Delivery of end‐of‐life care in an emergency department–based intensive care unit

Leith, Thomas; Haas, Nathan L.; Harvey, Colleen K; Chen, Cynthia; Tallman, Crystal Ives; Bassin, Benjamin S.

doi:10.1002/emp2.12258

Cited by 7 publications

(29 citation statements)

References 23 publications

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“…Fifteen studies emerged from the United States [29][30][31][32][33]35,[39][40][41][42][43][44][45][46]50 ; two each from France 38,48 and Singapore 28,36 ; and one each from Finland, 34 Ireland, 47 Canada, 37 and Taiwan. 49 The study designs employed by the included studies were retrospective (n = 11), 28,29,34,[38][39][40][41][42][43]46,50 prospective cohort (n = 5), 31,33,36,37,48 randomized controlled trial (n = 2), 22,32 quasi-experimental (n = 2), 47,49 pilot (n = 1), 44 and crosssectional (n = 1). 45 One study employed a program development approach with no outcomes assessed.…”

Section: Study Characteristicsmentioning

confidence: 99%

Palliative care interventions for adults in the emergency department: A review of components, delivery models, and outcomes

Bayuo

Agbeko

Acheampong

et al. 2022

Academic Emergency Medicine

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Background Existing evidence suggest the emergence of palliative care (PC) services in the emergency department (ED). To gain insight into the nature of these services and provide direction to future actions, there is a need for a comprehensive review that ascertains the components of these services, integration models, and outcomes. Methods A scoping review design was employed and reported according to the PRISMA extension guidelines for scoping reviews. Extensive searches in peer‐reviewed databases (CINAHL, EMBASE, PubMed, Cochrane Library, and Medline) and gray literature sources (Trove, MedNar, OpenGrey, and the Agency for Healthcare Research and Quality) were undertaken and supplemented with hand searching. Titles, abstracts, and full text were reviewed in duplicate. Studies were eligible for inclusion if they reported on a PC intervention implemented in the ED for adults. Codes were formulated across the included studies, which facilitated the conduct of a narrative synthesis. Results Twenty‐three studies were retained with the majority (n = 15) emerging from the United States. The components of PC interventions in the ED were categorized as: (1) screening, (2) goals of care discussion and communication, (3) managing pain and other distressing symptoms in the ED, (4) transitions across care settings, (5) end‐of‐life (EoL) care, (6) family/caregiver support, and (7) ED staff education. Traditional PC consultations and integrated ED–PC services were the main modes of delivery. PC in the ED can potentially improve patient symptoms, facilitate access to relevant services, reduce length of stay, improve care at the EoL, facilitate bereavement and postbereavement support for family members, and improve ED staff confidence in delivering PC. Conclusions PC implementation in the ED may potentially improve patient and family outcomes. More studies are needed, however, to standardize trigger or screening tools. More prospective studies are also needed to test PC interventions in the ED.

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Section: Study Characteristicsmentioning

confidence: 99%

Palliative care interventions for adults in the emergency department: A review of components, delivery models, and outcomes

Bayuo

Agbeko

Acheampong

et al. 2022

Academic Emergency Medicine

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“…Multiple recent studies have demonstrated benefits of ED‐ICUs, including observed reduction in mortality, reduction in rates of ICU admission or hospitalization, and reductions in hospital LOS. 18 , 19 , 26 , 27 , 28 , 29 , 30 Centers with high rates of ED boarding of patients who are critically ill and those considering implementing an ED‐ICU can consider these findings in the context of their individual practice environments to best mitigate detrimental effects of ED boarding of patients who are critically ill on the local scale. With increasing numbers of ED‐ICUs and more centers considering implementing similar units, continued assessment of outcomes (including prospective research) to guide further development is essential.…”

Section: Discussionmentioning

confidence: 99%

“…Patients transferred for end‐of‐life care were excluded. 19 The sample size was determined by the time interval of data collection: although EC3 opened in February 2015, we included patients from August 1, 2017, forward to allow a “wash out” period given the operational and clinical complexities of implementing an ED‐ICU.…”

