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Emergency physician-based intensive care unit for critically ill patients visiting emergency department
American Journal of Emergency Medicine xxx (xxxx) xxx
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Emergency physician-based intensive care unit for critically ill patients visiting emergency department Hwain Jeong a, Yoon Sun Jung a,⇑, Gil Joon Suh a,b, Woon Yong Kwon a,b, Kyung Su Kim a, Taegyun Kim a, So Mi Shin a, Min Woo Kang c, Min Sung Lee a a b c
Division of Critical Care Medicine, Department of Emergency Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea Department of Emergency Medicine, Seoul National University College of Medicine, Seoul 03080, Republic of Korea Department of Emergency Medicine, CHA Bundang Medical Center, Gyeonggi-do 13496, Republic of Korea
a r t i c l e
i n f o
Article history: Received 11 April 2019 Received in revised form 11 August 2019 Accepted 17 September 2019 Available online xxxx Keywords: Emergency medicine Emergency department Intensive care units Transfer Mortality
a b s t r a c t Background: To provide a prompt and optimal intensive care to critically ill patients visiting our emergency department (ED), we set up and ran a specific type of emergency intensive care unit (EICU) managed by emergency physician (EP) intensivists. We investigated whether this EICU reduced the time interval from ED arrival to ICU transfer (ED-ICU interval) without altering mortality. Methods: This was a retrospective study conducted in a tertiary referral hospital. We collected data from ED patients who were admitted to the EICU (EICU group) and other ICUs including medical, surgical, and cardiopulmonary ICUs (other ICUs group), from August 2014 to July 2017. We compared these two groups with respect to demographic findings, including the Acute Physiology and Chronic Health Evaluation II (APACHE II) score, ED-ICU interval, ICU mortality, and hospital mortality. Results: Among the 3440 critically ill patients who visited ED, 1815 (52.8%) were admitted to the EICU during the study period. The ED-ICU interval for the EICU group was significantly shorter than that for the other ICUs group by 27.5% (5.0 ± 4.9 vs. 6.9 ± 5.4 h, p < 0.001). In multivariable analysis, the ICU mortality (odds ratio = 1.062, 95% confidence interval 0.862–1.308, p = 0.571) and hospital mortality (odds ratio = 1.093, 95% confidence interval 0.892–1.338, p = 0.391) of the EICU group were not inferior to those of the other ICUs group. Conclusions: The EICU run by EP intensivists reduced the time interval from ED arrival to ICU transfer without altering hospital mortality. Ó 2019 Elsevier Inc. All rights reserved.
1. Introduction Clinical outcomes of critically ill patients visiting the emergency department (ED) depends on timely resuscitation and subsequent optimal intensive care [1]. Therefore, when initial resuscitation at the ED is completed, patients should be transferred to the intensive care unit (ICU) as soon as possible. Delayed transfer to the ICU from the ED continues to be a worldwide problem in the emergency medical system [2–4]. This delay frequently occurs in overAbbreviations: EICU, Emergency Intensive Care Unit; ED, Emergency Department; EP, Emergency Physician; ED-ICU interval, ED-ICU interval, the time interval from ED arrival to ICU transfer. ⇑ Corresponding author at: Department of Emergency Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea. E-mail addresses: [email protected] (H. Jeong), [email protected] (Y.S. Jung), [email protected] (G.J. Suh), [email protected] (W.Y. Kwon), som0809@ naver.com (S.M. Shin).
crowded EDs of tertiary referral hospitals [4,5]. Previous studies reported that a greater than 6 h’ delay in transfer from the ED to the ICU was associated with increases in hospital length of stay, ICU mortality, and hospital mortality [1,6–10]. These data indicate that the contributing factors to delayed transfer should be identified and modified to improve clinical outcomes for critically ill patients visiting the ED. This delay is primarily caused by an increasing volume of critically ill patients in the ED and a lack of available ICU beds [1,11,12]. In addition, multiple decision steps by non-emergency physician intensivists are needed for ICU transfer, and this also contributes a delay [7,13–16]. Many previous studies have attempted to provide solutions to overcome these problems, such as, direct transfer from the computed tomography (CT) room to the surgical ICU (SICU) for trauma patients [13,16], direct referral for patients to ICUs’ intensivists in the ED [7], or a unit within the ED capable of performing ICU treatment [17,18].
https://doi.org/10.1016/j.ajem.2019.09.021 0735-6757/Ó 2019 Elsevier Inc. All rights reserved.
Please cite this article as: H. Jeong, Y. S. Jung, G. J. Suh et al., Emergency physician-based intensive care unit for critically ill patients visiting emergency department, American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.09.021
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In the Republic of Korea, delayed transfer of critically ill patients from the ED to the ICU also frequently occurs. Therefore, the Korean government designated 12 Regional Emergency Medical Centers across the country and established the emergency ICU (EICU) in these regional centers only for critically ill patients visiting the ED. Our institute is one of these Regional Emergency Medical Centers, and we set up a 12-bed EICU in April 2004 beside the ED. Furthermore, we have set up and run an additional system for EICU management, in which emergency physicians (EPs) work as EICU intensivists. They provide initial resuscitation to critically ill patients at the ED and transfer them to the EICU for continuing intensive care by the same intensivists without delay. For ten years (2004–2013), we set up our EICU system and ran the EICU. However, we had not evaluated the efficacy of this system on the time interval from ED arrival to ICU transfer (ED-ICU interval) or the impact of this system on ICU and hospital mortalities in critically ill patients visiting the ED. Therefore, we designed this study to evaluate the efficacy of our EP intensivists-based EICU system. We hypothesized that the ED-ICU interval of patients admitted to the EICU would be shorter than the ED-ICU interval of patients admitted to other ICUs. We also hypothesized that ICU and hospital mortalities of patients admitted to the EICU would not be inferior to those of patients admitted to other ICUs.
