ED Intensivists and ED Intensive Care Units☆

YAJEM-53381; No of Pages 4 American Journal of Emergency Medicine xxx (2012) xxx–xxx

Contents lists available at SciVerse ScienceDirect

journal homepage: www.elsevier.com/locate/ajem

1 Controversies

2 ED intensivists and ED intensive care units☆

a, b c d Q1 3 Scott D. Weingart MD ⁎, Robert L. Sherwin MD , Lillian L. Emlet MD , Isaac Tawil MD , 4 Julie Mayglothling MDe, Jon C. Rittenberger MDf

5 a Division of Emergency Critical Care, Mount Sinai School of Medicine, New York, NY, USA 6 b Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, MI, USA 7 c Departments of Critical Care Medicine & Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA 8 d Department of Surgery/ Department of Emergency Medicine, University of New Mexico Health Science Center, Albuquerque, NM, USA Q29 e Department of Emergency Medicine & Department of Surgery, Division of Trauma/Critical Care, Virginia Commonwealth University, Richmond, VA, USA 10 f Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, USA 11

12 13 In recent years, a group of emergency physicians (EPs) have The new field of emergency medicine critical care has outpaced the 45 14 chosen to pursue fellowship training in critical care. With this terms needed to describe it. Table 1 lists a vocabulary for the various 46 15 training, an EP can practice in inpatient critical care units. However, practice patterns associated with this emerging subspecialty [20]. 47 16 another role is open to these practitioners as well: the role of the 17 emergency department (ED) intensivist (EDI) [1]. Some EDs have 1. Models of practice 48 18 formed units capable of providing aggressive critical care during the 19 patient's ED stay. These ED intensive care units (EDICUs) allow critical The practice model of the small number of ED intensivists 49 20 care to be provided to the patient regardless of the availability of an currently in the United States has emerged in an ad hoc fashion. 50 21 intensive care unit (ICU) bed. This has coalesced into 2 forms of practice: the resource intensivist 51 22 All EPs must be adept at resuscitation, which generally model and the hybrid EDICU [20]. Examples of these practice models 52 23 encompasses the diagnosis and stabilization of a critically ill patient are provided at http://emcrit.org/edicu. 53 24 for the first 20 to 60 minutes of their ED stay. After this period, the 25 traditional ED system is predicated on the patient rapidly moving 1.1. The resource intensivist model 54 26 upstairs to a critical care unit. However, overcrowding in almost all 27 hospitals in the United States has led to a situation in which it may In this model, the ED intensivist fulfills a standard clinical role in the 55 28 be hours or unfortunately in some cases days before a patient may attending roster of an emergency program. Whenever a critically ill 56 29 get an ICU bed [2-4]. Even 20 years ago, Fromm et al [5] reported patient is in the department, EDIs can lend their additional expertise 57 30 wait times for an ICU bed of up to 11 hours. Similarly, Varon et al whether they are primarily caring for the patient or advising a colleague. 58 31 [6] found critical care patients spending more than 18 hours in the This exposes all members of the clinical team to the advanced level of care 59 32 ED without an ICU bed. The Institute of Medicine discovered that and unique aspects of ED critical care. Just as 1 toxicologist on an attending 60 33 these times have not improved in the past few years and, in many staff can elevate an entire department's care of poisoned patients, the 61 34 EDs, have become worse [7]. presence of an ED intensivist may lead to similarly improved treatment. 62 35 Most EDs are not designed or staffed [8-10] to provide care beyond This clinical role can be augmented with didactics, simulation, liaison 63 36 the initial resuscitation period, and yet, the patient remains in the with the ICU, quality improvement, research, and protocol creation and 64 37 department, sometimes languishing without optimal care [4,6,11-16]. management. Interactions with the leadership of the other critical care 65 38 Even with ample staffing, the meticulous management requirements areas of the hospital are also bolstered when an ED intensivist can bridge 66 39 in the care of the critically ill are unappealing to some EPs [17]. For the the gap between emergency medicine and intensive care medicine. Not 67 40 patient, it is obviously desirable to receive the same evidence-based unlike the ED emergency medical services specialist who streamlines 68 41 aggressive intensive care regardless of location in the hospital. By care between prehospital and ED settings, the ED intensivist may be 69 42 bringing the intensive therapies of the ICU to the bedside in the ED, integral in facilitating consistent care for critical illnesses in which the 70 43 the EDI may mitigate the negative effects of hospital overcrowding on first few hours of intervention cannot be limited by patient locale. 71 44 the critically ill patient [18,19]. Resource intensivists may not limit their service to the ED. In some 72 centers (see http://emcrit.org/edicu), resource intensivists may contin- 73 ue the patient's critical care in other areas of the hospital when they are 74 not working in the ED. Emergency department intensivists may be 75 ☆ Prior presentations: None. called into the hospital as part of a dedicated service for a postcardiac 76 ⁎ Corresponding author. Department of Emergency Critical Care, Elmhurst 77 Hospital Center, Elmhurst, NY 11373, USA. Tel.: +1 718 334 3053. arrest or severe sepsis case and continue the resuscitation and E-mail address: [email protected] (S.D. Weingart). management even after the patient has gone to their ICU bed. 78

