Much of the discussion surrounding emergency medicine seems to focus on how to keep lower-acuity patients out of the ED, or at least how to move them through to discharge faster. While it is true that many EDs see a high percentage of low-acuity or fast-track patients, there are also EDs that are overwhelmed with patients at the other end of the acuity spectrum. The University of Michigan Health System’s (UMHS) adult ED in Ann Arbor is a case in point.
“We don’t have a fast track anymore because I don’t have enough patients to keep people busy. We use the Emergency Severity Index (ESI) here, and our ESI 4s and 5s [make up] less than 10% of our patients,” explains Jennifer Gegenheimer-Holmes, RN, BSN, MHSA, CEN, the director of operations for the Department of Emergency Medicine at UMHS. “We take a lot of transfers from other hospitals, and the acuity and complexity of our patients is fairly high.”
These critical care patients require more time and resources than lower-acuity patients, often creating backlogs and long waits. This creates different flow issues faced by EDs that see a high number of lower-acuity patients. Recognizing the challenge of high-acuity patients, UMHS has just unveiled a new unit designed specifically for the most critically ill emergency patients. Dubbed the Massey Emergency Critical Care Center, or EC3, this new branch of the ED is the first such center in the country, and it could well provide a model for other referral centers that manage and care for a high number of patients on the upper end of the acuity spectrum.
Cohort critically ill patients
There were multiple factors involved with the drive to develop EC3, but chief among them was the fact that the number of patients coming to the ED was continuing to increase, and the acuity of these patients was on the rise, with about one-third requiring admission to the hospital.
“As our patients are getting better therapies for cancer, heart failure, and other disease states, they are living longer. These patients are coming in and they are actually sicker,” explains Kyle Gunnerson, MD, an emergency physician, critical care specialist, and leader of the EC3. “Dovetail that with the crisis for the critical folks upstairs who have also seen shortages in resources. We don’t have enough ICU [intensive care unit] beds and we don’t have enough intensivists — especially in large, tertiary referral centers like UMHS and other big centers in the area. The ICUs are running almost at capacity.”
With all of these forces converging, it is like a “perfect storm brewing,” says Gunnerson. “What happens is you have a 3-5% increase in the amount of patients each year filling up the ED, the acuity is going up, and we can’t get [patients] upstairs into the ICU quick enough, so they end up sitting down in the ED waiting for an average of six to nine hours for an ICU bed. Sometimes, we even have these patients for 24 hours.”
Also contributing to the problem is the fact that emergency physicians are not really trained to provide more than the early stages of critical care, says Gunnerson. “Emergency medicine [providers are] really good for doing the resuscitations, the CPR [cardiopulmonary resuscitation], the acute treatment, but once that happens, we are really not trained to do the next phase: the titrating, the fine tuning, the critical care, and really getting down into the details of what critical care needs are required,” he explains. “And at the same time we are having to deal with all the people coming in the door. We are responsible for 18 to 20 other patients; we’ve got 40 people in the waiting room and we’ve got another 40 people waiting to be admitted.”
To address all of these factors, the EC3 is being equipped with five resuscitation/trauma bays, nine patient rooms, and emergency providers who have undergone additional training in critical care. Further, there will be one nurse for every two patients to facilitate the closer monitoring required for these sicker patients.
“This is really a treatment area within our ED where we are cohorting our critical patients, where we have additional, extensive monitoring, and closer patient-to-nurse ratios so we can really focus our attention on the first 6-12 hours,” says Gegenheimer-Holmes. “We can make sure that when these patients move to the next care unit they are in a place where the handoff can be done safely.”
Further, administrators anticipate that the EC3 will take some pressure off the hospital’s ICUs.
“We will have another set of doctors and teams to manage these sick patients before they go to the ICU, and that way we can start their treatments early, we can start titrating their therapies, we can start even potentially de-escalating care, and, in some cases, reserve that precious commodity of an ICU for another patient. If we can get a patient better, he may be able to go straight to a [hospital] floor,” says Gunnerson. “There are a lot of potential benefits to having this model down here in the ED, and that is what prompted us to try this kind of new health care delivery model for acute critical care.”
Provide training in critical care
To staff the EC3, the hospital is looking to emergency physicians who have undergone extra training in critical care. “The [American Board of Medical Specialties] has just passed an approved pathway now where ED residents can do a two-year fellowship in critical care, either through anesthesiology, internal medicine, or surgery. They can sit for the boards, and then have full hospital privileges to round in an ICU,” says Gunnerson. “They are trained through the fellowship to take care of patients with that detail and expertise, and so now these [physicians] are coming out with a different mentality. They understand the problems in the ED and they understand the problems up in the ICUs.”
Extra training is required for the nurses who will be staffing the EC3 as well. It’s a paradigm shift for emergency nurses because while they have been treating critical care patients for years, the mindset has always been to stabilize them quickly and move them out, observes Gegenheimer-Holmes.