Board of our institute (IRB Number: 1805-162-948). Written informed consent was waived. 2.2. Data collection We collected data from critically ill patients who visited the ED and were admitted to the EICU or other ICUs (MICU, SICU, or CPICU) from August 2014 to July 2017. Data were collected from the electronic medical records (EMR) at our institution and included patient demographics, the Acute Physiology and Chronic Health Evaluation II (APACHE II) score during the first 24 h, EDICU interval, ICU mortality, and hospital mortality. 2.3. Statistics For univariate analysis, Student’s t-test and Chi-square test were used. For multivariable analysis, logistic regression analysis was applied. Data are presented as the means and standard deviation (SD) or number and percent (%). P-values of <0.05 were considered statistically significant, and significance levels quoted are two-sided. Statistical analyses were performed using IBM SPSS version 23.0 for Windows (SPSS, Chicago, IL). 3. Results
2. Methods 2.1. Study setting and population This was a retrospective observational study conducted at a tertiary referral hospital in Seoul, Republic of Korea. This hospital has 1306 beds for adult patients and 245 for pediatric patients. Annually, 1.94 million of outpatients visit, and 0.5 million patients are admitted to this hospital. Greater than 50,000 adult patients visit the ED annually. This hospital has 4 adult ICUs (64 beds) including the medical ICU (MICU, 22 beds), SICU (22 beds), cardiopulmonary ICU (CPICU, 8 beds), and EICU (12 beds). The MICU, SICU, and CPICU primarily care for critically ill patients who are either admitted to the wards for medical diagnosis/treatments or who undergo planned surgery. In contrast, the EICU is an emergency facility only for critically ill patients visiting the ED. Five emergency physicians (EPs) worked in our EICU with two emergency medicine residents. They provide coverage 24 h a day. Three EPs were certified as intensivists after at least two years of critical care medicine fellowship from the Korean Society of Critical Care Medicine (KSCCM) and two EPs were in critical care medicine fellowship training. The ratio of nurses to patients in the EICU was 1:2. When critically ill patients visit the ED with an Emergency Severity Index (ESI) level 1 [19], triage nurses notify the EICU intensivists directly. When a non-ESI level 1 patient’s clinical condition deteriorates during the ED stay, ED physicians/nurses also notify the EICU intensivists. EICU intensivists provide initial resuscitation to the patients in the ED resuscitation room and routinely admit them to the EICU as soon as possible. If there are no available beds in the EICU, the EICU intensivists call other ICU intensivists and transfer the patients accordingly. If patients experience specific problems necessitating particular interventions by specialists including emergency surgery, EICU intensivists also call specialists who assist in deciding a patients referral to the EICU or other ICUs. In the present study, we compared patients who were directly admitted to the EICU (the EICU group) with those admitted to other ICUs from the ED (the other ICUs group). The primary outcome was hospital mortality during the study period. Secondary outcomes included ED-ICU interval and ICU mortality. This study was performed in compliance with the Declaration of Helsinki (Seoul, Korea, 2008), and was approved by the Institutional Review
3.1. The EICU group versus the other ICUs group During the study period, 3440 patients were admitted to various ICUs from the ED. Among them, 1815 patients (52.8%) were admitted to the EICU (Fig. 1). The mean age and APACHE II score
Fig. 1. Intensive care unit (ICU) disposition of critically ill patients visiting the emergency department (ED). (A) ICU disposition from the ED. Among 3,440 patients, 1,815 (52.8%) were admitted to the emergency intensive care unit (EICU). MICU, medical ICU; CPICU, cardiopulmonary ICU; SICU, surgical ICU. (B) Post-ICU disposition from the EICU. Among 1815 patients admitted to the EICU, 311 (17.1%) and 1014(55.9%) were moved to other ICUs and to the general wards, respectively. One hundred fifty-nine patients (8.8%) were transferred to other health care facilities (HCF).
Please cite this article as: H. Jeong, Y. S. Jung, G. J. Suh et al., Emergency physician-based intensive care unit for critically ill patients visiting emergency department, American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.09.021
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in the EICU group were higher than in the other ICUs group (p < 0.001 and <0.001, respectively) (Table 1). The numbers of patients who underwent emergency surgery or extracorporeal membrane oxygenation (ECMO) in the EICU group were fewer than in the other ICUs group (p < 0.001 and = 0.001, respectively) (Table 1). There were no significant differences in gender, mechanical ventilation, or renal replacement therapy between the two groups (Table 1). ED-ICU interval, length of ICU stay, and length of hospital stay in the EICU group were significantly shorter than in the other ICUs group (p < 0.001, = 0.013, and <0.001, respectively) (Table 1). ICU and hospital mortalities in the EICU group were higher than in the other ICUs group (p = 0.012 and = 0.006, respectively), in univariate analysis without adjusting APACHE II score (Table 1). 3.2. Univariate analysis for ICU and hospital mortalities Increased ICU mortality was associated with old age (p < 0.001), male gender (p = 0.011), admission to the EICU (p = 0.012), higher APACHE II score (p < 0.001), mechanical ventilation (p < 0.001), renal replacement therapy (p < 0.001), and ECMO (p < 0.001)
(Table 2). In contrast, emergency surgery was associated with decreased ICU mortality (p < 0.001) (Table 2). Increased hospital mortality was associated with old age (p < 0.001), male gender (p = 0.003), admission to the EICU (p = 0.006), longer ED-ICU interval (p = 0.021), higher APACHE II score (p < 0.001), mechanical ventilation (p < 0.001), renal replacement therapy (p < 0.001), and ECMO (p < 0.001) (Table 3). Similar to ICU mortality, emergency surgery was associated with decreased hospital mortality (p < 0.001) (Table 3). 3.3. Multivariable analysis for ICU and hospital mortalities Higher APACHE II score, mechanical ventilation, renal replacement therapy, and ECMO were all independently associated with both increased ICU and hospital mortalities. However, emergency surgery was independently associated with decreased ICU and hospital mortalities (Table 4). Admission to the EICU, which was significantly associated with increased ICU and hospital mortalities by univariate analysis, was NOT independently associated with increased ICU mortality (odds ratio = 1.010, 95% confidence interval: 0.862–1.308, p = 0.571) or increased hospital mortality (odds
Table 1 Patients’ characteristics in the EICU and other ICUs groups. EICU (N = 1815)
Age* Male APACHE II score* Required management Emergency operation Mechanical ventilation Renal replacement therapy ECMO
(Years)
(Yes) (Yes) (Yes) (Yes)
Disease classification Infectious Malignancy/hematologic Endocrinologic Neurologic Cardio/cerebrovascular Respiratory Gastrointestinal Soft tissues Urogenital Injury Others
Other ICUs (N = 1625)
P
N
(%)
N
(%)
64.9 ± 16.1 1080 20.9 ± 11.1
(59.5)
61.8 ± 17.6 922 18.8 ± 10.4
(56.7)
<0.001 0.101 <0.001
47 1020 404 22
(2.6) (56.2) (22.3) (1.2)
87 942 363 45
(5.4) (58.0) (22.3) (2.8)
<0.001 0.295 0.955 0.001
59 323 28 83 449 269 175 33 104 119 173
(3.3) (17.8) (1.5) (4.6) (24.7) (14.8) (9.6) (1.8) (5.7) (6.6) (9.5)
37 297 10 66 648 119 156 27 71 112 82
(2.3) (18.3) (0.6) (4.1) (39.9) (7.3) (9.6) (1.7) (4.4) (6.9) (5.0)
‘‘Other intensive care units” are medical ICU, surgical ICU, and cardiopulmonary ICU. ‘‘Others” includes psychologic, ophthalmologic, otolaryngologic, etc. EICU, emergency intensive care unit; ED, emergency department; APACHE II, Acute Physiology and Chronic Health Evaluation II; ECMO, extracorporeal membrane oxygenation. * Data were presented as mean ± standard deviation.
Table 2 Outcomes of the EICU and other ICUs groups. EICU (N = 1815) N ED-ICU interval* Length of ICU stay* Length of hospital stay* ICU mortality Hospital mortality
(Hours) (Days) (Days) (Death) (Death)
5.0 ± 4.9 4.8 ± 8.8 17.0 ± 28.8 388 416
Other ICUs (N = 1625) (%)
N
(21.4) (23.0)
6.9 ± 5.4 5.7 ± 12.9 25.3 ± 39.9 292 310
P
(%)
(18.0) (19.1)
<0.001 0.013 <0.001 0.012 0.006
‘‘Other intensive care units” are medical ICU, surgical ICU, and cardiopulmonary ICU. ‘‘Others” includes psychologic, ophthalmologic, otolaryngologic, etc. EICU, emergency intensive care unit; ED, emergency department; APACHE II, Acute Physiology and Chronic Health Evaluation II; ECMO, extracorporeal membrane oxygenation. * Data were presented as mean ± standard deviation.