Please cite this article as: Weingart SD, et al, ED intensivists and ED intensive care units, Am J Emerg Med (2012), http://dx.doi.org/10.1016/ j.ajem.2012.10.015 2 S.D. Weingart et al. / American Journal of Emergency Medicine xxx (2012) xxx–xxx t1:1 Table 1 The RED-ICU can become a cost-saving measure for a hospital with 129 New terminology strained intensive care resources; once patients are admitted to an 130 t1:2 t1:3 Emergency medicine critical care—a subspecialty of emergency medicine dealing with ICU, it often becomes difficult to transfer them out even when their 131 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 132 t1:4 EP intensivist—a physician who has completed a residency in emergency medicine then downgraded to a lower acuity bed before their entrance into the 133 and a fellowship in critical care. inpatient portion of the hospital. In most hospitals, the ED enjoys an 134 t1:5 ED critical care—emergency medicine critical care practiced specifically in the ED 135 t1:6 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 t1:7 Resuscitationists—EPs who have additional knowledge, training, and interest in the the ED umbrella, it can take advantage of this easier bed access. 136 care of the critically ill patient t1:8 EDICU—a unit within an ED with the same or similar staffing, monitoring, and 2. Clinical scenarios 137 capability for therapies as an ICU t1:9 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 138 the ED, there are certain clinical scenarios in which their unique skill 139 set can positively affect the care of the entire ED [20]. 140

