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A6287 - Effect of Implementation of Emergency Department Critical Care Response System on Patient Disposition and Outcome
Author Block: K. Morrissette1, C. D. Hypes2, J. M. Mosier3; 1University of Arizona, Tucson, AZ, United States, 2Emergency Medicine, Tucson, AZ, United States, 3Emergency Medicine, University of Arizona, Tucson, AZ, United States.
Rationale: Emergency Departments (ED) are a common site for initial resuscitation of critically ill patients in the hospital. Despite this specialization, longer emergency department stays have been associated with increased mortality in critical illness including sepsis, respiratory failure and GI bleeding. Emergency physicians trained in critical care medicine present a potential solution to this problem by providing dedicated critical care management during periods of ED patient boarding. We present a pilot response system, meant to address this high-risk period for critically ill patients by stationing a dedicated intensivist in the ED.Methods: This is an observational study of patients boarding in the ED awaiting a medical intensive care unit (MICU) bed. All adult MICU admissions from the ED were extracted from the electronic medical record. A total of 34 days were selected on the basis of convenience during the period of July 2017 - September 2017 during which an attending physician, board certified in both critical care medicine and emergency medicine, would be present for a 12-hour period. These physicians sole responsibility was to provide care for those patients whom the emergency physicians identified as intended for admission to the MICU. The patients were divided into two groups: patients with intensivist involvement and patients receiving standard care. Mortality was evaluated using the Fisher’s exact test.Results: During this time period 761 patients were admitted to the MICU from the ED, 113 were included in the trial group. Of these 113 patients 31 (24%) were either discharged to home, downgraded to floor status or transitioned to comfort care measures in the ED. The remaining 75 (66%) were admitted to the MICU. Of the 761 patients admitted to the MICU from the ED there was a significant difference in in-hospital mortality in the control group (109/686, 16%) versus those in the trial group (5/75, 7%) [p=0.03]. Patients with intensivist involvement during boarding had 2.67 times the odds of survival compared to patients without it. In a subgroup of patients requiring mechanical ventilation, mortality was lower for patients with ED based intensivist involvement: 17% (4/23) vs 33% (76/158). Conclusions: These early results suggest a benefit to patient survival as well as a shift in disposition associated with utilization of a dedicated emergency department critical care response system. Further study and analysis will be necessary to better understand patient characteristics, resource utilization, and examine additional outcome measures.