Please cite this article as: H. Jeong, Y. S. Jung, G. J. Suh et al., Emergency physician-based intensive care unit for critically ill patients visiting emergency department, American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.09.021
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Table 3 Contributing factors for ICU mortality. Survival(N = 2760) N Age* Male EICU admission ED-ICU interval* APACHE II score* Required management Emergency operation Mechanical ventilation Renal replacement therapy ECMO
(Years) (Yes) (Hours)
(Yes) (Yes) (Yes) (Yes)
Disease classification Infectious Malignancy/hematologic Endocrinologic Neurologic Cardio/cerebrovascular Respiratory Gastrointestinal Soft tissues Urogenital Injury Others
62.5 ± 17.1 1577 1427 6.0 ± 5.2 17.4 ± 9.1
(%) (57.1) (51.7)
Non-survival(N = 680) N (%)
P
67.2 ± 15.3 425 388 5.5 ± 5.3 29.9 ± 11.5
<0.001 0.011 0.012 0.053 <0.001
(62.5) (57.1)
128 1405 445 26
(4.6) (50.9) (16.1) (0.9)
6 557 322 41
(0.9) (81.9) (47.4) (6.0)
76 439 34 137 910 289 279 49 154 213 180
(2.8) (15.9) (1.2) (5.0) (33.0) (10.5) (10.1) (1.8) (5.6) (7.7) (6.5)
20 181 4 12 187 99 52 11 21 18 75
(2.9) (26.6) (0.6) (1.8) (27.5) (14.6) (7.6) (1.6) (3.1) (2.6) (11.0)
<0.001 <0.001 <0.001 <0.001
‘‘Other intensive care units” are medical ICU, surgical ICU, and cardiopulmonary ICU. ‘‘Others” includes psychologic, ophthalmologic, otolaryngologic, etc. EICU, emergency intensive care unit; ED, emergency department; ED-ICU interval, the interval from ED arrival to ICU admission; APACHE II, Acute Physiology and Chronic Health Evaluation II; ECMO, extracorporeal membrane oxygenation. * Data were presented as mean ± standard deviation.
Table 4 Contributing factors for hospital mortality. Survival (N = 2706) N Age* Male EICU admission ED-ICU interval* APACHE II score* Required management Emergency operation Mechanical ventilation Renal replacement therapy ECMO Disease classification Infectious Malignancy/hematologic Endocrinologic Neurologic Cardio/cerebrovascular Respiratory Gastrointestinal Soft tissues Urogenital Injury Others
(Years) (Yes) (Hours)
(Yes) (Yes) (Yes) (Yes)
62.6 ± 17.1 1541 1394 6.0 ± 5.2 17.3 ± 9.1
Non-survival (N = 726) (%) (56.9) (51.5)
N 66.8 ± 15.4 458 416 5.5 ± 5.3 29.5 ± 11.4
P
(%) (63.1) (57.3)
128 1361 430 26
(4.7) (50.3) (15.9) (1.0)
6 594 335 41
(0.8) (81.8) (46.1) (5.6)
75 428 34 128 891 287 275 48 154 209 177
(2.8) (15.8) (1.3) (4.7) (32.9) (10.6) (10.2) (1.8) (5.7) (7.7) (6.5)
21 191 4 20 203 101 56 12 21 21 76
(2.9) (26.3) (0.6) (2.8) (28.0) (13.9) (7.7) (1.7) (2.9) (2.9) (10.5)
<0.001 0.003 0.006 0.021 <0.001 <0.001 <0.001 <0.001 <0.001
‘‘Other intensive care units” are medical ICU, surgical ICU, and cardiopulmonary ICU. ‘‘Others” includes psychologic, ophthalmologic, otolaryngologic, etc. EICU, emergency intensive care unit; ED, emergency department; ED-ICU interval, the interval from ED arrival to ICU admission; APACHE II, Acute Physiology and Chronic Health Evaluation II; ECMO, extracorporeal membrane oxygenation. * Data were presented as mean ± standard deviation.
ratio = 1.093, 95% confidence interval: 0.892–1.338, p = 0.391) by multivariable analysis are described in Table 5. 4. Discussion We hypothesized that this system would save more ICU beds for critically ill ED patients and reduce decision steps for ICU trans-
fer, resulting in a reduced ED-ICU interval. Although the involved EP intensivists were certified by the KSCCM, there have been no real data evaluating EP intensivists’ capability of caring for ICU patients, until now. By univariate analysis, EICU admission increased both ICU and hospital mortalities. However, by multivariable analysis, adjusting the APACHE II score, EICU admission was not independently associated with increased ICU or hospital
Please cite this article as: H. Jeong, Y. S. Jung, G. J. Suh et al., Emergency physician-based intensive care unit for critically ill patients visiting emergency department, American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.09.021
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H. Jeong et al. / American Journal of Emergency Medicine xxx (xxxx) xxx Table 5 Multivariable analysis for ICU and hospital mortalities. ICU mortality
Age (years) Male gender EICU admission ED-ICU interval (hours) APACHE II score Required management Emergency operation Mechanical ventilation Renal replacement therapy ECMO
Hospital mortality
Odds ratio
95% Confidence interval
P
Odds ratio
95% Confidence interval
P
1.006 1.196 1.062 1.010 1.095
0.999–1.012 0.976–1.465 0.862–1.308 0.991–1.029 1.084–1.106
0.076 0.084 0.571 0.301 <0.001
1.003 1.252 1.093 1.007 1.094
0.997–1.009 1.027–1.527 0.892–1.338 0.989–1.026 1.083–1.105
0.391 0.026 0.391 0.452 <0.001
0.240 1.812 2.751 2.562
0.100–0.576 1.420–2.313 2.230–3.394 1.420–4.625
0.001 <0.001 <0.001 0.002
0.211 1.891 2.660 2.262
0.088–0.505 1.493–2.395 2.162–3.272 1.257–4.072
<0.001 <0.001 <0.001 0.006
EICU, emergency intensive care unit; ED, emergency department; ED-ICU interval, the interval from ED arrival to ICU admission; APACHE II, Acute Physiology and Chronic Health Evaluation II; ECMO, extracorporeal membrane oxygenation.
