Emergency Department Intensive Care Units—A Niche Offering or the Future of Critical Care?
Joseph E. Tonna, MD
The increase in emergency medicine trained residents pursuing critical care fellowship training has necessarily resulted in a broad reconsideration of the role that emergency departments should play in the care of the critically ill. While traditionally these emergency physician intensivists have worked inpatient ICUs, many are looking to elevate the care of the emergency department patient, in the emergency department. Increased emergency department length of stay due to boarding has only made this issue more important.
One recent development in the care of critically ill patients in the emergency department has been the development of emergency department intensive care units, or ED-ICUs. I had the pleasure of speaking with leaders of two forefront ED-ICUs: Dr. Scott Weingart of Stony Brook Resuscitation and Acute Critical Care Unit (RACC) and Dr. Ben Bassin from the University of Michigan Emergency Critical Care Center (EC3). Both institutions were early adopters of the ED-ICU and have each been very successful in implementing and sustaining an emergency department critical care practice.
Both Dr. Bassin and Dr. Weingart feel that ED-ICUs offer a significant opportunity to the emergency departments in which they exist. This benefit includes enhanced patient care, enhanced training, and financial benefits to the emergency department. While both of their ED-ICUs are located at academic centers, the key for a strong value proposition rested not in them being at academic centers, but in the acuity and volume of the department. While many academic centers are higher volume, and the benefit to teaching resident trainees can be inherently made, community centers with high volume and high acuity could just as easily benefit. Furthermore, as issues of “turf” wars are often less significant without residents, community offerings may offer a better environment in this regard.
Dr. Weingart and colleagues described in 2013 the role of emergency department critical care, including that of the ED-ICU.1 In that manuscript, they describe two models of ED-ICU care - the “resource intensivist model” and the “hybrid model.” In my discussion with Dr. Weingart, though, it became clear that as the specialty has evolved, a “stand alone ED-ICU” model has also emerged. The resource intensivist model is what many emergency departments with emergency physician intensivist have, where the emergency physician intensivist works standard emergency department shifts, lending expertise to critically ill patients as needed, but without an “assigned” role as an emergency intensivist or intensivist. The hybrid model, on the other hand, is one in which a dedicated area of the emergency department can ramp up care for critically ill patients with 1:1 or 1:2 nurse:patient ratios when needed and a dedicated physician providing intensive care to just those patients. This physician may or may not be a fellowship trained intensivist, though. The hybrid ED-ICU is, in essence, an evolved resuscitation bay, which exists to intentionally provide critical care for periods longer than a typical 60 minutes. Benefits of this model are that it is easier to implement and justify for departments wishing to expand into this area, as the costs are minimal, and allows for the unbridled provision and billing of critical care in the emergency department. The only additional costs are that of the ED-ICU physician role. If this role is re-appropriated from a pre-existing “resuscitation” shift, then there may be no additional cost. In periods of low acuity census, the hybrid model can skim higher acuity patients from the main ED who might not normally meet ICU criteria to alleviate the workload.
Providers in the hybrid ED-ICU are not expected to see patients in the main ED, allowing them the time to provide 4-6 hours of critical care for boarding patients. The downside of this model is that providers not rotating through the hybrid ED-ICU will never see critically ill patients, as patients are directly brought to the hybrid ED-ICU bay upon arrival to the department. A second model is the stand-alone ED-ICU, which involves the addition of new hospital ICU beds in an isolated unit in or near the emergency department. This stand-alone ED-ICU functions in parallel to the emergency department, with patients being first admitted to the ED, stabilized, and then admitted to the stand-alone ED-ICU. A benefit of this model is that critically ill patients will still pass through the emergency department, allowing providers not working in the dedicated unit to still see and care for them. Implementation of this model is, of course, more difficult, in that it involves de-novo creation of new ICU beds, which inherently influences the admission of patients to the other established ICUs. Depending on ICU bed census and turnover, this may or may not be welcome.
One question that I had for Drs. Weingart and Bassin was about the management of patients in the ED-ICU. What was the goal of the unit? Was it to decompress patients from the ED who were boarding, to change disposition of admitted patients from an ICU to the floor, or to elevate the care of patients in the ED? Dr. Bassin, the Director of Clinical Operations at the University of Michigan EC3, explained that at the University of Michigan, the goal for the EC3 was to make an impact on the disposition or care of the patient during the first 4-6 hours after admission. The EC3 and RACC both focus on medical conditions that can be altered with enhanced care in the first 4-6 hours, but without delaying definitive care that could be better provided in a different location. The Michigan model is taking this mandate seriously and doing research on their ability to modify the illness severity of patients within this period of time, compared to standard ICU admissions. Dr. Bassin says that this research mission is important early on, until the benefit of early ICU care through the emergency department is proven. Importantly, both units keep certain patients longer than 4-6 hours - specifically patients who can receive a defined duration of definitive care before then dispositioning to a lower level of inpatient care. The ability to provide complete care for patients who may rapidly transition to lower levels of care—such as patients with diabetic ketoacidosis (DKA), gastrointestinal bleeds (GIBs), airway watch or even palliation—is an important qualification for the ED-ICU.
In talking with Dr. Weingart, he pointed out that most emergency departments are likely under billing critical care at baseline. Accordingly, the addition of the ED-ICU is financially beneficial to the extent that there is increased provision of critical care and corresponding billing. The argument can be made that if under billing is baseline, then billing could be improved without the isolation of critically ill patients under a group of nurses and a physician. However, given the busy demands of an emergency department, most physicians do not have the ability to isolate themselves to a single patient for longer than 30 minutes. The isolation of an ED-ICU with corresponding nurses (RNs) and a physician facilitate this dedicated care. This model has worked well for Stony Brook RACC, which is a 25-bed unit, though Dr. Weingart says his experience has taught him that a 12-bed unit is more ideal. The Stony Brook RACC provides a pressure release value for the ED, allowing the offload of critically ill patients who are immediately recognized to require more care than is easy to provide in a fast-paced department. Patients admitted to the RACC are seen within 5 minutes, expediting critical care in those urgent first moments.
A final question I had for these intensivists was around the integration of the ED-ICU with the hospital, including backup in cases of further decompensation. Dr. Bassin describes the Michigan EC3 as a unit highly integrated with “upstairs” ICU care. Drs. Weingart and Bassin both talked about how important it was to ensure the ICU fellows from the destination admitting team are called to round on the patients in the ED-ICU. This model allows the emergency department to provide and bill for early critical care, including procedures and management, while keeping inpatient intensivists collaboratively involved.
It seems that the ED-ICU model, as seen in mature form in the Stony Brook Resuscitation and Acute Critical Care Unit (RACC) and in the University of Michigan Emergency Critical Care Center (EC3), is a viable and emerging forum for the provision of critical care in emergency medicine. As emergency intensivists, transitioning out of the upstairs ICU and recognizing the importance of providing critical care within our home shop should be something increasingly valued and developed among our community. The reality in most emergency departments is that patients not only board for hours, but that they often receive sub-par care after their initial “resuscitation,” languishing in our departments without ongoing reassessment. As emergency intensivists increasingly demonstrate their value within the larger critical care community, it becomes increasingly important for us to acknowledge the shortcomings of critical care within our own departments and capitalize on the opportunity to enhance this care, educate our own and even conduct research on the value of early emergency critical care.
- Weingart SD, Sherwin RL, Emlet LL, et al. ED intensivists and ED intensive care units. Am J Emerg Med. 2013;31(3):617-620.
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