Critical care sections in the ED

[Hamhock]

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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

 

[Dr Mantis Toboggan]

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 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

 

[Hamhock]

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.

Ah, yes. I may not have been clear. I am looking for exactly that. The critical care section may be staffed by anyone; just wondering if it is fully separate from the rest of the ED.
And...
If some faculty work only in this section.

Thanks for clarifying.

HH

 

[Fox800]

Hennepin’s stabilization room is like this, but it’s intended to be a throughout area and not an ED-ICU where people camp out.

 

[enalli]

How do these "ED-CCUs" work logistically? Say a patient comes in with an undifferentiated presentation that then becomes more critical (e.g. chest pain leading to asystole, abd pain that turns out to be DKA, etc.), do they get transferred to the ED-CCU area to be seen by a new doc? Does the reverse situation get downgraded to the regular ED (e.g. "severe stroke" that turns out to be hypoglycemia and is corrected appropriately, etc.)?

 

[doggydog]

These patients are usually seen originally in the main ED and then “transferred” to the critical care area.

The goal is usually to work them up/manage them and hopefully turn them around in <24 hours so they don’t need the MICU.

 

[turkeyjerky]

Hennepin’s stabilization room is like this, but it’s intended to be a throughout area and not an ED-ICU where people camp out.

Unless things have changed in the past 7 years HCMC's stab rooms are definitely not what the op was talking about. Those are really just (very nice) resus bays.

 

[southerndoc]

These patients are usually seen originally in the main ED and then “transferred” to the critical care area.

The goal is usually to work them up/manage them and hopefully turn them around in <24 hours so they don’t need the MICU.

That's ******ed. Open up more MICU beds and don't create a MICU in the ED. I'm all for brief stabilization rooms, but turning them around in <24 hours requires a MICU unless you can turn them around in <2 hours.

 

[Dr Mantis Toboggan]

Yes it is separate, was the Peds ED before the new children’s hospital opened. So it’s adjacent but separate. There are some faculty who primarily work there, not sure if they ONLY work there. Those would be the EM/CC people.

Ah, yes. I may not have been clear. I am looking for exactly that. The critical care section may be staffed by anyone; just wondering if it is fully separate from the rest of the ED.
And...
If some faculty work only in this section.

Thanks for clarifying.

HH

 

[alpinism]

Unless things have changed in the past 7 years HCMC's stab rooms are definitely not what the op was talking about. Those are really just (very nice) resus bays.

Yeah the basic premise of an ED-ICU is to manage critical patients for prolonged periods of time (up to 24hrs) before they're transferred upstairs.

An ED-ICU is usually a separate physical unit (5-10 beds) next to the ED with its own dedicated team of attendings, residents, nurses, etc.

 

[TooMuchResearch]

That's ******ed. Open up more MICU beds and don't create a MICU in the ED. I'm all for brief stabilization rooms, but turning them around in <24 hours requires a MICU unless you can turn them around in <2 hours.

Yeah, they're calling it an "ED-ICU," but it's really an ICU boarding area where they trick people into doing upstairs work.

 

[deleted547339]

Yeah, they're calling it an "ED-ICU," but it's really an ICU boarding area where they trick people into doing upstairs work.

Conversely, it can be a place where we trick downstairs people into letting us do upstairs work.

 

[deleted547339]

That's ******ed. Open up more MICU beds and don't create a MICU in the ED. I'm all for brief stabilization rooms, but turning them around in <24 hours requires a MICU unless you can turn them around in <2 hours.

Yea, but when you are at capacity in the hospital and MICU, it’s another solution. I attend in both. I have had MICU patients wait days for a bed on the floor, so if your short stay icu patients don’t make it upstairs, it helps that problem too.

 

[enalli]

Conversely, it can be a place where we trick downstairs people into letting us do upstairs work.

What kinds of things are you doing in an ED-ICU that you couldn't do in a regular ED? Bronchs? Prone positioning for ARDS? A-lines for everybody?

 

[deleted547339]

What kinds of things are you doing in an ED-ICU that you couldn't do in a regular ED? Bronchs? Prone positioning for ARDS? A-lines for everybody?

Not seeing psych and vag bleeders.

 

[enalli]

Not seeing psych and vag bleeders.

What's the advantage over the regular ICU, then? Having an ED-type schedule?

 

[deleted547339]

What's the advantage over the regular ICU, then? Having an ED-type schedule?

Not worrying about TPN, placement, etc.

 

[enalli]

Not worrying about TPN, placement, etc.

I get it now. It's an ingenious way of having your ICU cake and eating it too.

 

[TooMuchResearch]

Hmm, we just put our critically ill patients in the ICU

 

[deleted547339]

Hmm, we just put our critically ill patients in the ICU

Must be nice. Ours wait for days.