mortalities. These data indicate that our novel system effectively reduced the ED-ICU interval without altering ICU and hospital mortalities. Our novel EICU system has two features that distinguish it from previous systems to reduce the interval from ED arrival to ICU transfer. First, an independent emergency ICU from the ED was created for the intensive care of critically ill patients visiting the ED. There have been several studies that examined the performance of having an ICU connected to the ED, which is frequently known as hybrid resuscitation and ED ICU (RED-ICU) [17,18]. However, most of these RED-ICUs have a small number of beds and provide only transient critical care until patients are admitted to other ICUs within the hospital. Second, in our system, EP intensivists are continuously involved in the initial resuscitation in the ED and subsequent ICU care. Our novel system is similar to the trauma response system of major trauma centers. Many previous studies have shown that rapid response by trauma surgeons in the ED from initial resuscitation, rapid decision, and rapid transfer to the operating room or ICU can improve clinical outcomes of severely injured patients [8,13,16,20–22]. Our system also focused on a rapid response of EP intensivists from initial resuscitation in the ED, rapid decision and transfer to the EICU, and a continuous ICU care. Previous studies have reported that rapid transfer of critically ill patients from the ED to the ICU improves clinical outcomes [7,13,16,23]. However, in the present study, our novel system reduced the ED-ICU interval but failed to reduce ICU and hospital mortalities. Patients in the EICU group underwent fewer emergency surgeries and exhibited higher APACHE II scores than those in the other ICUs group. Such differences in patients’ characteristics and requested therapies might contribute to the clinical outcomes of the enrolled patients. Furthermore, the difference in the ED-ICU interval was only 1.9 h. Hence, this small difference might not actually affect the clinical outcomes of the enrolled patients. To ensure more available ICU beds, EICU intensivists tried to transfer stabilized EICU patients to the ward or other facilities as soon as possible. As such, ICU length of stay in the EICU group was shorter than in the other ICUs group. However, the mean ED-ICU interval was still five hours. During the study period, 95% or more EICU beds were occupied by critically ill patients admitted from the ED. Therefore, the reduction in the ED-ICU interval was not sufficient. From August 2017, we expanded our EICU bed number from 12 to 20, and the number of annual admitted patients increased from 650 to 1300. Future studies investigating the efficacy of the expanded EICU may reveal additional evidences supporting the benefits of our novel system. The present study has the following limitations. This was a single-center retrospective study. In Korea, each of the 12 Regional Emergency Medical Centers across the country has an EICU of their
own. However, EICU management systems differ from each other according to resources and policy. To confirm our results, multicenter prospective studies operating under an integrated protocol are needed. Second, the present study did not include data from 2004 during which time the EICU was created, showing only the most recent three years, from 2014 to 2017. Unfortunately, APACHE II scores of ICU patients were routinely recorded in our EMR system only from 2014, so we were unable to compare severity scores between the EICU and other ICU groups before the study period. Third, the present study failed to show the benefits of our EICU system by comparing data from before and after the system was developed. The EICU was created and run from 2004. However, the EMR of our institute was set up and used from 2006. Thus we could not collect data before 2004. Fourth, the present study used data only from ED patients who were admitted to the ICU. Other ICUs included a large portion of non-ED patients, potentially introducing selection bias in our data collection.
5. Conclusions More than a half of critically ill patients who visited the ED were resuscitated in the ED, transferred to the EICU, and managed in the EICU by the same EP intensivists. Our novel EICU system significantly reduced the ED-ICU interval. Furthermore, this system did not increase ICU or hospital mortalities. These data suggest that our novel system providing initial resuscitation and subsequent transfer to the EICU for continuing intensive care by EP intensivists may help reduce the ED stay of critically ill patients visiting the ED without altering ICU and hospital mortalities.
Funding sources This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Author contributions Study concept and design: H. J., Y. S. J., and G. J. S. Acquisition of the data: T. K., S. M. S., M. W. K., and M. S. L. Analysis and interpretation of the data: W. Y. K., S. M. S., M. W. K., and M. S. L. Drafting of the manuscript: H. J., Y. S. J., G. J. S., and W. Y. K. Critical revision of the manuscript for important intellectual content: Y. S. J., G. J. S., and K. S. K. Statistical expertise: K. S. K. and T. K. Final approval of the version to be submitted: all authors
Please cite this article as: H. Jeong, Y. S. Jung, G. J. Suh et al., Emergency physician-based intensive care unit for critically ill patients visiting emergency department, American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.09.021
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Declaration of Competing Interest H. J., Y. S. J., G. J. S., W. Y. K., K. S. K., T. K., S. M. S., M. W. K., and M. S. L. report no conflict of interests. Appendix A. Supplementary material Supplementary data to this article can be found online at https://doi.org/10.1016/j.ajem.2019.09.021. References [1] Chalfin DB, Trzeciak S, Likourezos A, Baumann BM, Dellinger RP. DELAY-ED study group. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit Care Med 2007;35:1477–83. https://doi.org/10.1097/01.CCM.0000266585.74905.5A. [2] Wen CP, Tsai SP, Chung WS. A 10-year experience with universal health insurance in Taiwan: measuring changes in health and health disparity. Ann Intern Med 2008;148:258–67. https://doi.org/10.7326/0003-4819-148-4200802190-00004. [3] Institute of Medicine Committee on the Future of Emergency Care in the U.S. Health System. The future of emergency care in the United States health system. Ann Emerg Med 2006;48:115–20. https://doi.org/10.1016/j. annemergmed.2006.06.015. [4] Herring AA, Ginde AA, Fahimi J, Alter HJ, Maselli JH, Espinola JA, et al. Increasing critical care admissions from U.S. emergency departments, 2001– 2009. Crit Care Med 2013;41:1197–204. https://doi.org/10.1097/ CCM.0b013e31827c086f. [5] Cowan RM, Trzeciak S. Clinical review: emergency department overcrowding and the potential impact on the critically ill. Crit Care 2005;9:291–5. https:// doi.org/10.1186/cc2981. [6] García-Gigorro R, de la Cruz Vigo F, Andrés-Esteban EM, Chacón-Alves S, Morales Varas G, Sánchez-Izquierdo JA, et al. Impact on patient outcome of emergency department length of stay prior to ICU admission. Med Intensiva 2017;41:201–8. https://doi.org/10.1016/j.medin.2016.05.008. [7] McCoy JV, Gale AR, Sunderram J, Ohman-Strickland PA, Eisenstein RM. Reduced hospital duration of stay associated with revised emergency department-intensive care unit admission policy: a before and after Study. J Emerg Med 2015;49:893–900. https://doi.org/10.1016/ j.jemermed.2015.06.067. [8] Siletz A, Jin K, Cohen M, Lewis C, Tillou A, Cryer HM, et al. Emergency department length of stay in critical nonoperative trauma. J Surg Res 2017;15 (214):102–8. https://doi.org/10.1016/j.jss.2017.02.079. [9] Huang CH, Chen WJ, Ma MH, Chang WT, Lai CL, Lee YT. Factors influencing the outcomes after in-hospital resuscitation in Taiwan. Resuscitation 2002;53:265–70. https://doi.org/10.1016/S0300-9572(02)00024-2.
