ED-ICU: What’s the point?

[CCM-MD]

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Paper in JAMA last week:

Association of an Emergency Department–Based ICU With Survival and Inpatient ICU Admissions

This cohort study compares 30-day mortality and inpatient intensive care unit (ICU) admissions before and after the implementation of a novel emergency department–based ICU.

jamanetwork.com

So, the whole point of the ED-ICU is to improve the care of patients that cannot get a bed in an actual ICU. What I fail to understand is, why spend money building an “ED-ICU” when you could spend the same money building more ICU beds? Is it for some reason cheaper to build an ICU in the ED? Though, I don’t see why that would be the case.

What’s the point?

 

[DrGasPasser]

Paper in JAMA last week:

Association of an Emergency Department–Based ICU With Survival and Inpatient ICU Admissions

This cohort study compares 30-day mortality and inpatient intensive care unit (ICU) admissions before and after the implementation of a novel emergency department–based ICU.

jamanetwork.com

So, the whole point of the ED-ICU is to improve the care of patients that cannot get a bed in an actual ICU. What I fail to understand is, why spend money building an “ED-ICU” when you could spend the same money building more ICU beds? Is it for some reason cheaper to build an ICU in the ED? Though, I don’t see why that would be the case.

What’s the point?

There is a cost savings from multiple angles for hospitals with high volumes and acuity. Michigan runs the EC3 as an out-patient extension of the ED which lowers the cost of care delivered to patients who can be admitted to the floor from the EC3 without ever setting foot in an in-patient ICU. An indirect positive effect on hospital revenue is the decrease in patients being admitted to the ICU from the ED is offset by increased volume of hospital inter-facility transfers; the total ICU admission rates for Michigan went up despite the EC3 absorbing a significant portion of the volume.

Finally, 1 % adjusted mortality reduction across the entire ED population is huge. They are basically saving a life every other day with a NNT roughly 300. We have restructured our entire health system’s approach to stroke and STEMI over the past 20 years at untold massive costs for nowhere close to the mortality impact across the populations with those conditions, let alone entire ED populations. The unspoken implication of these findings is that EP-Intensivist are very good at quickly implementing resuscitation. They deliver critical care services quickly and seem to do really well sorting through patients with undifferentiated shock. The ability to quickly tackle these undifferentiated patients and make them “floor worthy” (or even dischargable) in 9-12 is value added over a 24 hour stay in a MICU.

 

[CCM-MD]

Interesting. So patients in "EC3", are not technically admitted to the hospital and remain "outpatient" because it functions as an extension of the emergency department.

Where is the money saved though? You could make another ICU elsewhere in the hospital and do the same thing? Because the hospital is still paying for a nurse who has 2 patients, respiratory therapists, EM physicians ("with or without CCM training"), PAs, residents, pharmacists... the unit is fully staffed and all the equipment and medications that is required to care for these patients is still the same. Only big difference is that maybe the hospital isn't getting paid for it because guess insurance isn't paying for "ICU" care because the patient is in an extension of the ED and not physically in an ICU.

And I don't know if you can necessarily extrapolate the findings to EP-intensivists because the study mentioned that not all of these patients were cared for by physicians trained in critical care.

 

[DrGasPasser]

To the best of my knowledge, Michigan’s financial data on the EC3 has yet to be published. Thus, the cost of starting and running an EC3 might or might not be equal to adding an identical number of ICU beds elsewhere in the hospital. A lot of factors such as an institution’s existing physical plant, plans for growth, CONs, etc. can impact this cost analysis. Having listened to Dr. Gunnerson speak, I get the impression that Michigan was constrained for inpatient space, but the ED could foot it in their old peds ED making the start-up much more affordable. Daily cost savings comes from an ability to more rapidly turnover select populations of critically ill patients compared to other ICUs. Conditions like DKA, CHF, and undifferentiated shock are dispositioned to the floor faster from the EC3 than other ICU beds for a host of reasons. I suspect that efficient use of care protocols and proximity to advanced imaging play a roll. That makes sense to me as it can take an hour for a STAT CT in my SICU; the EC3 is 20 yards from the scanner.

To your point, I believe that Univ Maryland’s outfit is actually located on the top floor of Shock Trauma’s physical plant and accepts inter-facility critical care transfers. They are supposedly very pleased with the space which also relies on care protocols and rapid access to imaging for undifferentiated patients. So, each institution is a little unique in how they want to meet their institution’s critical care needs, and an EC3 is not right for everyone.