79 1.2. The hybrid model 2.1. Airway management 141

80 Many EDs already have a dedicated area for the resuscitation of Although airway techniques are in the skillset of all EPs, the EDI 142 81 critically ill patients. Some have even assigned dedicated attending can bring additional advanced options to an ED. Experience with 143 fi 82 staf ng to these areas for at least a portion of the day. In this fiberoptic bronchoscope-aided intubations is possessed by a fraction 144 83 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 145 84 abilities of this resuscitation area to allow for the care of critically ill have experience with percutaneous and open tracheostomies [25].In 146 fi 85 patients beyond the rst hour. This unit can now offer a similar an ED program, the EDI can provide the initial education, skills review, 147 86 intensity of care as these patients will receive when their ICU bed and just-in-time training in the performance of emergent surgical 148 87 becomes available. The resuscitation bay can evolve to become a airways and the management of emergencies in patients with existing 149 88 hybrid resuscitation and ED ICU (RED-ICU). tracheostomies and laryngectomies. 150 89 The RED-ICU then becomes the destination of any new sick 90 patients brought to the department as well as any patients that 2.2. Respiratory failure 151 91 decompensate while being cared for in the main ED areas. 92 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 152 93 If the EDIs create protocols and care pathways, their EP colleagues can experience with the management of acute and chronic respiratory 153 94 continue a more advanced care than standard ED management even failure. This gives the EDI knowledge of advanced modes of invasive 154 95 when the EDI is not on shift. This is supplemented with by the and noninvasive ventilation and the salvage of ARDS patients. Most 155 Q3 96 availability of the EDI or other critical care physicians for consultation emergency residencies offer little training in the extubation of 156 97 by telephone for any difficult situations that may arise. patients, but the EDI is facile with assessment of extubation fitness, 157 98 In existing RED-ICUs, a key to success has been staffing the unit ventilatory weaning, and the extubation of patients who have 158 99 with dedicated residents and/or attending physicians whose respon- resolved the condition, which necessitated intubation [26]. 159 100 sibilities do not include noncritical patients. Although these physi- 101 cians may help out when the patient load in the RED-ICU is light, it is 2.3. Shock 160 102 understood that their time on these shifts should be used to maximize 103 the care of the critically ill patients in the ED. An extensive knowledge of hemodynamic monitoring, vasoactive 161 104 Equally vital to the success of a unit such as this is the nursing staff. agents, and the ramifications of alterations of oxygen delivery and the 162 105 Either by specific training or by spending time in standard ICUs, ED microcirculation give the EDI a unique perspective on how the early 163 106 nurses can gain the advanced skills necessary for the expanded practice 107 model. However, there must be enough nurses available to allow the 108 provision of intensive care; in our experience, 1 nurse for every 2 Table 2 t2:1 109 patients is the minimum to allow optimal care of the sickest patients. In RED-ICU or stand-alone EDICU capabilities 110 particular circumstances, such as postcardiac arrest management, ideal t2:2 • Advanced hemodynamic monitoring: arterial pressure, continuous cardiac output, t2:3 111 management may require 1 nurse to concentrate solely on the patient. mixed/central venous oxygen saturation 112 In addition, the nurses that staff the RED-ICU bolster the consistency of • Respiratory monitoring: quantitative end-tidal carbon dioxide t2:4 113 care and adherence to unit protocols when outside rotators are staffing • Neuroinvasive monitoring: fiberoptic intraparenchymal pressure monitoring, t2:5 114 the unit. For a description of the nursing staffing patterns and solutions external ventricular drainage, and multimodality monitoring. These monitors then allow resuscitation targeted to cerebral perfusion pressure and regional/global brain 115 to nursing shortages in 1 RED-ICU, see the online appendix. tissue oxygenation. 116 The potential capabilities of an integrated RED-ICU are delineated • Ventilation with advanced rescue modes: airway pressure release ventilation, high t2:6 117 in Table 2. Although not all of these modalities may be immediately frequency oscillatory ventilation, proning. 118 available to a newly created RED-ICU, the goal is to create a unit • Echocardiography: optimally with capabilities for transesophageal as well as t2:7 transthoracic. 119 capable of matching the baseline care of the hospital's ICUs. • Targeted temperature management for postarrest and neurologic emergencies t2:8 120 This hybrid RED-ICU then becomes a release valve for hospitals • Nutrition (for stand-alone EDICU) t2:9 121 with a scarcity of ICU beds. Instead of the ED boarding time of critically • Fiberoptic bronchoscopy: for diagnosis and pulmonary toilet t2:10 122 ill patients being a potential hazard, it instead becomes an integrated • Continuous renal replacement therapies t2:11 • ⁎ t2:12 123 part of their critical care. Furthermore, there are a number of patients Cardiac support devices, such as aortic balloon pumps • Extracorporeal membrane oxygenation⁎ t2:13 124 who at the time of admission clearly require a critical care bed but, • Prophylactic measures: deep venous thrombosis prophylaxis, stress ulcer t2:14 125 when exposed to high-level intensive care for 4 to 6 hours, become prevention, ventilator-associated pneumonia measures 126 suitable for a step-down bed outside an ICU [19,21]. Examples of this ⁎ Only initiation and not ongoing maintenance of these therapies should be 127 group include those patients with severe diabetic ketoacidosis, acute established in RED-ICUs, as these patients benefit from stand-alone units with intimate 128 pulmonary edema, and toxicological overdose [22-24]. familiarity with these therapies for the maintenance phases. t2:15

Please cite this article as: Weingart SD, et al, ED intensivists and ED intensive care units, Am J Emerg Med (2012), http://dx.doi.org/10.1016/ j.ajem.2012.10.015 S.D. Weingart et al. / American Journal of Emergency Medicine xxx (2012) xxx–xxx 3

