UMEM Educational Pearls

CCM recently published Stanford's experience with their Emergency Critical Care Program (ECCP), an ED based intensivist consultation/management model staffed by EM/CC during peak hours with the "goals of improving care of the critically ill in the ED, offloading the ED team, and optimizing ICU bed utilization without the need for a dedicated physical space." 

Conclusions:

This is the third group to document decrease in overall mortality utilizing an early or dedicated critical care consult model. EC3 and the CCRU here at UMMC have also both shown improvements in patient transfer and resource utilization metrics. As with all studies in this space, there are many limitations to these studies in both design and generalizability, even amongst each other. However, the literature is replete with data that increased boarding time in the ED for critically ill patients is associated with worse outcomes and these studies are now a body of complementary and growing evidence that teams such as this can perhaps bridge that gap. Hopefully come to an ED near you soon...

 

Study Details:

Objectives: To determine whether implementation of an Emergency Critical Care Program (ECCP) is associated with improved survival and early downgrade of critically ill medical patients in the emergency department (ED).

Design: Single-center, retrospective cohort study from a tertiary academic medical center using ED-visit data between 2015 and 2019 for adult medical patients presenting to the ED with a critical care admission order within 12 hours of arrival.

Pre and post intervention (2017) cohort analysis of patients when facility implemented dedicated bedside critical care by an ED-based intensivist "following initial resuscitation by the ED team". A difference-in-differences (DiD) analysis compared the change in outcomes for patients arriving during ECCP hours (2 pm to midnight, weekdays) between the preintervention period (2015–2017) and the intervention period (2017–2019) to the change in outcomes for patients arriving during non-ECCP hours (all other hours).

Primary outcomes: In-hospital mortality and proportion of patients downgraded to non-ICU status while in the ED within 6 hours

Results:

• The primary cohort included 2,250 patients
• emergency critical care Sequential Organ Failure Assessment (eccSOFA) score. The DiDs for the eccSOFA-adjusted inhospital mortality decreased by 6.0% (95% CI, –11.9 to –0.1)
  • Largest difference in the intermediate illness severity group (DiD, –12.2%; 95% CI, –23.1 to –1.3)
• The increase in ED downgrade less than 6 hours was not statistically significant (DiD, 4.8%; 95% CI, –0.7 to 10.3%) for all patients
  • The intermediate group was statistically significant (DiD, 8.8%; 95% CI, 0.2–17.4).

 

 

References

Mitarai, Tsuyoshi; Gordon, Alexandra June; Nudelman, Matthew J et al. Association of an Emergency Critical Care Program With Survival and Early Downgrade Among Critically Ill Medical Patients in the Emergency Department. Critical Care Medicine ():10.1097/CCM.0000000000005835.

Gunnerson KJ, Bassin BS, Havey RA, et al.: Association of an emergency department–based intensive care unit with survival and inpatient intensive care unit admissions. JAMA Netw Open 2019; 2:e197584

Tran QK, O’Connor J, Vesselinov R, et al.: The critical care resuscitation unit transfers more patients from emergency departments faster and is associated with improved outcomes. J Emerg Med 2020; 58:280–289