[10] Cardoso LT, Grion CM, Matsuo T, Anami EH, Kauss IA, Seko L, et al. Impact of delayed admission to intensive care units on mortality of critically ill patients: a cohort study. Crit Care 2011;15:R28. https://doi.org/10.1186/cc9975. [11] Hung SC, Kung CT, Hung CW, Liu BM, Liu JW, Chew G, et al. Determining delayed admission to intensive care unit for mechanically ventilated patients in the emergency department. Crit Care 2014;18:485. https://doi.org/10.1186/ s13054-014-0485-1. [12] Mathews KS, Durst MS, Vargas-Torres C, Olson AD, Mazumdar M, Richardson LD. Effect of emergency department and ICU occupancy on admission decisions and outcomes for critically ill patients. Crit Care Med 2018;46:720–7. https://doi.org/10.1097/CCM.0000000000002993. [13] Ko A, Harada MY, Dhillon NK, Patel KA, Kirillova LR, Kolus RC, et al. Decreased transport time to the surgical intensive care unit. Int J Surg 2017;42:54–7. https://doi.org/10.1016/j.ijsu.2017.04.030. [14] Harris S, Singer M, Rowan K, Sanderson C. Delay to admission to critical care and mortality among deteriorating ward patients in UK hospitals: a multicentre, prospective, observational cohort study. Lancet 2015;26(385 Suppl 1):S40. https://doi.org/10.1016/S0140-6736(15)60355-5. [15] Howell E, Bessman E, Marshall R, Wright S. Hospitalist bed management effecting throughput from the emergency department to the intensive care unit. J Crit Care 2010;25:184–9. https://doi.org/10.1016/j.jcrc.2009.08.004. [16] Fuentes E, Shields JF, Chirumamilla N, Martinez M, Kaafarani H, Yeh DD, et al. ‘‘One-way-street” streamlined admission of critically ill trauma patients reduces emergency department length of stay. Intern Emerg Med 2017;12:1019–24. https://doi.org/10.1007/s11739-016-1511-x. [17] Aslaner MA, Akkasß M, Erog˘lu S, Aksu NM, Özmen MM. Admissions of critically ill patients to the ED intensive care unit. Am J Emerg Med 2015;33:501–5. https://doi.org/10.1016/j.ajem.2014.12.006. [18] Weingart Scott D, Sherwin Robert L, Emlet Lillian L, Tawil Isaac, Mayglothling Julie, Rittenberger Jon C. ED intensivists and ED intensive care units. Am J Emerg Med 2013;31(3):617–20. https://doi.org/10.1016/j.ajem.2012.10.015. [19] Tanabe P, Gimbel R, Yarnold PR, Kyriacou DN, Adams JG. Reliability and validity of scores on the emergency severity index version 3. Acad Emerg Med. 2004;11(1):59–65. https://doi.org/10.1197/j.aem.2003.06.013. [20] Celso B, Tepas J, Langland-Orban B, Pracht E, Papa L, Lottenberg L, et al. A systematic review and meta-analysis comparing outcome of severely injured patients treated in trauma centers following the establishment of trauma systems. J Trauma 2006;60:371–8. https://doi.org/10.1097/01. ta.0000197916.99629.eb. [21] Statement on managed care and the trauma system. American College of Surgeons. Bull Am Coll Surg 1995;80:86–7. [22] Lerner EB, Moscati RM. The golden hour: scientific fact or medical ‘‘urban legend”? Acad Emerg Med 2001;8:758–60. https://doi.org/10.1111/j.15532712.2001.tb00201.x. [23] Durie ML, Darvall JN, Hadley DA, Tacey MA. A ‘‘Code ICU” expedited review of critically ill patients is associated with reduced emergency department length of stay and duration of mechanical ventilation. J Crit Care 2017;42:123–8. https://doi.org/10.1016/j.jcrc.2017.07.011.
Please cite this article as: H. Jeong, Y. S. Jung, G. J. Suh et al., Emergency physician-based intensive care unit for critically ill patients visiting emergency department, American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.09.021
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American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Emergency physician-based intensive care unit for critically ill patients visiting emergency department Hwain Jeong a, Yoon Sun Jung a,⇑, Gil Joon Suh a,b, Woon Yong Kwon a,b, Kyung Su Kim a, Taegyun Kim a, So Mi Shin a, Min Woo Kang c, Min Sung Lee a a b c
Division of Critical Care Medicine, Department of Emergency Medicine, Seoul National University Hospital, Seoul 03080, Republic of Korea Department of Emergency Medicine, Seoul National University College of Medicine, Seoul 03080, Republic of Korea Department of Emergency Medicine, CHA Bundang Medical Center, Gyeonggi-do 13496, Republic of Korea
a r t i c l e
i n f o
Article history: Received 11 April 2019 Received in revised form 11 August 2019 Accepted 17 September 2019 Available online xxxx Keywords: Emergency medicine Emergency department Intensive care units Transfer Mortality
a b s t r a c t Background: To provide a prompt and optimal intensive care to critically ill patients visiting our emergency department (ED), we set up and ran a specific type of emergency intensive care unit (EICU) managed by emergency physician (EP) intensivists. We investigated whether this EICU reduced the time interval from ED arrival to ICU transfer (ED-ICU interval) without altering mortality. Methods: This was a retrospective study conducted in a tertiary referral hospital. We collected data from ED patients who were admitted to the EICU (EICU group) and other ICUs including medical, surgical, and cardiopulmonary ICUs (other ICUs group), from August 2014 to July 2017. We compared these two groups with respect to demographic findings, including the Acute Physiology and Chronic Health Evaluation II (APACHE II) score, ED-ICU interval, ICU mortality, and hospital mortality. Results: Among the 3440 critically ill patients who visited ED, 1815 (52.8%) were admitted to the EICU during the study period. The ED-ICU interval for the EICU group was significantly shorter than that for the other ICUs group by 27.5% (5.0 ± 4.9 vs. 6.9 ± 5.4 h, p < 0.001). In multivariable analysis, the ICU mortality (odds ratio = 1.062, 95% confidence interval 0.862–1.308, p = 0.571) and hospital mortality (odds ratio = 1.093, 95% confidence interval 0.892–1.338, p = 0.391) of the EICU group were not inferior to those of the other ICUs group. Conclusions: The EICU run by EP intensivists reduced the time interval from ED arrival to ICU transfer without altering hospital mortality. Ó 2019 Elsevier Inc. All rights reserved.
1. Introduction Clinical outcomes of critically ill patients visiting the emergency department (ED) depends on timely resuscitation and subsequent optimal intensive care [1]. Therefore, when initial resuscitation at the ED is completed, patients should be transferred to the intensive care unit (ICU) as soon as possible. Delayed transfer to the ICU from the ED continues to be a worldwide problem in the emergency medical system [2–4]. This delay frequently occurs in overAbbreviations: EICU, Emergency Intensive Care Unit; ED, Emergency Department; EP, Emergency Physician; ED-ICU interval, ED-ICU interval, the time interval from ED arrival to ICU transfer. ⇑ Corresponding author at: Department of Emergency Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea. E-mail addresses: [email protected] (H. Jeong), [email protected] (Y.S. Jung), [email protected] (G.J. Suh), [email protected] (W.Y. Kwon), som0809@ naver.com (S.M. Shin).
crowded EDs of tertiary referral hospitals [4,5]. Previous studies reported that a greater than 6 h’ delay in transfer from the ED to the ICU was associated with increases in hospital length of stay, ICU mortality, and hospital mortality [1,6–10]. These data indicate that the contributing factors to delayed transfer should be identified and modified to improve clinical outcomes for critically ill patients visiting the ED. This delay is primarily caused by an increasing volume of critically ill patients in the ED and a lack of available ICU beds [1,11,12]. In addition, multiple decision steps by non-emergency physician intensivists are needed for ICU transfer, and this also contributes a delay [7,13–16]. Many previous studies have attempted to provide solutions to overcome these problems, such as, direct transfer from the computed tomography (CT) room to the surgical ICU (SICU) for trauma patients [13,16], direct referral for patients to ICUs’ intensivists in the ED [7], or a unit within the ED capable of performing ICU treatment [17,18].
https://doi.org/10.1016/j.ajem.2019.09.021 0735-6757/Ó 2019 Elsevier Inc. All rights reserved.