164 actions in the ED can affect the patient's long-term outcome. discussions on palliation and withdrawal of care. This permits 220 165 Emergency department intensivists also have experience in rescue adaption of care goals to best reflect the patient's wishes early during 221 166 techniques such as intraaortic balloon pulsation and extracorporeal their care. The EDI may also have additional time and the opportunity 222 167 life support, when initial attempts at hemodynamic stabilization have for multiple discussions with the family and patient to discuss end-of- 223 168 failed. These devices can be placed in the ED [27,28] until the patient is life issues [33]. 224 169 transferred to a specialized unit. 3. Advantages to emergency medicine residency programs 225 170 2.4. Sepsis A residency program with an EDI on faculty will provide residents 226 171 Since Emanuel River's early goal-directed therapy (EGDT) study, with more in-depth exposure and potentially greater knowledge and 227 172 the ED has taken a primary role in the care of the critically ill septic appreciation of the role of critical care in the ED. In addition, the EDI is 228 173 patient [29]. In addition to elucidating a bundle of therapies to expert at adapting advanced critical care management techniques to 229 174 manage the severely septic patient early in their hospital course, the the unique environment of the ED. 230 175 study demonstrated that critical care in the ED is possible and Although many resuscitation topics are covered, there are no 231 176 lifesaving. One of the primary interventions present in the treatment specific critical care topics in the model curriculum of emergency 232 177 group but not the control group of the EGDT study was an ED critical medicine residents [34]. In some of our own programs, a dedicated ED 233 178 care team member at the bedside to direct therapy and optimize care. critical care lecture series and the trauma lecture series are both 234 179 Emergency department intensivists possess a broad knowledge on taught by EDIs [35]. 235 180 antibiotic choices, aggressive source control, and advanced monitor- 181 ing of the severely septic patient. Bronchoscopy skills allow the EDI to 4. Advantages to all hospital types 236 182 obtain bronchoalveolar lavage samples for early pneumonia organism 183 identification. Emergency department intensivists are well suited to provide 237 quality improvement for ED mortalities and address discrepancies in 238 184 2.5. Postcardiac arrest care and therapeutic hypothermia the care of critically ill patients early in their course. At the hospital 239 level, they can act as champion for initiatives such as severe sepsis 240 185 Aggressive treatment of the postarrest syndrome, especially care, therapeutic hypothermia, deep sedation, and advanced airway 241 186 with an emphasis on early and consistent maintenance of induced management. 242 187 hypothermia, is critical for good outcome in patients after cardiac Because EDIs have trained in both emergency medicine and critical 243 188 arrest [30,31]. This level of care is beyond the resources of many care, they are an excellent resource for any hospital-wide protocols 244 189 conventional EDs for longer than the first hour of care. The EDI can dealing with resuscitative medicine and critical care. Their expertise 245 190 spearhead a hospital postarrest program or be the primary also makes them the ideal liaison between the ED and the ICUs. 246 191 clinician in the actual clinical management of these patients (see In many community centers, the ED physician may be the only 247 192 online appendix). attending physician in the hospital at night. An EDI staffing the ED in 248 these hospitals can provide a dramatic advantage by their availability 249 193 2.6. Trauma for consultation or by managing critically ill patients in the ED until 250 intensivists arrive in the morning. 251 194 Emergency department intensivists who have received their 195 critical care training in a surgical/trauma program are uniquely suited 5. Financial considerations 252 196 to organize a trauma resuscitation program. Mastery of all aspects of 197 the early management of the critically ill trauma patient including Early intensive care may lead to a reduction in inpatient admission 253 198 blood component transfusion, decisions on conservative vs operative days and lead to a significant cost savings. At Henry Ford Hospital, 254 199 management, timing of angiographic interventions, surgical airways, early intervention by a critical care team soon after the patient's 255 200 and the provision of damage-control resuscitation are in the purview arrival in the ED, lead to a savings of 11.5 million dollars per year and 256 201 of a trauma-trained EDI. The presence of such an EDI may allow a 3800 hospital days [36]. Studies of EGDT for severe sepsis patients 257 202 surgery department to safely reduce their on-call staffing, so long as a have also shown cost benefits when intensive care is provided during 258 203 surgeon is readily available for the trauma cases that will require the patient's ED stay [37-39]. 259 204 operative intervention [32]. Each hospital depending on payer mix and geography will have an 260 individual approach to maximizing the financial benefits of EDIs and 261 205 2.7. Procedures EDICUs. However, critical care billing for much of the time the EDI 262 spends treating critically ill patients is appropriate. Patients being 263 206 Emergency department intensivists by nature of their training and treated in departments with EDIs will likely have necessary, advanced 264 207 experience with potential complications may serve as hospital procedures performed in the ED rather than deferring them to the 265 208 proceduralists. The unique practice patterns of many EDIs allow unit staff. Procedural billing, at least with the current reimbursement 266 209 ample time for meticulous sterile technique. Emergency department system, is some of the best reimbursed care for the critically ill patient. 267 210 intensivists have also garnered experience dealing with the long-term 211 complications of procedures and how to rectify them. In some 6. Arguments against ED intensive care 268 212 hospitals, the EDI may be an ideal practitioner to place elective Q4213 bedside percutaneous tracheostomies, PICC, and arterial lines. Many ED administrators are reluctant to cede their staff and 269 physical plant to the care of the critically ill patient due to the belief 270 214 2.8. Palliative care that stabilizing the patient in the ED will slow the patient moving 271 upstairs to the ICU. In addition, they are concerned that once an ED 272 215 Aggressive ED critical care can be directed toward either a curative can care for these patients at the level of an ICU, the hospital 273 216 or a palliative path. All of the advanced therapies and monitoring expectation will become that they will do so consistently regardless 274 217 modalities an EDI brings to the ED should be balanced with a focus on of the circumstances of the department. Many department leaders 275 218 palliation and end-of-life care when appropriate. Given their training, are reluctant to add this additional burden to an already over- 276 219 EDIs have mastered the intricacies of advanced directives and family whelming degree of responsibility. A separate staffing pattern for the 277

