EXECUTIVE SUMMARY

As demand for critical care increases, EDs can become backlogged with patients awaiting space in an inpatient ICU. However, studies show that an excessive wait negatively affects outcomes. To solve this problem, the University of Michigan Health System pioneered a new model of care that involved placing an ICU within their flagship adult ED. Called the Emergency Critical Care Center (EC3), the approach has not only accelerated ICU-level care to critically ill patients who present to the ED, it also has reduced ED-based admissions to inpatient ICUs.

First opened in February 2015, the EC3 is equipped with five resuscitation trauma bays and nine patient rooms within 7,800 square feet of space. It is staffed by six nurses and three providers.

All patients are seen and assessed in the ED first. Generally, staff decide within two hours if patients need care in the EC3. Staff in the EC3 manage critically ill patients for the first six to 12 hours of their care.

Data show that risk-adjusted 30-day mortality rates decreased from 2.13% in emergency patients presenting to the ED before implementation of the EC3 to 1.83% in patients who presented to the ED after implementation. This translates into an additional life saved every 36 hours, according to investigators. Analysts also found that ED-based admissions to an inpatient ICU declined from 3.2% before implementation of the EC3 to 2.7% after implementation.

Investigators note that while an ED-based ICU probably is not affordable for many medical centers, the approach can be scaled to suit hospitals with different sizes and needs.


As demand for critical care increases, EDs often find themselves overwhelmed with patients requiring ICU-level care, but no empty beds. The result is a boarding problem and potentially worse outcomes for patients. Studies have shown that critically ill patients who wait longer than six hours in the ED for an ICU bed record longer inpatient stays and higher mortality rates. Yet in the United States, data show that roughly one-third of ED patients destined for an inpatient ICU bed fall into this group.

To address this problem, the University of Michigan Health System decided to pioneer a new model of care designed to accelerate critical care to ED patients requiring ICU-level services. The Emergency Critical Care Center (EC3) opened in February 2015 at the University of Michigan Medical Center (UMMC). Now, recent data show that not only has EC3 succeeded in improving outcomes for patients, it also has reduced inpatient ICU admissions and provided a rich educational experience for the emergency physicians, nurses, and other healthcare personnel who train to work there.1

While operating such a unit likely is resource- and cost-prohibitive for many hospitals, EC3 administrators note that it offers a scalable roadmap for other EDs that struggle to manage the increasing volume of patients who present with critical care needs.

Equipped with five resuscitation trauma bays and nine patient rooms within 7,800 square feet of space, the EC3 sits adjacent to the main adult ED, a busy department that handles about 75,000 patients per year. Furthermore, while physicians and nurses who staff the EC3 all have received some training in critical care medicine, they must be able to float between the EC3 and the ED as needed.

Patients who eventually go to the EC3 always are seen in the ED first, explains Benjamin Bassin, MD, EC3’s director of operations and assistant professor of emergency medicine at the University of Michigan Medical School. “Most of our residents will go on to work at places that don’t have an ED-ICU,” explains Bassin, who co-authored the recent study about EC3. “We don’t want to dilute their experience of learning to take care of critically ill patients and the initial resuscitation/stabilization phase.”

While the EC3 will take any critically ill patient, a decision on whether a patient requires that level of care typically is made after about two hours. “That generally gives [the resident and the emergency medicine attending physician] the time to do all the diagnostics, the initial stabilizing procedures, imaging, and workups to get an idea of what is happening and what the trajectory is for the patient,” Bassin shares. “At that point, the primary ED attending [physician] and the resident managing the patient will then consult with the EC3 attending physician. Then, they will together decide if the patient is appropriate for the EC3.”

Most critically ill patients deemed to require ICU-level care will go to the EC3. “The majority of our patients are the medically critically ill. Even if there is an available bed upstairs in the medical ICU, if we have the capacity [in the EC3] we will take the patient for the first six to 12 hours of their care,” Bassin says. “In a very short amount of time, we can deliver those early first hours of critical care to get them stabilized.”

This care may involve everything from placing patients on ventilators, inserting lines, titrating medicines, and obtaining all the needed labs and advanced imaging studies. Further, EC3 providers will engage with appropriate consultants on the case and speak with family members, Bassin adds. “We tie all of those pieces together pretty quickly,” he notes.

The result of this process is generally accelerated care for the patient, improved outcomes, and reduced inpatient ICU use, according to the study results. Looking at the electronic medical records of a cohort of ED visits between Sept. 1, 2012, and July 31, 2017, investigators compared data from before and after the EC3 was implemented.

