American Journal of Emergency Medicine 31 (2013) 617–620 Contents lists available at SciVerse ScienceDirect American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem Controversies ED intensivists and ED intensive care units☆ Scott D. Weingart MDa,⁎, Robert L. Sherwin MDb, Lillian L. Emlet MDc, Isaac Tawil MDd, Julie Mayglothling MDe, Jon C. Rittenberger MDf a Division of Emergency Critical Care, Mount Sinai School of Medicine, New York, NY, USA b Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, MI, USA c Departments of Critical Care Medicine & Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA d Department of Surgery/ Department of Emergency Medicine, University of New Mexico Health Science Center, Albuquerque, NM, USA e Department of Emergency Medicine & Department of Surgery, Division of Trauma/Critical Care, Virginia Commonwealth University, Richmond, VA, USA f Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA In recent years, a group of emergency physicians (EPs) have The new field of emergency medicine critical care has outpaced the chosen to pursue fellowship training in critical care. With this terms needed to describe it. Table 1 lists a vocabulary for the various training, an EP can practice in inpatient critical care units. However, practice patterns associated with this emerging subspecialty [20]. another role is open to these practitioners as well: the role of the emergency department (ED) intensivist (EDI) [1]. Some EDs have formed units capable of providing aggressive critical care during the 1. Models of practice patient's ED stay. These ED intensive care units (EDICUs) allow critical care to be provided to the patient regardless of the availability of an The practice model of the small number of ED intensivists intensive care unit (ICU) bed. currently in the United States has emerged in an ad hoc fashion. All EPs must be adept at resuscitation, which generally This has coalesced into 2 forms of practice: the resource intensivist encompasses the diagnosis and stabilization of a critically ill patient model and the hybrid EDICU [20]. Examples of these practice models for the first 20 to 60 minutes of their ED stay. After this period, the are provided at http://emcrit.org/edicu. traditional ED system is predicated on the patient rapidly moving upstairs to a critical care unit. However, overcrowding in almost all 1.1. The resource intensivist model hospitals in the United States has led to a situation in which it may be hours or unfortunately in some cases days before a patient may In this model, the ED intensivist fulfills a standard clinical role in the get an ICU bed [2-4]. Even 20 years ago, Fromm et al [5] reported attending roster of an emergency program. Whenever a critically ill wait times for an ICU bed of up to 11 hours. Similarly, Varon et al patient is in the department, EDIs can lend their additional expertise [6] found critical care patients spending more than 18 hours in the whether they are primarily caring for the patient or advising a colleague. ED without an ICU bed. The Institute of Medicine discovered that This exposes all members of the clinical team to the advanced level of care these times have not improved in the past few years and, in many and unique aspects of ED critical care. Just as 1 toxicologist on an attending EDs, have become worse [7]. staff can elevate an entire department's care of poisoned patients, the Most EDs are not designed or staffed [8-10] to provide care beyond presence of an ED intensivist may lead to similarly improved treatment. the initial resuscitation period, and yet, the patient remains in the This clinical role can be augmented with didactics, simulation, liaison department, sometimes languishing without optimal care [4,6,11-16]. with the ICU, quality improvement, research, and protocol creation and fi Even with ample staf ng, the meticulous management requirements management. Interactions with the leadership of the other critical care in the care of the critically ill are unappealing to some EPs [17]. For the areas of the hospital are also bolstered when an ED intensivist can bridge patient, it is obviously desirable to receive the same evidence-based the gap between emergency medicine and intensive care medicine. Not aggressive intensive care regardless of location in the hospital. By unlike the ED emergency medical services specialist who streamlines bringing the intensive therapies of the ICU to the bedside in the ED, care between prehospital and ED settings, the ED intensivist may be the EDI may mitigate the negative effects of hospital overcrowding on integral in facilitating consistent care for critical illnesses in which the the critically ill patient [18,19]. first few hours of intervention cannot be limited by patient locale. Resource intensivists may not limit their service to the ED. In some centers (see