, Belle A, Lee S, Bassin BS, Medlin RP, Sjoding MW, Ward KR. Prediction of episode of hemodynamic instability using an electrocardiogram based analytic: a retrospective cohort study. BMC Anesthesiol 2023; 23:324. [PMID: 37737164 PMCID: PMC10515416 DOI: 10.1186/s12871-023-02283-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 09/14/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND Predicting the onset of hemodynamic instability before it occurs remains a sought-after goal in acute and critical care medicine. Technologies that allow for this may assist clinicians in preventing episodes of hemodynamic instability (EHI). We tested a novel noninvasive technology, the Analytic for Hemodynamic Instability-Predictive Indicator (AHI-PI), which analyzes a single lead of electrocardiogram (ECG) and extracts heart rate variability and morphologic waveform features to predict an EHI prior to its occurrence. METHODS Retrospective cohort study at a quaternary care academic health system using data from hospitalized adult patients between August 2019 and April 2020 undergoing continuous ECG monitoring with intermittent noninvasive blood pressure (NIBP) or with continuous intraarterial pressure (IAP) monitoring. RESULTS AHI-PI's low and high-risk indications were compared with the presence of EHI in the future as indicated by vital signs (heart rate > 100 beats/min with a systolic blood pressure < 90 mmHg or a mean arterial blood pressure of < 70 mmHg). 4,633 patients were analyzed (3,961 undergoing NIBP monitoring, 672 with continuous IAP monitoring). 692 patients had an EHI (380 undergoing NIBP, 312 undergoing IAP). For IAP patients, the sensitivity and specificity of AHI-PI to predict EHI was 89.7% and 78.3% with a positive and negative predictive value of 33.7% and 98.4% respectively. For NIBP patients, AHI-PI had a sensitivity and specificity of 86.3% and 80.5% with a positive and negative predictive value of 11.7% and 99.5% respectively. Both groups performed with an AUC of 0.87. AHI-PI predicted EHI in both groups with a median lead time of 1.1 h (average lead time of 3.7 h for IAP group, 2.9 h for NIBP group). CONCLUSIONS AHI-PI predicted EHIs with high sensitivity and specificity and within clinically significant time windows that may allow for intervention. Performance was similar in patients undergoing NIBP and IAP monitoring.
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Affiliation(s)
- Bryce Benson
- Fifth Eye Inc, 110 Miller Avenue, Suite 300, Ann Arbor, MI, 48104, USA
| | - Ashwin Belle
- Fifth Eye Inc, 110 Miller Avenue, Suite 300, Ann Arbor, MI, 48104, USA
| | - Sooin Lee
- Fifth Eye Inc, 110 Miller Avenue, Suite 300, Ann Arbor, MI, 48104, USA
| | - Benjamin S Bassin
- Department of Emergency Medicine, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI, 48109-5301, USA
- Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, NCRC 10-A103 2800 Plymouth Road, Ann Arbor, MI, 48109, USA
| | - Richard P Medlin
- Department of Emergency Medicine, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI, 48109-5301, USA
- Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, NCRC 10-A103 2800 Plymouth Road, Ann Arbor, MI, 48109, USA
| | - Michael W Sjoding
- Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, NCRC 10-A103 2800 Plymouth Road, Ann Arbor, MI, 48109, USA
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI, 48109-5642, USA
| | - Kevin R Ward
- Department of Emergency Medicine, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI, 48109-5301, USA.
- Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, NCRC 10-A103 2800 Plymouth Road, Ann Arbor, MI, 48109, USA.
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Haas NL, Sell J, Cranford JA, Korley FK, Bassin BS. The Two-Bag Method for Management of Adult Diabetic Ketoacidosis-Experience With 634 Patients. J Intensive Care Med 2023:8850666231175387. [PMID: 37170641 DOI: 10.1177/08850666231175387] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
PURPOSE To compare key resource utilization and safety outcomes of adult emergency department (ED) patients in diabetic ketoacidosis (DKA) managed via the Two-Bag or traditional One-Bag method. MATERIALS AND METHODS This is a retrospective review at an academic medical center ED. Patients were included if >18 years, met diagnostic criteria for DKA (pH ≤ 7.30, bicarbonate ≤ 18 mmol/L, anion gap ≥ 10), and were managed via a standardized order set (either Two-Bag or One-Bag Method). Comparisons used independent-groups t-tests for continuous variables and χ2 tests for binary variables. RESULTS We identified 634 patients with DKA managed via the Two-Bag method, and 107 managed via the One-Bag method. Cohorts were similar in demographics and presenting laboratories. The Two-Bag Method was associated with 8.1 h shorter to first bicarbonate >18 mmol/L (11.9 vs 20.0, P < .001), and 24 fewer IV fluid bags (5.3 vs 29.7, P < .001). Incidence of hypokalemia (potassium <3.0 mmol/L) was 53% lower in the Two-Bag cohort (6.6 vs 14.0%, P = .03); incidence of hypoglycemia (glucose <70 mg/dL) was 5.8 versus 10.3%, P = .16. CONCLUSIONS For adult ED patients in DKA, the Two-Bag Method was associated with faster resolution of acidosis, fewer IV fluid bags charged, lower incidence of hypokalemia, and trend toward lower incidence of hypoglycemia compared to the One-Bag Method.
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Affiliation(s)
- Nathan L Haas
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
- Division of Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
- The Max Harry Weil Institute for Critical Care Research and Innovation, Ann Arbor, MI, USA
| | - Jordan Sell
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - James A Cranford
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Frederick K Korley
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
- The Max Harry Weil Institute for Critical Care Research and Innovation, Ann Arbor, MI, USA
| | - Benjamin S Bassin
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
- Division of Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
- The Max Harry Weil Institute for Critical Care Research and Innovation, Ann Arbor, MI, USA
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Schmitzberger FF, Hall AE, Hughes ME, Belle A, Benson B, Ward KR, Bassin BS. Detection of Hemodynamic Status Using an Analytic Based on an Electrocardiogram Lead Waveform. Crit Care Explor 2022; 4:e0693. [PMID: 35620767 PMCID: PMC9116956 DOI: 10.1097/cce.0000000000000693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES Delayed identification of hemodynamic deterioration remains a persistent issue for in-hospital patient care. Clinicians continue to rely on vital signs associated with tachycardia and hypotension to identify hemodynamically unstable patients. A novel, noninvasive technology, the Analytic for Hemodynamic Instability (AHI), uses only the continuous electrocardiogram (ECG) signal from a typical hospital multiparameter telemetry monitor to monitor hemodynamics. The intent of this study was to determine if AHI is able to predict hemodynamic instability without the need for continuous direct measurement of blood pressure. DESIGN Retrospective cohort study. SETTING Single quaternary care academic health system in Michigan. PATIENTS Hospitalized adult patients between November 2019 and February 2020 undergoing continuous ECG and intra-arterial blood pressure monitoring in an intensive care setting. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS One million two hundred fifty-two thousand seven hundred forty-two 5-minute windows of the analytic output were analyzed from 597 consecutive adult patients. AHI outputs were compared with vital sign indications of hemodynamic instability (heart rate > 100 beats/min, systolic blood pressure < 90 mm Hg, and shock index of > 1) in the same window. The observed sensitivity and specificity of AHI were 96.9% and 79.0%, respectively, with an area under the curve (AUC) of 0.90 for heart rate and systolic blood pressure. For the shock index analysis, AHI's sensitivity was 72.0% and specificity was 80.3% with an AUC of 0.81. CONCLUSIONS The AHI-derived hemodynamic status appropriately detected the various gold standard indications of hemodynamic instability (hypotension, tachycardia and hypotension, and shock index > 1). AHI may provide continuous dynamic hemodynamic monitoring capabilities in patients who traditionally have intermittent static vital sign measurements.