On a related note, Bill Barsan also told me that the EC3 was a game changer for Michigan’s domination of NIH and industry funding for the ED.

 

[jdh71]

Paper in JAMA last week:

Association of an Emergency Department–Based ICU With Survival and Inpatient ICU Admissions

This cohort study compares 30-day mortality and inpatient intensive care unit (ICU) admissions before and after the implementation of a novel emergency department–based ICU.

jamanetwork.com

So, the whole point of the ED-ICU is to improve the care of patients that cannot get a bed in an actual ICU. What I fail to understand is, why spend money building an “ED-ICU” when you could spend the same money building more ICU beds? Is it for some reason cheaper to build an ICU in the ED? Though, I don’t see why that would be the case.

What’s the point?

It gets the ball rolling on *certain* acutely presenting complaints that you can turn around pretty quick DKA and CHF without shock and needing C/BiPap like at a university hospital where you have to sell your first born to get a bed in the next 8-12 hours.

You would likely need to have the right kind of volume to make this thing work really well.

 

[CCM-MD]

It gets the ball rolling on *certain* acutely presenting complaints that you can turn around pretty quick DKA and CHF without shock and needing C/BiPap like at a university hospital where you have to sell your first born to get a bed in the next 8-12 hours.

You would likely need to have the right kind of volume to make this thing work really well.

I get what you are saying. But one could argue that if you had more "actual" ICU beds that perhaps getting a bed would become easier.

In Weingart terminology: maybe it would be less necessary to provide the "upstairs" care "downstairs" if you just made more "upstairs".

 

[CCM-MD]

Looking back on things... in residency we kind of had an ED-ICU because we often had MICU patients boarding in the ED for quite a while. We would keep the less sick DKA type patients in the ED and eventually get them admitted to the floor.

Perhaps the reason I don't understand the reasoning behind this is because in Fellowship we somehow always had ICU beds. In fact, it was a sometimes a giant pain in the ass to get patients out of the ICU because there weren't floor beds available!

 

[jdh71]

I get what you are saying. But one could argue that if you had more "actual" ICU beds that perhaps getting a bed would become easier.

In Weingart terminology: maybe it would be less necessary to provide the "upstairs" care "downstairs" if you just made more "upstairs".

Which is true. And the reason this stuff works nicely in a place like Michigan is likely the inertia getting a patient accepted and then physically admitted to the ICU especially in a teaching hospital.

 

[DrGasPasser]

There is a sentiment percolating around these ED resuscitation centers that traditional ICUs in America provide excellent longitudinal critical care over the long haul, but ED resuscitation centers do better at actual acute resuscitation - especially involving resuscitation of undifferentiated shock. Because of this, patients might be better off spending several hours (8-23) in a resuscitation center even if an ICU bed is available upstairs. I suspect this notion was born out of the era of EGDT and perpetuated by the proliferation of time-based resuscitative core measures for sepsis, stroke, etc.

This paper does not answer that question. However, I bet a study looking at this specific question is in the back of someone’s head...

 

[jdh71]

There is a sentiment percolating around these ED resuscitation centers that traditional ICUs in America provide excellent longitudinal critical care over the long haul, but ED resuscitation centers do better at actual acute resuscitation - especially involving resuscitation of undifferentiated shock. Because of this, patients might be better off spending several hours (8-23) in a resuscitation center even if an ICU bed is available upstairs. I suspect this notion was born out of the era of EGDT and perpetuated by the proliferation of time-based resuscitative core measures for sepsis, stroke, etc.

This paper does not answer that question. However, I bet a study looking at this specific question is in the back of someone’s head...

The problem with the likely eventual paper is that most ED and ICUs in America aren't in huge academic centers where this may be the case.

 

[DrGasPasser]

The problem with the likely eventual paper is that most ED and ICUs in America aren't in huge academic centers where this may be the case.

I’m not sure it’s a big problem since these large academic centers see a disproportionately high number and acuity of patients compared to their community brethren. I seem to recall that academic / tertiary centers represent roughly 10% of America’s ED’s but handle close to 30% of the volume. Acuity at these large centers is higher than in the community based on a number of criteria such as ICU admission rate, ISI score, etc. This trend will only accelerate as America continues shunting high acuity patients to these “Level 1/Comprehensive/etc.” centers.

