DOI: 10.12809/hkmj176902
© Hong Kong Academy of Medicine. CC BY-NC-ND 4.0
MEDICAL PRACTICE
A paradigm shift in the provision of improved critical
care in the emergency department
KM Yim, MB, ChB, FHKCEM1,2;
HF Ko, MB, BS, FHKCEM1; Marc LC Yang, MB, ChB, FHKCEM1;
TY Li, MB, BS, FHKCEM1; S Ip, APN1; J Tsui, APN1
1 Accident and Emergency Department,
Queen Elizabeth Hospital, Jordan, Hong Kong
2 Intensive Care Unit, Queen Elizabeth
Hospital, Jordan, Hong Kong
Corresponding author: Dr KM Yim (anferneeyim@gmail.com)
Abstract
With Hong Kong’s ageing population, advancement
of medical technologies and hospital congestion, it is not uncommon for
emergency physicians to encounter complicated critically ill patients in
daily practice. It becomes a fundamental role of emergency physicians to
initiate timely diagnostic and therapeutic interventions to save a
patient’s life and improve their prognosis. It is the reason a critical
care service has been developed in emergency departments worldwide over
the last decade. This article shares how emergency department
intensivists can contribute to this novel model of care with some
illustrative cases. Advanced airway and peri-intubation management,
difficult mechanical ventilation, treatment of shock, circulatory
arrest, and metabolic disturbances can be safely and efficiently handled
in the current emergency department setting. Obstacles, barriers, and
the road ahead will be discussed.
Introduction
The provision of a critical care service in the
emergency department (ED) was once considered synonymous with an intensive
care unit (ICU). Nonetheless with more and more critically ill patients
presenting to the ED, it is not uncommon for them to remain there for the
first 1 to 2 hours of treatment. Examples include patients with
out-of-hospital cardiac arrest and post-arrest care, septic shock, and
status asthmaticus. In addition, ICU overcrowding results in some patients
with relatively less critical disease entities such as diabetic
ketoacidosis or hypokalaemia being triaged out from ICU admission.
Nonetheless these patients still require close monitoring and intervention
that are beyond the capacity of a general medical ward. It would be ideal
for this group of patients to receive the same evidence-based aggressive
intensive care measures regardless of their location within the hospital.
An emergency department intensivist (EDI) can provide such care. Emergency
department intensivist refers to a dually qualified emergency medicine
(EM) and intensive care fellows who practises ED critical care as part of
their clinical role.1
The development of an intensive care subspecialty
under the umbrella of emergency medicine is increasing rapidly around the
world. For example, such combined training is provided by the Australian
College of Emergency Medicine and College of Intensive Care Medicine of
Australia, the Royal College of Emergency Medicine and the Faculty of
Intensive Care Medicine in the United Kingdom, as well as the American
Board of Internal Medicine, American Board of Emergency Medicine, and
American Board of Medical Specialties in the United States. In our region,
emergency physicians in mainland China, Taiwan, Singapore, Japan, and
Macau are providing a critical care service in their EDs and some are even
running their separate Emergency-ICU as well. As one of the preeminent
medical hubs in Asia, we followed the trend several years ago. We have a
well-established training pathway in Hong Kong for those wishing to attain
dual fellowship qualification in EM and intensive care medicine (ICM). A
memorandum of understanding was signed between the Hong Kong College of
Anaesthesiologists and the Hong Kong College of Emergency Medicine in
2012. In order to become a dually qualified EDI, an Emergency Medicine
fellow is required to complete a 2-year rotation in an accredited ICU and
1 year in an accredited anaesthesia training centre. The trainee should
fulfil the training requirements of the ICM programme including regular
tutorials, research projects, and success in a final examination to obtain
the dual qualification.
