Association of an Emergency Department-embedded Critical Care Unit with Hospital Outcomes and Intensive Care Unit Utilization

George L Anesi, Jayaram Chelluri, Zaffer A Qasim, Marzana Chowdhury, Rachel Kohn, Gary E Weissman, Brian Bayes, M Kit Delgado, Benjamin S Abella, Scott D Halpern, John C Greenwood
Annals of the American Thoracic Society 2020 July 22

RATIONALE: A small but growing number of hospitals are experimenting with emergency department (ED)-embedded critical care units (ED-CCUs) in an effort to improve the quality of care for critically ill patients with sepsis and acute respiratory failure (ARF).

OBJECTIVE: To evaluate the potential impact of an ED-CCU at the Hospital of the University of Pennsylvania among patients with sepsis and ARF admitted from the ED to a medical ward or intensive care unit (ICU) from January 2016 to December 2017.

METHODS: The exposure was eligibility for admission to the ED-CCU, defined as meeting a clinical definition for sepsis or ARF and admission to the ED during the intervention period on a weekday. The primary outcome was hospital length of stay (LOS); secondary outcomes included total ED plus ICU LOS, hospital survival, direct admission to the ICU, and unplanned ICU admission. Primary interrupted time series analyses were performed using ordinary least squares regression comparing monthly means. Secondary retrospective cohort and before-after analyses utilized multivariable Cox proportional hazard and logistic regression.

RESULTS: In the baseline and intervention periods, 3,897 patients met inclusion criteria for sepsis and 1,865 patients met criteria for ARF. Among patients admitted with sepsis, opening of the ED-CCU was not associated with hospital LOS (β = -1.82 days, 95% CI -4.50-0.87, p = 0.17 for the first month after ED-CCU opening compared to baseline; β = -0.26 days, 95% CI -0.58-0.06, p = 0.10 for subsequent months). Among patients admitted with ARF, the ED-CCU was not associated with a significant change in hospital LOS for the first month after ED-CCU opening (β = -3.25 days, 95% CI -7.86-1.36, p = 0.15) but was associated with a 0.64-day per-month shorter hospital LOS for subsequent months (β = -0.64 days, 95% CI -1.12--0.17, p = 0.01). This result persisted among higher acuity patients requiring ventilatory support, but was not supported by alternative analytic approaches. Among patients admitted with sepsis who did not require mechanical ventilation or vasopressors in the ED, the ED-CCU was associated with an initial 9.9% reduction in direct ICU admissions in the first month (β = -0.099, 95% CI -0.153--0.044, p = 0.002), followed by a 1.1% per-month increase back towards baseline in subsequent months (β = 0.011, 95% CI 0.003-0.019, p = 0.009). This relationship was supported by alternative analytic approaches and was not seen in ARF. No associations with ED plus ICU LOS, hospital survival, or unplanned ICU admission were observed among patients with sepsis or ARF.

CONCLUSIONS: The ED-CCU was not associated with clinical outcomes among patients admitted with sepsis or ARF. Among less sick septic patients, the ED-CCU was initially associated with reduced rates of direct ICU admission from the ED. Additional research is necessary to further evaluate the impact and utility of the ED-CCU model.

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