For my own shop, I’m very interested in a model that bridges Michigan’s EC3 that accepts patients only through the ED and Maryland’s center that only accepts transfers. I’d like a hybrid multidisciplinary resuscitative ICU that can take patients from the ED, accept critical transfers, and even tackle our rapid response needs on the floor - a “Central Intensivist” model on steroids if you will. I suspect that CMS and private payers will soon grow wise to our practice of accepting every ED transfer to our ED no matter how stable or how worked-up the patient comes. Many of these patients could be accepted directly to an ICU bed, but instead go to the ED where another out-patient bill is generated (and the ED made more crowded) while we find the perfect resident to write their H&P.

 

[jdh71]

I’m not sure it’s a big problem since these large academic centers see a disproportionately high number and acuity of patients compared to their community brethren. I seem to recall that academic / tertiary centers represent roughly 10% of America’s ED’s but handle close to 30% of the volume. Acuity at these large centers is higher than in the community based on a number of criteria such as ICU admission rate, ISI score, etc. This trend will only accelerate as America continues shunting high acuity patients to these “Level 1/Comprehensive/etc.” centers.

For my own shop, I’m very interested in a model that bridges Michigan’s EC3 that accepts patients only through the ED and Maryland’s center that only accepts transfers. I’d like a hybrid multidisciplinary resuscitative ICU that can take patients from the ED, accept critical transfers, and even tackle our rapid response needs on the floor - a “Central Intensivist” model on steroids if you will. I suspect that CMS and private payers will soon grow wise to our practice of accepting every ED transfer to our ED no matter how stable or how worked-up the patient comes. Many of these patients could be accepted directly to an ICU bed, but instead go to the ED where another out-patient bill is generated (and the ED made more crowded) while we find the perfect resident to write their H&P.

Maybe my point wasn’t clear the way I said it. This may be a good model for academic centers where there have these long waits but there is no way to translate that out into community from a study of a place like a Michigan or Maryland. Other places like where I work would likely see no benefit from something like this.

 

[DrGasPasser]

Maybe my point wasn’t clear the way I said it. This may be a good model for academic centers where there have these long waits but there is no way to translate that out into community from a study of a place like a Michigan or Maryland. Other places like where I work would likely see no benefit from something like this.

I agree. The faculty at Michigan have said that an EC3 needs a particular volume and diversity of critically ill patients to be successful, and those factors are typically at major academic centers. From a financial standpoint, a key predictor of success seems to center around transfers - your facility needs to be a major regional referral center for the dollars to make sense. In Michigan’s case, the EC3 keeps enough moderate acuity patients out of the ICU so that those in-patient ICU beds can be given to much higher acuity transfers that will capture a mountain of downstream revenue. Maryland’s approach is to more directly target transfers making it easy for community facilities to offload their sickest patients which in terms gives Maryland that downstream revenue. I suppose in Maryland’s case it was much easier to create one multidisciplinary short-stay ICU with an acceptance mindset than try to change the culture of 10 different ICUs away from being a block to transfers.

Bottom line, healthcare in America is shifting away from hospital beds for floor patients; we will be sending those patients home. Increasingly, in-patient beds will be directed to step-down and ICU level care. An EC3 concept that fulfills early resuscitative roles and allows the sickest patients to better access a tertiary/quaternary system could be a financial winner for big institutions with big institutional barriers to access.

 

[jdh71]

I agree. The faculty at Michigan have said that an EC3 needs a particular volume and diversity of critically ill patients to be successful, and those factors are typically at major academic centers. From a financial standpoint, a key predictor of success seems to center around transfers - your facility needs to be a major regional referral center for the dollars to make sense. In Michigan’s case, the EC3 keeps enough moderate acuity patients out of the ICU so that those in-patient ICU beds can be given to much higher acuity transfers that will capture a mountain of downstream revenue. Maryland’s approach is to more directly target transfers making it easy for community facilities to offload their sickest patients which in terms gives Maryland that downstream revenue. I suppose in Maryland’s case it was much easier to create one multidisciplinary short-stay ICU with an acceptance mindset than try to change the culture of 10 different ICUs away from being a block to transfers.

