382 Utilization of an Emergency Department-Based Intensive Care Unit Peaks Near Emergency Department Shift Turnover Times

Abstract

The Emergency Critical Care Center (EC3) is an ED-based ICU (ED-ICU) that opened at Michigan Medicine in 2015 to improve timely access to critical care for patients in the ED. ED patients requiring intensive care are initially evaluated and managed in the main ED prior to transfer to a separate group of EC3 providers. The timing of patient transfers to EC3 may have an impact on patient outcomes and optimal provider staffing models, but has not been previously studied. In our main adult ED, physician sign out occurs at 0700, 1500, and 2300, whereas EC3 physician sign out occurs at 0800 and 2000. ED sign out has previously been described as among the most dangerous times in a patient’s hospital stay, and problems with communication during transitions of care are a common source of medical errors. An electronic medical record search identified all patients managed in EC3 in 2016 and 2017. De-identified patient data, including ED arrival time, EC3 consult order time, time changed to EC3 status, and reason for consult were queried and analyzed. Patients were divided into 24 cohorts based on the hour of day of ED arrival time. A total of 160,198 ED visits were queried, 5,308 (3.3%) EC3 status patients were included for analysis. EC3 consult reasons included severe sepsis/septic shock (15%), altered mental status/overdose (10%), metabolic, including DKA/electrolytes (9%), GI bleed (7%), respiratory distress/respiratory failure (5%), and other (41%). The number of ED arrivals per hour was 6,675±3,042 (mean±SD). The maximum occurred between 1131-1230 (10,353), and gradually declined to a minimum between 0431-0530 (2,234). The number of EC3 consults placed per hour was 221±85, with relative maximums occurring near ED sign out times: 2231-2330 (372) and 1431-1530 (365). The minimum were placed between 0731-0830 (88), shortly after ED sign out. During daytime hours (0831-2030), there were 111,640 ED arrivals and 2,826 EC3 consults (2.5%), while during night hours (2031-0830) there were 48,558 ED visits and 2,482 EC3 consults (5.1%). The median interval from ED arrival time to EC3 consult order was 161 minutes [range 6-1,434; IQR 144-174]. Relative minimums were observed for patients arriving shortly prior to ED sign out times: 0431-0530 (120 minutes), 1231-1330 (145 minutes), and 2131-2230 (135 minutes). Relative maximums were observed for patients arriving shortly after ED sign out times: 0731-0830 (177 minutes), 1631-1730 (218 minutes), and 2331-0030 (179 minutes). EC3 utilization was highest near ED sign out times, and utilization was dissimilar to overall ED arrival patterns. This finding may aid other institutions implementing ED-ICU’s for operational planning, staffing models, and timing of sign outs. Investigating methods to smooth and load level transitions of care from the ED to an ED-ICU may provide insight into more effective resource utilization, staffing models, and patient throughput. Patients arriving immediately prior to ED sign out received earlier consults to EC3, suggesting these patients may have been preferentially transferred to the ED-ICU rather than signed out to the next team of main ED providers. Future studies could investigate whether an ED-ICU model improves critically ill patients’ outcomes by minimizing ED provider handoffs.