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Affiliation(s)
| | - Ashley E Hall
- Department of Emergency Medicine, Michigan Medicine, Ann Arbor, MI
| | - Morgan E Hughes
- Department of Emergency Medicine, Michigan Medicine, Ann Arbor, MI
| | | | | | - Kevin R Ward
- Department of Emergency Medicine, Michigan Medicine, Ann Arbor, MI
- Department of Emergency Medicine, Division of Critical Care, Michigan Medicine, Ann Arbor, MI
- Max Harry Weil Institute for Critical Care Research and Innovation, Michigan Medicine, Ann Arbor, MI
| | - Benjamin S Bassin
- Department of Emergency Medicine, Michigan Medicine, Ann Arbor, MI
- Department of Emergency Medicine, Division of Critical Care, Michigan Medicine, Ann Arbor, MI
- Max Harry Weil Institute for Critical Care Research and Innovation, Michigan Medicine, Ann Arbor, MI
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Puls HA, Haas NL, Cranford JA, Medlin RP, Bassin BS. Emergency department length of stay and outcomes of emergency department–based intensive care unit patients. J Am Coll Emerg Physicians Open 2022; 3:e12684. [PMID: 35229083 PMCID: PMC8861538 DOI: 10.1002/emp2.12684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/24/2022] [Accepted: 01/31/2022] [Indexed: 11/18/2022] Open
Abstract
Objective Emergency department (ED) boarding of patients who are critically ill is associated with poor outcomes. ED‐based intensive care units (ED‐ICUs) may mitigate the risks of ED boarding. We sought to analyze the impact of ED length of stay (LOS) before transfer to an ED‐ICU on patient outcomes. Methods We retrospectively analyzed adult ED patients managed in the ED‐ICU at a US medical center. Bivariate and multivariable linear regressions tested ED LOS as a predictor of inpatient ICU and hospital LOS, and separate bivariate and multivariable logistic regressions tested ED LOS as a predictor of inpatient ICU admission, 48‐hour mortality, and hospital mortality. Multivariable analyses’ covariates were age, sex, Charlson Comorbidity Index (CCI), Emergency Severity Index, and eSimplified Acute Physiology Score (eSAPS3). Results We included 5859 ED visits with subsequent care in the ED‐ICU. Median age, CCI, eSAPS3, ED LOS, and ED‐ICU LOS were 62 years (interquartile range [IQR], 48–73 years), 5 (IQR, 2–8), 46 (IQR, 36–56), 3.6 hours (IQR, 2.5–5.3 hours), and 8.5 hours (IQR, 5.3–13.4 hours), respectively, and 46.3% were women. Bivariate analyses showed negative associations of ED LOS with hospital LOS (β = −3.4; 95% confidence interval [CI], −5.9 to −1.0), inpatient ICU admission (odds ratio [OR], 0.86, 95% CI, 0.84–0.88), 48‐hour mortality (OR, 0.89; 95% CI, 0.82–0.98), and hospital mortality (OR, 0.89; 95% CI, 0.85–0.92), but no association with inpatient ICU LOS. Multivariable analyses showed a negative association of ED LOS with inpatient ICU admission (OR, 0.91; 95% CI, 0.88–0.93), but no associations with other outcomes. Conclusions We observed no significant associations between ED LOS before ED‐ICU transfer and worsened outcomes, suggesting an ED‐ICU may mitigate the risks of ED boarding of patients who are critically ill.
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Affiliation(s)
- Henrique A. Puls
- Department of Emergency Medicine University of Michigan Ann Arbor Michigan USA
| | - Nathan L. Haas
- Department of Emergency Medicine University of Michigan Ann Arbor Michigan USA
- Division of Critical Care, Department of Emergency Medicine University of Michigan Ann Arbor Michigan USA
- Michigan Center for Integrative Research in Critical Care Ann Arbor Michigan USA
| | - James A. Cranford
- Department of Emergency Medicine University of Michigan Ann Arbor Michigan USA
| | - Richard P. Medlin
- Department of Emergency Medicine University of Michigan Ann Arbor Michigan USA
| | - Benjamin S. Bassin
- Department of Emergency Medicine University of Michigan Ann Arbor Michigan USA
- Division of Critical Care, Department of Emergency Medicine University of Michigan Ann Arbor Michigan USA
- Michigan Center for Integrative Research in Critical Care Ann Arbor Michigan USA
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Haas NL, Medlin RP, Cranford JA, Boyd C, Havey RA, Losman ED, Rice MD, Bassin BS. An emergency department-based intensive care unit is associated with decreased hospital length of stay for upper gastrointestinal bleeding. Am J Emerg Med 2021; 50:173-177. [PMID: 34371325 DOI: 10.1016/j.ajem.2021.07.057] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 06/28/2021] [Accepted: 07/27/2021] [Indexed: 10/20/2022] Open
Abstract
INTRODUCTION Upper gastrointestinal bleeding (UGIB) is associated with substantial morbidity, mortality, and intensive care unit (ICU) utilization. Initial risk stratification and disposition from the Emergency Department (ED) can prove challenging due to limited data points during a short period of observation. An ED-based ICU (ED-ICU) may allow more rapid delivery of ICU-level care, though its impact on patients with UGIB is unknown. METHODS A retrospective observational study was conducted at a tertiary U.S. academic medical center. An ED-ICU (the Emergency Critical Care Center [EC3]) opened in February 2015. Patients presenting to the ED with UGIB undergoing esophagogastroduodenoscopy within 72 h were identified and analyzed. The Pre- and Post-EC3 cohorts included patients from 9/2/2012-2/15/2015 and 2/16/2015-6/30/2019. RESULTS We identified 3788 ED visits; 1033 Pre-EC3 and 2755 Post-EC3. Of Pre-EC3 visits, 200 were critically ill and admitted to ICU [Cohort A]. Of Post-EC3 visits, 682 were critically ill and managed in EC3 [Cohort B], whereas 61 were critically ill and admitted directly to ICU without care in EC3 [Cohort C]. The mean interval from ED presentation to ICU level care was shorter in Cohort B than A or C (3.8 vs 6.3 vs 7.7 h, p < 0.05). More patients in Cohort B received ICU level care within six hours of ED arrival (85.3 vs 52.0 vs 57.4%, p < 0.05). Mean hospital length of stay (LOS) was shorter in Cohort B than A or C (6.2 vs 7.3 vs 10.0 days, p < 0.05). In the Post-EC3 cohort, fewer patients were admitted to an ICU (9.3 vs 19.4%, p < 0.001). The rate of floor admission with transfer to ICU within 24 h was similar. No differences in absolute or risk-adjusted mortality were observed. CONCLUSION For critically ill ED patients with UGIB, implementation of an ED-ICU was associated with reductions in rate of ICU admission and hospital LOS, with no differences in safety outcomes.