By bringing intensive care monitoring and therapies
to the ED, EDI may provide timely, life-saving treatment to critically ill
patients and mitigate the negative effect of ICU overcrowding by reducing
the number of patients who progress to multi-organ dysfunction and
reducing the need for ICU admission.2
3 Nonetheless international studies
have emphasised that most EDs have not been designed or staffed to provide
care beyond the initial resuscitation period in the first 20 to 60
minutes.4 5 Our ED has been transformed over the last few years to
overcome such limitations. Examples include an expanded and dedicated
resuscitation area in the ED; provision of the ability to perform basic
hemodynamic monitoring, including measurements of arterial blood pressure,
non-invasive cardiac output monitoring device, echocardiogram machines;
mechanical ventilation capability, including high flow nasal cannula and
conventional ICU ventilator; and an exchange programme for ED nursing
staff so that they may develop proficiency in haemodynamic monitoring and
mechanical ventilation.
Hybrid and resource intensivist models
There are two models of practice of EDI worldwide:
the resource intensivist model and the hybrid model. In the former, the
EDI plays a standard clinical role in the specialist roster of ED.
Whenever a critically ill patient presents to the department, the EDI can
provide additional expertise either as the primary physician or as an
adviser. This has the benefit of exposing all clinical team members to the
same level of care. It is similar to the toxicology model in the ED
wherein the toxicologist can improve an entire department’s care of
poisoned patients. The presence of EDIs may lead to similarly improved
management. In the hybrid model, the ED resuscitation area is transformed
to act as an ED-ICU. In this model, the EDI can easily shift the abilities
of this resuscitation area to allow for the care of critically ill
patients beyond the first hour and provide a similar intensity of care to
that available in the ICU.1
Our department adopts a mixed resource intensivist
and hybrid model of care. Three of the four qualified EDIs in Hong Kong
work in the department and act as resource intensivists. From November
2016, our department commenced provision of an ED specialist-led service
specifically for all critically ill patients who presented to our
resuscitation room between 08:00 and 18:00 on weekdays. About one third of
such duties were assumed by the three EDIs, providing other clinical team
members with opportunities to keep up-to-date with their skills,
knowledge, and practice of managing critically ill patients. Physically,
we have an expanded and dedicated area (Fig) that can care for up to six critically ill
patients at any one time. Emergency department intensivists may decide the
level of care required and this will depend on the clinical situation of
the patient and review of the available resources and administrative
considerations. At other times, EDIs are assigned duties in the normal EP
roster. Emergency department intensivists can also provide on-site advice
to emergency physicians upon request. The critical care team endeavours to
incorporate critical care skills into routine ED practice, such that
manpower utilisation is optimised and patient workflow is not altered. The
team can function as a bridge that enables better communication between
the ED and the ICU. Quality assurance is achieved by regular critical care
audits, research, and sharing of local and international experience.
Figure. Extended resuscitation area for patients requiring intensive care in the emergency department of Queen Elizabeth Hospital
Extended triage and advanced resuscitation strategy
We aimed to adopt an extended triage strategy. This
involves the targeting of critically ill patients who require close
monitoring with timely initiation of resuscitative and therapeutic
measures in the presence of a readily reversible condition. Examples
include metabolic diseases such as diabetic ketoacidosis and severely
poisoned patients. The primary goal is to institute early aggressive
therapy and monitoring. The patient can either be escalated to care in the
ICU if a suboptimal response to therapy is evident, or admitted to a
general ward if they show signs of recovery. Overseas study has quoted a
11.1% reduction in ICU admissions (patients were instead admitted to the
general ward) after therapy was administered in the ED. It proved a
preventive role of the ED in disease progression and ICU resource
utilisation.6
The increasing complexity of critically ill
patients demands sophisticated skills and knowledge, both in the early
diagnostic process and initial management. Examples include refractory
septic shock, acute respiratory distress syndrome, and refractory cardiac
arrest. Emergency department intensivists can provide advanced
resuscitation to those patients in the ED who are awaiting ICU admission.
