My name is Matt Johnson. I am a surgical critical care fellow at Albany Medical Center. However, I'm going to be presenting on the resource intensivist team at Washington Hospital Center. This is another ED-based approach similar to what we've heard from Stanford as well as from Henry Ford. I don't have any disclosures. So a little bit about Hospital Center. It's a 912-bed quaternary referral center, and it has all the accoutrement that comes with that. We're a level one trauma center, comprehensive stroke and cardiac center, as well as a burn center. We have about 100 ICU beds, as well as 27 intermediate care beds. And our emergency department has approximately 50 beds, although that flexes based on boarding and staffing. We see approximately 87,000 ED visits a year and have about 25% admission rate. MedStar as a whole has a 30-person EM residency. That's across three classes. And most recently, we have a total of 16 dual-trained physicians in emergency medicine and various subspecialties of critical care. And our flow looks like the flow of any of our emergency departments. Patients come in through either the front door or via EMS, and they're sent to a couple of different emergency department teams. These teams are an emergency medicine physician who's one-to-one with a resident of some type or an APP. And we shoot for a four-to-one nursing ratios. And typically, these patients are seen and evaluated by the ED team. And then the ultimate disposition is up to that ED team. However, most hospitals have seen increasing volume over the last few years. And with that has been increased acuity of the patients, as well as increased ED boarding. And so to combat this, we thought of the idea of a resource intensivist team. And so this was a team of a dual-trained emergency medicine physician in both emergency medicine and critical care, as well as a senior EM resident. There weren't any other changes to our staffing for this team. And we deployed it during times of increased volume, very similar time period, 2 to 10 PM. And our ultimate goal was to improve patient flow, bring critical care down to the bedside of these emergency department patients, and provide improved resident education at the bedside of these critically ill patients. And so when our resource intensivist team is deployed to the emergency department, we still have our typical flow. Patients are initially brought to their primary ED teams. And it's those same teams that we would have the rest of the time. However, if the ED team deems a patient is critically ill, they can shunt that patient to the resource intensivist team. The team then takes over the management of the patients at the bedside. We don't have a specific area that we locate these patients, and we don't change our nursing. It's the same nurse that had the patient prior to them being taken over by the resource intensivist team. No other changes are in our department. Now, this is the most common way you get to our resource intensivist team. Less commonly, we will take patients directly from EMS. These are typically patients in cardiac arrest, respiratory failure, and the resource intensivist team takes over the patients at the bedside. Once they take over, they continue to manage the patient until they get disposed to their ultimate location, whether that's an ICU or an OR. Or at the end of their shift, if they're still in the department, they'll be shunted back to that primary ED team. And when we looked at some of our data, the biggest thing is that we saw 24, almost 25% downgrade rate. And this is from initially deeming these patients as critically ill down to a lower level of care, whether that was an intermediate level of care, a floor, or less commonly, even home. We looked at a bunch of different things as well as far as the management of these patients. And an interesting finding was that these patients had a faster time to first antibiotics, about one and a half hours compared to four and a half hours from arrival to the emergency department. It's a little bit biased. These patients were much sicker like you would expect from a patient that are managed by a resource intensivist team. But ultimately, very interesting given all the pressure we're all put on for surviving sepsis guidelines. The biggest pros I see from our team is that we didn't have any change in space or nursing. That's super difficult with all of our emergency departments where we're already stretched. And we just added this team to our standard care. So it was really easy to roll out. And then we're also able to target our care to the patients where they were, no matter where they were in the emergency department. And then again, being an academic emergency department, resident education was super important to us. And so we were able to provide that one-to-one care at the bedside of these critically ill patients instead of providing EM education up in an ICU or purely based on didactics. Now, of course, with pros, we have a couple of cons. And we benefit from having a huge number of dual trained physicians in our emergency department already. And we realized that not every institution has that. So we've benefited pretty greatly from that. We also increased our physician staffing. We added another physician during these times. And so you could raise the question is whether there was a better utility of that physician, whether OBS or triage or something like that. And that wasn't something that we've looked at thus far. And then the last thing that's been brought up is was there a loss of opportunities to the rest of the emergency department? We're taking these critically ill patients away from other EM physicians, and they're losing that opportunity to manage the patient that why a lot of us went into emergency medicine in the first place. I think for me, the biggest thing is that this is a really portable system. We have very similar systems that we've already heard about at Stanford and Henry Ford, but also where I'm currently doing fellowship, we use the very same system where we deploy a resource intensivist to our emergency department when we have high QD patients. And I thought the study out of the Eastern Shore of Maryland was also very interesting. We're all very large academic centers, but the Eastern Shore is a smaller group of hospitals. And they had a very similar system where when a patient was deemed critically ill that was boarding at an outside institution, they would send a physician to those institutions to try to take over the management while they're getting disposed. Ultimately, we think our resource intensivist team has been great for us, but as everyone has spoken about, each system needs to figure out what helps them manage their patients that are boarding in the emergency department. Thanks. Thank you.

resource intensivist team

emergency department

critical care

patient flow

resident education