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Affiliation(s)
- Nathan L Haas
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA; Division of Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA; Michigan Center for Integrative Research in Critical Care, Ann Arbor, MI, USA.
| | - Richard P Medlin
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - James A Cranford
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Caryn Boyd
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Renee A Havey
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA; Division of Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Eve D Losman
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA; Division of Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Michael D Rice
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA
| | - Benjamin S Bassin
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA; Division of Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA; Michigan Center for Integrative Research in Critical Care, Ann Arbor, MI, USA
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Turer RW, Arribas M, Balgord SM, Brooks S, Hopson LR, Bassin BS, Medlin R. Clinical Informatics Training During Emergency Medicine Residency: The University of Michigan Experience. AEM Educ Train 2021; 5:e10518. [PMID: 34041427 PMCID: PMC8138099 DOI: 10.1002/aet2.10518] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/30/2020] [Accepted: 08/08/2020] [Indexed: 06/12/2023]
Abstract
Clinical informatics (CI) is a rich field with longstanding ties to resident education in many clinical specialties, although a historic gap persists in emergency medicine. To address this gap, we developed a CI track to facilitate advanced training for senior residents at our 4-year emergency medicine residency. We piloted an affordable project-based approach with strong ties to operational leadership at our institution and describe specific projects and their outcomes. Given the relatively low cost, departmental benefit, and unique educational value, we believe that our model is generalizable to many emergency medicine residencies. We present a pathway to defining a formal curriculum using Kern's framework.
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Affiliation(s)
- Robert W. Turer
- Departments of Emergency Medicine and Biomedical InformaticsVanderbilt University Medical CenterNashvilleTNUSA
- Department of Emergency MedicineUniversity of MichiganAnn ArborMIUSA
| | - Miguel Arribas
- Department of Emergency MedicineUniversity of MichiganAnn ArborMIUSA
| | - Sarah M. Balgord
- Department of Emergency MedicineUniversity of MichiganAnn ArborMIUSA
| | - Stephanie Brooks
- Department of Emergency MedicineUniversity of MichiganAnn ArborMIUSA
| | - Laura R. Hopson
- Department of Emergency MedicineUniversity of MichiganAnn ArborMIUSA
| | - Benjamin S. Bassin
- Department of Emergency MedicineUniversity of MichiganAnn ArborMIUSA
- Michigan Center for Integrative Research in Critical Care (M‐CIRCC)Ann ArborMIUSA
- Department of Emergency MedicineDivision of Critical CareAnn ArborMIUSA
| | - Richard Medlin
- Department of Emergency MedicineUniversity of MichiganAnn ArborMIUSA
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10
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Hsu CH, Meurer WJ, Domeier R, Fowler J, Whitmore SP, Bassin BS, Gunnerson KJ, Haft JW, Lynch WR, Nallamothu BK, Havey RA, Kidwell KM, Stacey WC, Silbergleit R, Bartlett RH, Neumar RW. Extracorporeal Cardiopulmonary Resuscitation for Refractory Out-of-Hospital Cardiac Arrest (EROCA): Results of a Randomized Feasibility Trial of Expedited Out-of-Hospital Transport. Ann Emerg Med 2021; 78:92-101. [PMID: 33541748 PMCID: PMC8238799 DOI: 10.1016/j.annemergmed.2020.11.011] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 11/08/2020] [Accepted: 11/16/2020] [Indexed: 01/14/2023]
Abstract
STUDY OBJECTIVE Outcomes of extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest depend on time to therapy initiation. We hypothesize that it would be feasible to select refractory out-of-hospital cardiac arrest patients for expedited transport based on real-time estimates of the 911 call to the emergency department (ED) arrival interval, and for emergency physicians to rapidly initiate ECPR in eligible patients. METHODS In a 2-tiered emergency medical service with an ECPR-capable primary destination hospital, adults with refractory shockable or witnessed out-of-hospital cardiac arrest were randomized 4:1 to expedited transport or standard care if the predicted 911 call to ED arrival interval was less than or equal to 30 minutes. The primary outcomes were the proportion of subjects with 911 call to ED arrival less than or equal to 30 minutes and ED arrival to ECPR flow less than or equal to 30 minutes. RESULTS Of 151 out-of-hospital cardiac arrest 911 calls, 15 subjects (10%) were enrolled. Five of 12 subjects randomized to expedited transport had an ED arrival time of less than or equal to 30 minutes (overall mean 32.5 minutes [SD 7.1]), and 5 were eligible for and treated with ECPR. Three of 5 ECPR-treated subjects had flow initiated in less than or equal to 30 minutes of ED arrival (overall mean 32.4 minutes [SD 10.9]). No subject in either group survived with a good neurologic outcome. CONCLUSION The Extracorporeal Cardiopulmonary Resuscitation for Refractory Out-of-Hospital Cardiac Arrest trial did not meet predefined feasibility outcomes for selecting out-of-hospital cardiac arrest patients for expedited transport and initiating ECPR in the ED. Additional research is needed to improve the accuracy of predicting the 911 call to ED arrival interval, optimize patient selection, and reduce the ED arrival to ECPR flow interval.
