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JAMA Netw Open. 2019 Jul 3;2(7):e197584. doi: 10.1001/jamanetworkopen.2019.7584.

Association of an Emergency Department-Based Intensive Care Unit With Survival and Inpatient Intensive Care Unit Admissions.

Author information

Department of Anesthesiology, Michigan Medicine, University of Michigan, Ann Arbor.
Department of Emergency Medicine, Michigan Medicine, University of Michigan, Ann Arbor.
Division of Emergency Critical Care, Michigan Medicine, University of Michigan, Ann Arbor.
Michigan Center for Integrative Research in Critical Care, Ann Arbor.
Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor.
Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor.
School of Dentistry, University of Michigan, Ann Arbor.



Increased patient acuity, decreased intensive care unit (ICU) bed availability, and a shortage of intensivist physicians have led to strained ICU capacity. The resulting increase in emergency department (ED) boarding time for patients requiring ICU-level care has been associated with worse outcomes.


To determine the association of a novel ED-based ICU, the Emergency Critical Care Center (EC3), with 30-day mortality and inpatient ICU admission.

Design, Setting, and Participants:

This retrospective cohort study used electronic health records of all ED visits between September 1, 2012, and July 31, 2017, with a documented clinician encounter at a large academic medical center in the United States with approximately 75 000 adult ED visits per year. The pre-EC3 cohort included ED patients from September 2, 2012, to February 15, 2015, when the EC3 opened, and the post-EC3 cohort included ED patients from February 16, 2015, to July 31, 2017. Data analyses were conducted from March 2, 2018, to May 28, 2019.


Implementation of EC3, an ED-based ICU designed to provide rapid initiation of ICU-level care in the ED setting and seamless transition to inpatient ICUs.

Main Outcomes and Measures:

The main outcomes were 30-day mortality among ED patients and rate of ED to ICU admission.


A total of 349 310 visits from a consecutive sample of ED patients (mean [SD] age, 48.5 [19.7] years; 189 709 [54.3%] women) were examined; the pre-EC3 cohort included 168 877 visits and the post-EC3 cohort included 180 433 visits. Implementation of EC3 was associated with a statistically significant reduction in risk-adjusted 30-day mortality among all ED patients (pre-EC3, 2.13%; post-EC3, 1.83%; adjusted odds ratio, 0.85; 95% CI, 0.80-0.90; number needed to treat, 333 patient encounters; 95% CI, 256-476). The risk-adjusted rate of ED admission to ICU decreased with implementation of EC3 (pre-EC3, 3.2%; post-EC3, 2.7%; adjusted odds ratio, 0.80; 95% CI, 0.76-0.83; number needed to treat, 179 patient encounters; 95% CI, 149-217).

Conclusions and Relevance:

Implementation of a novel ED-based ICU was associated with improved 30-day survival and reduced inpatient ICU admission. Additional research is warranted to further explore the value of this novel care delivery model in various health care systems.

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