So I'm Ben Bassin, I am the director of EC3, which is the Emergency Critical Care Center at University of Michigan. I've been the director since it opened in 2015. Start by saying Go Blue, National Champs. Say Go Lions, I've been waiting 40 years to say that. So that's good too. So just talk a little about our model, what's known nationally now as EC3 or locally as EC3. Our model is more of an ED facing unit, right around the front end. We're in the emergency department as a standalone unit within our ED. At Michigan, not different than probably many of your ordinary care academic medical centers, we have very siloed critical care, or historically have. We have a unit, specialized ICUs for most disease processes. And in the ED, we frequently take care of all of these patients as we're the entry point for over 50% of hospital admissions. But frequently, patients are waiting for geographic-based critical care, waiting to get to the unit they need to get to to get ongoing delivery. Once you transition from the resuscitation phase to the early critical care phase, the model of EC3 was to be kind of more critical care agnostic, knowing that emergency physicians can care for these patients in the first hours of their illness. But if you staff it and resource it appropriately, there's a good chance that emergency physicians, nurses, and emergency intensivists can continue that care so the patient gets the care when they need it, not where they need it. So that's really our model. Again, the inputs to the ED are the same, triage, EMS, helicopter, transfers. Again, as the biggest coordinate care referral center in Michigan, we take transfers from all over the state and other states around us. And we have now five resuscitation bays. We have about 100 ED treatment rooms. Then EC3 is a nine-bed critical care unit kind of embedded within that that allows us a flexible level of care delivery within the ED. We opened almost nine years ago now, because a couple of weeks ago would be nine years ago, that we opened is what I think is the first kind of geographically based and destination unit within an ED or first ED ICU of a physical unit in the country. This is just kind of a floor plan of what it looks like. In the front is five resuscitation bays around the kind of horn is nine critical care rooms are all built kind of inpatient ICU standards. So they're large. We can deliver most care that you could deliver in an ICU in these spaces and have for the last 10 years almost. This is just our staffing model. We have two attendings, 12-hour shifts each. We are kind of buffered with critical care fellows from around the institution, as well as advanced practice providers and residents from many specialties, certainly senior emergency medicine residents. We have an ICU nursing staffing model. So we're two to one with a kind of a charge nurse for the area. We can flex the one to one or one to two when needed. When we have ECMO patients that are patients that need a high level of bedside critical care. And then we have dedicated RT pharmacy and in ED lab that supports our work as well. This is kind of over the years, this number is a little higher now. This is a little old, but we've seen about 18,000 patients in EC3 over the years. This is kind of where they go from EC3. So only about a third will go on to need inpatient ICU admission after we're kind of done. About 60% will still be admitted to the hospital, but to non-ICU level of care. About 8% will go home from EC3 and not require admission to the hospital to any level of care. About 2% will expire in EC3. Many of these are end of life patients or present with non-survivable injuries or illnesses and their end of life is carried through in EC3. We did publish kind of two, but I think might be seminal works in kind of the space of EDICUs. First one is 2019, the one on the left in JAMA Network Open. And that was really about what does this model of care do from a quality standpoint? And the two big endpoints were overall 30-day mortality for all comers, pre and post, two years pre and two years post the EDICU opening, and then also ICU admission rate. And so 30-day mortality decreased by 15% with the opening of the EDICU across all comers to the ED. That's over about 600,000 patients. And then ICU admission rates decreased by about 13%, again, across all comers. But the question then became, and was in the editorial that was published with our paper, was you can't really say it provides higher value until you can say at what cost, right? Because if you have unlimited assets, which none of us do, but in theory you can get quality with deploying significant resources if you have unlimited money, which nobody has. So we had to kind of think about what is the cost to do this model and does it really provide value? So quality at what unit cost? So then we published the second paper in JAMA Network Open just last, or in 2022, that really looked at cost. And so this took about 235,000 ED visits and looked at the pre-EDICU and the post-ICU cohorts and then looked at what was the cost per ED encounter. And that's the cost on the facility side across the entire hospital