Editor's Note: In 2014, a team from Advocate Christ Medical Center in Oak Lawn, Illinois, was awarded the EMRA Be the Change Grant for their “ICU Boarders” proposal. Resolving to address the quality and safety of ICU-level care in the ED, the team put its Be the Change Grant award to use during the past year.
Like many emergency departments, the ED at Advocate Christ Medical Center has been plagued with overcrowding, compounded by a shortage of available inpatient critical care beds. As a result, in years past, it was not atypical for critically ill patients to spend hours or even days in the ED, waiting for transfer to the medical intensive care unit (MICU). These patients became, in essence, “ICU boarders” who warranted dedicated ICU-level critical care, but remained under the care of emergency department physicians who were simultaneously managing dozens of other patients. Transfer delays of this scale are not unique. In emergency departments across the country, critically ill patients often wait 18 hours or longer for ICU beds.1 These patients experience poorer outcomes than those who are promptly transferred to the ICU; some reports show patients with more than a 6-hour delay in transfer from the ED to the ICU incur increases in both hospital length of stay and mortality.2 As interns in the ED at Advocate Christ Medical Center, we observed countless areas for improvement in our management of critically ill patients and were inspired to tackle this problem.
Under the guidance of experienced faculty, we directed our efforts to implementing solutions at the institutional level. In May 2014, we formed a team of leaders from emergency medicine, internal medicine, critical care medicine, emergency department nursing, intensive care nursing, pharmacy, respiratory therapy, information technology, and eICU. This team instituted the ICU Boarders Project, a resident-driven, hospital-wide effort to improve the quality of critical care in the ED.
The main objective of the ICU Boarders Project is to deliver the same level of intensive care to critically ill patients waiting in our ED as that received by patients who are already in the MICU. After months of strategizing, designing and planning, as well as conducting hospital-wide training sessions for ED and ICU physicians, residents, nurses, administration, and other staff, the ICU Boarders Project team implemented the following new protocols:
eICU monitoring: Integration of the eICU into the ED has been the key to the success of this project. Four ED rooms are now equipped with fully capable, two-way, audiovisual eICU towers by which remotely-based eICU intensivists can monitor and manage patients at the same level currently done in the MICU. When these ED rooms are used for this purpose, they are considered to be virtual MICU beds.
Immediate transition to inpatient: When initial ED stabilization is completed, a critically ill patient is accepted by an intensivist and is immediately converted to inpatient status, rather than waiting for transport to an ICU to initiate inpatient status. The new “inpatient” is then assigned to one of the virtual MICU beds, and eICU monitoring is initiated.
Immediate ICU-level critical care management: When a patient has inpatient status and a virtual MICU bed assignment, the intensivist can set the inpatient ICU orders with the bedside nurse and plan management with the eICU intensivist. The bedside nurse and two intensivists work together to manage the patient in the same fashion as currently done in the MICU.
ED staff intervention: MICU and eICU intensivists actively manage the patients in virtual MICU rooms, but ED physicians remain available to assist at the request of the intensivists/nursing team.
ICU-level nursing: Critical care nurses from the MICU are assigned to the bedside of patients in virtual MICU beds in the ED. Their responsibilities are essentially the same as nurses assigned to patients physically located in the MICU.
Information technology (IT) and electronic medical record (EMR) integration: Newly designed IT and EMR tools allow for seamless transition of care, simplified order entry, streamlined information channels, and minimized duplications.
Medication orders: New EMR order sets and protocols were designed that support conversion of ED orders to inpatient orders, and designated roles were established for medication entry. These elements have resulted in zero medication errors for all eICU enrolled patients so far.
Implementation
The ICU Boarders Project kicked off in February. Not surprisingly, unforeseen issues have continued to arise, almost on a weekly basis. Our processes and protocols have already undergone dozens of revisions.
Our next goal is to collect and analyze data to gain an objective understanding of how our new practices compare to prior, and we are in the process of obtaining IRB approval for a retrospective database review.