Good morning. Let me see a show of hands of everybody who works in the emergency department. Great, and let me see a show of hands of everybody who works in the ICU. Fantastic. So I want you guys to look over at each other, introduce yourselves, all right? This is an ED-centric, you know, supposed, you know, a series right now, but everything that we've been talking about, and especially when we address the boarding issues on our critically ill patients, it does not exist in isolation. The solution to this is going to have to be a collaboration with our multidisciplinary partners in the emergency department and in the ICU. So even though this, again, may be kind of focused on what we can do early, it cannot exist without the multidisciplinary care of upstairs meeting downstairs. So this is a little bit about me here. You don't want to hear about this. Disclosures, routine, there is nothing really about the talk going forward that I have a conflict with other than at the very end, we're gonna talk about a model that I was fortunate enough to help lead and create. And our goals and objectives for the next few minutes in this is we're gonna try and define the scope of what critically ill patients boarding in the emergency department is. And then there are a few mitigation strategies that have been proposed, and there's also been some recent outcomes based on some models that address these. So the big question about this, is there really a problem? It sounds like it's a big enough problem to make it to the final day of Congress. But really, is this something that we're living with and having a problem with day to day? Well, a few years ago, Society of Critical Care Medicine and American College of Emergency Physicians actually did agree this was a big problem for both specialties. And so we formed a task force, but actually Dr. Westman is one of the co-chairs. And several of the slides you've seen today and throughout Congress has come out of that task force. Again, bringing both in critical care and emergency medicine together to come up with some of these solutions, and actually defining the problem. When we did try and define the problem, and come to some statistics of what's going on out there, it's really hard, because there really is no accepted universal definition of ED boarding. Estimates are all over the board, from 2% to almost 90%. And it depends on what you use as your defining metrics for this. So sometimes it's based on hours, like two, four, six hours before patients are actually admitted to the ICU. Other papers actually just look at metrics, such as number of intubated patients, how long they spend in the ED. However, we do have some hard facts that we can kind of look at, and base an estimate of what really we're dealing with. And you've seen some of this before earlier. The number of ED critical care patients has increased, admitted to the ICU, by 80% for intubated patients in the last 10 years. And then if you look at what this really means, about 250,000 patients a year receive mechanical ventilation in the ED, with the median length of stay greater than three hours. And this is old data. So now fast forward to where we are today, and that is increased. Now, what does that really mean? Is that really a problem? Well, for about 15 years, even not even addressing in today's situation, over about a 15 year period, several authors have looked at time in the ED before being admitted to an ICU for various disease states, such as neurologic emergencies, respiratory failure, cardiac arrest, general medical admissions. And they found out through this that the longer you stay in the emergency department waiting for these ICU beds, your mortality starts to increase. So much that the magic hour seems to be somewhere around three to four hours. So keep that in mind. Three to four hours mortality starts to go up while you're waiting for a bed in the ICU. So then when you add that in to our current situation of increasing boarding time for all patients, including the ICU patients, this can take on a little bit of perspective. As mentioned earlier, you can see that total admissions from the ED to the ICU has increased over from 1.2 to 2.2 million. The admission rate has increased as well. But let's look at something more daunting, more challenge to us. If you look at the growth, even though the number of admissions to the ICU has grown at about 10% a year, the number of hours delivered of critical care in the ED or the time that they've been spending in the ED, that has increased by almost 25% a year. So the time that these patients are spending in the ED is going up and it's outpacing even our own metric of looking at ICU admissions. So that magic hour of four really now comes into play when you see that almost one third of all the ICU admitted patients are in the ED for about six hours. So with that and looking at the consensus paper between the two societies, there's some mitigation strategies that have been proposed and even are going on today in various institutions. There are some ED-based solutions and some of these can be broken down into target interventions. And these basically are bringing fairly straightforward care bundles down to the emergency department, such as pain and agitation sedation strategies, which is a care bundle. Also care bundles around the ventilator. These are some things that can be introduced and adopted into the emergency department. Other things that are suggested to improve outcome or what we can do for our patients are just basically going to the bedside more, more frequent hemodynamic monitoring, infection prevention strategies, et cetera. Sometimes some institutions are actually looking at surge capacity, looking, trying to improve