Descriptive Analysis of Extubations Performed in an Emergency Department-based Intensive Care Unit

Abstract

Extubation of appropriate patients in the emergency department (ED) may be a strategy to avoid preventable or short-stay intensive care unit (ICU) admissions, and could allow for increased ventilator and ICU bed availability when demand outweighs supply. Extubation is infrequently performed in the ED, and a paucity of outcome data exists. Our objective was to descriptively analyze characteristics and outcomes of patients extubated in an ED-ICU setting. Methods: We conducted a retrospective observational study at an academic medical center in the United States. Adult ED patients extubated in the ED-ICU from 2015-2019 were retrospectively included and analyzed. Results: We identified 202 patients extubated in the ED-ICU; 42% were female and median age was 60.86 years. Locations of endotracheal intubation included the ED (68.3%), outside hospital ED (23.8%), and emergency medical services/prehospital (7.9%). Intubations were performed for airway protection (30.2%), esophagogastroduodenoscopy (27.7%), intoxication/ingestion (17.3%), respiratory failure (13.9%), seizure (7.4%), and other (3.5%). The median interval from ED arrival to extubation was 9.0 hours (interquartile range 6.2-13.6). One patient (0.5%) required unplanned re-intubation within 24 hours of extubation. The attending emergency physician (EP) at the time of extubation was not critical care fellowship trained in the majority (55.9%) of cases. Sixty patients (29.7%) were extubated compassionately; 80% of these died in the ED-ICU, 18.3% were admitted to medical-surgical units, and 1.7% were admitted to intensive care. Of the remaining patients extubated in the ED-ICU (n = 142, 70.3%), zero died in the ED-ICU, 61.3% were admitted to medical-surgical units, 9.9% were admitted to intensive care, and 28.2% were discharged home from the ED-ICU. Conclusion: Select ED patients were safely extubated in an ED-ICU by EPs. Only 7.4% required ICU admission, whereas if ED extubation had not been pursued most or all patients would have required ICU admission. Extubation by EPs of appropriately screened patients may help decrease ICU utilization, including when demand for ventilators or ICU beds is greater than supply. Future research is needed to prospectively study patients appropriate for ED extubation.

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

“…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.…”

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

“…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.…”

“…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.…”

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

“…13 Patients in the ED requiring ongoing critical care can be transferred to EC3 regardless of inpatient ICU bed availability, and common indications for transfer have been previously described. 13 The ED-ICU model has previously been associated with improved patient mortality and reduced ICU use [13][14][15][16][17]…”

“…Patients in the ED requiring ongoing critical care can be transferred to EC3 regardless of inpatient ICU bed availability, and common indications for transfer have been previously described 13 . The ED‐ICU model has previously been associated with improved patient mortality and reduced ICU use 13–17 and may offer an opportunity to reduce ICU admissions among patients receiving end‐of‐life care or for whom ICU admission is not in alignment with goals of care.…”