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Affiliation(s)
- Cindy H Hsu
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI; Michigan Center for Integrative Research in Critical Care, University of Michigan Medical School, Ann Arbor, MI; Department of Surgery, University of Michigan Medical School, Ann Arbor, MI.
| | - William J Meurer
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI; Michigan Center for Integrative Research in Critical Care, University of Michigan Medical School, Ann Arbor, MI; Department of Neurology, University of Michigan Medical School, Ann Arbor, MI
| | - Robert Domeier
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI; Saint Joseph Hospital, University of Michigan Medical School, Ann Arbor, MI
| | - Jennifer Fowler
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Sage P Whitmore
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Benjamin S Bassin
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI; Michigan Center for Integrative Research in Critical Care, University of Michigan Medical School, Ann Arbor, MI
| | - Kyle J Gunnerson
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI; Michigan Center for Integrative Research in Critical Care, University of Michigan Medical School, Ann Arbor, MI
| | - Jonathan W Haft
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - William R Lynch
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Brahmajee K Nallamothu
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Renee A Havey
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Kelley M Kidwell
- Department of Biostatistics, University of Michigan Medical School, Ann Arbor, MI
| | - William C Stacey
- Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, MI
| | - Robert Silbergleit
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Robert H Bartlett
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI; Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, MI
| | - Robert W Neumar
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI; Michigan Center for Integrative Research in Critical Care, University of Michigan Medical School, Ann Arbor, MI; Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, MI
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11
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Haas NL, Bassin BS, Kota S, Puls HA, Hyzy RC, Napolitano LM, Blank R, McSparron JI, Kota SS, Ward KR. Rapid development of a novel portable negative pressure device. Int J Tuberc Lung Dis 2021; 24:737-739. [PMID: 32718412 DOI: 10.5588/ijtld.20.0282] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- N L Haas
- University of Michigan Medical School, Ann Arbor, MI, Michigan Center for Integrative Research in Critical Care, Ann Arbor, MI
| | - B S Bassin
- University of Michigan Medical School, Ann Arbor, MI, Michigan Center for Integrative Research in Critical Care, Ann Arbor, MI
| | - S Kota
- Michigan Center for Integrative Research in Critical Care, Ann Arbor, MI, University of Michigan College of Engineering, Ann Arbor, MI
| | - H A Puls
- University of Michigan Medical School, Ann Arbor, MI
| | - R C Hyzy
- University of Michigan Medical School, Ann Arbor, MI, Michigan Center for Integrative Research in Critical Care, Ann Arbor, MI
| | - L M Napolitano
- University of Michigan Medical School, Ann Arbor, MI, Michigan Center for Integrative Research in Critical Care, Ann Arbor, MI
| | - R Blank
- University of Michigan Medical School, Ann Arbor, MI, Michigan Center for Integrative Research in Critical Care, Ann Arbor, MI
| | - J I McSparron
- University of Michigan Medical School, Ann Arbor, MI, Michigan Center for Integrative Research in Critical Care, Ann Arbor, MI
| | - S S Kota
- University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA, ,
| | - K R Ward
- University of Michigan Medical School, Ann Arbor, MI, Michigan Center for Integrative Research in Critical Care, Ann Arbor, MI, University of Michigan College of Engineering, Ann Arbor, MI
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12
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Bassin BS, Haas NL, Puls HA, Kota S, Kota SS, Ward KR. Rapid development of a portable negative pressure procedural tent. Int J Tuberc Lung Dis 2021; 24:740-743. [PMID: 32718413 DOI: 10.5588/ijtld.20.0317] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- B S Bassin
- University of Michigan Medical School, Ann Arbor, MI, Michigan Center for Integrative Research in Critical Care, Ann Arbor, MI
| | - N L Haas
- University of Michigan Medical School, Ann Arbor, MI, Michigan Center for Integrative Research in Critical Care, Ann Arbor, MI
| | - H A Puls
- University of Michigan Medical School, Ann Arbor, MI, Michigan Center for Integrative Research in Critical Care, Ann Arbor, MI
| | - S Kota
- Michigan Center for Integrative Research in Critical Care, Ann Arbor, MI, FlexSys Inc., Ann Arbor, MI
| | - S S Kota
- University of Toledo College of Medicine and Life Sciences, Toledo, OH
| | - K R Ward
- University of Michigan Medical School, Ann Arbor, MI, Michigan Center for Integrative Research in Critical Care, Ann Arbor, MI, University of Michigan College of Engineering, Ann Arbor, MI, USA, ,
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13
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Du J, Gunnerson KJ, Bassin BS, Meldrum C, Hyzy RC. Effect of an emergency department intensive care unit on medical intensive unit admissions and care: A retrospective cohort study. Am J Emerg Med 2021; 46:27-33. [PMID: 33714051 DOI: 10.1016/j.ajem.2021.02.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 01/23/2021] [Accepted: 02/14/2021] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVE Evaluate the impact of an emergency critical care center (EC3) on the admissions of critically ill patients to a critical care medicine unit (CCMU) and their outcomes. METHODS This was a retrospective before/after cohort study in a tertiary university teaching hospital. To improve the care of critically ill patients in the emergency department (ED), a 9-bed EC3 was opened in the ED in February 2015. All critically ill patients in the emergency department must receive intensive support in EC3 before being considered for admission to the CCMU for further treatment. Patients from the emergency department account for a significant proportion of the patients admitted to the CCMU. The proportions of patients admitted to the CCMU from the ED were analyzed 1 year before and 1 year after the opening of the EC3. We also compared the admission data, demographic data, APACHE III scores and patient outcomes among patients admitted from ED to the CCMU in the year before and the year after the opening of the EC3. RESULT The establishment of the EC3 was associated with a decreased proportion of patients admitted to the CCMU from the ED (OR 0.73 95% CI 0.63-0.84, p < 0.01), a decrease in the proportion of patients with sepsis admitted from the ED (OR 0.68, 95% CI, 0.54-0.87, p < 0.01) and a decrease in the proportion of patients with gastrointestinal bleeding admitted from the ED (OR 0.49, 95% CI 0.28-0.84, p < 0.05). Following the establishment of the EC3, patients admitted to the CCMU had a higher APACHE III score in 2015 (74.85 ± 30.42 vs 72.39 ± 29.64, p = 0.015). Fewer low-risk patients were admitted to the CCMU for monitoring following the opening of the EC3 (112 [6.8%] vs. 181 [9.3%], p < 0.01). Propensity score matching analysis showed that the opening of the EC3 was associated with improved 60-day survival (HR 0.84, 95% CI 0.70-0.99, p = 0.046). CONCLUSION Following the opening of the EC3, the proportion of CCMU admissions from the ED decreased. The EC3 may be most effective at reducing the admission of lower-acuity patients with GI bleeding and possibly sepsis. The EC3 may be associated with improved survival in ED patients.
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Affiliation(s)
- Jiang Du
- Pulmonary and Critical Care Department, The University of Michigan Health System, MI, USA; Shanghai General Hospital of Shanghai Jiaotong University, Shanghai, China
| | - Kyle J Gunnerson
- Emergency Department, The University of Michigan Health System, MI, USA
| | - Benjamin S Bassin
- Pulmonary and Critical Care Department, The University of Michigan Health System, MI, USA
| | - Craig Meldrum
- Pulmonary and Critical Care Department, The University of Michigan Health System, MI, USA
| | - Robert C Hyzy
- Pulmonary and Critical Care Department, The University of Michigan Health System, MI, USA.
