By Dorothy Brooks
With ICU-level resources often limited, especially in rural areas, investigators with the University of Vermont Health Network based in Burlington implemented a new service designed to expand the reach of critical care expertise across the health system, which includes a tertiary hospital, two community hospitals, and three critical access hospitals.
The critical care transition (CCT) service is designed for patients with critical care needs who present to EDs within the network as well as to provide peer-to-peer support and guidance to the emergency providers caring for these patients, but that is not all.
“We wanted to be as inclusive as possible in reaching patients who have critical care needs outside the walls of the ICU, and that is how we landed on the idea of a three-modality model,” explains Katelin Morrissette, MD, a co-developer of the service and one of the physicians manning the CCT service, all of whom are double boarded in emergency medicine (EM) and critical care medicine (CCM). “We offer consults to ED patients and patients on the inpatient floors at the tertiary site; and then we also do tele-ICU consults for ED patients at the other network sites, either prior to transfer [to the ICU] or in avoidance of a transfer in some cases.”
The thinking behind the concept is that by accelerating expert consultations to patients with critical care needs, outcomes can be improved and ICU-level resources can be managed more efficiently. Pilot testing of the approach, which took place from October 2022 to April 2023 with eight shifts for the CCT service per month, suggests that such benefits are indeed within reach, and that stakeholders (such as emergency providers and nurses) give the new service high marks.1
While the model continues to be refined, investigators tell EDM that sustaining such a model depends on having enough volume to support the EM/CCM physicians manning the CCT service. Also, considerable effort needs to go toward the coding and billing end of the equation to ensure that mechanisms are in place to facilitate adequate reimbursement.
Morrissette explains that from the start of the CCT service, investigators were proactive in trying to collect data not only on things they were doing but also on what things they were avoiding by having an ICU physician available early on. “We developed our own tools in the Epic [electronic medical record] so that we could document … where there were services, [such as] a cath lab that we didn’t have to call in on off hours,” she says. “That really allowed us to demonstrate a value beyond just the RVUs [relative value unit] that we generated.”
The key is having a process that makes it easy for emergency providers at the network hospitals to quickly connect with the CCT service. “Let’s say a patient comes in with respiratory failure and needs to be intubated,” explains Morrissette. “If the emergency provider has questions about management, he or she would call the transfer center and ask to speak with the CCT physician.”
The transfer center would create an encounter in the tele-software, and the CCT physician would simply open that encounter, notes Morrissette. “We have virtual carts with [computers] at all of the network sites,” she says. “That hardware and technology was already in place prior to this service. It just wasn’t necessarily utilized for this particular patient population.”
Since all participating hospitals are in-network, the CCT physicians have access to all labs and imaging, adds Morrissette. “We can see the patient, and we can talk with the provider or the nurse in real time,” she says, noting that such connections typically can be made quickly.
“A huge part of this effort was working with all of the network emergency department physicians, talking about what their needs were, and addressing any hardware issues,” shares Morrissette. “We had to make sure everyone was onboard, that they knew how to find us, and that they knew what we could offer, so we did a lot of that work up front.”
One example of how emergency physicians have used the CCT service involves the case of a patient with heart failure who presented to the ED. “He had a lot of comorbidities and he was a complex [case], but at the time his biggest problem was volume overload,” explains Morrissette. “As ICU physicians, we will routinely use large doses of Lasix [a diuretic], much larger doses than would typically be used in the ED [for such cases].”
Morrissette notes that she was comfortable doing that with this patient while monitoring his electrolytes, and his condition quickly improved, enabling him to come off of bilevel positive airway pressure (BiPAP). “We were able to do that in under four hours and avoid an ICU stay for him,” she recalls. “He felt much better and it was much better patient care to be proactive in this case.”
The way the CCT service managed this case left a positive impression on the ED nurse involved with the patient’s care, shares Morrissette. “One of the big concerns early on from ED nurses was that [the CCT service] would result in them keeping higher acuity patients for a longer period of time, putting additional strain on the ED. But ultimately, this patient got out of the ED faster than he otherwise would have [without the intervention of the CCT service].”
The resolution of the case turned the ED nurse into an advocate for the new service, observes Morrissette.
Two other case examples are notable because they illustrate not only how early critical care expertise can help to avoid costs, but also enhance the skills of emergency practitioners over time, notes Morrissette. “Two nights in a row, a Friday night and a Saturday night, just by total chance, two very similar patients came into the ED with symptomatic bradycardia after the cath lab would have closed,” she says.
The typical workflow in these cases would have been to call in a cardiologist, open up the cath lab, and place a transvenous pacer in the patients, explains Morrissette. However, because the EM/CCM physician was there, he was able to assist the emergency physician in carrying out the procedure. “It is definitely part of [an emergency medicine physician’s] scope of practice, but it is not something you do very often,” she says.
The procedure went well in the first patient’s case, negating the need to call in a cardiologist and open up the cath lab. When a similar case presented the next evening, the emergency physician who performed the procedure on the first patient with the help of the EM/CCM physician was able to place the transvenous pacer on the second patient, again without the need to call in a cardiologist and open up the cath lab, explains Morrissette.
As a result of these cases, the emergency medicine staff involved became appreciative of the CCT service despite there being some initial concerns that having such a service might take away some of the higher acuity patients that ED physicians want to feel a sense of ownership for, explains Morrissette. “The EM/CCM physician was there to supervise a peer who had less experience with a procedure … and increased the scope of practice [for the physician],” she says. “In both cases, the procedures were done in the moment without having to open up the cath lab, and the patients were stabilized much quicker than they otherwise would have been.”
Such examples are important in demonstrating the value of having a CCT service because it can be hard to measure what the cost-benefit is of avoiding certain procedures or admissions. “Accumulating those cases is what gives us evidence that we’ve been able to improve value,” says Morrissette.
When looking at data on the CCT service through August 2023, investigators report that the disposition of 266 patients seen during this period was changed following CCT service intervention, although it is unclear what percentage of these changes were the result of the CCT intervention. Further, the researchers note there was a trend toward a reduction in short ICU stays in patients seen by the CCT service physicians. This suggests that the earlier involvement of critical care expertise leads to improved use of healthcare resources.
Morrissette anticipates that the CCT service will evolve further with more experience. “We’re still in that realm of [providing] high value at low volume, so we’re going to have to do more brainstorming, probably in the next few months, about how we might provide this service for more things,” she says. “We’re still looking for ways we can really maximize our impact.”
For other hospitals or EDs interested in exploring a similar approach, Morrissette advises that it is critical to first understand your needs, and then tailor your solution accordingly. “Talk to a wide spectrum of stakeholders,” she says, noting that is important to understand all of their workflows and communication strategies.
Also, Morrissette emphasizes that the coding and billing aspects are complex. “Right now we don’t generate revenue from all of our consults [because] a lot of [them are] peer support, but we had to make sure that our billers and coders understand that [aspect] when they’re reading our charts,” she says. “We email them after every shift to say here are our patients … and this is what services we provided.”
REFERENCE
- Morrissette K, Lentz S, Herrington R, et al. Critical care anywhere: A novel emergency care consult service in a rural health network. NEJM Catal Innov Care Deliv 2023; 4(10). Sept. 2023. doi: 10.1056/CAT.23.0154.
With ICU-level resources often limited, especially in rural areas, investigators with the University of Vermont Health Network based in Burlington implemented a new service designed to expand the reach of critical care expertise across the health system, which includes a tertiary hospital, two community hospitals, and three critical access hospitals.
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