Thank you for coming to my session. It's titled Time Zero, ICU-K on Arrival to the ED. So my last name is pronounced TET, H is silence. So I'm an assistant clinical professor at Stanford and I'm training emergency medicine and critical care. So welcome to California and to the Bay Area. I have no conflicts of interest to disclose. So the objectives of my talk today are to discuss ED boarding of the critically ill and their outcomes as the background to dive into the literature on improving ICU-K in the ED from recent years. So I'd like to take you to a day in the emergency department. And I often think of it as a very complex highway system. People of all socioeconomic backgrounds use the highway to get to their destination. And the destination may be getting admitted to an ICU, getting admitted to trauma service after a major accident or being transferred to a psychiatric hospital. It is very chaotic. People cannot live in the highway. They get on and they get off. And I am sure that you've been stuck in the highway recently, but did you know that in the last 10 years highways are getting more congested? Similarly, ED patients' volumes have increased by 30%. And this is from 2005 to 2015. And the recent data actually shows that the volumes have increased most. And the visits among the critically ill have increased by 80%. So the increase in ED volumes are not just because of low-acuity visits. However, at the same time, there is a minimal growth in ED capacity and inpatient ICU beds. And this data shows that the ICU patients, the amount of time they spend in the ED waiting for a bed have increased over time. And in fact, 33% of patients wait at least six hours to get a bed in the ICU. The problem with boarding is when patients wait for a long time in the ED, they have a higher mortality. And especially for critically ill patients, that mortality directly increase with the duration of boarding time. So one study found that patients who were boarding longer than 24 hour had a mortality as high as 57% compared to 37% if they were to get immediately admitted to an ICU. So you may ask why mortality is worse with boarding. There are several reasons. Similar to the highway system, ED was never designed to house patients for a long time. The training and focus of care has always been to stabilize patients and to move them. So after taking care of a critically ill patient, the emergency medicine physician will have to move on to the next incoming trauma or the next patient with chest pain. Similarly, the patient-to-nurse ratio is never designed for long-term care. Because of those reasons, if you look among patients who got successfully resuscitated after an out-of-hospital cardiac arrest, their survival-to-discharge odds ratio goes down if the boarding time increases in the ED. If we look among patients who are intubated, the probability of the ventilator being a lung protective ventilation goes down if ED becomes a crowded place. If we look among patients who are admitted for severe sepsis and septic shock, there is an increased odds of delay in administering second-dose antibiotics if ED is crowded. And that delay happens in 31% of patients. And some patients are delayed for a six-hour, some patients are delayed for longer than 12 hours. So now you may start to feel stress, like the driver's stuck in traffic. We all like to experience the highway system that's not congested, and we can get to the destination smoothly. But in reality, our healthcare system is starting to look like the picture on the left. The highway is congested, and the stress of it carries all the way towards the destination. So how do we improve the situation? Here's a spoiler alert. It's very similar to traffic control. Building more hospitals don't solve the problem. Luckily, there has been several task forces looking at this situation at a national level. Recently, Society of Critical Care Medicine and ASAP, American College of Emergency Physicians, joined task forces to understand the implication of this. The mitigation strategies can be from the ED, from the hospital, or at a regional, at a national level. And resuscitation care units have been proposed as a strategy that can help from all three systems So in terms of ED solutions, they include making sure that we care for the critically ill patients in the ED as if they are in the ICU, with proper sedation, infection prevention, and hemodynamic monitoring. However, it does require that staffing is appropriately designed for that. So we tested this at our institution. In 2015, we started having dual-trained ED and ICU nurses in the ED 24-7. So after a critically ill patient is admitted to ICU, but while they are boarding in the ED, these ECC nurses take care of the patients together with the primary nurse. And so in compared to the pre-intervention period, a higher percentage of patients were downgraded from ever needing ICU level of care. And so we improved the patient flow. But not only that, even though there was a higher percentage of downgrades, the mortality remains the same, even though there was an increase in ED visits after 2015. So the presence of adequately trained staff is protecting from a higher mortality expected with a worse boarding situation. In terms of solutions from the hospital, it often needs to come from a multidisciplinary site and there is an interdependence of OR, ED, floor and transfer centers, all competing for the same ICU. But to top it off, majority of US hospitals are operating at a surge level and they are functioning at a crisis level. So your hospital, like mine, is likely reinventing ways to improve input, throughput and output at the hospital level. And one strategy I'd like