Critical care sections in the ED

[citymd1234]

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Many hospital ICUs don't have fellowship trained CCM docs.

Many EDs don't have EM trained docs. Doesn't mean that its optimal or the right thing to do.

 

[TooMuchResearch]

Many EDs don't have EM trained docs. Doesn't mean that its optimal or the right thing to do.

Sure, but along the same lines, which is better:
A) patient sits in on a vent in the ED for 24 hours getting minimal care or
B) patient gets critical care attention from a doctor comfortable taking care of sick patients but is not CCM trained.

Now what if you had to pick between having no ED and an ED staffed by non-BCEM? If it were my community and the other nearest hospital was 30+ miles away, I'd probably want the non-BCEM.

 

[citymd1234]

Sure, but along the same lines, which is better:
A) patient sits in on a vent in the ED for 24 hours getting minimal care or
B) patient gets critical care attention from a doctor comfortable taking care of sick patients but is not CCM trained.

Now what if you had to pick between having no ED and an ED staffed by non-BCEM? If it were my community and the other nearest hospital was 30+ miles away, I'd probably want the non-BCEM.

This gets back to my initial points:
1) Non-CCM ED docs taking care of ICU level patients for 24 hrs is out of our scope of practice. No other way to slice it.
2) Creating an ED-ICU that is then touted as an accomplishment just de-incentivizes the hospital from actually fixing the underlying ICU capacity and flow problems. In fact, it probably normalizes a 24 hour ED stay for ICU patients under the care of a non-CCM trained physician. This is completely unacceptable. If you are the University of Michigan, something tells me you can do better.
3) Non-BCEM physicians working in EDs happens in rural places with no other options. That's better than nothing. We shouldn't apply that same thinking to some of the world's greatest medical centers.

 

[namethatsmell]

This gets back to my initial points:
1) Non-CCM ED docs taking care of ICU level patients for 24 hrs is out of our scope of practice. No other way to slice it.

Are there people here stating that they prefer non-CCM docs over CCM docs attending in an ICU?

2) Creating an ED-ICU that is then touted as an accomplishment just de-incentivizes the hospital from actually fixing the underlying ICU capacity and flow problems. In fact, it probably normalizes a 24 hour ED stay for ICU patients under the care of a non-CCM trained physician. This is completely unacceptable. If you are the University of Michigan, something tells me you can do better.

You are correct that on some level creating an ED-ICU could give an administrator a chance obviate his/her responsibility to flow and capacity issues, but I suspect if an ED had enough political clout to create this type of unit in the first place they are probably already doing whatever they can to address these issues. I also thought a purpose of these ED-ICUs is to try to turn select patients around in less than a day so they can be admitted to a step-down unit while keeping an upstairs ICU bed open for the expected-to-be-sicker-longer patient who can then go upstairs faster from the ED. Ie the DKA'er gets better faster since their care up front is maximized in the EDICU and they're spared the wasted hours of "waiting to go upstairs" time and "waiting for them to get tucked in by the ICU team now that they're up here" time where they're not treated as aggressively as they could be.

3) Non-BCEM physicians working in EDs happens in rural places with no other options. That's better than nothing. We shouldn't apply that same thinking to some of the world's greatest medical centers.

Unfortunately major medical centers also confront issues logistical issues like a lack of physical space and difficulty obtaining enough staff to utilize their allowed number of licensed beds (or to apply to increase their number).

 

[citymd1234]

Are there people here stating that they prefer non-CCM docs over CCM docs attending in an ICU?



You are correct that on some level creating an ED-ICU could give an administrator a chance obviate his/her responsibility to flow and capacity issues, but I suspect if an ED had enough political clout to create this type of unit in the first place they are probably already doing whatever they can to address these issues. I also thought a purpose of these ED-ICUs is to try to turn select patients around in less than a day so they can be admitted to a step-down unit while keeping an upstairs ICU bed open for the expected-to-be-sicker-longer patient who can then go upstairs faster from the ED. Ie the DKA'er gets better faster since their care up front is maximized in the EDICU and they're spared the wasted hours of "waiting to go upstairs" time and "waiting for them to get tucked in by the ICU team now that they're up here" time where they're not treated as aggressively as they could be.



Unfortunately major medical centers also confront issues logistical issues like a lack of physical space and difficulty obtaining enough staff to utilize their allowed number of licensed beds (or to apply to increase their number).

Thank you. I really appreciate the broken down logical answer.

 

[Fox800]

It’s funny how ICU boarding is magically solved when we threaten to transfer an intubated patient to another hospital. Can’t lose that $$$. Magically staffing appears and the stars align.

 

[DrGasPasser]

Unless they have changed it, Michigan has regular boarded EM faculty staff their CC unit (EC3). They have some sort of boot camp for them.

I interviewed for a CCM fellowship this year at Michigan and was told that the EC3 is now mostly run by critical care fellows from IM and anesthesia programs, and supervised by EM-CCM faculty. Some nights are still covered by EM attendings who are not CC boarded but have completed resuscitation, research, and stroke fellowships (or have other backgrounds that align with critical care). On these nights, the fellows always have access to on-call intensivists much like other ICUs that don’t have in-house attending coverage.


Other places with ED critical care centers or similar facilities are Henry Ford and Uiv Maryland.

 

[kemper6036]

I would like to create a list of academic EDs with separate sections dedicated to critical care. Please note* if there are faculty there who are able to ONLY work in the critical care section. Are these faculty also CCM trained and do they work in the unit as well?

I'll start, but please correct me as needed and add on:

U Michigan
Kings County-Downstate
Stony Brook

HH

i think Penn has a version of EC3, not sure what they call it. I'm michigan trained so they are all EC3 to me

 

[leviathan]

I would like to create a list of academic EDs with separate sections dedicated to critical care. Please note* if there are faculty there who are able to ONLY work in the critical care section. Are these faculty also CCM trained and do they work in the unit as well?

I'll start, but please correct me as needed and add on:

U Michigan
Kings County-Downstate
Stony Brook

HH

My academic ED has routinely two or three of my ICU patients who wait for days in the ER before getting an ICU bed. But I don't think that's what you're referring to. 😉