 

[HopefulEMed]

Sinai in Manhattan has a separate "resuscitation-section" as does Elmhurst's (part of Sinai's EM). If it weren't for these sections, there would be a lot of casualty given NYC's limited space, immense boarding problems, and volume. It's not unsual for us to ICU-level care for many hours down in the ED. I personally think it makes us better resuscitationists.

 

[citymd1234]

Last I checked, we're not trained to take care of ICU patients for the first 24 hours of their hospital stay. That's actually well outside what I would consider our scope of practice. I'm sure the ER bills a ton for these services. Just another way to make doctors take on liability by forcing them to practice outside their scope of practice. All while the department/hospital makes out well financially.

I had a colleague salivate over EC3 at a conference to the brink of absurdity. For those ED/ICU trained folks that eat this stuff up, maybe consider that needing an ICU in the ED is a massive failure of your hospital system. And by promoting these "units" for your own academic record, you are just putting patients in danger.

 

[HLxDrummer]

My hospital has a problem getting people to the OR quickly so if it's just a basic appy we cut them open in our ED-OR and send them home.

 

[citymd1234]

My hospital has a problem getting people to the OR quickly so if it's just a basic appy we cut them open in our ED-OR and send them home.

You too? We've started doing this and our hospital bottom line has gone through the roof. Granted we've had a few bad outcomes and a few ED docs getting sued, but the hospital CEO got a huge bonus!

 

[enalli]

Last I checked, we're not trained to take care of ICU patients for the first 24 hours of their hospital stay. That's actually well outside what I would consider our scope of practice. I'm sure the ER bills a ton for these services. Just another way to make doctors take on liability by forcing them to practice outside their scope of practice. All while the department/hospital makes out well financially.

I had a colleague salivate over EC3 at a conference to the brink of absurdity. For those ED/ICU trained folks that eat this stuff up, maybe consider that needing an ICU in the ED is a massive failure of your hospital system. And by promoting these "units" for your own academic record, you are just putting patients in danger.

Depends on who is staffing these units. There is a growing number of EM-trained folks going into CCM fellowships.

 

[citymd1234]

Depends on who is staffing these units. There is a growing number of EM-trained folks going into CCM fellowships.

Fine if staffed by those trained in CCM. Many are not apparently. Also stick by that needing an ICU in the ED is a horrendous failure of the hospital system.

 

[HLxDrummer]

You too? We've started doing this and our hospital bottom line has gone through the roof. Granted we've had a few bad outcomes and a few ED docs getting sued, but the hospital CEO got a huge bonus!

Ya it's a little stressful trying to see these vag bleeders in the hallway at 4 PPH while the new grad NP is taking out the appy but somebody with a clipboard and a white coat said it was going smoothly so that's good news!

 

[Siggy]

Not worrying about TPN, placement, etc.

Placement?
Tele, step down, LTAC, hospice. Easiest dispo ever.

TPN: Dear pharmacist, please manage. Dear pharmacist, the sodium is high, stop putting sodium in the TPN. Thanks!

 

[deleted547339]

Placement?
Tele, step down, LTAC, hospice. Easiest dispo ever.

TPN: Dear pharmacist, please manage. Dear pharmacist, the sodium is high, stop putting sodium in the TPN. Thanks!

Yea, because LTAC beds just appear.

 

[Hamhock]

And by promoting these "units" for your own academic record, you are just putting patients in danger.

Really? On what data or experience are you making this assertion?

Do you feel this way about Shock Trauma in Baltimore? How about the EC3 in Michigan?

I suspect you haven't worked much in one of these units, have little exposure to EM-CCM docs, and probably haven't managed enough critical care patients to make such a judgement -- nevermind accuse some of the leaders of emergency medicine of actively endangering patients for personal and professional advancement.

HH

 

[Hamhock]

Despite my last post in reply to @citymd1234, I didn't start this thread to discuss the pros and cons of ED-ICUs or isolated resuscitation bays.

Rather, I was hoping posters could identify other hospitals where the critical care patients are separated from the general ED population and managed by EM or EM-CCM docs only focused on the critical care patients. I am particularly interested in these units that hire docs who don't have to take shifts in the "general ED".

@HopefulEMed identified Elmhurst as an example; adding to my list in the OP.

Anyone able to add some more sites?

HH

 

[Siggy]

Yea, because LTAC beds just appear.

Assuming the patient has insurance, yep. I haven't really had an issue getting a patient to LTAC quickly. The biggest issue is one of the major insurances wants 21 vent days prior to transfer if its just a failure to liberate issue... but that just becomes taking a knee and running out the clock.

Besides... that's why the case manager is a part of interdisciplinary rounds.