Specifically, analysts examined 168,877 ED visits from before the EC3 opened its doors and 180,433 visits following unit implementation. They found that risk-adjusted 30-day mortality rates decreased from 2.13% before implementation of the EC3 to 1.83% after. This translates into an additional life saved every 36 hours, according to Bassin. Investigators also found that ED-based admissions to an inpatient ICU declined from 3.2% before implementation of the EC3 to 2.7% after.

In cases where patients require surgery, interventional cardiology procedures, or any other services that cannot be provided in the EC3, patients typically will bypass the unit for a service that can provide them with definitive care. For instance, trauma patients are taken directly to a trauma-burn ICU, Bassin notes. “We don’t want to get in the way of any time-sensitive intervention,” he says.

However, when there are empty beds in the EC3 and people to be seen in the ED, the unit will pull in patients from the waiting room, even if they are not critically ill. This keeps the space from sitting empty while there is demand for ED capacity, Bassin explains. “We want everybody [in the EC3] to be able to take care of general emergency medicine patients when needed,” he says.

In fact, Bassin notes that it is not unusual for the EC3 to take on patients who may not be critically ill, but nonetheless require procedures that take time to complete. For instance, if a patient has choked on a chicken bone and needs an upper endoscopy along with sedation and intubation, that patient may be cared for in the EC3. “We will pull those [types of] patients in because they are very time-intensive for the regular ED to manage,” he explains. “We are kind of an incremental resource for the ED overall.”

The number of patients in the EC3 tends to follow the traditional volume curve in the ED, Bassin states. “When the ED gets busy, we get busy because the same percentage of critically ill patients ... remains constant with some variation,” he says. “Between 11 a.m. and 11 p.m. on Monday through Friday, the EC3 is very busy. Sunday morning at 3 a.m., the ED is not very busy. [The EC3] may be less busy as well, but in general we try to stay full. We flex our capacity [to care for] patients who may benefit from an extra set of hands.”

All 21 of the attending physicians who work in the EC3 are board-certified or trained in emergency medicine. Eight of the 21 also are board-certified in critical care medicine, Bassin notes. However, he says that all these physicians have committed to keep up with continuing education in critical care medicine. “We are also standing up for the ongoing quality review of care delivered in the EC3,” he adds.

In addition to the attending physicians, the EC3 employs physician assistants who specialize in emergency medicine and have some additional critical care training. There also are critical care fellows who rotate through the unit. Further, senior residents who are interested in critical care, both from emergency medicine and other specialties in the hospital, spend time in the EC3, Bassin observes.

Nurses who want to work in the EC3 have to work in the ED first, explains Renee Havey, MS, RN, CCRN, ACNS-BC, CEN, a clinical nurse specialist in adult emergency services at UMMC. “Even if we have someone who has ICU experience, they have to be oriented to the ED and work there usually about a year or a year and a half. Then, they can get trained for the EC3, but it is always with the understanding that they are an ED nurse first,” says Havey, another study co-author.

While Havey started her career as a staff nurse in the ICU, most nurses who express interest in working in the EC3 come from the emergency medicine setting. “A lot of people feel it is the next step in their professional growth in our department, to be able to critically think and manage complex situations,” she explains. “Now, there are patients and scenarios where you are getting some of these advance lab values back and you have to act on them.”

The role requires flexibility and adaptability because situations always are changing, Havey shares. “We may not have many patients in the EC3, so the nurses will go out and help with triage in the ED,” she says. “But then we may get a bunch of [critically ill patients], and we will have to pull those nurses back to the unit. This [requires] nurses to be able to ... accept those changes and just ride with them.”

Training the nurses to work in the EC3 presents some challenges, Havey acknowledges. “A number of people want to work back there, and we can only train so many people at a given time,” she says.

Further, once nurses are fully oriented to work in the EC3, they have gained highly valuable skills and often are presented with other opportunities, so staff turnover is a continuing issue. For instance, some nurses have decided they really like working in critical care medicine, so they go on to work fulltime in an inpatient ICU, Havey notes. In other instances, nurses in the EC3 have opted to further their education and become certified registered nurse anesthetists.

While it is clear that the EC3 offers a rich educational environment for nurses, the continuing exodus of highly trained staff keeps administrators busy. “That is one challenge I am constantly faced with: keeping staff back there who are competent and can handle very critical situations while also addressing the needs of the rest of the department,” Havey says.