Please cite this article as: H. Jeong, Y. S. Jung, G. J. Suh et al., Emergency physician-based intensive care unit for critically ill patients visiting emergency department, American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.09.021
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In the Republic of Korea, delayed transfer of critically ill patients from the ED to the ICU also frequently occurs. Therefore, the Korean government designated 12 Regional Emergency Medical Centers across the country and established the emergency ICU (EICU) in these regional centers only for critically ill patients visiting the ED. Our institute is one of these Regional Emergency Medical Centers, and we set up a 12-bed EICU in April 2004 beside the ED. Furthermore, we have set up and run an additional system for EICU management, in which emergency physicians (EPs) work as EICU intensivists. They provide initial resuscitation to critically ill patients at the ED and transfer them to the EICU for continuing intensive care by the same intensivists without delay. For ten years (2004–2013), we set up our EICU system and ran the EICU. However, we had not evaluated the efficacy of this system on the time interval from ED arrival to ICU transfer (ED-ICU interval) or the impact of this system on ICU and hospital mortalities in critically ill patients visiting the ED. Therefore, we designed this study to evaluate the efficacy of our EP intensivists-based EICU system. We hypothesized that the ED-ICU interval of patients admitted to the EICU would be shorter than the ED-ICU interval of patients admitted to other ICUs. We also hypothesized that ICU and hospital mortalities of patients admitted to the EICU would not be inferior to those of patients admitted to other ICUs.
Board of our institute (IRB Number: 1805-162-948). Written informed consent was waived. 2.2. Data collection We collected data from critically ill patients who visited the ED and were admitted to the EICU or other ICUs (MICU, SICU, or CPICU) from August 2014 to July 2017. Data were collected from the electronic medical records (EMR) at our institution and included patient demographics, the Acute Physiology and Chronic Health Evaluation II (APACHE II) score during the first 24 h, EDICU interval, ICU mortality, and hospital mortality. 2.3. Statistics For univariate analysis, Student’s t-test and Chi-square test were used. For multivariable analysis, logistic regression analysis was applied. Data are presented as the means and standard deviation (SD) or number and percent (%). P-values of <0.05 were considered statistically significant, and significance levels quoted are two-sided. Statistical analyses were performed using IBM SPSS version 23.0 for Windows (SPSS, Chicago, IL). 3. Results
2. Methods 2.1. Study setting and population This was a retrospective observational study conducted at a tertiary referral hospital in Seoul, Republic of Korea. This hospital has 1306 beds for adult patients and 245 for pediatric patients. Annually, 1.94 million of outpatients visit, and 0.5 million patients are admitted to this hospital. Greater than 50,000 adult patients visit the ED annually. This hospital has 4 adult ICUs (64 beds) including the medical ICU (MICU, 22 beds), SICU (22 beds), cardiopulmonary ICU (CPICU, 8 beds), and EICU (12 beds). The MICU, SICU, and CPICU primarily care for critically ill patients who are either admitted to the wards for medical diagnosis/treatments or who undergo planned surgery. In contrast, the EICU is an emergency facility only for critically ill patients visiting the ED. Five emergency physicians (EPs) worked in our EICU with two emergency medicine residents. They provide coverage 24 h a day. Three EPs were certified as intensivists after at least two years of critical care medicine fellowship from the Korean Society of Critical Care Medicine (KSCCM) and two EPs were in critical care medicine fellowship training. The ratio of nurses to patients in the EICU was 1:2. When critically ill patients visit the ED with an Emergency Severity Index (ESI) level 1 [19], triage nurses notify the EICU intensivists directly. When a non-ESI level 1 patient’s clinical condition deteriorates during the ED stay, ED physicians/nurses also notify the EICU intensivists. EICU intensivists provide initial resuscitation to the patients in the ED resuscitation room and routinely admit them to the EICU as soon as possible. If there are no available beds in the EICU, the EICU intensivists call other ICU intensivists and transfer the patients accordingly. If patients experience specific problems necessitating particular interventions by specialists including emergency surgery, EICU intensivists also call specialists who assist in deciding a patients referral to the EICU or other ICUs. In the present study, we compared patients who were directly admitted to the EICU (the EICU group) with those admitted to other ICUs from the ED (the other ICUs group). The primary outcome was hospital mortality during the study period. Secondary outcomes included ED-ICU interval and ICU mortality. This study was performed in compliance with the Declaration of Helsinki (Seoul, Korea, 2008), and was approved by the Institutional Review
3.1. The EICU group versus the other ICUs group During the study period, 3440 patients were admitted to various ICUs from the ED. Among them, 1815 patients (52.8%) were admitted to the EICU (Fig. 1). The mean age and APACHE II score
Fig. 1. Intensive care unit (ICU) disposition of critically ill patients visiting the emergency department (ED). (A) ICU disposition from the ED. Among 3,440 patients, 1,815 (52.8%) were admitted to the emergency intensive care unit (EICU). MICU, medical ICU; CPICU, cardiopulmonary ICU; SICU, surgical ICU. (B) Post-ICU disposition from the EICU. Among 1815 patients admitted to the EICU, 311 (17.1%) and 1014(55.9%) were moved to other ICUs and to the general wards, respectively. One hundred fifty-nine patients (8.8%) were transferred to other health care facilities (HCF).