Please cite this article as: Weingart SD, et al, ED intensivists and ED intensive care units, Am J Emerg Med (2012), http://dx.doi.org/10.1016/ j.ajem.2012.10.015 4 S.D. Weingart et al. / American Journal of Emergency Medicine xxx (2012) xxx–xxx

278 critically ill patients in the ED may alleviate these problems, but the [10] Goldstein RS. Management of the critically ill patient in the emergency 340 341 279 department: focus on safety issues. Crit Care Clin 2005;21:81-9 viii-ix. funding for such a staff is a major issue that would need to be [11] Chalfin DB, Trzeciak S, Likourezos A, Baumann BM, Dellinger RP. Impact of delayed 342 280 weighed in each institution. transfer of critically ill patients from the emergency department to the intensive 343 281 Another argument against ED critical care is that the care of the care unit. Crit Care Med 2007;35:1477-83. 344 345 282 [12] Pines JM, Pollack Jr CV, Diercks DB, Chang AM, Shofer FS, Hollander JE. The affected patients can be provided by in-patient intensivists who come association between emergency department crowding and adverse cardiovascular 346 283 down to the ED. This would obviate the need to create a dedicated ED outcomes in patients with chest pain. Acad Emerg Med 2009;16:617-25. 347 284 intensive care staff. This may be a workable solution in hospitals with [13] Carr BG, Kaye AJ, Wiebe DJ, Gracias VH, Schwab CW, Reilly PM. Emergency 348 349 285 a surfeit of intensivists, but across the United States, this situation is a department length of stay: a major risk factor for pneumonia in intubated blunt trauma patients. J Trauma 2007;63:9–12. 350 286 rarity [2]. [14] McCaig LF, Burt CW. National hospital ambulatory medical care survey emergency 351 287 Because ED intensive care is a nascent subspecialty, it is unknown department summary. Adv Data 2001;2003:1–29. 352 fi 353 288 whether the planned provision of intensive care in the ED will [15] United States General Accounting Of ce. HOSPITAL EMERGENCY DEPARTMENTS Crowded Conditions Vary among Hospitals and Communities. In; 2003. 354 289 engender new political turf battles. The recent announcement of a [16] Nelson M, Waldrop RD, Jones J, Randall Z. Critical care provided in an urban 355 290 certification path for EPs through internal medicine leads to some emergency department. Am J Emerg Med 1998;16:56-9. 356 357 291 optimism that other specialties may accept this new role for [17] Gupta R, Butler RH. Fellowship training in critical care may not be helpful for emergency physicians. Ann Emerg Med 2004;43:420-1 [author reply 1–2]. 358 292 emergency medicine practitioners. [18] Pronovost PJ, Angus DC, Dorman T, Robinson KA, Dremsizov TT, Young TL. 359 Physician staffing patterns and clinical outcomes in critically ill patients: a 360 systematic review. JAMA 2002;288:2151-62. 361 293 7. The need for research [19] Nguyen HB, Rivers EP, Havstad S, et al. Critical care in the emergency department: 362 a physiologic assessment and outcome evaluation. Acad Emerg Med 2000;7: 363 1354-61. 364 294 Although a few centers have already begun to use EDIs and ED- [20] Weingart S. In: Chiu W, Farcy D, Flaxman A, editors. Critical care emergency 365 295 ICUs (see online appendix), the benefits at this point are mostly medicine. New York: McGraw-Hill Professional; 2011. p. 1. 366 367 296 [21] Garrard C, Young D. Suboptimal care of patients before admission to intensive anecdotal. Research is needed to demonstrate that the expenses of an care. is caused by a failure to appreciate or apply the ABCs of life support. BMJ 368 297 ED critical care program are counterbalanced by demonstrable 1998;316:1841-2. 369 298 patient-outcome benefits. An ED critical care model can improve [22] Sacchetti A, Ramoska E, Moakes ME, McDermott P, Moyer V. Effect of ED 370 371 299 patient outcomes and may be a financially beneficial path for hospitals management on ICU use in acute pulmonary edema. Am J Emerg Med 1999;17: 571-4. 372 300 already on tight budgets, but a comprehensive cost analysis has not [23] Buist MD, Moore GE, Bernard SA, Waxman BP, Anderson JN, Nguyen TV. Effects of a 373 301 yet been performed. medical emergency team on reduction of incidence of and mortality from 374 375 302 A registry-based of ED critical care patients is in its nascent stages unexpected cardiac arrests in hospital: preliminary study. BMJ 2002;324:387-90. [24] Mallick P, Upadhyay S, Senthilnathan T, Weingart S. A protocol of bolus-dose 376 303 at the Elmhurst Hospital Center in New York City. Hopefully, as data nitroglycerin and non-invasive ventilation to avert intubation in emergency 377 304 accrue, many of the perceived advantages of early critical care in the department acute pulmonary edema. Houston, TX: Society of Critical Care 378 379 305 ED will be proven and accepted. Medicine; 2012. [25] Marinaro J, Tawil I, Clark R, Keiler-Green A, Crandall CS. Emergency medicine 380 intensivist performed percutaneous tracheostomy: performance and safety 381 assessment. In: SCCM Annual Meeting; 2010; Miami, Florida; 2010. 382 306 8. Conclusion [26] Weingart SD, Menaker J, Truong H, Bochicchio K, Scalea TM. Trauma patients can 383 be safely extubated in the emergency department. J Emerg Med 2011;40:235-9. 