Section: Methodsmentioning

confidence: 99%

Emergency department length of stay and outcomes of emergency department–based intensive care unit patients

et al. 2022

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Objective Emergency department (ED) boarding of patients who are critically ill is associated with poor outcomes. ED‐based intensive care units (ED‐ICUs) may mitigate the risks of ED boarding. We sought to analyze the impact of ED length of stay (LOS) before transfer to an ED‐ICU on patient outcomes. Methods We retrospectively analyzed adult ED patients managed in the ED‐ICU at a US medical center. Bivariate and multivariable linear regressions tested ED LOS as a predictor of inpatient ICU and hospital LOS, and separate bivariate and multivariable logistic regressions tested ED LOS as a predictor of inpatient ICU admission, 48‐hour mortality, and hospital mortality. Multivariable analyses’ covariates were age, sex, Charlson Comorbidity Index (CCI), Emergency Severity Index, and eSimplified Acute Physiology Score (eSAPS3). Results We included 5859 ED visits with subsequent care in the ED‐ICU. Median age, CCI, eSAPS3, ED LOS, and ED‐ICU LOS were 62 years (interquartile range [IQR], 48–73 years), 5 (IQR, 2–8), 46 (IQR, 36–56), 3.6 hours (IQR, 2.5–5.3 hours), and 8.5 hours (IQR, 5.3–13.4 hours), respectively, and 46.3% were women. Bivariate analyses showed negative associations of ED LOS with hospital LOS (β = −3.4; 95% confidence interval [CI], −5.9 to −1.0), inpatient ICU admission (odds ratio [OR], 0.86, 95% CI, 0.84–0.88), 48‐hour mortality (OR, 0.89; 95% CI, 0.82–0.98), and hospital mortality (OR, 0.89; 95% CI, 0.85–0.92), but no association with inpatient ICU LOS. Multivariable analyses showed a negative association of ED LOS with inpatient ICU admission (OR, 0.91; 95% CI, 0.88–0.93), but no associations with other outcomes. Conclusions We observed no significant associations between ED LOS before ED‐ICU transfer and worsened outcomes, suggesting an ED‐ICU may mitigate the risks of ED boarding of patients who are critically ill.

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“…More broadly, as focus is shifting from proving the benefit of LPV to proving it can be implemented and adhered to, an ED-ICU is one strategy to increase LPV adherence (39). Additionally, these findings add to the robust patient and resource utilization outcomes in other common disease states associated with an ED-ICU (26)(27)(28)(29)(30)(31). Health systems may consider these results when determining the feasibility of ED-ICU implementation and future work should examine outcomes associated with ED-ICUs at other institutions.…”

Section: Discussionmentioning

confidence: 99%

“…To combat this and to optimize early delivery of high-quality critical care, ED-based ICUs (also known as Resuscitative Care Units) have been implemented at a small number of institutions across the United States (25). In other disease processes, an ED-ICU has been associated with improved outcomes, including decreased mortality, inpatient ICU admission, and resource utilization (15,(26)(27)(28)(29)(30)(31). There are no prior investigations on the impact of an ED-ICU on adherence to LPV for ED patients receiving mechanical ventilation.…”

mentioning

confidence: 99%

Initiation of a Lung Protective Ventilation Strategy in the Emergency Department: Does an Emergency Department-Based ICU Make a Difference?

Harvey

Haas²,

Chen

et al. 2022

Critical Care Explorations

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BACKGROUND: Lung protective ventilation (LPV) is a key component in the management of acute respiratory distress syndrome and other acute respiratory pathology. Initiation of LPV in the emergency department (ED) is associated with improved patient-centered and system outcomes, but adherence to LPV among ED patients is low. The impact of an ED-based ICU (ED-ICU) on LPV adherence is not known. METHODS: This single-center, retrospective, cohort study analyzed rates of adherence to a multifaceted LPV strategy pre- and post-implementation of an ED-ICU. LPV strategy components included low tidal volume ventilation, avoidance of severe hyperoxia and high plateau pressures, and positive end-expiratory pressure settings in alignment with best-evidence recommendations. The primary outcome was adherence to the LPV strategy at time of ED departure. RESULTS AND CONCLUSIONS: A total of 561 ED visits were included in the analysis, of which 60.0% received some portion of their emergency care in the ED-ICU. Adherence to the LPV strategy was statistically significantly higher in the ED-ICU cohort compared with the pre-ED-ICU cohort (65.8% vs 41.4%; p < 0.001) and non-ED-ICU cohort (65.8% vs 43.1%; p < 0.001). Among the ED-ICU cohort, 92.8% of patients received low tidal volume ventilation. Care in the ED-ICU was also associated with shorter ICU and hospital length of stay. These findings suggest improved patient and resource utilization outcomes for mechanically ventilated ED patients receiving care in an ED-ICU.

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Delivery of end‐of‐life care in an emergency department–based intensive care unit

Cited by 7 publications

References 23 publications

Palliative care interventions for adults in the emergency department: A review of components, delivery models, and outcomes

Palliative care interventions for adults in the emergency department: A review of components, delivery models, and outcomes

Emergency department length of stay and outcomes of emergency department–based intensive care unit patients

Initiation of a Lung Protective Ventilation Strategy in the Emergency Department: Does an Emergency Department-Based ICU Make a Difference?

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