It is well established that more rapid and aggressive treatment of sepsis
and septic shock patients can reduce in-hospital mortality.7 The objective of advanced resuscitation is to stabilise
acute physiological derangement, working up the underlying causes of acute
deterioration, and initiating timely life-sustaining therapies. The
following clinical case of septic shock illustrates how the EDI can
integrate critical care into ED practice.
We were referred a 40-year-old female with
multi-lobar pneumonia and septic shock from a nearby private hospital in
February 2017. Intensive care unit staff were immediately consulted and
agreed to take the patient. Since an isolation facility was not
immediately available within the ICU, it was expected that the patient
would remain in the ED for at least 2 hours. On presentation, her
saturation was 85% in a non-rebreathing mask, respiratory rate was 40/min,
and she was in distress. Her blood pressure was 80/50 mm Hg and heart rate
130/min. Chest X-ray showed diffuse bilateral infiltration. After
performing rapid sequence intubation with adequate pre-oxygenation, she
remained in profound septic shock. The EDI managed her according to the
latest Surviving Sepsis Campaign Guideline.8
The management strategy in the first 3 hours of presentation included
adequate fluid resuscitation, lactate measurement, blood culture, and
administration of a broad-spectrum antibiotic. Fluid responsiveness was
frequently assessed by bedside echocardiography. Despite these measures
that also included 2 litres of crystalloid, the patient remained
hypotensive. Non-invasive blood pressure monitoring may not be optimal in
this setting. Once thought to be within the ICU domain, arterial blood
pressure monitoring is now readily available in ED. An arterial line can
provide continuous blood pressure readings for vasopressor titration as
well as enable the EDI to obtain valuable information about fluid
responsiveness and perform frequent blood sampling. An arterial line and a
central venous catheter were inserted into the patient using an aseptic
technique and ultrasound guidance in accordance to international
guidelines.9 Noradrenaline was the
vasopressor of choice and the dose was titrated to maintain mean arterial
pressure above 65 mm/Hg. Ceftriaxone was administered at a door-to-needle
time of 30 minutes after blood culture. The first point-of-care lactate
level was 6 mmol/L. After nearly 2 hours of aggressive resuscitation, the
patient was transferred to ICU for further management. The lactate level
on arrival was 3 mmol/L, demonstrating a significant improvement in
perfusion. Urine pneumococcal antigen was positive. She was weaned off the
vasopressor on day 2, and she was extubated and discharged to the general
ward on day 3.
We have also encountered other clinical cases where
the extended triage and advanced resuscitation approach were adopted. A
brief period of intensive therapy in the ED can alter the clinical
trajectory with improved outcome and reduced resource utilisation for many
crashing patients in the ED who have readily reversible conditions, eg,
acute pulmonary oedema, diabetic ketoacidosis, and hypokalaemic periodic
paralysis. Emergency physicians possess the skills required for airway
management in the majority of patients and an EDI can lend additional
support. This is especially true for those patients with a difficult
airway, as well as hypoxic and hypotensive patients.10 11 12 13 14 15 16 Use of ventilation strategies in patients with
respiratory failure are also within the realm of the EDI, eg, intubated
asthmatic patients with high airway pressure connected to an ICU
ventilator.17 18
Extracorporeal cardiopulmonary resuscitation (ECPR)
describes the application of percutaneous extracorporeal life support to
the arresting patient, and aims to improve the survival to hospital
discharge rate in cardiac arrest.19
Over the past decade, it has emerged as a salvage therapy in patients with
refractory cardiac arrest. An algorithm has been described that involves
screening of patients by an emergency physician for their suitability for
ECPR, rapid access to the femoral vessels, and initiation of bypass in
appropriate cases, without interruption of optimal traditional
resuscitative efforts.20 The role
of EDIs in this critical moment cannot be overemphasised. Since all EDIs
have received extracorporeal life support (ECLS) training during their
pursuit of ICU fellowship, they can liaise with intensivists in the
identification of suitable candidate patients following application of
strict inclusion/exclusion criteria, supervise ongoing resuscitation, as
well as perform vascular cannulation. We recently initiated ECPR on a
40-year-old male in January 2016, with a history of diabetes and
hypertension and witnessed cardiac arrest in the ED. The time to ECPR
activation was 20 minutes from cardiac arrest. The time to establishment
of an ECLS circuit was 50 minutes. Although the patient succumbed 3 days
later due to advanced triple vessel disease not amenable to percutaneous
coronary intervention or surgery, this case illustrates how the EDI can
contribute to this novel therapeutic option in selected patients.