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in the EICU group were higher than in the other ICUs group (p < 0.001 and <0.001, respectively) (Table 1). The numbers of patients who underwent emergency surgery or extracorporeal membrane oxygenation (ECMO) in the EICU group were fewer than in the other ICUs group (p < 0.001 and = 0.001, respectively) (Table 1). There were no significant differences in gender, mechanical ventilation, or renal replacement therapy between the two groups (Table 1). ED-ICU interval, length of ICU stay, and length of hospital stay in the EICU group were significantly shorter than in the other ICUs group (p < 0.001, = 0.013, and <0.001, respectively) (Table 1). ICU and hospital mortalities in the EICU group were higher than in the other ICUs group (p = 0.012 and = 0.006, respectively), in univariate analysis without adjusting APACHE II score (Table 1). 3.2. Univariate analysis for ICU and hospital mortalities Increased ICU mortality was associated with old age (p < 0.001), male gender (p = 0.011), admission to the EICU (p = 0.012), higher APACHE II score (p < 0.001), mechanical ventilation (p < 0.001), renal replacement therapy (p < 0.001), and ECMO (p < 0.001)
(Table 2). In contrast, emergency surgery was associated with decreased ICU mortality (p < 0.001) (Table 2). Increased hospital mortality was associated with old age (p < 0.001), male gender (p = 0.003), admission to the EICU (p = 0.006), longer ED-ICU interval (p = 0.021), higher APACHE II score (p < 0.001), mechanical ventilation (p < 0.001), renal replacement therapy (p < 0.001), and ECMO (p < 0.001) (Table 3). Similar to ICU mortality, emergency surgery was associated with decreased hospital mortality (p < 0.001) (Table 3). 3.3. Multivariable analysis for ICU and hospital mortalities Higher APACHE II score, mechanical ventilation, renal replacement therapy, and ECMO were all independently associated with both increased ICU and hospital mortalities. However, emergency surgery was independently associated with decreased ICU and hospital mortalities (Table 4). Admission to the EICU, which was significantly associated with increased ICU and hospital mortalities by univariate analysis, was NOT independently associated with increased ICU mortality (odds ratio = 1.010, 95% confidence interval: 0.862–1.308, p = 0.571) or increased hospital mortality (odds
Table 1 Patients’ characteristics in the EICU and other ICUs groups. EICU (N = 1815)
Age* Male APACHE II score* Required management Emergency operation Mechanical ventilation Renal replacement therapy ECMO
(Years)
(Yes) (Yes) (Yes) (Yes)
Disease classification Infectious Malignancy/hematologic Endocrinologic Neurologic Cardio/cerebrovascular Respiratory Gastrointestinal Soft tissues Urogenital Injury Others
Other ICUs (N = 1625)
P
N
(%)
N
(%)
64.9 ± 16.1 1080 20.9 ± 11.1
(59.5)
61.8 ± 17.6 922 18.8 ± 10.4
(56.7)
<0.001 0.101 <0.001
47 1020 404 22
(2.6) (56.2) (22.3) (1.2)
87 942 363 45
(5.4) (58.0) (22.3) (2.8)
<0.001 0.295 0.955 0.001
59 323 28 83 449 269 175 33 104 119 173
(3.3) (17.8) (1.5) (4.6) (24.7) (14.8) (9.6) (1.8) (5.7) (6.6) (9.5)
37 297 10 66 648 119 156 27 71 112 82
(2.3) (18.3) (0.6) (4.1) (39.9) (7.3) (9.6) (1.7) (4.4) (6.9) (5.0)
‘‘Other intensive care units” are medical ICU, surgical ICU, and cardiopulmonary ICU. ‘‘Others” includes psychologic, ophthalmologic, otolaryngologic, etc. EICU, emergency intensive care unit; ED, emergency department; APACHE II, Acute Physiology and Chronic Health Evaluation II; ECMO, extracorporeal membrane oxygenation. * Data were presented as mean ± standard deviation.
Table 2 Outcomes of the EICU and other ICUs groups. EICU (N = 1815) N ED-ICU interval* Length of ICU stay* Length of hospital stay* ICU mortality Hospital mortality
(Hours) (Days) (Days) (Death) (Death)
5.0 ± 4.9 4.8 ± 8.8 17.0 ± 28.8 388 416
Other ICUs (N = 1625) (%)
N
(21.4) (23.0)
6.9 ± 5.4 5.7 ± 12.9 25.3 ± 39.9 292 310
P
(%)
(18.0) (19.1)
<0.001 0.013 <0.001 0.012 0.006
‘‘Other intensive care units” are medical ICU, surgical ICU, and cardiopulmonary ICU. ‘‘Others” includes psychologic, ophthalmologic, otolaryngologic, etc. EICU, emergency intensive care unit; ED, emergency department; APACHE II, Acute Physiology and Chronic Health Evaluation II; ECMO, extracorporeal membrane oxygenation. * Data were presented as mean ± standard deviation.
Please cite this article as: H. Jeong, Y. S. Jung, G. J. Suh et al., Emergency physician-based intensive care unit for critically ill patients visiting emergency department, American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.09.021
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Table 3 Contributing factors for ICU mortality. Survival(N = 2760) N Age* Male EICU admission ED-ICU interval* APACHE II score* Required management Emergency operation Mechanical ventilation Renal replacement therapy ECMO
(Years) (Yes) (Hours)
(Yes) (Yes) (Yes) (Yes)
Disease classification Infectious Malignancy/hematologic Endocrinologic Neurologic Cardio/cerebrovascular Respiratory Gastrointestinal Soft tissues Urogenital Injury Others
62.5 ± 17.1 1577 1427 6.0 ± 5.2 17.4 ± 9.1
(%) (57.1) (51.7)
Non-survival(N = 680) N (%)
P
67.2 ± 15.3 425 388 5.5 ± 5.3 29.9 ± 11.5
<0.001 0.011 0.012 0.053 <0.001
(62.5) (57.1)
128 1405 445 26
(4.6) (50.9) (16.1) (0.9)
6 557 322 41
(0.9) (81.9) (47.4) (6.0)
76 439 34 137 910 289 279 49 154 213 180
(2.8) (15.9) (1.2) (5.0) (33.0) (10.5) (10.1) (1.8) (5.6) (7.7) (6.5)
20 181 4 12 187 99 52 11 21 18 75
(2.9) (26.6) (0.6) (1.8) (27.5) (14.6) (7.6) (1.6) (3.1) (2.6) (11.0)
<0.001 <0.001 <0.001 <0.001
‘‘Other intensive care units” are medical ICU, surgical ICU, and cardiopulmonary ICU. ‘‘Others” includes psychologic, ophthalmologic, otolaryngologic, etc. EICU, emergency intensive care unit; ED, emergency department; ED-ICU interval, the interval from ED arrival to ICU admission; APACHE II, Acute Physiology and Chronic Health Evaluation II; ECMO, extracorporeal membrane oxygenation. * Data were presented as mean ± standard deviation.
Table 4 Contributing factors for hospital mortality. Survival (N = 2706) N Age* Male EICU admission ED-ICU interval* APACHE II score* Required management Emergency operation Mechanical ventilation Renal replacement therapy ECMO Disease classification Infectious Malignancy/hematologic Endocrinologic Neurologic Cardio/cerebrovascular Respiratory Gastrointestinal Soft tissues Urogenital Injury Others
(Years) (Yes) (Hours)
(Yes) (Yes) (Yes) (Yes)
62.6 ± 17.1 1541 1394 6.0 ± 5.2 17.3 ± 9.1
Non-survival (N = 726) (%) (56.9) (51.5)
N 66.8 ± 15.4 458 416 5.5 ± 5.3 29.5 ± 11.4
P
(%) (63.1) (57.3)
128 1361 430 26
(4.7) (50.3) (15.9) (1.0)
6 594 335 41
(0.8) (81.8) (46.1) (5.6)
75 428 34 128 891 287 275 48 154 209 177
(2.8) (15.8) (1.3) (4.7) (32.9) (10.6) (10.2) (1.8) (5.7) (7.7) (6.5)
21 191 4 20 203 101 56 12 21 21 76
(2.9) (26.3) (0.6) (2.8) (28.0) (13.9) (7.7) (1.7) (2.9) (2.9) (10.5)
<0.001 0.003 0.006 0.021 <0.001 <0.001 <0.001 <0.001 <0.001
‘‘Other intensive care units” are medical ICU, surgical ICU, and cardiopulmonary ICU. ‘‘Others” includes psychologic, ophthalmologic, otolaryngologic, etc. EICU, emergency intensive care unit; ED, emergency department; ED-ICU interval, the interval from ED arrival to ICU admission; APACHE II, Acute Physiology and Chronic Health Evaluation II; ECMO, extracorporeal membrane oxygenation. * Data were presented as mean ± standard deviation.
