A well-developed system is in place for patients who suffer traumatic injuries. In each community, paramedics and emergency medical technicians (EMTs) know where to take patients who need specialized trauma care. However, what about critically ill patients who need rapid evaluation and treatment? Such patients may have to sit in an ED until space is available in an appropriate ICU, and for patients with time-sensitive critical care needs, this lack of speedy access to specialized care can lead to negative outcomes. For some EDs, this state of affairs also can put a squeeze on space, staffing, and other resources that are in constant demand.
Recognizing this gap, the University of Maryland Medical Center (UMMC) in Baltimore developed a six-bed unit designed to accelerate care to these specific patients. Dubbed the critical care resuscitation unit (CCRU), the new space is modeled after UMMC’s trauma resuscitation unit, but with resources and staff geared toward non-trauma, critically ill patients, many of whom require life-saving care. It’s a model that developers believe could deliver benefits at many other large medical centers that serve a high number of critically ill patients.
Focus on Critical Care Needs
The CCRU serves a function that most ICUs or EDs do not serve, explains Thomas Scalea, MD, FACS, director of the program in trauma at the University of Maryland School of Medicine (UMSOM) and the physician-in-chief of the shock trauma center at UMMC.
“EDs see a large volume of patients and their job is to sort through and get people where they belong: home, the operating room, or wherever. They are not designated to provide intensive care to a small number of people,” he observes. “ICUs are intended to provide longitudinal care to people who are very sick. They are not designed to do rapid evaluation. The CCRU does both. It does rapid evaluation, stabilization, and provides critical care.”
While not all medical centers require such a specialized unit, it can fulfill a vital function for large tertiary or quaternary care centers, many of which receive hundreds of transfer patients from smaller facilities every year, Scalea notes.
“If you have [these critically ill patients] land in the ED, you have half their needs covered, but not all of them,” he says. “If you have them land in the ICU, you have to make a bed, which is also true for EDs, which are very crowded places these days.This is designed specifically to serve those purposes.”
In place at UMMC since July 2013, developers say the CCRU has been highly successful at its mission of accelerating care to critically ill patients while also enabling UMMC to care for more patients. For example, in its first year of operation, critically ill transfer patients to UMMC increased by 64.5% over the previous year, and these patients were processed at a much faster clip. The average transfer time was 129 minutes as compared to 234 minutes before the creation of the CCRU. In addition, for patients requiring surgery, the median time to arrival dropped dramatically (from 223 to 118 minutes) as did the time to the operating room (3,424 to 1,113 minutes). Investigators add that average length of stay fell from 17 days to 13 days, and they observed a trend toward lower mortality as well.1
In the past, transfers often were delayed because there was no space available in an appropriate ICU, Scalea observes. However, now the CCRU is available 24/7 to commence care of these patients right away, speeding access to diagnostics, specialty care, and even surgery when required. Staff then move patients to an appropriate setting for ongoing care.
“If you are a large tertiary care center, like we are, or a quaternary care center, you need to be able to do this because a lot of patients are transferred in. Where do you have them land?” Scalea asks.
Work Across Specialties
Patients admitted to the CCRU present with a wide range of complex critical care needs that require immediate attention, observes Lewis Rubinson, MD, PhD, an associate professor of medicine at UMSOM and director of the CCRU. These include patients with large ruptured blood vessels, aortic dissections, stroke patients who require neuro interventional radiologic procedures, patients with aneurysmal bleeds in their heads, and patients who require surgery but the surgeon at their hospital is not comfortable managing them, he explains.
“Yes, these patients [might otherwise] remain in the ED, but the bigger issue is that the ED has nowhere to send them for their care and they are likely to have a bad outcome,” Rubinson says. “Different hospitals have different capabilities, and when a patient exceeds their capabilities there is no formal system of how these people get to somewhere else unless it is within their own hospital network system, and even then it can be hit or miss.”
For example, a referral center within a hospital system may say it can accept a patient, and that administrators will call when they have an open ICU bed, but the delays involved come at a cost.
“Some ED physician is in a world of hurt because he has a patient who needs something he can’t provide, and he is just witness to watching the patient get suboptimal care,” Rubinson observes.
When deliberating how to address these gaps at UMMC, administrators noted that adding more ICU capacity would make a difference, but even adding two more beds to each of its seven specialized ICUs wouldn’t solve the problem if there was a surge in strokes that exceeded the capacity of the neuro ICU, Rubinson says.
“Our idea was don’t build additional capacity in every single unit because we can’t economically maintain that, and we can’t be sure [appropriate ICU space] will always be available,” he explains. “Instead, the thinking was [creating] one place that can work across specialties that is able to accept people at a moment’s notice without a worry for a definitive ICU bed afterwards.”
Streamline Transfer Process
Recognizing that the transfer process is a key component, UMMC has taken steps to streamline the approach.
“We didn’t need to build a transfer center. We already had that. We just didn’t have systematic and organizational control of how those referrals happen, and that is really what we took over,” Rubinson explains.
There is now a systematic approach for determining which patients go to which units and when, and there is also specialized support for incoming patients.
