On Podcast 168, I discussed Michigan's EC3 stand-alone EDICU. The folks from the EC3 recently published on their first 2.5 years of operation in a before and after trial.
I gathered a bunch of my EC3 buddies to discuss the article.
On the call, you will hear:
- Bob Neumar, Chair of EM
- Kyle Gunnerson, Division Chief of Emergency Critical Care and Director of the EC3
- Ben Bassin, Operations Director for the EC3
- Renee Havey, CNS for the EC3
- Nate Haas, EC3 Faculty
Tell us what you think below
Now on to the Wee…
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Scott Weingart
An ED Intensivist from NY.
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I’m not really clear on where the benefits of the EC3 come from. The resuscitation unit absolutely makes sense, but here it seems like you’re just admitting a patient to a different ICU. What is different about admitting a patient at 90 minutes to the EC3, they go there, and are taken care of, and admitting a patient at 90 minutes to the ICU, they go there, and get presumably the same care? Is this model really only beneficial when patients aren’t able to move to the ICU in a timely manner?
yeah it is an interesting ? with a stand-alone ICU.
Possibilities include:
1. ICU Is run by EM rather than specialty specific
2. Pts get ICU beds the moment the team wants one as opposed to 12-36 hrs later like it would be without EDICU
3. Pts leave critical care the moment they are able to avoiding the badness of iatrogenesis in ICUs
4. EDICUS are unlikely to build superbugs like most of the ICUs that host long-term crit care patients
Hi Andrew – I might be able to help a bit. It may not be as obvious because it is in the appendix/supplemental tables of our JAMA paper, but I think there are several significant impacts of the ED-ICU model: 1) Only 30% of the patients who come in to EC3 critically ill go on to need an inpatient ICU bed in the hospital. The rest are able to safely go to a lower level of care (gen care, tele) within 8-10 hrs of being in EC3 without an increased rate of bouncing from that level of care to the ICU after admission 2) 10% of our patients who arrive critically ill (or would at least require an ICU bed in most institutions d/t intubation, etc) ar able to be discharged from EC3 and never require any bed in the hospital which is a win for the patient and the health system which is capacity constrained. 3) EC3 serves as a filter for who truly needs an inpatient ICU bed. Our “short stay” ICU admissions (ICU stay 30% since EC3 opened. This saves ICU resources for the sickest patients who truly need constrained ICU beds/resources. 4) Because we are small… Read more »
Hey Scott. Great episode.
This data makes me a little uncomfortable as a physician working in a setting where this model of care is either a long way off, or more likely never coming. I wonder if it is possible to break down the components of this care a little bit more, and focus on the parts that we really think are contributing to the benefit. Is it just the added time at the bedside (which might be hard to recreate in a busy ED)? Or are there other parts of critical care, such as head of bed elevation, appropriate sedation, chlorhex etc, that we just aren’t trained to do well in ED? If the later, a podcast or checklist to try to help community docs like me provide the same kind of care you are providing in the ED/ICU would be really helpful.
All the best
Justin
I’m sorry to say, but I think most of the benefits of EDICUS (prob. all of the benefits of the original EGDT study) comes down to docs and nurses at the bedside.
Hi Justin,
Great point. I think its several things (see my response to Andrew above). There is certainly value to have more time at the bedside with additional resources to really give us time to think and see trends and trajectory in critical illness evolve. Of course, having more aggressive nursing ratios, RT present is very favorable. However, there are lots of smaller things that could be done in a smaller shop with less resources. There is a joint task force between SCCM and ACEP that is the process of publishing a white paper on the boarding of critically ill patients in the ED and part of that paper is a checklist that can be rolled out in multiple different ED environments to address some simple ED-CC interventions in the first few hours that can have a profound impact on the patient’s course (HOB elevation, as light as sedation as possible, chlorhexadine mouth rinse, lung protective tidal volumes, consistent transfusion standards, etc). Feel free to reach out to me to discuss more.
Honestly – even if it is just more time at the bedside, the information is incredibly valuable. We are always performing triage of some sorts. This tells me that half hour extra at the bedside might have a mortality benefit. That is really important information. Most days that means spending the extra time, but it depends a but on what the waiting room looks like. Data like this should probably also force us to analyze our ED nursing ratios.
Luckily where I work I should almost always be able to get patients to the ICU within an hour or so.
Looking forward to more research on this area – but pretty clear we need tighter ties between critical care and emergency, whatever the actual geography looks like.
Wondering how billing/admitting works for this model. Right now I’m looking at this from the perspective of my ED obs unit. We “admit” to the obs unit but if they transfer to inpatient status the are “admitted” by the inpatient docs because the ED docs don’t have admitting priviledges. Are you placing admit orders to get these patients to EC3 or do they stay ED status and just move to a new room? How are you billing for these stays? My hospital is always packed and the obs unit usually just ends up with bed holds and not true obs unit patients. How do you prevent EC3 from being an overflow ICU or just another area the hospital can put bed holds?
both the EC3 and my RACC Unit are out-patient units. We both independently looked into the pluses and minuses of becoming an inpt unit and the advantages were almost all on the out-pt side. We bill these patients as critical care, EM, and/or OBs.