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14
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Haas NL, Bassin BS, A Puls H, Ward KR. Use of a negative pressure procedural tent in the Emergency Department during the COVID-19 pandemic. Am J Emerg Med 2021; 48:354-356. [PMID: 33546955 PMCID: PMC7839862 DOI: 10.1016/j.ajem.2021.01.064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 01/21/2021] [Accepted: 01/23/2021] [Indexed: 12/14/2022] Open
Affiliation(s)
- Nathan L Haas
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA; Division of Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA; Michigan Center for Integrative Research in Critical Care, Ann Arbor, MI, USA.
| | - Benjamin S Bassin
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA; Division of Critical Care, Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA; Michigan Center for Integrative Research in Critical Care, Ann Arbor, MI, USA
| | - Henrique A Puls
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA; Michigan Center for Integrative Research in Critical Care, Ann Arbor, MI, USA
| | - Kevin R Ward
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA; Michigan Center for Integrative Research in Critical Care, Ann Arbor, MI, USA; Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
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15
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Ives Tallman CM, Harvey CE, Laurinec SL, Melvin AC, Fecteau KA, Cranford JA, Haas NL, Bassin BS. Impact of Providing a Tape Measure on the Provision of Lung-protective Ventilation. West J Emerg Med 2021; 22:389-393. [PMID: 33856327 PMCID: PMC7972369 DOI: 10.5811/westjem.2020.10.49104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 10/02/2020] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Emergency department (ED) patients are frequently ventilated with excessively large tidal volumes for predicted body weight based on height, which has been linked to poorer patient outcomes. We hypothesized that supplying tape measures to respiratory therapists (RT) would improve measurement of actual patient height and adherence to a lung-protective ventilation strategy in an ED-intensive care unit (ICU) environment. METHODS On January 14, 2019, as part of a ventilator-associated pneumonia prevention bundle in our ED-based ICU, we began providing RTs with tape measures and created a best practice advisory reminding them to record patient height. We then retrospectively collected data on patient height and tidal volumes before and after the intervention. RESULTS We evaluated 51,404 tidal volume measurements in 1,826 patients over the 4 year study period; of these patients, 1,579 (86.5%) were pre-intervention and 247 (13.5%) were post-intervention. The intervention was associated with a odds of the patient's height being measured were 10 times higher post-intervention (25.1% vs 3.2%, P <0.05). After the bundle was initiated, we observed a significantly higher percentage of patients ventilated with mean tidal volumes less than 8 cubic centimeters per kilogram (93.9% vs 84.5% P < 0.05). CONCLUSION Patients in an ED-ICU environment were ventilated with a lung-protective strategy more frequently after an intervention reminding RTs to measure actual patient height and providing a tape measure to do so. A significantly higher percentage of patients had height measured rather than estimated after the intervention, allowing for more accurate determination of ideal body weight and calculation of lung-protective ventilation volumes. Measuring all mechanically ventilated patients' height with a tape measure is an example of a simple, low-cost, scalable intervention in line with guidelines developed to improve the quality of care delivered to critically ill ED patients.
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Affiliation(s)
- Crystal M Ives Tallman
- University of Michigan Medical School, Department of Emergency Medicine, Ann Arbor, Michigan.,University of Michigan Medical School, Department of Anesthesiology/Critical Care, Ann Arbor, Michigan
| | - Carrie E Harvey
- University of Michigan Medical School, Department of Emergency Medicine, Ann Arbor, Michigan.,University of Michigan Medical School, Division of Emergency Critical Care, Ann Arbor, Michigan
| | - Stephanie L Laurinec
- University of Michigan Medical School, Department of Emergency Medicine, Ann Arbor, Michigan.,University of Michigan Medical School, Division of Emergency Critical Care, Ann Arbor, Michigan.,University of Michigan, Center for Integrative Research in Critical Care, Ann Arbor, Michigan
| | - Amanda C Melvin
- University of Michigan Medical School, Department of Emergency Medicine, Ann Arbor, Michigan.,University of Michigan Medical School, Division of Emergency Critical Care, Ann Arbor, Michigan
| | - Kimberly A Fecteau
- University of Michigan Medical School, Department of Respiratory Care, Ann Arbor, Michigan
| | - James A Cranford
- University of Michigan Medical School, Department of Emergency Medicine, Ann Arbor, Michigan.,University of Michigan, Center for Integrative Research in Critical Care, Ann Arbor, Michigan
| | - Nathan L Haas
- University of Michigan Medical School, Department of Emergency Medicine, Ann Arbor, Michigan.,University of Michigan Medical School, Division of Emergency Critical Care, Ann Arbor, Michigan.,University of Michigan, Center for Integrative Research in Critical Care, Ann Arbor, Michigan
| | - Benjamin S Bassin
- University of Michigan Medical School, Department of Emergency Medicine, Ann Arbor, Michigan.,University of Michigan Medical School, Division of Emergency Critical Care, Ann Arbor, Michigan.,University of Michigan, Center for Integrative Research in Critical Care, Ann Arbor, Michigan
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16
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Leith TB, Haas NL, Harvey CE, Chen C, Ives Tallman C, Bassin BS. Delivery of end-of-life care in an emergency department-based intensive care unit. J Am Coll Emerg Physicians Open 2020; 1:1500-1504. [PMID: 33392556 PMCID: PMC7771771 DOI: 10.1002/emp2.12258] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/14/2020] [Accepted: 09/02/2020] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVE Intensive care unit (ICU) admissions near the end of life have been associated with worse quality of life and burdensome costs. Patients may not benefit from ICU admission if appropriate end-of-life care can be delivered elsewhere. The objective of this study was to descriptively analyze patients receiving end-of-life care in an emergency department (ED)-based ICU (ED-ICU). METHODS This is a retrospective analysis of patient outcomes and resource use in adult patients receiving end-of-life care in an ED-ICU. In 2015, an "End of Life" order set was created to standardize delivery of palliative therapies and comfort measures. We identified adult patients (>18 years) receiving end-of-life care in the ED-ICU from December 2015 to March 2020 whose clinicians used the end-of-life order set. RESULTS A total of 218 patients were included for analysis; 50.5% were female, and the median age was 73.6 years. The median ED-ICU length of stay was 13.3 hours (interquartile range, 7.4-20.6). Two patients (0.9%) were admitted to an inpatient ICU, 117 (53.7%) died in the ED-ICU, 77 (35.3%) were admitted to a non-intensive care inpatient service, and 22 (10.1%) were discharged from the ED-ICU. CONCLUSIONS An ED-ICU can be used for ED patients near the end of life. Only 0.9% were subsequently admitted to an ICU, and 10.1% were discharged from the ED-ICU. This practice may benefit patients and families by avoiding costly ICU admissions and benefit health systems by reducing ICU capacity strain.