“We had [already] implemented some critical care procedures that typically would be done in the ICU, but because we were trying to move those patients through to be ready and available for the next critical patient that may arrive, we were really handing off patients at a time that really may not be ideal,” explains Gegenheimer-Holmes.
Consequently, to equip about 40 emergency nurses with the additional skills they would need to provide critical care for a longer period of time in the new unit, the ED has been partnering with the hospital’s critical care units upstairs. “There has been a great team effort over about a six-month period,” explains Gegenheimer-Holmes. “We rotated the nurses up to the different ICUs, and we sent them through the same critical care nursing orientation that the nurses who are hired into critical care go through.”
While personnel from the critical care units on the upper floors have been thoroughly supportive of the new unit in the ED, keeping the training fresh among the emergency staff has been difficult. “It is very challenging to try to learn how to do these new things and then come back into a place where you are not doing them yet,” says Gegenheimer-Holmes.
However, now that the EC3 is open, the nurses who received the extra critical care training can begin using these new skills and also precepting some of the other emergency nurses. “In order to keep everyone’s skills up, we will limit the numbers just so the nurses are rotating through [the EC3] on a regular basis and aren’t spending too much time away from the unit,” says Gegenheimer-Holmes. She adds that eventually about one-third of the emergency nurses will be equipped with the critical care training needed to work in the EC3.
Identify patients for protocolized care
As the training proceeds, administrators are gradually ramping up capacity. The EC3 officially opened in late February with just four beds available for critical patients. When construction is complete and the unit is fully operational later this spring, there will be nine beds available, staffed by five nurses on duty at any given time, explains Gegenheimer-Holmes. One nurse will care for a single patient while functioning as the team leader.
When personnel are assigned to the EC3 that will be their only assignment, but there will be flexibility built into the system to accommodate patient volume, explains Gunnerson. “When we are very slow [in the EC3], and they need a lot of extra hands out in the main ED, personnel can be pulled from the EC3 out to the main ED, and vice versa. If we need some extra help up in the EC3, the appropriate nurses that have the appropriate training will be pulled up to the EC3 for additional staffing,” he says. “The nice thing is that they are our own nurses.”
The types of patients who will be sent to the EC3 will be those on the “far extreme of either complexity or critical care needs,” explains Gunnerson, noting that it is not a designation that can be simply summed up in terms of an ESI assignment. For instance, he explains that a patient who is categorized as ESI 3 may have several issues, none of which is all that severe when viewed in isolation, but the care that is ultimately required may be very labor intensive or intense.
“The EC3 will really be for those patients for whom early intervention and protocolized care can be initiated,” says Gegenheimer-Holmes. “Most of the patients who will come to the EC3 have medical problems [such as] sepsis, a GI [gastrointestinal] bleed, a subarachnoid hemorrhage, or post-cardiac arrest.”
In some cases, the handoff to an EC3 team will take place in the resuscitation bay. Patients from other hospitals may also be sent directly to the ECS if physicians determine their needs are appropriate for the unit. And in other cases, patients might come through triage to the main ED, but then later get sent to the EC3 once clinicians become more familiar with their conditions or there is some deterioration status. In fact, that is precisely what happened in the case of the very first patient to be cared for in the new unit on February 16th.
“The patient had been in the ED receiving care for an hour or so and began to decompensate. It was a patient who needed dialysis. We were going to admit him to the dialysis unit, but we do have the capability to initiate dialysis in the critical care center [EC3],” says Gegenheimer-Holmes. “This was a patient who was becoming unstable, so we moved him over to the EC3, and we did the same thing with another patient later in the afternoon.”
The EC3 is not designed for trauma patients who will most likely be sent to a trauma-specific ICU where they will be cared for by a trauma team once they are stabilized in the ED, explains Gegenheimer-Holmes. She notes that the critical care unit is also not the likely destination for patients with acute myocardial infarctions (MI) because there is already an effective pathway in place for patients with ST segment elevation (STEMI) MIs to be quickly transitioned to the cath lab.
The UMHS has six specialized adult ICUs upstairs, and now it has the EC3 as well. But even with all of these specialized care options, the main ED at UMHS is still largely taking care of patients with a relatively high level of acuity.
However, Gunnerson anticipates that the EC3 will ease pressure on the ED, shortening wait times and facilitating patient flow. “Before, when we didn’t have this [critical care unit], we were having to take care of five, six, or seven of these [critical care] patients smattered throughout the ED, and it really drained the resources,” he says. “You can imagine someone waiting for an ICU bed for eight, nine, or 10 hours, and using all the nursing resources on that assignment in that one room.”
What happens is the room can’t be turned over, and then you multiply the problem by seven or eight, and you have decreased the ED’s capacity by 10%, explains Gunnerson. “We are hoping that by decompressing that complexity and that higher level of care from the main ED … it will open up rooms so that we will … see a decrease in wait times to get patients back, and a decrease of patients leaving without being seen.”