Napoleon famously said, “Geography is destiny.” Is this true in your hospital? Some days, it seems that your location in the hospital determines the level of care delivered. Does your emergency department provide the same excellent care as your intensive care unit?
Critically ill patients stay in the ED for a long time, and they deserve optimal care when they are there. In fact, their time in the ED might just be more important to their outcome than later in their hospital stay. They should be getting the ideal care that they would get upstairs in the ICU.
Patients in the ICU get good nursing ratios, high-end monitors, and teams of people looking after them. We work equally hard in the ED, but sometimes it appears that the level of care we achieve is not quite as polished.
Several barriers exist for delivering high-level care in the ED. Staff may not have the same degree of knowledge and skill of the latest evidence or procedures. EDs also typically lack optimal resources, including health care workers (fewer pharmacists, RTs, and nurses), and gear (fewer gadgets and less monitoring capability). But most importantly, the primary resource crunch in the ED is time. Patients stream through the doors, and emergency physicians and nurses often lack the time to optimize their critically ill patients fully.
Despite these barriers, delivering excellent critical care in the ED is an important goal for patient outcomes. Given an understanding of the challenges, here is a Top 10 list of ideas for improving ICU care in the ED for critically ill patients. My goal is to inspire you to pick one or two of these ideas and to start incorporating them into your hospital. Some of these are long-term planning ideas that may require a five- or 10-year plan, but some of them you can implement tomorrow. I start with those that are most difficult to implement and work toward the easiest.
10. Develop an ED-ICU or dedicated resuscitation area: This area should have dedicated physician staffing and a high nursing ratio, with beds devoted to critical care and acute resuscitation. Typical patients could include sepsis, shock, arrhythmias, cardiac arrest, and trauma. This model is described by Scott Weingart in his 2013 paper. (Am J Emerg Med 2013;31:617.)
This could be an excellent rotation for your emergency medicine residents and ICU fellows. Staff love to work in this environment, so recruitment is easy. Patients benefit from dedicated focus and care, so outcomes can improve. Some patients may avoid ICU admission altogether if they can be fully managed in the ED-ICU. Clearly, this idea is not one that you can pull off tomorrow, but there is no reason you can't work this into your five-year plan.
9. Create a mobile resuscitation team: This will assist with ED resuscitation or ED critical care. Many hospitals have adopted this model. Some places only have this team on inpatient wards, but they can also be a valuable resource for the ED. If you have a team like this, get them to start coming to your ED to help out. If you already have this, feel lucky because not everyone else does! Bringing in a skilled team to complement ED care can raise the intensity of care delivered.
8. Develop a one-year fellowship in ED-ICU and resuscitation. If that seems like too much work, start with a one-month rotation. This is generally considered an engaging topic, so it is easy to recruit teachers and students. You then have fellows to help staff the ED-ICU you are planning.
Some places will combine a specific ED-ICU fellowship with a trauma or resuscitation fellowship. There are many variations on this theme, and it may not be a lot of additional work to develop this if you already have a fellowship program. The upside is that you start to engage a group of skilled resuscitation experts among your attendings who are teaching and the fellows who are training. This starts to improve the knowledge and skills across the group and raises the level of expertise available on the average ED shift.
7. Hire an ED intensivist. Do you need an easier option? Hire an ED-ICU physician, and let him organize the fellowship or the ED-ICU. Hiring ED intensivists into your group also helps to fix the knowledge and skill gaps. They can educate and do research. This is a relatively painless solution to start bridging the gaps.
6. Track data around quality in resuscitation. Track sepsis outcomes, adherence to post-arrest quality indicators, time to the OR from the trauma room, and peri-shock pause. Track whatever outcome interests you. Assessing quality metrics and delivering feedback to the stakeholders is a huge driver for effective change. This can be enormously successful as a strategy for improving the quality of critical care delivered in the ED, particularly if you can track outcomes over time and have a longitudinal feedback mechanism.
5. Develop ED-ICU team-training days. Create a skills course or a simulation day for ED-ICU training that includes residents, nurses, and attendings, and run mock codes or resuscitations. It is ideal to do some of this training physically inside your ED because in situ simulation is a great method for training. But you can also do it in your sim lab or even a conference room. Training days help to improve gaps in knowledge or skills.
4. Hold joint ED-ICU rounds, preferably regularly. This is an even easier solution for fixing knowledge gaps. Ideally, they will be multidisciplinary. Having joint rounds increases knowledge and collaboration, but more importantly, can help forge relationships with your ICU colleagues, which leads me to solution number 3.
3. Make a friend in the other department. If you work in the ED, invite her downstairs and blow her mind about what we can achieve there. If you work in the ICU, invite her up into the ivory tower to see if you can recruit her. These relationships are valuable. Once you have made a friend, it is much easier to call her for advice or to discuss a case. Understanding each other's worlds better will let us work together more easily, and patients will benefit from this collaboration.
2. Build decision support and educational tools. Make a checklist, a protocol, or a poster or build decision support into your computer system. These are easy tools that you can place at the bedside to help clinicians deliver better critical care.
Perhaps after joint ED-ICU rounds, the speakers can provide a page of teaching points that are posted in the ED. These bedside tools can be valuable for ED staff who may be less experienced or less comfortable with critical care.
1. Spend an extra 10 minutes. Last but not least, the easiest tip is perhaps the one with the greatest potential impact. When you have a critically ill patient in your ED, spend an extra 10 minutes at the bedside. Don't just intubate, and then walk away to call the ICU. Those first minutes or hours in the ED make a huge difference for critically ill patients. This is the concept behind the golden hour of trauma (Md State Med J 1975;24:37), around early aggressive resuscitation for sepsis (New Engl J Med 2013;369:840), around resuscitation for so many critical patients.
After you intubate, spend 10 minutes optimizing the patient's hemodynamics or the ventilator. After you get a pulse back on your cardiac arrest patient, spend 10 minutes on excellent post-ROSC care. Take 10 minutes to reassess the volume status of your septic patient and give him antibiotics. Those 10 minutes might just be the most important thing you do at work all day.
When it comes to saving lives, it's worth some time and effort to create a better system. Let's create EDs where we deliver the highest quality care in the hospital.
Dr. Gray wrote this article based on a lecture she gave at SMACC, the Social Media and Critical Care Conference. Find more information about SMACC athttp://www.smacc.net.au. Follow the conference on Twitter at@smaccteam and @smaccinfo.