The obstacles that we are facing
Providing critical care in the ED is a paradigm
shift in the local ED setting. There remains much to be learned.
Emergency department overcrowding and staff
shortages are the main obstacles to the provision of a critical care
service in the ED. Many will argue that stabilising the critically ill
patient in ED will slow their transfer to ICU. Resources may be directed
to these patients while the care of non–critically ill patients will be
compromised. Departmental leaders are reluctant to place an additional
burden on staff who already have an overwhelming workload, especially
during admission blocks and long waiting time. A separate medical and
nursing staff roster for critically ill patients may alleviate the
problem. Others may argue that critical care in the ED should be provided
by in-patient intensivists who come down to the ED. Nonetheless with a
scarcity of intensivists throughout the territory as well as a tremendous
workload, this may not be possible.
Leaders’ initiatives, colleagues’ acceptance, and
devotion of emergency physicians are the keys to success. Even with
adequate staffing, the meticulous management requirements in the care of
critically ill patients do not appeal to some emergency physicians.2 In addition to regular departmental case conferences
and in-house training, a course on emergency care of critically ill
patients will be organised on a regular basis by the Hong Kong College of
Emergency Medicine for doctors and nurses who work in the ED. The course
will be tailor-made to suit the unique Hong Kong ED environment. Emergency
care of critically ill patients focuses on initial stabilisation and
advanced resuscitation techniques with lectures, simulations, and hands-on
workshops. Through education and experience sharing, more and more
emergency physicians may choose to join us to provide evidence-based
aggressive care for critically ill patients in their own ED.
Conclusion
The benefits of providing critical care in the ED
in reducing ICU length of stay and reducing ICU admission have been
illustrated by studies in the United States.3
6 Nonetheless local data are
lacking. There is a need to conduct research in order to convince
administrators that more proximal delivery of critical care in the ED,
before ICU admission, may decrease downstream ICU costs and yield
significant system savings.
We established a critical care registry in January
2017 for critically ill patients who present to our ED. A total of 100
cases were seen in 6 months. The outcome can be quantified by measuring
patient improvement in physiological parameters using Acute Physiology and
Chronic Health Evaluation II, Simplified Acute Physiology Score II, and
Multiple Organ Dysfunction Score during their ED stay.3 Intensive care unit length of stay and mortality can be
evaluated in future cost-effectiveness analyses.21
22 Hopefully, as data accrue, many
of the perceived advantages of early critical care in the ED will be
proven and accepted.
Declaration
All authors have no conflicts of interest to
disclose. All authors had full access to the data, contributed to the
study, approved the final version for publication, and take responsibility
for its accuracy and integrity.