to talk about is creation of resuscitation care unit. I'm gonna take you to the resuscitation care unit at University of Michigan. It's a nine bed ED ICU called EC3. ED nurses with critical care experience staff EC3 at a two to one nursing ratio and a separate emergency medicine physicians with critical care experience staffs EC3, together with residents and fellow. So patients are brought to the emergency department and they're triaged in regular emergency department treatment rooms by the primary clinicians. But once the patient is determined to need an ICU level of care, they are transferred to EC3 treatment rooms. And from EC3, patients can be sent to the OR, ICU, to the floor or discharge. And I'm gonna talk about several papers coming from these investigators. So compared to pre-intervention period after creation of EC3, there is a decrease in ED to ICU admissions. And short stay admissions, meaning ICU length of stay less than 24 hours also got better, also got reduced. And the risk adjusted mortality for all ED to ICU admissions also got better, so reduced. And if we look at cost effectiveness of the model, EC3 is associated with similar inflation adjusted total direct cost per ED encounter. So the hospital used RCC, which is the ratio of cost to charge to determine the facility cost. So the investigator added RCC plus the charges for the ED encounter to find out the total direct cost per ED encounter. And that cost remains around 4,800. But at the same time, the net revenue per ED encounter increased by 7%. And can ED ICU mitigate the risk associated with boarding critically ill patients in the ED? So by using multivariable regression analysis, the investigators are trying to find out whether there's an association between boarding time prior to ED ICU transfer and then worse outcomes. And the outcomes they investigated were 48 hour mortality, hospital mortality, hospital length of stay, and inpatient ICU length of stay. And there was no association found between boarding time and any of the worse outcomes. So the presence of ED ICU is mitigating the risk associated with boarding critically ill patients in the ED. If we look among patients who have an upper GI bleed compared to pre-intervention period, there is a decreased hospital length of stay by one day after creation of EC3. And fewer patients were admitted to an ICU. So I hope our gastroenterology colleagues are in this talk because having an early EGD is important and we need you. And in this paper, they found out that after creation of EGC3, EGD happens in 55% of the time while patients were in EC3 compared to 12% of the time in the pre-intervention period. But EC3 also allows for us to deliver palliative and end-of-life care. So 2% of all ED ICU admissions were for end-of-life care. And among those patients, 10% were discharged home, hospice, or to a facility. The majority of patients were admitted to the floor or passed away in the ED ICU. So reducing the need for an ICU admissions. And we as emergency medicine providers with ICU experience, we can actually start the discussions on palliative care early and can change the trajectory of patient's clinical care. And we all know that having patients on lung protective ventilation is crucial to prevent ventilator-associated lung injury. And after creation of EC3, the percentage of patients who are on lung protective ventilation strategy improved to 65%. So similar to University of Michigan, the majority of other hospitals, the systems have also investigated ways to improve care of the critically ill in the ED. You know, Henry Ford and Stony Brook have hybrid ED ICU. University of Maryland and UPenn have resuscitation units. And some care models are personnel-based. So meaning there is no dedicated unit that critical care trained personnel takes care of the patient, you know, critically ill patients. So Henry Ford and Stanford are personnel-based model. So you can tell that I'm not biased at all about this talk. And since this is a pretty new field, I'm sure there's gonna be a lot more evidence-based papers, published papers coming in the near future. Even this weekend, I saw several abstract presentations from CCIU at University of Maryland. And our group presented the data on the outcomes of DKA in our ED ICU model. We also have a paper coming up about our outcomes overall. So stay tuned for more information. And I think there is also a session tomorrow on ED ICU proof tomorrow as well in SCCM. So in summary, you know, boarding critically ill patients in the ED have negative outcomes, not only on the patient, but also on the whole system. And resuscitation care units can be a solution to improve outcomes of ICU border. So you may ask, how does the future look? With crowding, I think, you know, with population growth, we're likely to see no crowding. And if you follow real estate at all, physical space is a tight commodity, especially in the Bay Area. So how is there light at the end of the road? I think we may need to think outside the box in the future of critical care. Luckily, we live in a very materialistic world and equipments like ventilator or medicine are easier to achieve. But if the care of a critically ill patient requires adequately trained staff, can that care be provided regardless of the location? As long as the right person is providing the right care at the right time. I think in the future, ICU may become a location to house the sickest of the sick among the critically ill. And we may need to reconsider the criteria SCCM guidelines on who needs a unit admissions. With that, thank you for your time.

critically ill patients

emergency department

boarding

mortality rates

resuscitation care units