Background: Critically ill patients require time dependent and resource intense interventions. In February 2015 our institution initiated a novel intensive care unit within the Emergency Department (ED-ICU) with the goal to enhance timely resuscitation and management of critically ill patients prior to inpatient admission. As a result of early intervention in the ED-ICU, ongoing care needs can potentially be downgraded and prevent the need for admission to the Medical ICU (MICU). This approach has potential to reallocate ICU resources to the most critically ill patients and impact hospital based IM resident training by altering where care is provided and by whom.
Purpose: To assess the impact of ED-ICU implementation on the number of admissions to the MICU, procedural experience, and resident perceptions regarding ICU educational experience.
Description:
Methods: Admissions and billing data for all MICU patients was reviewed over the first quarter before and after implementation of the ED-ICU. Additionally procedure data for a single unit was evaluated. A survey was disseminated to all PGY-2 through PGY-4 Internal Medicine (IM) and Emergency Medicine (EM) residents regarding their ICU experience.
Results: There was a non-significant decrease in the proportion of MICU patients admitted from the ER (-6%, p=0.2) and the inpatient wards (-4%, P=0.18) after implementation of ED-ICU, and a significant increase in the proportion of patients transferred from outside institutions (+7%, p=0.01) (Table 1).
IM residents reported (n=87/110, 79.1% response rate) implementation of the ED-ICU had a negative impact on their ICU training (49%), with 24% feeling their ICU experience was unchanged (Table 2). Free text comments suggested the major concern expressed was decreased procedural opportunities, especially central lines, and less experience stabilizing patients early in their course.
Procedural billing data indicate that the number of central lines performed by IM residents in the MICU increased by 2% while arterial lines decreased by 16%, thoracenteses by 63% and paracenteses by 10%.
Conclusions: Implementation of a novel ED-ICU led to a non-significant reduction in the proportion of admissions from the ED and inpatient services to the MICU, with a statistically significant increase in the number of outside hospital ICU transfers. IM trainees felt that the ED-ICU had a negative impact on their MICU educational experience. There was a decrease in the overall number of procedures performed, but no impact on central lines. Future analysis should include evaluation of the impact on patient outcomes by this early intervention, further exploration of the discordance between the residents’ perceived and observed impact on procedure training, and whether additional experiences will be needed to assure management of conditions such as sepsis andearly goal directed therapy or diabetic ketoacidosis that may be more rapidly reversed are preserved in hospital based IM resident training.