Quality Is Not the Only Part of the Emergency Department–Based Intensive Care Unit Value Equation | Critical Care Medicine | JAMA Network Open | JAMA Network
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Invited Commentary
Emergency Medicine
July 24, 2019

Quality Is Not the Only Part of the Emergency Department–Based Intensive Care Unit Value Equation

Author Affiliations
  • 1School of Medicine, Department of Emergency Medicine, University of Alabama at Birmingham
JAMA Netw Open. 2019;2(7):e197570. doi:10.1001/jamanetworkopen.2019.7570

Critical illness and injury exact an enormous toll on patients, their families, and society. Initially conceived of and deployed in 1959,1 the delivery of intensive care is expensive and resource intensive and currently consumes $0.40 of each dollar spent annually on health care in the United States.2 With an aging population and rapid growth in the volume and acuity of patients requiring critical care, the demand for intensive care unit (ICU) services continues to outstrip the supply of qualified intensivists.3 Acknowledging the shortage of critical care services, emergency departments (EDs) are now providing 3 times as many hours of critical care as they did in 2001.4 These shifts in critical care delivery, outside traditional ICU settings, have resulted in higher in-hospital mortality rates and length of stay.5 In response, there is mounting interest in developing and implementing alternative solutions to providing in-patient critical care services in nontraditional health care settings.

Gunnerson and colleagues6 describe a novel solution to the emerging intensive care crisis—an ED-based ICU, or ED-ICU. Their unique 14-bed unit, the Joyce and Don Massey Family Foundation Emergency Critical Care Center (EC3) at the University of Michigan, is composed of 5 trauma and medical resuscitation bays and 9 ICU patient rooms housed immediately adjacent to the ED. Patients presenting to the ED requiring intensive care are initially seen by traditional ED staff in the usual manner, and care is then transitioned to the EC3, where critical care is delivered by emergency physicians with and without critical care fellowship training. By using a standard set of evidence-based protocols, the staff of EC3 is able to accommodate patients with a wide variety of diagnoses common to the ICU, including septic shock, gastrointestinal tract bleeding, status epilepticus, and diabetic ketoacidosis, among others.

The implementation of this novel ED-ICU concept within a large academic medical center that treats 75 000 patients in the ED annually was associated with meaningful reductions in 30-day mortality among all patients in the ED and in the subset of patients admitted to the ICU.6 Furthermore, these reductions were accomplished while simultaneously reducing the numbers of both overall and short-stay ICU admissions annually. Although these successes are remarkable, they are even more impressive when taken in the context of temporal increases in annual ED volume, acuity (indicated by lower mean emergency severity index scores), and length of stay during the study period and greater mean age and medical complexity (represented by increasing Charlson Comorbidity Index scores) of the comparison cohort.

Although the findings reported by Gunnerson et al6 are notable and provide hope of a novel solution to the contemporary crisis of providing timely, high-quality critical care, the reproducibility of EC3 units at scale beyond a few large, specialized academic centers is uncertain without essential fiscal details. These considerations include the financing of EC3, both for initial capital (eg, physical plant creation and equipment acquisition) and ongoing personnel (eg, physicians, advanced practice providers, nursing staff, and ancillary health professionals), operational costs (eg, disposable equipment and specific training requirements for these specialized staff and physicians), and the role of foundation funding for these operations. Furthermore, the financial model of EC3, either generating its own independent stream of previously untapped revenue or as a cost-recovery mechanism for the institution, which otherwise forgoes income for boarding patients admitted to the ICU in the ED, is unspecified. Given the current regulatory environment, the mechanism for physicians and advanced practice providers in the ED-ICU to document and bill for services separately and distinctly from the index ED visit is also not described in detail and is absolutely essential to understanding the utility of an ED-ICU. These details serve to contextualize the viability of an ED-ICU concept within the daily operations of an ED and the larger health care institution. Without clarity around these economic realities, it is impossible to determine whether an EC3-like model is generalizable, scalable, and fiscally sustainable to address the intensive care crisis.

Although Gunnerson et al6 clearly demonstrate that the quality of health care being provided by the ED-ICU and the larger ED appears to be superior to the status quo via universally agreed-on metrics, quality is only the numerator of the value equation when examining health care solutions. Without essential information that equates the quotient of quality and cost to value (Q/C = V),7 it is impossible to objectively quantify whether the benefits of an ED-ICU model are preferable to institutional policies that facilitate patient throughput in the ICU (ie, shortening admission and discharge cycles and prioritizing inpatient discharges and transfers) or simply adding more beds to the ICU. Without data to determine the value of an EC3-like ED-ICU model, the feasibility and sustainability of its widespread adoption are largely uncertain, given the current economic pressures in health care.

The contemporary crisis facing critical care has been building for decades, increasingly straining hospital personnel and resources, while relying on emergency physicians and ED staff to fill in the gap. Gunnerson et al6 shed light on a unique ED-ICU model that could provide additional services to critically ill patients outside a traditional ICU environment. Unfortunately, without additional operational information, including cost-effectiveness data to inform the health care value equation, it is difficult to herald this model of an ED-ICU as anything more than novel.

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Article Information

Published: July 24, 2019. doi:10.1001/jamanetworkopen.2019.7570

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2019 Kurz MC et al. JAMA Network Open.

Corresponding Author: Erik P. Hess, MD, MSc, School of Medicine, Department of Emergency Medicine, University of Alabama at Birmingham, 619 19th St S, OHB 251, Birmingham, AL 35249-7013 (ehess@uabmc.edu).

Conflict of Interest Disclosures: Dr Kurz reported grants from the University of Alabama at Birmingham General Endowment Fund and grants and personal fees from Zoll Medical Corp outside the submitted work. No other disclosures were reported.

References
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Barrett  ML, Smith  MW, Elixhauser  A, Honigman  LS, Pines  JM. Utilization of intensive care services, 2011: Healthcare Cost and Utilization Project statistical brief #185. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb185-Hospital-Intensive-Care-Units-2011.pdf. Published December 2014. Accessed June 17, 2019.
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Angus  DC, Kelley  MA, Schmitz  RJ, White  A, Popovich  J  Jr; Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS).  Caring for the critically ill patient: current and projected workforce requirements for care of the critically ill and patients with pulmonary disease: can we meet the requirements of an aging population?  JAMA. 2000;284(21):2762-2770. doi:10.1001/jama.284.21.2762PubMedGoogle ScholarCrossref
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Herring  AA, Ginde  AA, Fahimi  J,  et al.  Increasing critical care admissions from U.S. emergency departments, 2001-2009.  Crit Care Med. 2013;41(5):1197-1204. doi:10.1097/CCM.0b013e31827c086fPubMedGoogle ScholarCrossref
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Chalfin  DB, Trzeciak  S, Likourezos  A, Baumann  BM, Dellinger  RP; DELAY-ED Study Group.  Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit.  Crit Care Med. 2007;35(6):1477-1483. doi:10.1097/01.CCM.0000266585.74905.5APubMedGoogle ScholarCrossref
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Gunnerson  KJ, Bassin  BS, Havey  RA,  et al.  Association of an emergency department–based intensive care unit with survival and inpatient intensive care unit admissions.  JAMA Netw Open. 2019;2(7):e197584. doi:10.1001/jamanetworkopen.2019.7584Google Scholar
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Porter  ME.  What is value in health care?  N Engl J Med. 2010;363(26):2477-2481. doi:10.1056/NEJMp1011024PubMedGoogle ScholarCrossref
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