Bottom line, healthcare in America is shifting away from hospital beds for floor patients; we will be sending those patients home. Increasingly, in-patient beds will be directed to step-down and ICU level care. An EC3 concept that fulfills early resuscitative roles and allows the sickest patients to better access a tertiary/quaternary system could be a financial winner for big institutions with big institutional barriers to access.

Though I’m not convinced there is that much of a shift away from floor patients. Much of the acute illness coming into the hospital is coming within the context of multiple other chronic comorbid conditions that themselves may even be in a state of deviation from baseline and they need to be watched while initiating their initial treatments for signs of further decompensation either in the area being treated or one of their comorbid conditions. 2-3 days is often what you need.

I would agree that LONG hospital admits are going away if that was more of what you meant.

 

[CCM-MD]

I have a hard time accepting the trend of decreasing floor admissions when every ED I go to is so full of patients waiting for beds that the hallways have become full of patients and theres barely any space to walk sometimes.

I have read somewhere that there is a trend in an increasing number of ICU beds vs total hospital beds in general. I am sure that is driven by financial reasons... because hospitals probably profit more from an ICU bed than a floor bed.

 

[DrGasPasser]

I have a hard time accepting the trend of decreasing floor admissions when every ED I go to is so full of patients waiting for beds that the hallways have become full of patients and theres barely any space to walk sometimes.

I have read somewhere that there is a trend in an increasing number of ICU beds vs total hospital beds in general. I am sure that is driven by financial reasons... because hospitals probably profit more from an ICU bed than a floor bed.

Hospital bed number in the U.S.| Statista

Trends indicate that the overall number of hospital beds in the U.S.

www.statista.com

The total number of hospital beds decreased by 35% between 1975 and 2012 (1.5M to 950K). This happened despite the population growing and becoming older/sicker. From 2012-2017 the overall number of beds stabilized with a continued trend away from med-surg beds and toward higher acuity ICU and step-down beds. LTCHs, SNFs, and home health have revolutionized what stays in the hospital over the past 30 years.

Hospitals that cannot learn to provide routine floor care in an outpatient setting will wither and die under today’s reimbursement models.

As for hospital profits, high performing hospitals operate with 3-5% margins. Compare that to big tech that boasts 15-20% margins. Greedy hospitals and insurers are not the problem; large swaths of the population who enjoy government-imposed price controls (or don’t pay a cent for their care) are.

 

[NicMouse64]

Hospital bed number in the U.S.| Statista

Trends indicate that the overall number of hospital beds in the U.S.

www.statista.com

The total number of hospital beds decreased by 35% between 1975 and 2012 (1.5M to 950K). This happened despite the population growing and becoming older/sicker. From 2012-2017 the overall number of beds stabilized with a continued trend away from med-surg beds and toward higher acuity ICU and step-down beds. LTCHs, SNFs, and home health have revolutionized what stays in the hospital over the past 30 years.

Hospitals that cannot learn to provide routine floor care in an outpatient setting will wither and die under today’s reimbursement models.

As for hospital profits, high performing hospitals operate with 3-5% margins. Compare that to big tech that boasts 15-20% margins. Greedy hospitals and insurers are not the problem; large swaths of the population who enjoy government-imposed price controls (or don’t pay a cent for their care) are.

Source, Dr. Administrator?

 

[DrGasPasser]

Source, Dr. Administrator?

American Hospital Association. You can go to their website.

Or, the simplest of Google or PubMed searches will return essentially identical information from numerous sources.

I’m not an administrator. I am an attending with 14 years of experience in academics, military, and community having a passing awareness of what is going on around me. Anyone out of residency for more than a decade who hasn’t noticed the recent closure of hospitals (resulting in a decrease in hospital beds) is blind.

 

[Modanq]

To be honest not many ED residents are interested in critical care fellowship. Unless things have changes in the recent past. Its 2 years and when push comes to shove it doesn't really offer increased compensation for ED folks.

 

[DrGasPasser]

To be honest not many ED residents are interested in critical care fellowship. Unless things have changes in the recent past. Its 2 years and when push comes to shove it doesn't really offer increased compensation for ED folks.

I think that we are too early to gauge EM interest in CCM since pathways to certification are less than 5-10 years old. This is particularly true for anesthesia-based programs. Our program has seen an uptick in EM interest over the past 3 years.