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Affiliation(s)
| | - Nathan L. Haas
- Department of Emergency MedicineUniversity of MichiganAnn ArborMichiganUSA
- Department of Emergency MedicineDivision of Critical CareUniversity of MichiganAnn ArborMichiganUSA
- Michigan Center for Integrative Research in Critical CareUniversity of MichiganAnn ArborMichiganUSA
| | - Carrie E. Harvey
- Department of Emergency MedicineUniversity of MichiganAnn ArborMichiganUSA
- Department of Emergency MedicineDivision of Critical CareUniversity of MichiganAnn ArborMichiganUSA
| | - Cynthia Chen
- Department of Emergency MedicineUniversity of MichiganAnn ArborMichiganUSA
| | - Crystal Ives Tallman
- Department of Emergency MedicineUniversity of MichiganAnn ArborMichiganUSA
- Department of Emergency MedicineDivision of Critical CareUniversity of MichiganAnn ArborMichiganUSA
| | - Benjamin S. Bassin
- Department of Emergency MedicineUniversity of MichiganAnn ArborMichiganUSA
- Department of Emergency MedicineDivision of Critical CareUniversity of MichiganAnn ArborMichiganUSA
- Michigan Center for Integrative Research in Critical CareUniversity of MichiganAnn ArborMichiganUSA
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17
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Munzer BW, Bassin BS, Peterson WJ, Tucker RV, Doan J, Harvey C, Sefa N, Hsu CH. In-situ Simulation Use for Rapid Implementation and Process Improvement of COVID-19 Airway Management. West J Emerg Med 2020; 21:99-106. [PMID: 33052819 PMCID: PMC7673893 DOI: 10.5811/westjem.2020.7.48159] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 07/06/2020] [Accepted: 07/29/2020] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION The coronavirus disease 2019 (COVID-19) pandemic presents unique challenges to frontline healthcare workers. In order to safely care for patients new processes, such as a plan for the airway management of a patient with COVID-19, must be implemented and disseminated in a rapid fashion. The use of in-situ simulation has been used to assist in latent problem identification as part of a Plan-Do-Study-Act cycle. Additionally, simulation is an effective means for training teams to perform high-risk procedures before engaging in the actual procedure. This educational advance seeks to use and study in-situ simulation as a means to rapidly implement a process for airway management in patients with COVID-19. METHODS Using an airway algorithm developed by the authors, we designed an in-situ simulation scenario to train physicians, nurses, and respiratory therapists in best practices for airway management of patients with COVID-19. Physician participants were surveyed using a five-point Likert scale with regard to their comfort level with various aspects of the airway algorithm both before and after the simulation in a retrospective fashion. Additionally, we obtained feedback from all participants and used it to refine the airway algorithm. RESULTS Over a two-week period, 93 physicians participated in the simulation. We received 81 responses to the survey (87%), which showed that the average level of comfort with personal protective equipment procedures increased significantly from 2.94 (95% confidence interval, 2.71-3.17) to 4.36 (4.24-4.48), a difference of 1.42 (1.20-1.63, p < 0.001). There was a significant increase in average comfort level in understanding the physician role with scores increasing from 3.51 (3.26-3.77) to 4.55 (2.71-3.17), a difference of 1.04 (0.82-1.25, p < 0.001). There was also increased comfort in performing procedural tasks such as intubation, from 3.08 (2.80-3.35) to 4.38 (4.23-4.52) after the simulation, a difference of 1.30 points (1.06-1.54, p < 0.001). Feedback from the participants also led to refinement of the airway algorithm. CONCLUSION We successfully implemented a new airway management guideline for patients with suspected COVID-19. In-situ simulation is an essential tool for both dissemination and onboarding, as well as process improvement, in the context of an epidemic or pandemic.
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Affiliation(s)
- Brendan W Munzer
- Michigan Medicine, Department of Emergency Medicine, Ann Arbor, Michigan
| | - Benjamin S Bassin
- Michigan Medicine, Department of Emergency Medicine, Ann Arbor, Michigan
- Michigan Center for Integrative Research in Critical Care, Ann Arbor, Michigan
| | - William J Peterson
- Michigan Medicine, Department of Emergency Medicine, Ann Arbor, Michigan
| | - Ryan V Tucker
- Michigan Medicine, Department of Emergency Medicine, Ann Arbor, Michigan
| | - Jessica Doan
- Michigan Medicine, Department of Emergency Medicine, Ann Arbor, Michigan
| | - Carrie Harvey
- Michigan Medicine, Department of Emergency Medicine, Ann Arbor, Michigan
| | - Nana Sefa
- Michigan Medicine, Department of Emergency Medicine, Ann Arbor, Michigan
| | - Cindy H Hsu
- Michigan Medicine, Department of Emergency Medicine, Ann Arbor, Michigan
- Michigan Center for Integrative Research in Critical Care, Ann Arbor, Michigan
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18
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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19
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Haas NL, Larabell P, Schaeffer W, Hoch V, Arribas M, Melvin AC, Laurinec SL, Bassin BS. Descriptive Analysis of Extubations Performed in an Emergency Department-based Intensive Care Unit. West J Emerg Med 2020; 21:532-537. [PMID: 32421498 PMCID: PMC7234716 DOI: 10.5811/westjem.2020.4.47475] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 04/20/2020] [Indexed: 12/19/2022] Open
Abstract
Introduction Extubation of appropriate patients in the emergency department (ED) may be a strategy to avoid preventable or short-stay intensive care unit (ICU) admissions, and could allow for increased ventilator and ICU bed availability when demand outweighs supply. Extubation is infrequently performed in the ED, and a paucity of outcome data exists. Our objective was to descriptively analyze characteristics and outcomes of patients extubated in an ED-ICU setting. Methods We conducted a retrospective observational study at an academic medical center in the United States. Adult ED patients extubated in the ED-ICU from 2015–2019 were retrospectively included and analyzed. Results We identified 202 patients extubated in the ED-ICU; 42% were female and median age was 60.86 years. Locations of endotracheal intubation included the ED (68.3%), outside hospital ED (23.8%), and emergency medical services/prehospital (7.9%). Intubations were performed for airway protection (30.2%), esophagogastroduodenoscopy (27.7%), intoxication/ingestion (17.3%), respiratory failure (13.9%), seizure (7.4%), and other (3.5%). The median interval from ED arrival to extubation was 9.0 hours (interquartile range 6.2–13.6). One patient (0.5%) required unplanned re-intubation within 24 hours of extubation. The attending emergency physician (EP) at the time of extubation was not critical care fellowship trained in the majority (55.9%) of cases. Sixty patients (29.7%) were extubated compassionately; 80% of these died in the ED-ICU, 18.3% were admitted to medical-surgical units, and 1.7% were admitted to intensive care. Of the remaining patients extubated in the ED-ICU (n = 142, 70.3%), zero died in the ED-ICU, 61.3% were admitted to medical-surgical units, 9.9% were admitted to intensive care, and 28.2% were discharged home from the ED-ICU. Conclusion Select ED patients were safely extubated in an ED-ICU by EPs. Only 7.4% required ICU admission, whereas if ED extubation had not been pursued most or all patients would have required ICU admission. Extubation by EPs of appropriately screened patients may help decrease ICU utilization, including when demand for ventilators or ICU beds is greater than supply. Future research is needed to prospectively study patients appropriate for ED extubation.