staffing based on critically ill patients, and that's something that has potential going forward. However, not one of these is standing out as saying this is the way we have to do this. Other solutions are coming down from the hospital-based. These are based such as ICU alert teams, which is deploying teams of intensivists, nurse dyad going down to the emergency department, taking care of the patients, as well as going to the floor, maybe managing the patient on the floor and not needing an ICU bed, therefore creating more capacity. And again, like mentioned at the beginning of the lecture, improving interdepartmental collaboration, triage, moving these patients around strategically, putting, everybody doesn't want to talk about it, but canceling OR cases, et cetera. These are things that are going on today to try and address this problem of how do I get our patients to the ICU? Now when we talk about bringing in ED ICU teams, there's a whole spectrum of what that means, especially when it comes to resource allocation. On the left-hand side is basically an intensivist consult model, and that's where you just have a critical care specialist, dyad or triad, however big you want to make the team, that comes down to the bedside, like a SWAT team, manages the patient in conjunction with the primary ED team, and that sometimes can be on a 24-hour schedule or it could even be such as peak times for ICU patients, such as 10 a.m. to 10 p.m., et cetera. And then as resources are increased, that model can be expanded. On the far right, you see more of a resource-intense model, and this is where an actual ICU structurally is built within an ED, or beds are allocated for that model, and that's where nursing staffing and ICU-trained physicians are staffed in the same way as you would upstairs. That also comes with teams, such as pharmacists, respiratory therapy, et cetera. And as you can imagine, this is on the far extreme of resource-intense. And then you have something in the middle that has a combination or a component of both of these models in a hybrid model. And going forward, the next three models I'm gonna talk about are a mix of these three designs in this type of paradigm. So I'm gonna talk about three models here. One model is going to be the CCRU, which is out of University of Maryland, that's more of an inpatient model, okay, that's a hybrid inpatient type of ICU design. The other one is at Henry Ford Hospital, which is an ED-based ICU delivery model. And then the last one is gonna be the University of Michigan So the critical care resuscitation unit is not based in the ED, that's at University of Maryland. But interestingly, it is a hybrid, and it does affect boarding. It's an inpatient multidisciplinary ICU designed to increase the transfers for non-trauma patients, getting them from the outside smaller hospitals into the University of Maryland. It was started in 2013. How this can really affect the emergency department is that the smaller EDs then can offload some of their circuit patients to an inpatient ICU that's not in their own system. It's been successful, and now it handles over 20% of total transfers a year, and it really focuses and seems to make an impact on those specially surgical patients, such as the cardiac surgery, neurosurgery, and emergency general surgery cases that are not trauma. They have actually come and published their results a few years ago. This, again, as all of the three studies that we've looked at are gonna talk about, are a pre- and post-implementation design study. So the CCRU study was, again, a pre and post, looking at the first year of operation as their impact, as their treatment arm, which was from 2013 to 2014. Then they looked at one control, which was actually a year before they opened, a whole year of what happened to patients being admitted to their institution to an ICU. And then control two was at the same time that they opened, but patients admitted to an ICU that was not the CCRU. And you can see the patient distribution here. Now what they found out over this time frame was that the CCRU decreased the time to transfer almost in half for getting patients from outside hospitals into their unit. They also found that these patients were getting emergent surgeries a lot sooner than the other two models. So not only were they getting to the ICU, they're also having definitive treatment quicker, sooner than this model was incorporated. And then during a logistic regression model, they found that this also improved mortality. So patients in the CCRU model were able to affect outside hospitals, getting those patients to an ICU quicker, getting them to a definitive therapy, such as an emergent surgery quicker, and in that case, it improved mortality. Now Henry Ford is a hybrid model. Henry Ford Category 1 is a place within the emergency department. This is a large urban hospital in Detroit, Michigan. It's been around, this model has been around for over 30 years. It's a geographic area that is on the same floor plan as the emergency department, but it's staffed somewhere between an ICU and the regular ED staffing, as far as nurses and physicians go, somewhere in between. And it's been that way, again, for 30 years with a culture of this rapid triage and rapid corralling of these sicker patients over time. It was renovated in the early 2000s as after early Goldrick therapy, actually you may have remembered that, somebody in the room here, showed that that was as effective for early intervention for patients. And the team was formed, called an early intervention team. Again, that was formed around 2000s, and this is a dual trained team of emergency medicine intensivists. And they're available for consult on these Category 1 patients. Again, so