Is the Critical Care Resuscitation Unit Sustainable: A 5-Year Experience of a Beneficial and Novel Model.

Background: The 6-bed critical care resuscitation unit (CCRU) is a unique and specialized intensive care unit (ICU) that streamlines the interhospital transfer (IHT-transfer between different hospitals) process for a wide range of patients with critical illness or time-sensitive disease. Previous studies showed the unit successfully increased the number of ICU admissions while reducing the time of transfer in the first year of its establishment. However, its sustainability is unknown. Methods: This was a descriptive retrospective analysis of adult, non-trauma patients who were transferred to an 800-bed quaternary medical center. Patients transferred to our medical center between January 1, 2014 and December 31, 2018 were eligible. We used interrupted time series (ITS) and descriptive analyses to describe the trend and compare the transfer process between patients who were transferred to the CCRU versus those transferred to other adult inpatient units. Results: From 2014 to 2018, 50,599 patients were transferred to our medical center; 31,582 (62%) were non-trauma adults. Compared with the year prior to the opening of the CCRU, ITS showed a significant increase in IHT after the establishment of the CCRU. The CCRU received a total of 7,788 (25%) IHTs during this period or approximately 20% of total transfers per year. Most transfers (41%) occurred via ground. Median and interquartile range [IQR] of transfer times to other ICUs (156 [65-1027] minutes) were longer than the CCRU (46 [22-139] minutes, P < 0.001). For the CCRU, the most common accepting services were cardiac surgery (16%), neurosurgery (11%), and emergency general surgery (10%). Conclusions: The CCRU increases the overall number of transfers to our institution, improves patient access to specialty care while decreasing transfer time, and continues to be a sustainable model over time. Additional research is needed to determine if transferring patients to the CCRU would continue to improve patients' outcomes and hospital revenue.

Patterns of opioid prescribing in emergency departments during the early phase of the COVID-19 pandemic.

INTRODUCTION: The COVID-19 pandemic was superimposed upon an ongoing epidemic of opioid use disorder and overdose deaths. Although the trend of opioid prescription patterns (OPP) had decreased in response to public health efforts before the pandemic, little is known about the OPP from emergency department (ED) clinicians during the COVID-19 pandemic. METHODS: We conducted a pre-post study of adult patients who were discharged from 13 EDs and one urgent care within our academic medical system between 01/01/2019 and 09/30/2020 using an interrupted time series (ITS) approach. Patient characteristics and prescription data were extracted from the single unified electronic medical record across all study sites. Prescriptions of opioids were converted into morphine equivalent dose (MED). We compared the "Covid-19 Pandemic" period (C19, 03/29/2020-9/30/2020) and the "Pre-Pandemic" period (PP, 1/19/2020-03/28/2020). We used a multivariate logistic regression to assess clinical factors associated with opioid prescriptions. RESULTS: We analyzed 361,794 ED visits by adult patients, including 259,242 (72%) PP and 102,552 (28%) C19 visits. Demographic information and percentages of patients receiving opioid prescriptions were similar in both groups. The median [IQR] MED per prescription was higher for C19 patients (70 [56-90]) than for PP patients (60 [60-90], P < 0.001). ITS demonstrated a significant trend toward higher MED prescription per ED visit during the pandemic (coefficient 0.11, 95% CI 0.05-0.16, P = 0.002). A few factors, that were associated with lower likelihood of opioid prescriptions before the pandemic, became non-significant during the pandemic. CONCLUSION: Our study demonstrated that emergency clinicians increased the prescribed amount of opioids per prescription during the COVID-19 pandemic compared to the pre-pandemic period. Etiologies for this finding could include lack of access to primary care and other specialties during the pandemic, or lower volumes allowing for emergency clinicians to identify who is safe to be prescribed opioids.

The Critical Care Resuscitation Unit Transfers More Patients From Emergency Departments Faster and Is Associated With Improved Outcomes.

BACKGROUND: Transfer delays of critically ill patients from other hospitals' emergency departments (EDs) to an appropriate referral hospital's intensive care unit (ICU) are associated with poor outcomes. OBJECTIVES: We hypothesized that an innovative Critical Care Resuscitation Unit (CCRU) would be associated with improved outcomes by reducing transfer times to a quaternary care center and times to interventions for ED patients with critical illnesses. METHODS: This pre-post analysis compared 3 groups of patients: a CCRU group (patients transferred to the CCRU during its first year [July 2013 to June 2014]), a 2011-Control group (patients transferred to any ICU between July 2011 and June 2012), and a 2013-Control group (patients transferred to other ICUs between July 2013 and June 2014). The primary outcome was time from transfer request to ICU arrival. Secondary outcomes were the interval between ICU arrival to the operating room and in-hospital mortality. RESULTS: We analyzed 1565 patients (644 in the CCRU, 574 in the 2011-Control, and 347 in 2013-Control groups). The median time from transfer request to ICU arrival for CCRU patients was 108 min (interquartile range [IQR] 74-166 min) compared with 158 min (IQR 111-252 min) for the 2011-Control and 185 min (IQR 122-283 min) for the 2013-Control groups (p < 0.01). The median arrival-to-urgent operation for the CCRU group was 220 min (IQR 120-429 min) versus 439 min (IQR 290-645 min) and 356 min (IQR 268-575 min; p < 0.026) for the 2011-Control and 2013-Control groups, respectively. After adjustment with clinical factors, transfer to the CCRU was associated with lower mortality (odds ratio 0.64 [95% confidence interval 0.44-0.93], p = 0.019) in multivariable logistic regression. CONCLUSION: The CCRU, which decreased time from outside ED's transfer request to referral ICU arrival, was associated with lower mortality likelihood. Resuscitation units analogous to the CCRU, which transfer resource-intensive patients from EDs faster, may improve patient outcomes.