384 [27] Bellezzo JM, Shinar Z, Davis DP, et al. Emergency physician–initiated extracorpo- 385 307 fi Although the recent path for certi cation in critical care will allow real cardiopulmonary resuscitation. Resuscitation 2012;83:966-70. 386 308 EP intensivists to freely practice in inpatient ICUs, a unique path has [28] Shinar Z, Bellezzo J, Paradis N, et al. Emergency department initiation of 387 309 always existed for critical care–trained EPs to practice in the ED. The cardiopulmonary bypass: a case report and review of the literature. J Emerg 388 389 310 Med 2012;43:83-6. EDI can bring advanced care to the ED with a variety of practice [29] Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of 390 311 models. Additional benefits include teaching of both faculty and severe sepsis and septic shock. N Engl J Med 2001;345:1368-77. 391 312 trainees, expertise for protocol development, and increased collabo- [30] Neumar RW, Nolan JP, Adrie C, et al. Post-cardiac arrest syndrome: epidemiology, 392 393 313 ration between hospital departments. We hope the presence of EDIs pathophysiology, treatment, and prognostication. A consensus statement from the International Liaison Committee on Resuscitation (American Heart Association, 394 314 in our EDs will help to eliminate any disparities in the care of the Australian and New Zealand Council on Resuscitation, European Resuscitation 395 315 critically ill patient based solely on location in the hospital. Council, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, 396 Resuscitation Council of Asia, and the Resuscitation Council of Southern Africa); 397 the American Heart Association Emergency Cardiovascular Care Committee; the 398 Council on Cardiovascular Surgery and Anesthesia; the Council on Cardiopulmo- 399 316 References nary, Perioperative, and Critical Care; the Council on Clinical Cardiology; and the 400 Stroke Council. Circulation 2008;118:2452-83. 401 317 [1] Mayglothling JA, Gunnerson KJ, Huang DT. Current practice, demographics, and [31] Schober A, Sterz F, Herkner H, et al. Post-resuscitation care at the emergency 402 318 trends of critical care trained emergency physicians in the United States. Acad department with critical care facilities—a length-of-stay analysis. Resuscitation 403 319 Emerg Med 2010;17:325-9. 2011;82:853-8. 404 320 [2] Angus DC, Kelley MA, Schmitz RJ, White A, Popovich Jr J. Caring for the critically ill [32] Marinaro J. Is the answer to Dr. Green's question: “Emergency medicine trauma 405 321 patient. Current and projected workforce requirements for care of the critically ill specialists?”. Ann Emerg Med 2007;49:115 [author reply 6]. 406 322 and patients with pulmonary disease: can we meet the requirements of an aging [33] Quest TE, Asplin BR, Cairns CB, Hwang U, Pines JM. Research priorities for palliative 407 323 population? JAMA 2000;284:2762-70. and end-of-life care in the emergency setting. Acad Emerg Med 2011;18:e70-6. 408 324 [3] Lambe S, Washington DL, Fink A, et al. Trends in the use and capacity of California's [34] Perina DG, Beeson MS, Char DM, et al. The 2007 Model of the Clinical Practice of 409 325 emergency departments, 1990-1999. Ann Emerg Med 2002;39:389-96. Emergency Medicine: the 2009 update 2009 EM Model Review Task Force. Ann 410 326 [4] Svenson J, Besinger B, Stapczynski JS. Critical care of medical and surgical patients Emerg Med 2011;57:e1-15. 411 327 in the ED: length of stay and initiation of intensive care procedures. Am J Emerg [35] Nguyen J, Bernath K, Sherwin R, Levy P, Mango L. The ED-based Critical Care 412 328 Med 1997;15:654-7. Rotation: A two-year experience in a large urban hospital. Boston, MA: AEM 413 329 [5] Fromm Jr RE, Gibbs LR, McCallum WG, et al. Critical care in the emergency Research Assembly; 2010. 414 330 department: a time-based study. Crit Care Med 1993;21:970-6. [36] Rivers EP, Nguyen HB, Huang DT, Donnino MW. Critical care and emergency 415 331 [6] Varon J, Fromm Jr RE, Levine RL. Emergency department procedures and length of medicine. Curr Opin Crit Care 2002;8:600-6. 416 332 stay for critically ill medical patients. Ann Emerg Med 1994;23:546-9. [37] Shorr AF, Micek ST, Jackson Jr WL, Kollef MH. Economic implications of an 417 333 [7] Institute of Medicine Committee on the Future of Emergency Care in the United evidence-based sepsis protocol: can we improve outcomes and lower costs? Crit 418 334 States Health System. Hospital-based emergency care at the breaking point. Care Med 2007;35:1257-62. 419 335 Washington, DC: National Academies Press; 2007. [38] Huang DT, Clermont G, Dremsizov TT, Angus DC. Implementation of early goal- 420 336 [8] Gill FJ, Leslie GD, Grech C, Latour JM. A review of critical care nursing staffing, directed therapy for severe sepsis and septic shock: a decision analysis. Crit Care 421 337 education and practice standards. Aust Crit Care 2012. Med 2007;35:2090-100. 422 338 [9] Curley MA. Patient-nurse synergy: optimizing patients' outcomes. Am J Crit Care [39] Huang DT. Clinical review: impact of emergency department care on intensive 423 339 1998;7:64-72. care unit costs. Crit Care 2004;8:498-502. 424 425 426