 

[deleted547339]

Last I checked, we're not trained to take care of ICU patients for the first 24 hours of their hospital stay. That's actually well outside what I would consider our scope of practice. I'm sure the ER bills a ton for these services. Just another way to make doctors take on liability by forcing them to practice outside their scope of practice. All while the department/hospital makes out well financially.

I had a colleague salivate over EC3 at a conference to the brink of absurdity. For those ED/ICU trained folks that eat this stuff up, maybe consider that needing an ICU in the ED is a massive failure of your hospital system. And by promoting these "units" for your own academic record, you are just putting patients in danger.

Or maybe, just maybe, the doctors that spent an extra 2 years of their lives doing 80h/week getting destroyed by critical illness because they are passionate about critically ill patients know more about their care than you do and are trying to save lives in a broken healthcare system by making sure these patients don’t fall through the cracks and, instead, get expert care by those with the training to do so. And maybe this is a push from doctors to solve a problem the best way they see to do so, not some nepharious bean counter telling us what to do. And maybe it’s not people practicing outside of their scope, but doing exactly what they trained to do. But what do I know?

 

[deleted547339]

Assuming the patient has insurance, yep. I haven't really had an issue getting a patient to LTAC quickly. The biggest issue is one of the major insurances wants 21 vent days prior to transfer if its just a failure to liberate issue... but that just becomes taking a knee and running out the clock.

Besides... that's why the case manager is a part of interdisciplinary rounds.

Are you in a certificate of need state? Beds are hard to come by here.

 

[Siggy]

Are you in a certificate of need state? Beds are hard to come by here.

I honestly don't know what Florida is. However I know we refer out to at least 3 different LTACs (Select, Promise, Kindred).

 

[ScoutQ4]

I'm very curious about the role of ED-CCUs. I'm considering pursuing a CCM fellowship following residency with interests to primarily work soley in the ED following this training. I want to continue practicing emergency medicine but with more of a focus on the critically ill. The whole "upstairs care, downstairs" vibe, per say. Is this a reality? I also wonder if this is a "wasted" two extra years if my ultimate goal is to continue practicing in the ED.

 

[deleted547339]

I'm very curious about the role of ED-CCUs. I'm considering pursuing a CCM fellowship following residency with interests to primarily work soley in the ED following this training. I want to continue practicing emergency medicine but with more of a focus on the critically ill. The whole "upstairs care, downstairs" vibe, per say. Is this a reality? I also wonder if this is a "wasted" two extra years if my ultimate goal is to continue practicing in the ED.

It will likely be a wasted two years if you just want to practice EM. The only reason to do a CCM fellowship is if you want to attend in an ICU.

 

[SpacemanSpifff]

I'm very curious about the role of ED-CCUs. I'm considering pursuing a CCM fellowship following residency with interests to primarily work soley in the ED following this training. I want to continue practicing emergency medicine but with more of a focus on the critically ill. The whole "upstairs care, downstairs" vibe, per say. Is this a reality? I also wonder if this is a "wasted" two extra years if my ultimate goal is to continue practicing in the ED.

If your goal is to practice in the ED, it may not be worth your time.

 

[alpinism]

Despite my last post in reply to @citymd1234, I didn't start this thread to discuss the pros and cons of ED-ICUs or isolated resuscitation bays.

Rather, I was hoping posters could identify other hospitals where the critical care patients are separated from the general ED population and managed by EM or EM-CCM docs only focused on the critical care patients. I am particularly interested in these units that hire docs who don't have to take shifts in the "general ED".

@HopefulEMed identified Elmhurst as an example; adding to my list in the OP.

Anyone able to add some more sites?

HH

EMCrit has a list: ED Intensivist Roles

DRH has a full 5 bed ED-ICU now with a dedicated EM/CCM resident who runs the unit.

 

[gro2001]

Last I checked, we're not trained to take care of ICU patients for the first 24 hours of their hospital stay. That's actually well outside what I would consider our scope of practice. I'm sure the ER bills a ton for these services. Just another way to make doctors take on liability by forcing them to practice outside their scope of practice. All while the department/hospital makes out well financially.

I had a colleague salivate over EC3 at a conference to the brink of absurdity. For those ED/ICU trained folks that eat this stuff up, maybe consider that needing an ICU in the ED is a massive failure of your hospital system. And by promoting these "units" for your own academic record, you are just putting patients in danger.

You seem very confidently against these types of units. Have you worked in an ED with such a set up? Either in the role of staffing the critical care area, or of staffing the other areas?

 

[citymd1234]

Really? On what data or experience are you making this assertion?

Do you feel this way about Shock Trauma in Baltimore? How about the EC3 in Michigan?

I suspect you haven't worked much in one of these units, have little exposure to EM-CCM docs, and probably haven't managed enough critical care patients to make such a judgement -- nevermind accuse some of the leaders of emergency medicine of actively endangering patients for personal and professional advancement.