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Affiliation(s)
- Nathan L Haas
- University of Michigan, Department of Emergency Medicine, Ann Arbor, Michigan.,University of Michigan, Department of Emergency Medicine, Division of Critical Care, Ann Arbor, Michigan.,Michigan Center for Integrative Research in Critical Care, University of Michigan, Ann Arbor, Michigan
| | - Patrick Larabell
- University of Michigan, Department of Emergency Medicine, Ann Arbor, Michigan
| | - William Schaeffer
- University of Michigan, Department of Emergency Medicine, Ann Arbor, Michigan
| | - Victoria Hoch
- University of Michigan, Department of Emergency Medicine, Ann Arbor, Michigan
| | - Miguel Arribas
- University of Michigan, Department of Emergency Medicine, Ann Arbor, Michigan
| | - Amanda C Melvin
- University of Michigan, Department of Emergency Medicine, Ann Arbor, Michigan.,University of Michigan, Department of Emergency Medicine, Division of Critical Care, Ann Arbor, Michigan
| | - Stephanie L Laurinec
- University of Michigan, Department of Emergency Medicine, Ann Arbor, Michigan.,University of Michigan, Department of Emergency Medicine, Division of Critical Care, Ann Arbor, Michigan
| | - Benjamin S Bassin
- University of Michigan, Department of Emergency Medicine, Ann Arbor, Michigan.,University of Michigan, Department of Emergency Medicine, Division of Critical Care, Ann Arbor, Michigan.,Michigan Center for Integrative Research in Critical Care, University of Michigan, Ann Arbor, Michigan
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20
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Haas NL, Whitmore SP, Cranford JA, Tsuchida RE, Nicholson A, Boyd C, Gunnerson KJ, Gianchandani RY, Bassin BS. An Emergency Department-Based Intensive Care Unit is Associated with Decreased Hospital and Intensive Care Unit Utilization for Diabetic Ketoacidosis. J Emerg Med 2019; 58:620-626. [PMID: 31843318 DOI: 10.1016/j.jemermed.2019.10.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 09/27/2019] [Accepted: 10/13/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND Many emergency department (ED) patients in diabetic ketoacidosis (DKA) are admitted to an inpatient intensive care unit (ICU), while ICU capacity is under increasing strain. The Emergency Critical Care Center (EC3), a hybrid ED-ICU setting, opened with the goal of providing rapid initiation of ICU care in the ED. OBJECTIVE We sought to evaluate the impact of an ED-ICU on disposition and safety outcomes for adult ED patients in DKA. METHODS This was a retrospective pre-post cohort of ED visits from 2012-2018 at a single academic medical center. Adult ED patients in DKA (pH < 7.30, HCO3 < 18 mEq/L, anion gap > 14, and glucose > 250 mg/dL) immediately before (pre-EC3) and after (post-EC3) opening of an ED-ICU were identified. ED disposition and safety data were collected and analyzed. RESULTS We identified 631 patient encounters: 217 pre-EC3 and 414 post-EC3. Baseline demographics were similar between cohorts. Fewer patients in the post-EC3 cohort were admitted to an ICU (11.6% vs. 23.5%, p < 0.001, number needed to treat [NNT] = 8) or general floor bed (58.0% vs. 73.3%, p < 0.001, NNT = 6), and more were discharged from the ED (27.1% vs. 1.4%, p < 0.001, NNT = 4). Rates of hypokalemia (10.1% vs. 6.0%, p = 0.08) and admission to non-ICU with transfer to ICU within 24 h (0.5% vs. 0%, p = 0.30) did not differ. CONCLUSION Management of patients with DKA in an ED-ICU was associated with decreased ICU and hospital utilization with similar safety outcomes. Managing rapidly reversible critical illnesses in an ED-ICU may help obviate increasing strain facing many health care systems.
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Affiliation(s)
| | | | | | | | | | - Caryn Boyd
- University of Michigan, Ann Arbor, Michigan
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21
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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: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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22
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Kocher KE, Arora R, Bassin BS, Benjamin LS, Bolton M, Dennis BJ, Ham JJ, Krupp SS, Levasseur KA, Macy ML, O'Neil BJ, Pribble JM, Sherwin RL, Sroufe NS, Uren BJ, Nypaver MM. Baseline Performance of Real-World Clinical Practice Within a Statewide Emergency Medicine Quality Network: The Michigan Emergency Department Improvement Collaborative (MEDIC). Ann Emerg Med 2019; 75:192-205. [PMID: 31256906 DOI: 10.1016/j.annemergmed.2019.04.033] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 03/11/2019] [Accepted: 04/25/2019] [Indexed: 11/30/2022]
Abstract
STUDY OBJECTIVE Large-scale quality and performance measurement across unaffiliated hospitals is an important strategy to drive practice change. The Michigan Emergency Department Improvement Collaborative (MEDIC), established in 2015, has baseline performance data to identify practice variation across 15 diverse emergency departments (EDs) on key emergency care quality indicators. METHODS MEDIC is a unique physician-led partnership supported by a major third-party payer. Member sites contribute electronic health record data and trained abstractors add supplementary data for eligible cases. Quality measures include computed tomography (CT) appropriateness for minor head injury, using the Canadian CT Head Rule for adults and Pediatric Emergency Care Applied Network rules for children; chest radiograph use for children with asthma, bronchiolitis, and croup; and diagnostic yield of CTs for suspected pulmonary embolism. Baseline performance was established with statistical process control charts. RESULTS From June 1, 2016, to October 31, 2017, the MEDIC registry contained 1,124,227 ED visits, 23.2% for children (<18 years). Overall baseline performance included the following: 40.9% of adult patients with minor head injury (N=11,857) had appropriate CTs (site range 24.3% to 58.6%), 10.3% of pediatric minor head injury cases (N=11,183) exhibited CT overuse (range 5.8% to 16.8%), 38.1% of pediatric patients with a respiratory condition (N=18,190) received a chest radiograph (range 9.0% to 62.1%), and 8.7% of pulmonary embolism CT results (N=16,205) were positive (range 7.5% to 14.3%). CONCLUSION Performance varied greatly, with demonstrated opportunity for improvement. MEDIC provides a robust platform for emergency physician engagement across ED practice settings to improve care and is a model for other states.
