Hi, everyone. Thank you for coming. I'm excited to discuss the topic of prolonged critical care in the emergency department. I'm an assistant clinical professor at Stanford University. I'm trained in both emergency medicine and critical care. So I have no conflicts of interest to disclose. So the objective of my talk today are to discuss a little bit of background on ED crowding and the effect on critically ill patients. And I'm going to discuss three papers published in the last year relevant to this topic. One is in regards to overnight stay in the EDs in France. And another paper is about critical care team in the ED. And the last paper is about critical care unit in the ED. So before coming to this conference to relax, I meant to learn, you probably witnessed that your hospital is getting congested, especially in the emergency department, like a traffic jam. In fact, from 2005 to 2015, there is an increase in ED visits by 30%. And at the same time, there is a minimal growth in hospital beds. And the percentage of hospital-based EDs actually decrease. So patients in the ED wait a long time to get admitted, which is known as boarding. The problem with boarding is patients who are in the ED longer than six hours have a higher in-hospital mortality. So for critically ill patients, the mortality increased with duration of boarding time. Patients boarding longer than 24 hours have a mortality of 57% compared to 37% if they were to get immediately admitted. So with this background information in mind, I'd like to take you to the first paper published in JAMA. It is a prospective cohort study at 97 EDs across France. The study evaluated 1,598 patients older than 75 years old who were admitted to the hospital from the ED on December 12 through 14, 2022. And the two groups were those who stay in the ED from midnight until 8 o'clock in the morning and those who were admitted to the hospital before midnight. So the outcomes were followed until discharge or 30 days. And I should mention that in France, the care of patients waiting for a physical ward bed are the responsibility of the ED team. Lucky for them, I guess. So the medium length of stay in the borders in ED was 23 hours, while the ward group was 7 hours and 35 minutes. In-hospital death is higher by 4% in the ED group for all-cause mortality. For the secondary outcomes, adverse events were higher, 30% compared to 23%. And out of all adverse events, the significant ones I'd like to mention were nocosomal infection, hypernatremia, and fall. And if we look at in-hospital length of stay, it's also longer by one day. So this is the first largest study across many EDs looking at elderly population. And just by staying overnight in the ED with a longer length of stay, that patient has a worse mortality and morbidity. So how do we solve these boring situations? How do we go from the congested traffic on the left of the picture to the smooth traffic on right? So there has been several task forces from SCCM and ASAP looking into this. Mitigation strategies can be organized as ED solutions, hospital solutions, or creation of resuscitation care units. In fact, there is a SCCM Congress session tomorrow on different models of resuscitation care units of teams in the ED. So the next paper I'd like to discuss regarding a resuscitation care team is a single-center retrospective cohort study at Stanford. So as a background, I'd like to explain the Emergency Critical Care Program, or ECCP, at Stanford. It was launched in 2017 for medical ICU patients. So a physician who is board-certifying both EM and critical care is staffed as an intensivist in the ED during the peak hours of patient volumes, which is 2 p.m. to midnight on the weekdays. So at that time, Stanford ED has already established the presence of an ICU trained nurse 24-7 to take care of critically ill patients. So what happened is after the initial resuscitation by the ED team, there is a dedicated best site critical care team for medical ICU patients. And the study's goal is to evaluate the outcomes of 2,250 critically ill patients before and after initiation of ECCP. So we looked at patients from 2015 to 2019. So a primary outcome was evaluating in-hospital mortality. They used difference-in-difference analysis to account for potential changes over time between pre-intervention and post-intervention period. So they used patients arriving to the ED doing non-ECCP hours for comparison. They also used surgical ICU patients as an alternative cohort. So there is a decrease in in-hospital mortality doing ECCP hours. And using difference-in-difference analysis, the mortality decrease was 6%, while the alternative cohort has no change in mortality. So to understand this mortality benefit better, patients are evaluated in regards to their severity of illness. Patient severity of illness is divided using ECC SOFR score, which is similar to SOFR score. Uses vital signs. Examine lab values in the emergency department. And the mortality benefit is 12% in patients with intermediate severity of illness. And investigators discussed the importance of early interventions and resuscitation. And especially for this cohort, intermediate severity of illness, providing a dedicated bedside critical care in the ED was very beneficial. Another primary outcome evaluated was whether ECCP saves the hospital ICU beds. So it identifies the patients who get downgraded from meeting ICU level of care within six hours. There is a 4.8% increase in patients who get downgraded with ECCP. But it wasn't statistically significant. But however, we look among patients with intermediate severity of illness, this group had an 8.8% increase in downgrades. And it was statistically significant. And the study also found that there is no increase in ED length of stay with the presence of critical care physicians in the ED. Or there is no increase in eventual bounce-up admissions to the ICU. So we've learned that the presence of ED and critical care intensivists help with mortality. So how about a resuscitation care unit in the ED that can adjust the traffic of critically ill patients and drive up or down the level of care they need? So the next paper I'm going to discuss is about the benefit of ED-based ICU at another institution and how this institution tackles the boarding crisis. This is based in the University of Michigan. It's a retrospective single-center observational study. So as a background, I'd like to take you to the resuscitation care unit at U of Michigan. It's a nine-bed ED ICU called EC3. ED nurses with critical care experience staff EC3 at a 2-to-1 nursing ratio. A separate emergency physician with critical care experience staffs EC3 with resident and fellows. So all adult ED patients are evaluated by ED clinicians. And if the patient is determined to need critical care, they can be moved to EC3. From the EC3, patients can be admitted to ICU, sent to the operating room, downgraded to a lower level of care or discharge. So the study's goal is to identify patients who decompensate it while boarding in the emergency department. So they look for patients who were initially admitted to a non-ICU level of care but upgraded to an ICU level of care while being in the ED. So a total of 1123 ED visits in nine years were identified. And there were three groups, pre-ED ICU group, post-ED ICU implementation with ED ICU care, and those who were admitted to ICU directly without ED ICU care. And the outcomes they study were ICU length of stay, hospital length of stay, mortality, and percentage of short stay ICU admissions. So mean ICU length of stay was 49% shorter for patients cared for in the ED ICU group. It was 47.4 hours compared to 92.3 hours. Comparing between the two groups after implementation of ED ICU, patients who had ED ICU then get admitted to inpatient ICU, this group two, still have a shorter length of stay compared to group three. The mean hospital length of stay is shorter too. It was over two days shorter for patients cared for in the ED ICU. And in-hospital mortality was similar across three groups. So now if we look at short stay ICU admissions, meaning patients who have a length of stay less than 24 hours, ED ICU group has the lowest emission rate of short stay ICU. So ED ICU was effective in preserving ICU beds for those who need ICU for a prolonged duration. So in summary, patients older than 75, vulnerable populations with a higher mortality and morbidity just by boarding overnight in the ED. And ICU and ED trained intensivists staffing the ED reduce mortality. And that benefit is most pronounced in patients who have intermediate severity of illness. And the ED ICU helps with length of stay for ICU, hospital, and many downstream resource preservations. So maybe we can all imagine a better future where traffic of critically ill patients is better controlling the ED. Thank you.

ED crowding

critically ill patients

Emergency Critical Care Program

mortality reduction

boarding crisis