HH

Answer me this. Are there non-CCM trained ED physicians working in these units?

Also, leaders in EM generally have done nothing other than sell their colleagues and specialty down the river for personal and professional advancement. Not sure they deserve much credit.

 

[Hamhock]

Answer me this. Are there non-CCM trained ED physicians working in these units?

Yes.

Also, leaders in EM generally have done nothing other than sell their colleagues and specialty down the river for personal and professional advancement. Not sure they deserve much credit.

Whoa! What?!?

The leaders of EM have created the very specialty of EM against significant odds and resistance. Are you suggesting this move was to "sell their colleagues"?

I see you have only a few posts. And based on the content of 50% of your posts, I suspect you are not only new to this forum, but to emergency medicine.

May I suggest you gain some more experience and knowledge about EM and medicine in general before attacking those who came before you with outlandish generalizations.

There are plenty of aspects of the current system of EM to direct your very apparent anger and grievence (ie CMGs). Perhaps after you learn more about the world of EM, you can funnel those feelings in actionable ways in an effort to improve the system.

HH

 

[deleted547339]

Yes.



Whoa! What?!?

The leaders of EM have created the very specialty of EM against significant odds and resistance. Are you suggesting this move was to "sell their colleagues"?

I see you have only a few posts. And based on the content of 50% of your posts, I suspect you are not only new to this forum, but to emergency medicine.

May I suggest you gain some more experience and knowledge about EM and medicine in general before attacking those who came before you with outlandish generalizations.

There are plenty of aspects of the current system of EM to direct your very apparent anger and grievence (ie CMGs). Perhaps after you learn more about the world of EM, you can funnel those feelings in actionable ways in an effort to improve the system.

HH

How very level headed of you.

 

[citymd1234]

Yes.



Whoa! What?!?

The leaders of EM have created the very specialty of EM against significant odds and resistance. Are you suggesting this move was to "sell their colleagues"?

I see you have only a few posts. And based on the content of 50% of your posts, I suspect you are not only new to this forum, but to emergency medicine.

May I suggest you gain some more experience and knowledge about EM and medicine in general before attacking those who came before you with outlandish generalizations.

There are plenty of aspects of the current system of EM to direct your very apparent anger and grievence (ie CMGs). Perhaps after you learn more about the world of EM, you can funnel those feelings in actionable ways in an effort to improve the system.

HH

1) How is it safe to have non-CCM trained EM docs taking care of patients in an ICU that just happens to be located in the ED?

2) It is clear to me that you are part of the machinery that is emergency medicine "leadership". Likely an academic. I would assume you are a top member of the ACEP as well, maybe even on the board.

Have you ever read "The Rape of Emergency Medicine"? That goes on to this day with our "leaders" selling us short daily. I interact with my EM colleagues in the community around the country and this is the going sentiment. Not sure what utopia others live in.

 

[deleted547339]

1) How is it safe to have non-CCM trained EM docs taking care of patients in an ICU that just happens to be located in the ED?

2) It is clear to me that you are part of the machinery that is emergency medicine "leadership". Likely an academic. I would assume you are a top member of the ACEP as well, maybe even on the board.

Have you ever read "The Rape of Emergency Medicine"? That goes on to this day with our "leaders" selling us short daily. I interact with my EM colleagues in the community around the country and this is the going sentiment. Not sure what utopia others live in.

What is your ax to grind?

 

[gutonc]

What is your ax to grind?

The correct question is "which returned, previously banned troll are you?".

 

[deleted547339]

The correct question is "which returned, previously banned troll are you?".

Psai, is that you? Lol.

 

[gutonc]

Psai, is that you? Lol.

Nah...Psai, for all his (myriad) faults, at least didn't troll specialty forums.

 

[citymd1234]

The correct question is "which returned, previously banned troll are you?".

Not a troll. Just speak truth.

I still fail to see how having non-CCM trained physicians managing an ICU is optimal patient care. If everyone working in those bays is CCM trained then that's totally fine. But if not, which has been noted that it isn't, then how is that optimal?

If that question makes you think I'm a troll, perhaps the troll isn't me?? No ax to grind, just asking what I think should be an obvious question to any EM doc. Also a question any of us would ask if my family member was in an ED-ICU.

 

[TooMuchResearch]

Not a troll. Just speak truth.

I still fail to see how having non-CCM trained physicians managing an ICU is optimal patient care. If everyone working in those bays is CCM trained then that's totally fine. But if not, which has been noted that it isn't, then how is that optimal?

If that question makes you think I'm a troll, perhaps the troll isn't me?? No ax to grind, just asking what I think should be an obvious question to any EM doc. Also a question any of us would ask if my family member was in an ED-ICU.

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