 

[KeikoTanaka]

Just out of curiosity, and maybe no one can answer this question but:

Do EM/IM dual-residency trained physicians perform better with intensive care patients despite not having done an intensive care fellowship directly? Does the basic IM training perhaps just open their eyes to a bit more of chronic conditions and how to treat them in a critical patient?

 

[deleted547339]

Just out of curiosity, and maybe no one can answer this question but:

Do EM/IM dual-residency trained physicians perform better with intensive care patients despite not having done an intensive care fellowship directly? Does the basic IM training perhaps just open their eyes to a bit more of chronic conditions and how to treat them in a critical patient?

They don’t see more critically ill patients in a meaningful way. To practice in a high acuity icu, you’ll need to be CCm trained.

Does extra knowledge make you a better doctor? Almost certainly. Is it worth 2 years if your just going to practice EM? Definitely not.

 

[DrGasPasser]

Just out of curiosity, and maybe no one can answer this question but:

Do EM/IM dual-residency trained physicians perform better with intensive care patients despite not having done an intensive care fellowship directly? Does the basic IM training perhaps just open their eyes to a bit more of chronic conditions and how to treat them in a critical patient?

EM/IM trained physicians will get 2-3 more ICU months in residency and are therefore probably a little more comfortable managing critically ill patients in an ICU environment than their EM-only trained colleagues. Yes, there are still a number of mostly community hospitals with open ICUs managed by IM hospitalists, but those numbers are shrinking. If you want to be an EP-intensivist, I strongly suggest that you look into a CCM fellowship after EM residency. If you really want to build an academic pedigree (think Manny Rivers, Kyle Gunnerson, etc.), then look into a 6-year EM/IM/CC program like at Ford, MD, Long Island Jewish, etc.

 

[Rekt]

I think that we are too early to gauge EM interest in CCM since pathways to certification are less than 5-10 years old. This is particularly true for anesthesia-based programs. Our program has seen an uptick in EM interest over the past 3 years.

As a current EM resident, there's a surprising amount of interest in CCM, including me. I think it will only become more popular as time goes on, both from an interest in and because the EM market is getting very saturated. Also as people realize how pointless ultrasound/sim/EMS/wilderness fellowships are as well in comparison.

 

[DrGasPasser]

_0

As a current EM resident, there's a surprising amount of interest in CCM, including me. I think it will only become more popular as time goes on, both from an interest in and because the EM market is getting very saturated. Also as people realize how pointless ultrasound/sim/EMS/wilderness fellowships are as well in comparison.

Yep. I was told this week that 2 of our EM seniors are applying - one already has signed contract for a medicine CCM position and the other is applying for the 2020 anesthesia CCM SF Match. The themes coming from residents are similar - they choose EM as a speciality based on their clerkship and AI experience at academic medical centers that see a disproportionately high acuity compared to the larger EM community job market. They were also relatively sheltered from the non-patient care barriers to job satisfaction such as patient experience, dealing with difficult consultants, etc. which helps to solidify the false expectations. So, residency was a bit of a rude awakening when they realized on community months or moonlighting that much of emergency medicine is serving as a clinic of convenience for those who seek to have their routine issues addressed after 5PM.

In other words, students who wish the be a doctor to really sick people for most of their careers need to realize that the price of admission is a minimum of FIVE, not three, years of post-graduate training. That is a minimum of 5; most of us who do this **** for a living spent a good bit more doing research years in addition to fellowship. Three years gets you a nice paycheck in the community (for now) seeing a few sick people among an ocean of ankle sprains, back pain, and functional abdominal pain.

 

[Food]

I came here to say that there is an increasing amount of interest in CCM fellowship for EM grads. I'm a recent grad (2017) and just started a critical care fellowship after working 2 years. I probably would not have done EM if there was no board certification pathway to critical care, which would have been painful because I really love acute resuscitation. The fact is, no other specialty gets to do rapid, acute resuscitation for undifferentiated patients - this is the most fun and intellectually satisfying part about the specialty. There are more of us realizing that it's worth doing an extra 2 years to learn how to manage these people after their acute phase and follow their ICU course. There is definite burn-out in EM and I've found that there are two ways to fix it - diversifying what you do (tox, EMS, work in academics/teaching/research), or work hard early and save enough to build passive income streams so you don't have to work as much.