“We do medical direction for our transport teams,” Rubinson notes. “We have 24/7 attending staff in house that have direct phone access so that when an outside ED is calling for consultation, they are calling both our subspecialists and our intensivist.”
The referring ED will receive immediate guidance on management of the patient even before the patient boards a helicopter or ambulance to be transferred.
“We are working with them on information so that when the patient gets here we can hit the ground running,” Rubinson observes. “If we know what drips they are on, we can already have those drips ready to go here. If we know they are coming for an ECMO [extracorporeal membrane oxygenation] evaluation, the ECMO circuit is already here ready to go rather than being caught on our heels.”
Crucial to the success of the transfer process is employing an attending provider on staff 24/7 who is fully knowledgeable about the capabilities of helicopter and ambulance critical care transport teams, Rubinson explains.
“We make [the transfer process] easier for referring facilities,” he says. “We have essentially made it a much smarter system.”
In fact, the CCRU process borrows heavily from the way trauma patients have been dealt with at UMMC for five decades.
“We [treat] 8,000 patients a year in trauma, and many of our patients come from other hospitals where they will get stabilized at that first hospital, and then when it is noted that they exceed the capabilities of that hospital, they will be brought here,” Rubinson explains. “We just modeled that same system for non-trauma [patients] because no one was formally doing that for non-trauma patients.”
Prioritize Admissions
To hear a description of the CCRU, it almost seems like an ED that operates at a higher level of complexity, but at the same time offers ICU-level care. Rubinson calls it an ICU with an ED attitude.
“We do all the things that an ICU does, which is very unlike what an ED does, but we have very much an ED attitude in that we need to be ready for the next patient, and we need to be moving [patients] out so that we can still be taking care of the community,” he explains. “We also have a huge interface with EMS.”
Rubinson adds that the workflow in a typical ICU is quite different than what you will find in a resuscitation unit.
“If you are rounding on 14 patients and it is 9 a.m., and you get two requests for transfer from an outside hospital, you still have your work rounds to do. [In a typical ICU], the patients will come, but the entire unit is not geared around making sure the patients get there and that they can be pounced upon immediately,” he explains. “For us, we really turn that around to where our rounds never get in the way of admissions, so admissions are always our priority.”
To accommodate the need for urgency, the CCRU has its own blood refrigerator and a mechanism for cutting through bureaucratic snags such as patients who are not registered correctly.
“When that happens, there is normally a delay in being able to write orders, but when a patient is dying you don’t want there to be any delay in being able to organize medicines or blood products,” Rubinson says. “We have a way that we already figured out from our trauma side of how to be able to manage that patient — even if [he or she is] improperly registered.
Rubinson adds that if every unit had to operate at such a high level, to the point where every charge nurse and every clerk was up to speed on the workarounds and the complexity involved, it would be an impossible task.
“However, because we concentrate it all in a small unit, we are really organized around [the mission],” he says.
The downside of a short-stay ICU unit like the CCRU is that it necessitates an additional handoff when the patient is transferred out of the unit to another ICU.
“We really need to make sure the handoffs go well because it is one additional unit that the patient is going to be in,” Rubinson notes. “Over our three years here, we have focused tremendously on standardized communication and multiple redundant levels of communication to make sure things are not lost in the handoffs.”
Target Resource-heavy Patients
In keeping with the importance of providing quick and efficient care, many of the providers staffing the CCRU are emergency physicians with added training in critical care.
“Since we happen to have the biggest training program for emergency physicians in critical care, we hired many of our own graduates,” Scalea explains.
Further, with the rapidly increasing number of transfer patients coming through the CCRU, expansion of the unit is in the planning stages.
“Hospital real estate is pretty cherished ... we are often right at capacity already, and we believe we could grow this if we had more beds,” Scalea says.
With greater capacity, the unit will alleviate crowding in UMMC’s own ED, but the mission will remain focused on those resource-heavy patients rather than just ICU patients, Rubinson suggests.
“If [our ED] has someone who really requires an enormous amount of resources ... such as a patient with profound ventilator needs, major vasopressor titration needs, or someone who is bleeding out ... then we will bring the patient up,” he explains.
The unit can even accelerate care to a patient with an urgent need for renal replacement therapy because it can handle dialysis and ultrafiltration right in the unit, Rubinson adds.
“The UMMC moves 11,000 patients from outside hospitals into our hospital, and that is a third of our admissions, so we are really the safety net for life-threatening care throughout the state,” Rubinson explains. “We need to be able to receive those patients and to immediately intervene.”
REFERENCE
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Scalea T, Rubinson L, Tran Q, et al. Critical care resuscitation unit: An innovative solution to expedite transfer of patients with time-sensitive critical illness. J Am Coll Surg 2016;222:614-621.
SOURCES
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Lewis Rubinson, MD, PhD, Associate Professor of Medicine, University of Maryland School of Medicine; Director, Critical Care Resuscitation Unit, University of Maryland Medical Center, Baltimore. Email: [email protected].
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Thomas Scalea, MD, FACS, Director, Program in Trauma, University of Maryland School of Medicine; Physician-in-Chief, Shock Trauma Center, University of Maryland Medical Center, Baltimore. Email: [email protected].
