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Intervention for Critically Ill Patients Lowered In-Hospital Mortality Rates

By Stacey Kusterbeck, Special for

A novel Emergency Critical Care Program (ECCP) resulted in significantly lower mortality rates for critically ill emergency department (ED) patients, according to recently published study results. “Our group is interested in novel ways of providing emergency critical care and what that means for the healthcare system, hospital, and our patients,” explains June Gordon, MD, one of the study authors and a clinical assistant professor of emergency medicine at Stanford Health Care.

Before the ECCP was created, the ED was facing significant issues with boarding. “Boarding is known to be associated with poor outcomes and longer hospital length of stay,” notes Tsuyoshi Mitarai, MD, another study author and a clinical associate professor of emergency medicine at Stanford University.

Some programs have improved outcomes by using alternative units to care for critically ill patients from the ED. “But not all hospitals have sufficient space or financial resources to create and sustain such units,” Mitarai notes. ECCP does not require a dedicated physical space or additional resources, other than ECC physicians themselves.

The researchers wanted to know if ECCP could improve survival rates and optimize ICU bed use concurrently. Investigators analyzed ED visits by 2,250 adults with a critical care admission order within 12 hours of arrival that occurred from 2015 to 2019.

Some patients received dedicated bedside critical care from an ED-based intensivist, following the initial resuscitation by the ED team. Bedside critical care may have included assessments and interventions, such as point-of-care echocardiography, vasopressor initiation and titration, initiation or adjustment of noninvasive positive pressure ventilation, and ventilator titration. The others received usual care.

In the intervention group, overall in-hospital mortality rates decreased by 6%. Patients in the intermediate severity of illness group recorded the steepest decline in in-hospital mortality rates. This suggests the MICU patients with intermediate severity of illness are particularly vulnerable for poor outcomes without an adequate level of care during the immediate post-ED resuscitation phase, says Mitarai.

The authors view their paper as a starting place for EDs to think about novel care delivery models for critically ill patients. “It highlights a particularly vulnerable group of patients who might benefit from more focused care,” Gordon offers.

Investigators concluded timely bedside care by a dedicated critical care-trained physician can help improve outcomes of the MICU patients in the ED and ICU bed use. “The ECCP is unique in that it does not require a dedicated physical space and hours of operation can be set based on the local needs,” Mitarai says.

Critically ill medical patients in the ED are a heterogeneous population with a wide range of pathologies and severity of illness. “Early and safe ED downgrade of appropriate patients by a program like ECCP would improve access to the ICU beds for ED patients with a clear ICU need,” Mitarai offers.

For more on this and related subjects, be sure to read the latest issues of ED Management.