ratio = 1.093, 95% confidence interval: 0.892–1.338, p = 0.391) by multivariable analysis are described in Table 5. 4. Discussion We hypothesized that this system would save more ICU beds for critically ill ED patients and reduce decision steps for ICU trans-
fer, resulting in a reduced ED-ICU interval. Although the involved EP intensivists were certified by the KSCCM, there have been no real data evaluating EP intensivists’ capability of caring for ICU patients, until now. By univariate analysis, EICU admission increased both ICU and hospital mortalities. However, by multivariable analysis, adjusting the APACHE II score, EICU admission was not independently associated with increased ICU or hospital
Please cite this article as: H. Jeong, Y. S. Jung, G. J. Suh et al., Emergency physician-based intensive care unit for critically ill patients visiting emergency department, American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.09.021
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H. Jeong et al. / American Journal of Emergency Medicine xxx (xxxx) xxx Table 5 Multivariable analysis for ICU and hospital mortalities. ICU mortality
Age (years) Male gender EICU admission ED-ICU interval (hours) APACHE II score Required management Emergency operation Mechanical ventilation Renal replacement therapy ECMO
Hospital mortality
Odds ratio
95% Confidence interval
P
Odds ratio
95% Confidence interval
P
1.006 1.196 1.062 1.010 1.095
0.999–1.012 0.976–1.465 0.862–1.308 0.991–1.029 1.084–1.106
0.076 0.084 0.571 0.301 <0.001
1.003 1.252 1.093 1.007 1.094
0.997–1.009 1.027–1.527 0.892–1.338 0.989–1.026 1.083–1.105
0.391 0.026 0.391 0.452 <0.001
0.240 1.812 2.751 2.562
0.100–0.576 1.420–2.313 2.230–3.394 1.420–4.625
0.001 <0.001 <0.001 0.002
0.211 1.891 2.660 2.262
0.088–0.505 1.493–2.395 2.162–3.272 1.257–4.072
<0.001 <0.001 <0.001 0.006
EICU, emergency intensive care unit; ED, emergency department; ED-ICU interval, the interval from ED arrival to ICU admission; APACHE II, Acute Physiology and Chronic Health Evaluation II; ECMO, extracorporeal membrane oxygenation.
mortalities. These data indicate that our novel system effectively reduced the ED-ICU interval without altering ICU and hospital mortalities. Our novel EICU system has two features that distinguish it from previous systems to reduce the interval from ED arrival to ICU transfer. First, an independent emergency ICU from the ED was created for the intensive care of critically ill patients visiting the ED. There have been several studies that examined the performance of having an ICU connected to the ED, which is frequently known as hybrid resuscitation and ED ICU (RED-ICU) [17,18]. However, most of these RED-ICUs have a small number of beds and provide only transient critical care until patients are admitted to other ICUs within the hospital. Second, in our system, EP intensivists are continuously involved in the initial resuscitation in the ED and subsequent ICU care. Our novel system is similar to the trauma response system of major trauma centers. Many previous studies have shown that rapid response by trauma surgeons in the ED from initial resuscitation, rapid decision, and rapid transfer to the operating room or ICU can improve clinical outcomes of severely injured patients [8,13,16,20–22]. Our system also focused on a rapid response of EP intensivists from initial resuscitation in the ED, rapid decision and transfer to the EICU, and a continuous ICU care. Previous studies have reported that rapid transfer of critically ill patients from the ED to the ICU improves clinical outcomes [7,13,16,23]. However, in the present study, our novel system reduced the ED-ICU interval but failed to reduce ICU and hospital mortalities. Patients in the EICU group underwent fewer emergency surgeries and exhibited higher APACHE II scores than those in the other ICUs group. Such differences in patients’ characteristics and requested therapies might contribute to the clinical outcomes of the enrolled patients. Furthermore, the difference in the ED-ICU interval was only 1.9 h. Hence, this small difference might not actually affect the clinical outcomes of the enrolled patients. To ensure more available ICU beds, EICU intensivists tried to transfer stabilized EICU patients to the ward or other facilities as soon as possible. As such, ICU length of stay in the EICU group was shorter than in the other ICUs group. However, the mean ED-ICU interval was still five hours. During the study period, 95% or more EICU beds were occupied by critically ill patients admitted from the ED. Therefore, the reduction in the ED-ICU interval was not sufficient. From August 2017, we expanded our EICU bed number from 12 to 20, and the number of annual admitted patients increased from 650 to 1300. Future studies investigating the efficacy of the expanded EICU may reveal additional evidences supporting the benefits of our novel system. The present study has the following limitations. This was a single-center retrospective study. In Korea, each of the 12 Regional Emergency Medical Centers across the country has an EICU of their
own. However, EICU management systems differ from each other according to resources and policy. To confirm our results, multicenter prospective studies operating under an integrated protocol are needed. Second, the present study did not include data from 2004 during which time the EICU was created, showing only the most recent three years, from 2014 to 2017. Unfortunately, APACHE II scores of ICU patients were routinely recorded in our EMR system only from 2014, so we were unable to compare severity scores between the EICU and other ICU groups before the study period. Third, the present study failed to show the benefits of our EICU system by comparing data from before and after the system was developed. The EICU was created and run from 2004. However, the EMR of our institute was set up and used from 2006. Thus we could not collect data before 2004. Fourth, the present study used data only from ED patients who were admitted to the ICU. Other ICUs included a large portion of non-ED patients, potentially introducing selection bias in our data collection.
5. Conclusions More than a half of critically ill patients who visited the ED were resuscitated in the ED, transferred to the EICU, and managed in the EICU by the same EP intensivists. Our novel EICU system significantly reduced the ED-ICU interval. Furthermore, this system did not increase ICU or hospital mortalities. These data suggest that our novel system providing initial resuscitation and subsequent transfer to the EICU for continuing intensive care by EP intensivists may help reduce the ED stay of critically ill patients visiting the ED without altering ICU and hospital mortalities.
Funding sources This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Author contributions Study concept and design: H. J., Y. S. J., and G. J. S. Acquisition of the data: T. K., S. M. S., M. W. K., and M. S. L. Analysis and interpretation of the data: W. Y. K., S. M. S., M. W. K., and M. S. L. Drafting of the manuscript: H. J., Y. S. J., G. J. S., and W. Y. K. Critical revision of the manuscript for important intellectual content: Y. S. J., G. J. S., and K. S. K. Statistical expertise: K. S. K. and T. K. Final approval of the version to be submitted: all authors
Please cite this article as: H. Jeong, Y. S. Jung, G. J. Suh et al., Emergency physician-based intensive care unit for critically ill patients visiting emergency department, American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.09.021
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Please cite this article as: H. Jeong, Y. S. Jung, G. J. Suh et al., Emergency physician-based intensive care unit for critically ill patients visiting emergency department, American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.09.021