Good morning. Thank you, everyone. My name is Namita J. Prakash, and I work at Henry Ford Hospital. I'm an EM intensivist there. And so I'm here to share with you the early intervention team journey. And much like what you just heard from Dr. Madurai at Stanford, we're an ED-based critical care consult service. I have some disclosures and nothing relevant to this particular talk. So Henry Ford Hospital is located in southeast Michigan in the heart of Detroit. And for anybody who's a football fan, we are now associated with the success of the Lions, which has been a long-term coming. And it's also the reason that the Michigan chapter was probably missing from the conference yesterday afternoon. The early intervention team actually dates back to the late 90s at Henry Ford Hospital. And it was started by Dr. Rivers as a response to the fact that we have a broad representation of critical care patients that arrived to the emergency department. And it was really bringing the ICU level of care down to the emergency department to think about those early interventions. The early intervention team origins focused around a opportunity for learning. As an academic site, we do have residents, and it's a resident elective. And it also gave us an opportunity to identify patients and enroll early in some of our prominent research. As time goes on now, in the early 2000s, addressing the evolving need of delivering critical care in the emergency department, some of the things that Henry Ford Hospital did to address that, it included expanding our critical care category one area, so one of the original hybrid ED RCUs where it was intensive care capable beds. But as time continued to go on, our problem was consistently a rise in boarding time. So ICU beds were full, despite the expansion to over 64 medical ICU beds at our Detroit campus. We're always full. We have boarders in the ED waiting for the medical ICU for 24, 48, 72 hours. And that volume and burden continued to rise. Simultaneously into closer to 2017, 2018, we started to have a critical mass of EM intensivist. And so it was a great time to start thinking about how do we further evolve to address the needs. And to do that, we needed to just define the problem, establish what the real needs were, evaluate what the best model was that would fit our needs. It was clear at that point that we didn't have the geographic space to add on to a geographic ED ICU like you heard with the University of Michigan model. We certainly did not have the finances to do that either. And so it really came down to how do we implement a program utilizing the existing resources to address the needs of our patients. In that process, it first began with identifying certain disease states and where would the need for critical intervention be. And so as a mass, we identified some high yield critical care groups, including postcardiac arrest, respiratory failure, sepsis, stroke, shock. What would the interventions be? And those are some of the things that we think about for ICU care and really building on that early concept from the EIT and thinking about how can we help support our teams deliver the care at the bedside. And then determining, helping determine the best disposition. I just told you, boarding is a major problem and it continues to be an expanding problem at the Detroit campus. So our roadmap included creating a system where the patients are arriving to the emergency department, they're going through our typical process, they're triaged to our category one area, they're evaluated by our emergency medicine team. And there's really two opportunities for the ED critical care consult team to get involved. One could be that the patient is deemed for admission to the ICU and they continue to board in the emergency department, they're boarding for the ICU. Another opportunity, however, might be that the EM category one attending physician has some discretion that, you know, it's clear that crowding is a problem, there's competing demands, perhaps I as the team leader leading my team clearly need some extra focused help for this particular patient. So with some suggested criteria, the discretion of the senior attending to consult the EIT team. So in 2023, now 2024, we are currently at a state where we have 10 EM critical care faculty available. Each of our faculty both work as emergency physicians as well as critical care intensivists between the medical ICU and the surgical ICUs. And we also have a portion of our time where our emergency medicine duties include the EIT service. This service is a Monday to Friday service, it's a consult service, 2 p.m. to 10 p.m. And we continue to have our academic mission and so it is available as a senior resident and ICU fellow elective rotation. Over the last few years, in the beginning, we launched in February 2018 with this more formalized model of EIT and you can see that we've seen a growth in the number of consultations. When we looked at our outcomes, so you know, one of the early theories when we launched in the design phase in 2017 and into 2018 was, okay, if we bring this early intervention to the emergency department, how is it going to impact our patients? And we started with a premise of perhaps it's going to impact our hospital length of stay. And so this data goes from 2018 to 2020, we had over 1,700 patients. These were patients who were being admitted to the ICU either after EIT consultation or as per usual care. Now what we did notice is that the patients who had EIT consultation had a higher boarding time. Hospital length of stay did not, it was not significantly different between the two groups. And I think what we did not anticipate is throughput challenges in the hospital side would be impacted more by social factors. Challenges to discharge to subacute rehabilitation that skyrocketed in 2019. And so that was something that we really had not anticipated in selecting that primary outcome. There really is, there's a bit of a selection bias. The service, when we looked at the modified SOFA scores for these patients, the patients that got an EIT consultation were more likely to have higher modified SOFA scores. So they were boarding in the emergency department longer, and they were sicker. And so really as a service that was designed to help offload the cognitive burden of caring for critically ill patients in the emergency department, we were a success. It worked. And we worked to serve that purpose. And it continues to work to serve that purpose as we continue to see a rise in the boarding times and the challenges with crowding that we're facing at Henry Ford Hospital. As a consultation model, the delivery of the impact of the interventions was a little bit more challenging, and understandably challenging. Unlike the Stanford model where you heard about the dedicated nurse to patient ratio that is both supported by the California rules, but also with the extra staffing of the ECSP. At Detroit, at Henry Ford, we did not have an extra ancillary support. So this is a physician consult-based service. So we've got the recommendations, but the delivery of those interventions are still going to be influenced by the crowding in the Category 1, because the nurse ratios are still exceeding. So a 16-bed Category 1 that has 30 patients in it, it's challenging at the best of times. So in summary, the early intervention team at Henry Ford Hospital continues to add value for its purpose. It serves that purpose as a response to the problem. And that problem is crowding and boarding of our critically ill patients. It serves its purpose to support the primary emergency department team. It is expanded for the clinician capacity of that team. And it allows us to deliver longitudinal critical care and complex critical care in the emergency department in an early manner. It's also a great teaching model for graduate and medical education, residents, and fellows. But we do recognize there are opportunities to support our nursing ratios to deliver those critical interventions. There's opportunities to expand to our health system emergency departments with the growth of telehealth and virtual consult models. The Detroit campus is the flagship of the Henry Ford Health System. But our satellite emergency departments and our other acute care hospital emergency departments are now also feeling the pain of crowding and boarding. And the critical care team-based service, is it to just a physician, or is it really about taking that concept of ICU multidisciplinary approach to the emergency department as well? Thank you so much. Thank you.

early intervention team

critical care

emergency department

staffing constraints

telehealth