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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

1
Department of Anesthesiology, Michigan Medicine, University of Michigan, Ann Arbor.
2
Department of Emergency Medicine, Michigan Medicine, University of Michigan, Ann Arbor.
3
Division of Emergency Critical Care, Michigan Medicine, University of Michigan, Ann Arbor.
4
Michigan Center for Integrative Research in Critical Care, Ann Arbor.
5
Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor.
6
Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor.
7
School of Dentistry, University of Michigan, Ann Arbor.

Abstract

Importance:

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.

Objective:

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.

Exposures:

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.

Results:

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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