Resource Intensivist Model
Detroit Receiving Hospital/Wayne State University
Detroit Receiving Hospital (DRH) has addressed the challenges of caring for critically ill ED patients with an ED-centric model. A novel emergency department-based critical care (ED-CC) rotation was established in 2006 for all PGY-2 emergency medicine residents. The ED-CC resident functions as a floating resident 7:00 am to 7:00 pm (Monday through Friday), providing support and adjunct care for all critically ill ED patients. This includes attending all medical and trauma codes and facilitating the delivery of protocol driven care (including induced hypothermia and the sepsis protocol). A supervising emergency physician is available to the ED-CC resident at all times and rounds with the ED-CC resident daily on all ICU admissions and consults. Each ICU patient with an ED length of stay of > 4 hours receives a checklist-driven quality of care review to assure exemplary patient management. Finally, an electronic medical record (EMR) based-alert system provides ongoing automated surveillance for patients who may be critically ill. This alert, which fires within the EMR, is useful to identify patients with a high likelihood of requiring ICU admission.
In 2010, the department appointed an ED Critical Care Director. The job description includes serving as the ED liaison to the MICU, assisting with protocol development, serving on both the system wide critical care committee and sepsis committees, new technology and device review and procurement, providing ongoing critical care education to the physicians and ED nursing staff and various critical care related administrative support for the ED. A collaborative and constructive ED-MICU relationship is fostered through regular meetings between the ED Critical Care Director and the Director of the MICU. The MICU team rounds twice daily on any MICU patients remaining in the ED and provides direct communication to the ED team. Concerns of care from the ICU teams are regarding ICU admissions are reviewed by the ED Critical Care Director and if appropriate, forwarded to the emergency department Care Quality Initiative committee for peer review and adjudication.
University of Pittsburgh Post Cardiac Arrest Service
At the University of Pittsburgh, the Post Cardiac Arrest Service provides emergent bedside consultation on post-cardiac arrest patients regardless of location in the hospital. This permits direct admission of a critically ill patient to the ED or ICU even during volume surges, with the knowledge that additional resources will be at the bedside. This group is comprised of EM and CCM attending physicians with expertise in the post-cardiac arrest syndrome, treatment with therapeutic hypothermia, and post-cardiac arrest neurologic prognostication. These physicians coordinate the care between the prehospital arena, the emergency department, intensive care unit, floors, and rehabilitation unit. This approach provides continuity for the patient, their family, and the treating team based on disease state rather than geographic location. Direct attending coverage permits the ED consulting physician to care for other patients while the Post Cardiac Arrest Service provides the first several hours of initial resuscitation and diagnostic workup to these resource-intensive patients. By adopting an approach where the physician is brought to the patient, a cadre of clinicians has developed expertise on the spectrum of needs for this low-frequency, high-consequence disease state, resulting in improved neurologic outcomes.18
From an educational standpoint, medical trainees value the dedicated one-on-one time with an attending who provides direct procedural or didactic teaching as part of the resuscitation. Close collaboration with other clinicians involved in the care of these patients improved cardiovascular and neurologic interventions for these patients and resulted in the development of a novel illness severity scale for this population.19-21 This group also provides the initial resuscitation to other critically ill patients involved in clinical trials. Thus, such an EDI model can yield clinical, educational, and investigative dividends.
University of New Mexico Health Science Center
UNMHSC may represent the largest ED-Intensivist group with five ED-ICU faculty members who staff the Trauma-Surgical and Neurosciences ICUs as well as the ED. This provides a strong critical care complement to the other subspecialties within our department such as Ultrasound, EMS, and Toxicology. In addition to the merits of this model within our academic Emergency Department as discussed earlier, this crossover has provided our institution with the ability to provide 24/7 in-hospital ICU coverage. This group also provides consultations and procedural back-up throughout the hospital during off hours. This was otherwise difficult to create and maintain given the decreasing numbers of fellowship graduates from other intensive care specialty groups. The involvement provided from this group matriculates at least one EM resident per year into critical care fellowships. Additionally, UNM provides a fourth year medical student rotation in ED-Critical Care to highlight this crossover at the student level.
Virginia Commonwealth University
VCU has a model similar to University of New Mexico. Four EDIs act as resource intensivists in the ED and provide coverage in the cardiac-surgical ICU, neurological ICU and surgical/trauma ICU.
RED-ICU (Hybrid Unit Model)
RACC at Elmhurst Hospital, Elmhurst NY
The Resuscitation and Critical Care (RaCC) at Elmhurst Hospital Center is a 7-bed unit capable of providing the same critical care modalities as an inpatient ICU. The unit is staffed by a full-time resident assigned only to the 7-beds as well as dedicated attending coverage for 22 hours per day. Nurse staffing is at a level of > 1 nurse per 2 patients. Crashing patients are placed in the unit directly at EMS arrival; additionally any patients decompensating in the main ED are transferred to the RaCC. When there are empty beds, sick, but non-critically ill patients are taken from the general ED to maximize resource utilization. This unit is an example of a RED-ICU hybrid unit as mentioned in the main body of the article.
The unit is directed by an ED Intensivist (SDW), who does a majority of his clinical time in this unit. When this EDI is not present, general EPs staff the unit as attendings. In the 7 years since the inception of this unit, the general attending staff has shown that advanced critical care is within the purview of any emergency physician so long as they have the dedicated time and support to take care of these resource-intensive patients.
A dedicated critical care lecture series is provided to the residency and aggressive nursing training is offered on an ongoing basis. Patients who clearly require ICU beds during their first hours are capable of being downgraded to lower acuity beds routinely after a few hours in the RaCC. This factor, along with early treatment of time dependent conditions such as sepsis and post-arrest and an aggressive approach to addressing questions of end-of-life issues, has led to the unit being a huge benefit for our ED.
Stand-Alone EDICU Model
To our knowledge, there are no examples of this model in the US. The authors are eager to communicate with any practitioners of this model.