Descriptive Analysis of Extubations Performed in an Emergency Department-based Intensive Care Unit

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

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

Characteristics of victims of trauma requiring invasive mechanical ventilation with a short stay in critical care

BACKGROUND

Many patients who are admitted to the intensive care unit (ICU) have needs which rapidly resolve and are discharged alive within 24 h. We sought to characterize the outcomes of critically ill trauma victims at our institution with a short stay in the ICU.

METHODS

We conducted a retrospective cohort study of all critically ill adult trauma victims presenting to our ED between January 1st, 2011 and December 31st, 2019. We included patients who were endotracheally intubated in either the prehospital setting or the ED and were admitted either to the operating room (OR), angiography suite, or ICU. Our primary outcome was the proportion of patients who were discharged alive from the ICU within 24 h.

RESULTS

We included 3869 patients meeting the criteria above who were alive at 24 h. This population was 78% male with a median age of 40 and 76% of patients suffered from blunt trauma. The median injury severity score (ISS) of the group was 21 [inter-quartile range (IQR) 11-30]. In-hospital mortality amongst the group was 12%. 17% of the group were discharged alive from the ICU within 24 h. Thirty-four percent of the group had an ISS ≤ 15. Of the group which left the ICU alive within 24 h, six patients (0.9%) died in the hospital, 2 % of patients were re-admitted to an ICU, and 0.6% of patients required re-intubation.

CONCLUSIONS

We found that 17% of patients who were intubated in the prehospital setting or emergency department and subsequently hospitalized were discharged alive from the ICU within 24 h.

Is the Critical Care Resuscitation Unit Sustainable: A 5-Year Experience of a Beneficial and Novel Model

Background. The 6-bed critical care resuscitation unit (CCRU) is a unique and specialized intensive care unit (ICU) that streamlines the interhospital transfer (IHT—transfer between different hospitals) process for a wide range of patients with critical illness or time-sensitive disease. Previous studies showed the unit successfully increased the number of ICU admissions while reducing the time of transfer in the first year of its establishment. However, its sustainability is unknown. Methods. This was a descriptive retrospective analysis of adult, non-trauma patients who were transferred to an 800-bed quaternary medical center. Patients transferred to our medical center between January 1, 2014 and December 31, 2018 were eligible. We used interrupted time series (ITS) and descriptive analyses to describe the trend and compare the transfer process between patients who were transferred to the CCRU versus those transferred to other adult inpatient units. Results. From 2014 to 2018, 50,599 patients were transferred to our medical center; 31,582 (62%) were non-trauma adults. Compared with the year prior to the opening of the CCRU, ITS showed a significant increase in IHT after the establishment of the CCRU. The CCRU received a total of 7,788 (25%) IHTs during this period or approximately 20% of total transfers per year. Most transfers (41%) occurred via ground. Median and interquartile range [IQR] of transfer times to other ICUs (156 [65–1027] minutes) were longer than the CCRU (46 [22–139] minutes, $P<0.001$ ). For the CCRU, the most common accepting services were cardiac surgery (16%), neurosurgery (11%), and emergency general surgery (10%). Conclusions. The CCRU increases the overall number of transfers to our institution, improves patient access to specialty care while decreasing transfer time, and continues to be a sustainable model over time. Additional research is needed to determine if transferring patients to the CCRU would continue to improve patients’ outcomes and hospital revenue.

Emergency department length of stay and outcomes of emergency department–based intensive care unit patients

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.

Initiation of a Lung Protective Ventilation Strategy in the Emergency Department: Does an Emergency Department-Based ICU Make a Difference?

BACKGROUND:

Lung protective ventilation (LPV) is a key component in the management of acute respiratory distress syndrome and other acute respiratory pathology. Initiation of LPV in the emergency department (ED) is associated with improved patient-centered and system outcomes, but adherence to LPV among ED patients is low. The impact of an ED-based ICU (ED-ICU) on LPV adherence is not known.

METHODS:

This single-center, retrospective, cohort study analyzed rates of adherence to a multifaceted LPV strategy pre- and post-implementation of an ED-ICU. LPV strategy components included low tidal volume ventilation, avoidance of severe hyperoxia and high plateau pressures, and positive end-expiratory pressure settings in alignment with best-evidence recommendations. The primary outcome was adherence to the LPV strategy at time of ED departure.

RESULTS AND CONCLUSIONS:

A total of 561 ED visits were included in the analysis, of which 60.0% received some portion of their emergency care in the ED-ICU. Adherence to the LPV strategy was statistically significantly higher in the ED-ICU cohort compared with the pre-ED-ICU cohort (65.8% vs 41.4%; p < 0.001) and non-ED-ICU cohort (65.8% vs 43.1%; p < 0.001). Among the ED-ICU cohort, 92.8% of patients received low tidal volume ventilation. Care in the ED-ICU was also associated with shorter ICU and hospital length of stay. These findings suggest improved patient and resource utilization outcomes for mechanically ventilated ED patients receiving care in an ED-ICU.

Extubating trauma patients in the emergency department

BACKGROUND

Trauma patients often require endotracheal intubation for urgent or emergent airway protection or to allow expeditious imaging when they cannot cooperate with the needed evaluation. These patients may occasionally be extubated in the emergency department (ED) when the trauma workup is negative for consequential injuries and eventually discharged from the ED. The timing and safety of discharging these patients is unclear.

OBJECTIVE

The objective of this study was to identify the adverse outcomes and evaluate the safety of extubating trauma patients who are clinically well following evaluation in the ED.

METHODS

Records of trauma patients who were intubated and then extubated in the ED at a single level 1 trauma referral center during the 4-year study period (Jan 2014 - Dec 2017) were retrospectively abstracted. The primary outcome was the incidence of a post-extubation complication, including desaturation, emesis, aspiration, need for sedative administration, or unplanned reintubation. Additional outcome measures included final disposition, duration of observation following extubation, ED length of stay and return to the hospital within 72 h.

RESULTS

There were 59 eligible patients identified over the study period, of whom 95% presented following blunt trauma. One patient (1.7%; 95% confidence interval 0-9) required unplanned reintubation and developed aspiration pneumonia following re-extubation. Forty-two (71%) of the patients were discharged from the ED following extubation and a period of post-extubation observation with a mean of 5.8 h (0.6-16.7 h). None of the patients who were discharged returned to the ED within 72 h with complications related to extubation (0%; 95% confidence interval 0-6%).

CONCLUSIONS

Patients presenting to the ED with possible acute traumatic injuries who are intubated and then extubated after trauma evaluation and resolution of the indication for intubation appear to have a low incidence of complication or return visit when discharged from the ED after a brief period of observation. Specific extubation and discharge criteria should be developed to ensure the safety of this practice. Further validation is required in the form of larger and prospective studies.

An emergency department-based intensive care unit is associated with decreased hospital length of stay for upper gastrointestinal bleeding

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.

Delivery of end-of-life care in an emergency department-based intensive care unit

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.