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Affiliation(s)
- Keith E Kocher
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI.
| | - Rajan Arora
- Department of Emergency Medicine and Pediatrics, Wayne State University, Detroit, MI; Children's Hospital of Michigan, Detroit, MI
| | - Benjamin S Bassin
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
| | | | - Michaelina Bolton
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI; Hurley Medical Center, Flint, MI
| | - Blaine J Dennis
- Beaumont Health System, Royal Oak, MI; Oakland University William Beaumont School of Medicine, Rochester, MI; Beaumont Hospital, Royal Oak and Troy, MI
| | - Jason J Ham
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI; Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Seth S Krupp
- Department of Emergency Medicine, Wayne State University, Detroit, MI; Henry Ford Health System, Detroit, MI
| | - Kelly A Levasseur
- Oakland University William Beaumont School of Medicine, Rochester, MI; Beaumont Health System, Royal Oak, MI; Beaumont Hospital, Royal Oak and Troy, MI; Beaumont Children's Hospital, Royal Oak, MI
| | - Michelle L Macy
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI; Child Health Evaluation and Research (CHEAR) Center, University of Michigan Medical School, Ann Arbor, MI; Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Brian J O'Neil
- Department of Emergency Medicine, Wayne State University, Detroit, MI
| | - James M Pribble
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
| | - Robert L Sherwin
- Department of Emergency Medicine, Wayne State University, Detroit, MI
| | - Nicole S Sroufe
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI; Department of Pediatrics, University of Michigan, Ann Arbor, MI
| | - Bradley J Uren
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
| | - Michele M Nypaver
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI; Department of Pediatrics, University of Michigan, Ann Arbor, MI
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23
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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24
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Haas NL, Gianchandani RY, Gunnerson KJ, Bassin BS, Ganti A, Hapner C, Boyd C, Cranford JA, Whitmore SP. The Two-Bag Method for Treatment of Diabetic Ketoacidosis in Adults. J Emerg Med 2018; 54:593-599. [PMID: 29628184 DOI: 10.1016/j.jemermed.2018.01.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 12/15/2017] [Accepted: 01/06/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND The "two-bag method" of management of diabetic ketoacidosis (DKA) allows for titration of dextrose delivery by adjusting the infusions of two i.v. fluid bags of varying dextrose concentrations while keeping fluid, electrolyte, and insulin infusion rates constant. OBJECTIVE We aimed to evaluate the feasibility and potential benefits of this strategy in adult emergency department (ED) patients with DKA. METHODS This is a before-and-after comparison of a protocol using the two-bag method operationalized in our adult ED in 2015. A retrospective electronic medical record search identified adult ED patients presenting with DKA from January 1, 2013 to June 30, 2016. Clinical and laboratory data, timing of medical therapies, and safety outcomes were collected and analyzed. RESULTS Sixty-eight patients managed with the two-bag method (2B) and 107 patients managed with the one-bag method (1B) were identified. The 2B and 1B groups were similar in demographics and baseline metabolic derangements, though significantly more patients in the 2B group received care in a hybrid ED and intensive care unit setting (94.1% vs. 51.4%; p < 0.01). 2B patients experienced a shorter interval to first serum bicarbonate ≥ 18 mEq/L (13.4 vs. 20.0 h; p < 0.05), shorter duration of insulin infusion (14.1 vs. 21.8 h; p < 0.05), and fewer fluid bags were charged to the patient (5.2 vs. 29.7; p < 0.01). Frequency of any measured hypoglycemia or hypokalemia trended in favor of the 2B group (2.9% vs. 10.3%; p = 0.07; 16.2% vs. 27.1%; p = 0.09; respectively), though did not reach significance. CONCLUSIONS The 2B method appears feasible for management of adult ED patients with DKA, and use was associated with earlier correction of acidosis, earlier discontinuation of insulin infusion, and fewer i.v. fluid bags charged than traditional 1B methods, while no safety concerns were observed.
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Affiliation(s)
- Nathan L Haas
- Department of Emergency Medicine, Michigan Medicine, Ann Arbor, Michigan
| | - Roma Y Gianchandani
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan; Division of Metabolism, Endocrinology and Diabetes, Michigan Medicine, Ann Arbor, Michigan
| | - Kyle J Gunnerson
- Department of Emergency Medicine, Michigan Medicine, Ann Arbor, Michigan; Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan; Division of Emergency Critical Care, Michigan Medicine, Ann Arbor, Michigan; Department of Anesthesiology/Critical Care, Michigan Medicine, Ann Arbor, Michigan
| | - Benjamin S Bassin
- Department of Emergency Medicine, Michigan Medicine, Ann Arbor, Michigan; Division of Emergency Critical Care, Michigan Medicine, Ann Arbor, Michigan
| | - Arun Ganti
- Department of Emergency Medicine, Michigan Medicine, Ann Arbor, Michigan
| | - Christopher Hapner
- Department of Emergency Medicine, Michigan Medicine, Ann Arbor, Michigan
| | - Caryn Boyd
- Department of Emergency Medicine, Michigan Medicine, Ann Arbor, Michigan
| | - James A Cranford
- Department of Psychiatry, Michigan Medicine, Ann Arbor, Michigan
| | - Sage P Whitmore
- Department of Emergency Medicine, Michigan Medicine, Ann Arbor, Michigan; Division of Emergency Critical Care, Michigan Medicine, Ann Arbor, Michigan; Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Michigan Medicine, Ann Arbor, Michigan
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Saxon KD, Kapadia AP, Juneja NS, Bassin BS. How To Teach Emergency Procedural Skills in an Outdoor Environment Using Low-Fidelity Simulation. Wilderness Environ Med 2014; 25:50-5. [DOI: 10.1016/j.wem.2013.11.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Revised: 10/19/2013] [Accepted: 11/06/2013] [Indexed: 11/29/2022]
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26
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White JM, Moorhead KD, Bassin BS. Emergency Medicine Resident-Run Wilderness Life Support Course Improves Confidence in Several Skill Areas of Wilderness Medicine Across Multiple Levels of Medical Providers. Wilderness Environ Med 2011. [DOI: 10.1016/j.wem.2011.08.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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27
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White NJ, Lindsell CJ, Bassin BS, Venkat A. Comparison of characteristics of admitted emergency department patients requiring cardiopulmonary resuscitation in the ICU and non-ICU setting. Arch Emerg Med 2008; 25:83-7. [DOI: 10.1136/emj.2007.051920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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