Emergency Providers' Pain Management in Patients Transferred to Intensive Care Unit for Urgent Surgical Interventions.

INTRODUCTION: Pain is the most common complaint for an emergency department (ED) visit, but ED pain management is poor. Reasons for poor pain management include providers' concerns for drug-seeking behaviors and perceptions of patients' complaints. Patients who had objective findings of long bone fractures were more likely to receive pain medication than those who did not, despite pain complaints. We hypothesized that patients who were interhospital-transferred from an ED to an intensive care unit (ICU) for urgent surgical interventions would display objective pathology for pain and thus receive adequate pain management at ED departure. METHODS: This was a retrospective study at a single, quaternary referral, academic medical center. We included non-trauma adult ED patients who were interhospital-transferred and underwent operative interventions within 12 hours of ICU arrival between July 2013 and June 2014. Patients who had incomplete ED records, required invasive mechanical ventilation, or had no pain throughout their ED stay were excluded. Primary outcome was the percentage of patients at ED departure achieving adequate pain control of ≤ 50% of triage level. We performed multivariable logistic regression to assess association between demographic and clinical variables with inadequate pain control. RESULTS: We included 112 patients from 39 different EDs who met inclusion criteria. Mean pain score at triage and ED departure was 8 (standard deviation 8 and 5 [3]), respectively. Median of total morphine equivalent unit (MEU) was 7.5 [5-13] and MEU/kg total body weight (TBW) was 0.09 [0.05-0.16] MEU/kg, with median number of pain medication administration of 2 [1-3] doses. Time interval from triage to first narcotic dose was 61 (35-177) minutes. Overall, only 38% of patients achieved adequate pain control. Among different variables, only total MEU/kg was associated with significant lower risk of inadequate pain control at ED departure (adjusted odds ratio = 0.22; 95% confidence interval = 0.05-0.92, p = 0.037). CONCLUSION: Pain control among a group of interhospital-transferred patients requiring urgent operative interventions, was inadequate. Neither demographic nor clinical factors, except MEU/kg TBW, were shown to associate with poor pain management at ED departure. Emergency providers should consider more effective strategies, such as multimodal analgesia, to improve pain management in this group of patients.

Critical Care Resuscitation Unit: An Innovative Solution to Expedite Transfer of Patients with Time-Sensitive Critical Illness.

BACKGROUND: Time-sensitive, critical surgical illnesses require care at specialized centers. Trauma systems facilitate patient transport to designated trauma centers, but formal systems for nontraumatic critical illness do not exist. We created the critical care resuscitation unit to expedite transfers of adult critically ill patients with time-sensitive conditions to a quaternary academic medical center, hypothesizing that this would decrease time to transfer, increase transfer volume, and improve outcomes. STUDY DESIGN: Critical care transfers to the University of Maryland Medical Center during the first year of the critical care resuscitation unit (July 2013 to June 2014) were compared with a previous year (July 2011 to June 2012). Times from transfer request to arrival and operating room and hospital mortality were compared. RESULTS: There was a 64.5% increase in transfers with a 93.6% increase in critically ill surgical patients. For patients requiring operation, median time to arrival and operating room (118 vs 223 minutes and 1,113 vs 3,424 minutes, respectively; p < 0.001 for both) and median hospital length of stay (13 vs 17 days; p < 0.001) were reduced significantly. There was a nonsignificant trend toward lower mortality (14.6% vs 16.5%; p = 0.27). CONCLUSIONS: The critical care resuscitation unit dramatically increased the volume of critically ill surgical patients. It decreased transfer times, increased volume, and, for those who required urgent operation, decreased time from initial referral to operating room. This benefit seems to be most marked in patients needing urgent operation. This might be a paradigm shift expediting the transfer of patients with time-sensitive critical illness to an appropriately resourced specialty center.

Comparison of COMPUTED TOMOGRAPHY Image Quality Using Intravenous vs. Intraosseous Contrast Administration in Swine.

BACKGROUND: Vascular access is essential in managing patients with significant injuries. It is required for medications, fluids, blood products, and radiographic contrast administration. Generally, this is accomplished through peripheral intravenous (i.v.) cannulation. In some patients, however, i.v. cannulation may be difficult or impossible. Intraosseous (i.o.) access is an acceptable alternative for many uses during resuscitation. However, adequacy of vascular enhancement with i.o. administration of contrast has not been studied. OBJECTIVES: This study was performed to assess the efficacy of i.o. administration of contrast agents for enhanced computed tomography (CT) imaging of the chest and abdomen. METHODS: We carried out a crossover study in mature mini-swine with peripheral i.v. and i.o. access established. Intraosseous access was obtained in the proximal humerus with fluoroscopic confirmation. Each animal underwent two trauma-protocol CT scans successively using the i.v. or i.o. routes of contrast administration. Wash-out between studies was established. The order for route of administration was randomized. Images were evaluated for adequacy of enhancement by two blinded board-certified radiologists. RESULTS: All images obtained with successful administration of i.o. contrast were judged adequately enhanced, whereas two from the i.v. route were judged to be inadequate by at least one of the radiologists. Two occurrences of failed i.o. needle placement occurred. One animal had complete contrast extravasation resulting in inadequate opacification. CONCLUSIONS: In this model, injection of contrast through a proximal humerus i.o. resulted in adequate enhancement of trauma-protocol CT images. Our results suggest that i.o. administration of contrast merits further investigation of its potential utility in patients when i.v. access would delay diagnostic evaluation.