There you go. First up, we'll have Dr. Tran talking about the experience from the critical care resuscitation unit. Thank you, Anne. And hello, everybody. I'm very happy to see that we have a good turnout today to talk about all these models of ICUs because these are all relevant to our emergency medicine nowadays. And I'm Quynh Tran. I'm one of the attending physician at the critical care resuscitation unit since it was opening its door in July, 2013. And no conflict of interest. So in the way to introduce our different models of ICU, I will start out with a little bit of about the staffing of the CCRU. So it is an ICU-based unit. It is staffed 24-7 with a, as of now, all dual-boarded emergency medicine critical care physicians as well as a advanced practice practitioner. We also have on our nursing staff, I would say about 30 FTE or so, at least three nurses per shift and a charge nurse. These nurses are required to have at least two years of previous ICU experience before they come and work with us. The model is a little flexible in a way where when we have a very sick patient, the charge nurse can take over one of those patients and then we can have two nurses or even more to come into the bedside for that patient so that we could continue our resuscitation. A little bit about the operation. So usually when patients, we, because we are an ICU-based, we take patients from different hospitals, units, ICU, ward, ED, when they call us, they will call in through a central access center to ask for a transfer request. And at the time, the personnel from that access center will connect the referring physician to the specialty physician for that patient as well as the specialty ICU that the patient would need to go to. And when that specialty ICU, say, the neuro-critical care ICU, when there is no bed, and usually that frequently is the case, they will call us and we will be on the phone call together to do the triage for that patient. So if the patient is deemed eligible as an ICU patient, then they should come to us, to the CCIU first. Or even if the patient is not a critically ill patient but they need an urgent surgical interventions, they also come to the CCIU as well. And then either on the phone at the triage phone or offline, the specialty physician will talk to us, the CCIU attending physician, about what is the overall role of care that we need to do for the patient as soon as the patient land into our unit. And then we will have a little huddle with our nurses to talk about what we need to get done for the patient upon arrival immediately. And this is a little bit data that we had about the operation from our unit, where we look at time to bed assignment. When we're on the, so we look at, because a median of, this is I think a data for 2018, the median time when the phone call, we pick up the phone call and on the time we say, all right, we have a bed for the patient, we will have sent for the patient now. It's about, the median is about eight minutes. So we looked at the data, the predictors that may be associated with those early bed assignment for these patients. And as you could see, the biggest thing is for stroke patients, those who would need to come immediately to get a thombectomy. And then down on the list, you would see that patients who on the phone, the surgeon say, I need to get this patient here so we get a surgical operation now. And then patient who had high SOFA score, because when we think that the patient is exceeding the capability of the sending facility, we bring the patient to us immediately. And then this a little bit about the operation of the CCRU over the years between 2014 to 2018. As you can see, here is the CCRU and here's the total medical central patient of transfer. We are about 30% or less than 30% of the total transfer of patients, adult patients into the medical center. But then when we look at total ICU transfer, we are about 60% of the medical center for all ICU transfer coming in every year. This is just a little bit introduction about the time for the CCRU when the physician call us and ask for a transfer and the time that we give them a bed. Little here is the ED time. At a time the ED, we take the ED entirely out of the equation because critically ill patients or urgent patient need to come to us and they don't have to go to the ED anymore. So their time is now open up to have for other ED transfer a lot better. But comparing to other ICUs of the institution, the CCRU still offer better or faster bed assignment for these patients. Just a quick pictures of how are the operation. I think this is a picture where we have to do a old bedside thoracotomy. This is another bedside laparotomy and this is a picture about, I think, cannulation for VV ECMO. Little introduction about the outcome for the patients coming through the CCRU. This is one of our early paper and we compare before the CCRU open and when we open a year after. Comparing to patient coming through us versus patient coming in through other ICU. Adjusting for a lot of these confounding factors including things like SOFA score, things like ESI when they come from the ED versus time from transfer request to arrival versus whether the patient is receiving a continuous infusion over outside. So these are the list of few of the factors that we assign for. And we saw that with that, patients going to the CCRU was associated about a 36% lower odds of mortality. A little bit, another paper when we're comparing patients who came to the CCRU versus the neuro-clinical care for stroke with large vessel occlusions. And we could see that for us, when the patient, when the referring physician asked for transfer, when they arrived to the CCRU, it was a little faster when we went through the neuro-clinical care unit. And then when we adjust for different confounding factors in our multivariable logistic regressions, we saw that in the interval from consult or transfer request to arrival at a CCRU, every minute is maybe associated with about a 1%, a delay of a minute is 1% increase out of mortality in these patients. Besides the other usual suspect for stroke patients, like NIH stroke score or aspects. This is a relatively newer paper that we had in AGM when we talked about all the patients who come to the CCRU with lactate greater than four. And we looked at them and we saw that for those patients who arrive in the CCRU, the change of lactate level is about almost two millimole per deciliter. And then the mean SOFA score when they arrive at the CCRU is about eight, with a change of 0.2. And when we put in a multivariable logistic regressions adjusting for all these different confounding factors, we found that every unit of SOFA score that we could reduce for these patients while they were in the CCRU about six hours to eight hours, it was associated about 24%, no, 16% of mortality, lower odds of mortality, as you can see SOFA clearance right here. And so that is just a little introduction about how the CCRU, how we bring in patients fast into a resuscitation unit, and what we provide for them, and how we improve patients' outcome. So, and that is about the CCRU. Thank you very much. Thank you.

Critical Care Resuscitation Unit

emergency medicine

patient outcomes

resource allocation

mortality reduction