we have a higher cohort of ill patients, not all of them are ICU bound, but if they're needed now, this EIT team can go and help manage and do consults for these patients. And again, this was a retrospective analysis, looking at those with EIT consults and those who aren't. So there was about 1,700 patients that were studied during this two year time frame. About 500 were EIT patients, or about 28%. One thing that was noted is that the EIT patients definitely were sicker, they had much higher SOFR scores and longer ED lengths of stay. However, there was no difference in mortality, no difference in ICU length of stay, no difference in hospital length of stay. Now, this doesn't necessarily mean that this model is not successful. I think one of the things, the limitations are there, but one of the things you have to really kind of understand, and I trained at Henry Ford before this team was there, is that there's a culture that already existed of early intervention, early recognition, of early identification. And so for those patients who were, the EIT team were consulted on, they were extremely sick, so they were an extremist. So one way to look at this actually is that you may have expected a much higher mortality in those patients to begin with. So did this study actually mitigate that higher mortality by having that EIT team present? It's hard to say, it wasn't designed for that. But that's one other thing that I would use as a potential server lining in the ultimate results of this. And finally, what we're gonna finish up with is our model at University of Michigan. It's a geographic ED-based ICU. It's a nine bed ICU with five resuscitation bays right next to our main emergency department. It was our old pediatric emergency department. It's ICU staffing ratio is the same as we have upstairs. The nurses go through very similar ICU training protocols and extensive ICU orientation. There's a mix between emergency medicine trained intensivist and EM trained physicians that go through FCCS training, et cetera. And we have a 24-7 model with residents, fellows, PA coverage, as well as with pharmacists, respiratory therapy, even physical therapy at our bedside, able to come to the bedside. The outcomes for this, again, this is a cohort pre and post. We looked at mortality and ICU utilization before and after we opened. It was roughly about a 900 day period and that was just limited to our electronic medical record capacity at the time. What we found of about 350,000 patients during this time was that there was a 15% reduction in 30 day mortality for all ED patients. All ED patients benefit from this model, not just the ones that were in their ICU. There was a 10% reduction in hospital mortality and this also went out to a 26% reduction in 24 hour mortality. So another way of looking at this, assuming you have an academic or a large center saying roughly around 75,000 patients a year, you save around 220 lives per year after EC3 had opened or that's about three lives saved per 1,000 ED visits or one life saved, for us anyway, every one and a half days. Now we also looked at resource utilization. We also, by having this model, we reduced ICU admissions by 13% in the setting of increasing acuity in our volume. We also had a 30% reduction in our short stay admissions. What this was really, where this model really shines is in those short turnaround, really sick patients that you can have a definitive outcome such as a GI bleed. And there was no significant difference of patients going through our EC3 and being downgraded, which means this was a very safe model. Those patients did not decompensate within the next 24 hours at any difference rate than our main ED patients. We just were able to pull together a very long, drawn out extensive cost analysis and was just recently published looking at, is this affordable, is this model affordable? And our short answer is yes. When we looked at the inflation adjusted total direct cost of each ED encounter, this remained unchanged throughout the pre-EC3 and the post-EC3 era. However, you look at the subpopulation of those actually receiving ICU level of care and we did see a reduced cost of 22%. And overall, our ICU level of RVU billing increased by 7%. However, knowing that the entire RVU model did not change, this was not a reflection of anything different in our billing strategies. So when you plug this in for the value equation, you see a higher quality, such as lower 30-day mortality, lower ICU admission rate, divided by a similar cost between both, or a lower cost, equals a much higher value for this. So wrapping this all up, boarding in the ED for our critically ill patients is increasing. It's associated with high morbidity, mortality. It seems to start to go up after around four hours. There's multiple staffing models out there that are being proposed. This ranges from very minimally labor intensive, or resource intense, to very high labor intense. It's extremely important that we work together as a team and with our hospital administration to come up with a specific team or a specific plan for your institution. The beautiful thing about the teams that are out there now doing this is that they're all different and they're all working in their own way. And more critical care delivery models need to be created and published and studied so we all can learn from them going forward. And ultimately, I couldn't think of a better mantra for this ED critical care together team approach to getting these resources to our patients than SCCM's mantra of right care right now. Thank you very much.

critically ill patients

boarding in the emergency department

collaboration between ED and ICU

mitigating boarding

critical care delivery models