References
1. Weingart SD, Sherwin RL, Emlet LL, Tawil
I, Mayglothling J, Rittenberger JC. ED intensivists and ED intensive care
units. Am J Emerg Med 2013;31:617-20. Crossref
2. Gupta R, Butler RH. Fellowship training
in critical care may not be helpful for emergency physicians. Ann Emerg
Med 2004;43:420-1. Crossref
3. Nguyen HB, Rivers EP, Havstad S, et al.
Critical care in the emergency department: a physiologic assessment and
outcome evaluation. Acad Emerg Med 2000;7:1354-61. Crossref
4. Gill FJ, Leslie GD, Grech C, Latour JM.
A review of critical care nursing staffing, education and practice
standards. Aust Crit Care 2012;25:224-37. Crossref
5. Goldstein RS. Management of the
critically ill patient in the emergency department: focus on safety
issues. Crit Care Clin 2005;21:81-9. Crossref
6. Rivers EP, Nguyen HB, Huang DT, Donnino
MW. Critical care and emergency medicine. Curr Opin Crit Care
2002;8:600-6. Crossref
7. Seymour CW, Gesten F, Prescott HC, et
al. Time to treatment and mortality during mandated emergency care for
sepsis. N Engl J Med 2017;376:2235-44. Crossref
8. Rhodes A, Evans LE, Alhazzani W, et al.
Surviving sepsis campaign: international guidelines for management of
sepsis and septic shock: 2016. Intensive Care Med 2017;43:304-77. Crossref
9. American Society of Anesthesiologists
Task Force on Central Venous Access, Rupp SM, Apfelbaum JL, et al.
Practice guidelines for central venous access: a report by the American
Society of Anesthesiologists task force on Central Venous Access.
Anesthesiology 2012;116:539-73. Crossref
10. Heffner AC, Swords DS, Nussbaum ML,
Kline JA, Jones AE. Predictors of the complication of postintubation
hypotension during emergency airway management. J Crit Care
2012;27:587-93. Crossref
11. Heffner AC, Swords DS, Neale MN, Jones
AE. Incidence and factors associated with cardiac arrest complicating
emergency airway management. Resuscitation 2013;84:1500-4. Crossref
12. Ramkumar V, Umesh G, Philip FA.
Preoxygenation with 20° head-up tilt provides longer duration of
non-hypoxic apnea than conventional preoxygenation in non-obese healthy
adults. J Anesth 2011;25:189-94. Crossref
13. Weingart SD, Levitan RM.
Preoxygenation and prevention of desaturation during emergency airway
management. Ann Emerg Med 2012;59:165-75.e1. Crossref
14. Baillard C, Fosse JP, Sebbane M, et
al. Noninvasive ventilation improves preoxygenation before intubation of
hypoxic patients. Am J Respir Crit Care Med 2006;174:171-7. Crossref
15. Wimalasena Y, Burns B, Reid C, Ware S,
Habig K. Apneic oxygenation was associated with decreased desaturation
rates during rapid sequence intubation by an Australian helicopter
emergency medicine service. Ann Emerg Med 2015;65:371-6. Crossref
16. Sakles JC, Mosier JM, Patanwala AE,
Arcaris B, Dicken JM. First pass success without hypoxemia is increased
with the use of apneic oxygenation during rapid sequence intubation in the
emergency department. Acad Emerg Med 2016;23:703-10. Crossref
17. Mannam P, Siegel MD. Analytic review:
management of life-threatening asthma in adults. J Intensive Care Med
2010;25:3-15. Crossref
18. Leatherman JW, McArthur C, Shapiro RS.
Effect of prolongation of expiratory time on dynamic hyperinflation in
mechanically ventilated patients with severe asthma. Crit Care Med
2004;32:1542-5. Crossref
19. Ortega-Deballon I, Hornby L, Shemie
SD, Bhanji F, Guadagno E. Extracorporeal resuscitation for refractory
out-of-hospital cardiac arrest in adults: a systematic review of
international practices and outcomes. Resuscitation 2016;101:12-20. Crossref
20. Bellezzo JM, Shinar Z, Davis DP, et
al. Emergency physician-initiated extracorporeal cardiopulmonary
resuscitation. Resuscitation 2012;83:966-70. Crossref
21. Cowan RM, Trzeciak S. Clinical review:
emergency department overcrowding and the potential impact on the
critically ill. Crit Care 2005;9:291-5. Crossref
22. Huang DT. Clinical review: impact of
emergency department care on intensive care unit costs. Crit Care
2004;8:498-502. Crossref