http://emcrit.org/edicu), resource intensivists may contin- ue the patient's critical care in other areas of the hospital when they are not working in the ED. Emergency department intensivists may be ☆ Prior presentations: None. called into the hospital as part of a dedicated service for a postcardiac ⁎ Corresponding author. Department of Emergency Critical Care, Elmhurst Hospital Center, Elmhurst, NY 11373, USA. Tel.: +1 718 334 3053. arrest or severe sepsis cases and continue the resuscitation and E-mail address: [email protected] (S.D. Weingart). management even after the patient has gone to their ICU bed. 0735-6757/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajem.2012.10.015 618 S.D. Weingart et al. / American Journal of Emergency Medicine 31 (2013) 617–620 Table 1 The RED-ICU can become a cost-saving measure for a hospital with New terminology strained intensive care resources; once patients are admitted to an Emergency medicine critical care—a subspecialty of emergency medicine dealing with ICU, it often becomes difficult to transfer them out even when their the care of the critically ill both in the ED and in the rest of the hospital illnesses have stabilized. The RED-ICU patients can be treated and EP intensivist—a physician who has completed a residency in emergency medicine then downgraded to a lower acuity bed before their entrance into the and a fellowship in critical care. inpatient portion of the hospital. In most hospitals, the ED enjoys an ED critical care—emergency medicine critical care practiced specifically in the ED ED intensivist (EDI)—EPIs who practice ED critical care as a portion of their clinical time increased priority for open beds, and because the RED-ICU is under Resuscitationists—EPs who have additional knowledge, training, and interest in the the ED umbrella, it can take advantage of this easier bed access. care of the critically ill patient EDICU—a unit within an ED with the same or similar staffing, monitoring, and 2. Clinical scenarios capability for therapies as an ICU RED-ICU—a hybrid resuscitation area and EDICU allowing a department to adopt the ED intensive care model with minimal cost and no changes to the physical plant Although any sick patient may benefit from the presence of EDIs in the ED, there are certain clinical scenarios in which their unique skill set can positively affect the care of the entire ED [20]. 1.2. The hybrid model 2.1. Airway management Many EDs already have a dedicated area for the resuscitation of Although airway techniques are in the skillset of all EPs, the EDI critically ill patients. Some have even assigned dedicated attending can bring additional advanced options to an ED. Experience with fi staf ng to these areas for at least a portion of the day. In this fiberoptic bronchoscope-aided intubations is possessed by a fraction circumstance, the addition of an ED intensivist can easily shift the of EPs, but all EDIs are skilled in the use of this device. Many EDIs also abilities of this resuscitation area to allow for the care of critically ill have experience with percutaneous and open tracheostomies [25].In fi patients beyond the rst hour. This unit can now offer a similar an ED program, the EDI can provide the initial education, skills review, intensity of care as these patients will receive when their ICU bed and just-in-time training in the performance of emergent surgical becomes available. The resuscitation bay can evolve to become a airways and the management of emergencies in patients with existing hybrid resuscitation and ED ICU (RED-ICU). tracheostomies and laryngectomies. The RED-ICU then becomes the destination of any new sick patients brought to the department as well as any patients that 2.2. Respiratory failure decompensate while being cared for in the main ED areas. When the EDI is not present, the RED-ICU is staffed by general EPs. A large portion of a critical care fellowship is spent gaining If the EDIs create protocols and care pathways, their EP colleagues can experience with the management of acute and chronic respiratory continue a more advanced care than standard ED management even failure. This gives the EDI knowledge of advanced modes of invasive and when the EDI is not on shift. This is supplemented with by the noninvasive ventilation and the salvage of acute respiratory distress availability of the EDI or other critical care physicians for consultation syndrome patients. Most emergency residencies offer little training in by telephone for any difficult situations that may arise. the extubation of patients, but the EDI is facile with assessment of In existing RED-ICUs, a key to success has been staffing the unit extubation fitness, ventilatory weaning, and the extubation of patients with dedicated residents and/or attending physicians whose respon- who have resolved the condition, which necessitated intubation [26].