admission. And we divided into the ED and the inpatient-centric portions, but the cost is for the entire ED, or sorry, the entire ED encounter for that patient. And this is cost. It's not charges, it's not revenue, it's cost. So it actually costs to deliver care on the facility side. And it was essentially neutral, pre and post-EDICU. So it came at not a higher cost of care to the health system to deliver care to these patients. And we had an increased revenue for this patient population post-EDICU and that resulted in a larger margin. You know, if cost stays the same, revenue increases and your margin increases. So we've also tried to publish some of our outcomes over the years over those 18,000 patients as well. These are all from papers that are published around the model. So some are centric to mortality that I talked about before, significant reduction in 30-day mortality across all patients. Essentially for every 330 patients that present to our ED, which is about every day and a half, one life is saved just by having an EDICU. For every 180 arrivals to our ED, one ICU bed is saved. We have a 30% reduction in short-stay ICU admissions. We consider those patients who stay in the ICU for less than 24 hours after they arrive from the ED, which then, as we know, are very hard to get out of the ICU because the floor bed is never available. We looked at how many patients do we extubate in EC3 that no longer have to be on mechanical ventilation. And out of those, only 7% subsequently required an ICU admission once they were extubated. People get critical care faster, because again, they're not waiting to get a bed in the geographic unit to get that care. We can provide that ongoing care that is sometimes difficult in an overrun ED when you have 50 people in your waiting room, you're taking care of 30 other patients, and it's hard to be at the bedside to deliver the true amount of critical care they need. We're now resourced to do that. People will say, well, if you just downgrade a bunch of patients and shove them to the floor instead of putting them in the ICUs, your numbers will look better. So then we had to look at what happens to those patients. Do they all of a sudden bounce to the ICUs in the middle of the night as rapid responses or other things? So despite sending 60% of our patients to the floor, there's no increase in the number of rapid responses going to the ICUs 24 hours after admission from the ED. We sent 20 times more decay patients home that don't need admission to the hospital at all. In fact, we are potentially training an entire cohort of future physicians who have no idea how to manage DKA because it never comes in the hospital anymore. So it might be a bit of a slippery slope, but that has happened. Minor intracranial hemorrhages frequently go home now or will get admitted to a floor level of care and don't need a neuro ICU bed. We do a lot of acute Luke and oncologic emergency care. We provide pharesis very quickly and have shown reduced mortality for this patient population. We do a lot of palliative care, stuff we never actually really planned for when we started. We wound up being kind of a location for a lot of front end palliative care in the hospital. While it's bittersweet, I think it's actually really well resourced and done very well. And we've talked to lots of patients' families who feel the experience who've gone through with other family members is optimized significantly by having an ED ICU in the ED on the front end. And they never have to be admitted to the hospital or follow their family member in their last 24 hours of life throughout the hospital. We, for patients with critical GI bleed, stay in the hospital almost four days less. We do a lot of endoscopy and EC3 and a lot of source control early and a lot of early aggressive resuscitation. We are much more compliant with our ventilation bundles than we were previously, as you can imagine. We can pay attention to that now. We get ABGs, we titrate our vent parameters within 30 minutes of intubation, which was previously very difficult to do in an ED, which is incredibly busy. And then, as I said before, this all comes at essentially cost-neutral model of care, which I think imparts its value. I'll just close by saying, you know, we've been around, we've been doing this for almost 10 years now, and we've talked to some, a lot of you probably work at a lot of these places. You may not have an ED ICU and you probably don't, but we have talked to a lot of places around the country about the model, and it's certainly not the right answer for lots of places, but it is for some. And so we've been happy to partner with lots of other places to talk about the model of care looks like, what it could look like, it may be very different than what we have, but it's been a great journey, and we've really, I think, had some significant impact, and I think there's a big future in this space of ED, critical care, and providing care at the front end. So with that, I'll finish and turn it over to Yoshi. Yeah. Thank you.

Emergency Critical Care Center

ICU integration

mortality reduction

resource allocation

critical care model