Despite the staffing challenges, Havey notes that the benefits the EC3 model provides are clear. “It is about getting critical care to the patient, and then also getting the patient to a ratio of providers and nurses who can actually give them the attention they need. Those are the big things,” she says. “A lot of things we have been able to implement in the EC3 or start earlier like chlorhexidine baths or chlorhexidine oral rinses for intubated patients. All of those things add up in the long run and help patients have better outcomes.”

There also have been some unanticipated benefits from the ED-ICU format. For instance, given that the EC3 tends to see a lot of sick patients who are at the end of their lives, providers quickly began to realize that the unit was a good place to engage in goals-of-care discussions and to work with families dealing with end-of-life decisions, Bassin explains.

“Previously, those discussions would happen in a curtained resuscitation bay with very little privacy and not a great environment,” he says. “We realized once the EC3 opened that this was actually a great spot to engage in those conversations with patients and families, and then to provide the care there.”

Providers in the EC3 can place patients on morphine drips, ask palliative care teams to come to the unit, and invite clergy or social workers to become involved, Bassin observes. “We now have an end-of-life protocolized order set, and we have training around it,” he says. “We work very closely with the palliative care team ... and it actually has become quite an effective way to deliver that kind of care in a way that is not only humane for the patient, but we have also gotten a lot of [positive] feedback from families.”

In particular, by keeping all the needed resources in one place, families can avoid dealing with multiple transitions of care when they really want to spend time with loved ones, Bassin explains. “It has worked out very well from that standpoint,” he reports.

Can a care model like the EC3 work for other hospitals and EDs? There are multiple factors to consider, according to Bassin. “Most academic medical centers do have a problem [in] that ICU capacity is at a premium and [space] is rarely available. A lot of patients coming into the ED require [the ICU] and can’t get there in a timely way,” he says. “[They’re] really struggling with those critically ill patients being boarded in the ED, and [they’re] trying to figure out a way to take care of them.”

However, while the EC3 model has been a good fit for UMMC, and interest in the model is high, Bassin acknowledges that the cost is prohibitive for many medical centers. “It is a very robust resource model, but it is not cheap,” he says. “This is a Cadillac version of [an ED-ICU], and it is not what everybody needs.”

Consequently, when ED or hospital leaders call to inquire about building their own EC3, Bassin always wants to know first what problem they are trying to solve. Then, he works with them to develop a solution that works. “You may not need [an EC3],” he says. “You may just need two extra ED beds with a dedicated nurse who has some extra critical care training and an extra ED attending physician who has some bandwidth to manage these patients for a longer period.”

While many interested callers immediately back off on the idea of building their own ED-ICU as soon as they hear about the costs and the staffing required, Bassin notes that they sometimes miss the point that the approach uses a scalable resource allocation model. “It doesn’t have to look like [the EC3], and it probably won’t look like [the EC3] at your place,” he says. “Use the guiding principles of why it was built ... to advocate at your shop for how to get patients better care and more timely care.”

While the EC3 is sort of a hybrid unit that integrates emergency medicine and critical care, most interest in the approach comes from the emergency medicine field. It is the ED that struggles most with backlogs of critically ill patients who are waiting for an ICU bed, Bassin observes. “It is really us [in emergency medicine] trying to figure out how to deal with this patient population,” he says.

However, as more inpatient intensivists become aware of the problem, they see the value the EC3 can offer in making ICU resources available, Bassin adds. “We can get the critical care going early on for patients [the inpatient ICUs] still may receive down the line, but [the patients] will have already had a lot of these things that need to be done in the first 24 hours. They can really start to advance their care earlier and get them out of their ICUs faster,” Bassin says.

On the nursing side, Havey’s advice for ED leaders interested in developing an EC3-like model is to contact the nursing leadership in the ICUs. “Make sure you have good relationships with them,” she says. “It is very important to standardize care and make sure you are not doing things that are totally different than what happens in the inpatient ICUs upstairs.” One way the EC3 keeps the dialogue with the critical care nurses upstairs going is by directing the nurses in the EC3 to rotate through the inpatient ICUs.

“Help them understand that you are not taking patients from them and that you are not hoarding patients,” Havey explains. “It is really about getting the critical care to the patient.”

REFERENCE

  1. Gunnerson KJ, Bassin BS, Havey RA, et al. Association of an emergency department-based intensive care unit with survival and inpatient intensive care unit admissions. JAMA Netw Open 2019;2:e197584.