Please cite this article as: Weingart SD, et al, ED intensivists and ED intensive care units, Am J Emerg Med (2012), http://dx.doi.org/10.1016/ j.ajem.2012.10.015 Our reference: YAJEM 53381 P-authorquery-v11

AUTHOR QUERY FORM

Journal: YAJEM Please e-mail or fax your responses and any corrections to: Elsevier E-mail: [email protected] Fax: +1 619 699 6721 Article Number: 53381

Dear Author,

Please check your proof carefully and mark all corrections at the appropriate place in the proof (e.g., by using on-screen annotation in the PDF file) or compile them in a separate list. Note: if you opt to annotate the file with software other than Adobe Reader then please also highlight the appropriate place in the PDF file. To ensure fast publication of your paper please return your corrections within 48 hours.

For correction or revision of any artwork, please consult http://www.elsevier.com/artworkinstructions.

Any queries or remarks that have arisen during the processing of your manuscript are listed below and highlighted by ﬂags in the proof. Click on the ‘Q’ link to go to the location in the proof.

Location Query / Remark: click on the Q link to go in article Please insert your reply or correction at the corresponding line in the proof Q1 Please confirm that given names and surnames have been identified correctly.

Q2 Please check the location provided in affiliation e.

Q3 Please spell out ARDS if it is an acronym.

Q4 Please spell out PICC if it is an acronym.

Please check this box if you have no corrections to make to the PDF file. □

Thank you for your assistance.

Page 1 of 1