 

[KeikoTanaka]

I came here to say that there is an increasing amount of interest in CCM fellowship for EM grads. I'm a recent grad (2017) and just started a critical care fellowship after working 2 years. I probably would not have done EM if there was no board certification pathway to critical care, which would have been painful because I really love acute resuscitation. The fact is, no other specialty gets to do rapid, acute resuscitation for undifferentiated patients - this is the most fun and intellectually satisfying part about the specialty. There are more of us realizing that it's worth doing an extra 2 years to learn how to manage these people after their acute phase and follow their ICU course. There is definite burn-out in EM and I've found that there are two ways to fix it - diversifying what you do (tox, EMS, work in academics/teaching/research), or work hard early and save enough to build passive income streams so you don't have to work as much.

I'm very interested in pursuing FM/EM or IM/EM residencies for this purpose (Ideally FM/EM as I'm a DO and I feel like FM allows more use of OMM in OP setting) of diversifying future workload. Do you think it's reasonable to work part time as a FM doctor while moonlighting/per diem in the ED when time permits? How do you plan on working in the ICU alongside ED work?

 

[deleted547339]

I'm very interested in pursuing FM/EM or IM/EM residencies for this purpose (Ideally FM/EM as I'm a DO and I feel like FM allows more use of OMM in OP setting) of diversifying future workload. Do you think it's reasonable to work part time as a FM doctor while moonlighting/per diem in the ED when time permits? How do you plan on working in the ICU alongside ED work?

No. Keeping up an outpatient practice is a different beast than shift work.

 

[DrGasPasser]

I'm very interested in pursuing FM/EM or IM/EM residencies for this purpose (Ideally FM/EM as I'm a DO and I feel like FM allows more use of OMM in OP setting) of diversifying future workload. Do you think it's reasonable to work part time as a FM doctor while moonlighting/per diem in the ED when time permits? How do you plan on working in the ICU alongside ED work?

It varies. Some do mostly one or the other, others divide their time more evenly. The more even the divide, the harder it can be unless your every clear with your employer(s) on the expectations.

 

[DrGasPasser]

I came here to say that there is an increasing amount of interest in CCM fellowship for EM grads. I'm a recent grad (2017) and just started a critical care fellowship after working 2 years. I probably would not have done EM if there was no board certification pathway to critical care, which would have been painful because I really love acute resuscitation. The fact is, no other specialty gets to do rapid, acute resuscitation for undifferentiated patients - this is the most fun and intellectually satisfying part about the specialty. There are more of us realizing that it's worth doing an extra 2 years to learn how to manage these people after their acute phase and follow their ICU course. There is definite burn-out in EM and I've found that there are two ways to fix it - diversifying what you do (tox, EMS, work in academics/teaching/research), or work hard early and save enough to build passive income streams so you don't have to work as much.

Amen, Brother Ben. I split my time after residency between military, federal govt, and traditional civilian practice for 10+ years and found that I struggle to empathize with 50% of ED patients in civilian hospitals. Needless to say, that can be a problem. I’d literally rather check prostates on Guantanamo detainees for a living than work for a CMG at a civilian hospital. Academic EM was a fun gig, but I found myself being a dispo monkey trying to push my resident’s patients through a system rather than actually doing or thinking about actual patient care. It is also becoming increasingly difficult to get NIH funding to study aspects of critical illness as an ED physician without CCM training.

So far, CCM has been the best way for me to feel like I’m actually helping sick people instead of being part of the problem that is America’s current approach to ED care.

 

[KeikoTanaka]

It varies. Some do mostly one or the other, others divide their time more evenly. The more even the divide, the harder it can be unless your every clear with your employer(s) on the expectations.

I imagined doing OP PCP like 75% and the other 25% of the time

 

[BigRedBeta]

_0


Yep. I was told this week that 2 of our EM seniors are applying - one already has signed contract for a medicine CCM position and the other is applying for the 2020 anesthesia CCM SF Match. The themes coming from residents are similar - they choose EM as a speciality based on their clerkship and AI experience at academic medical centers that see a disproportionately high acuity compared to the larger EM community job market. They were also relatively sheltered from the non-patient care barriers to job satisfaction such as patient experience, dealing with difficult consultants, etc. which helps to solidify the false expectations. So, residency was a bit of a rude awakening when they realized on community months or moonlighting that much of emergency medicine is serving as a clinic of convenience for those who seek to have their routine issues addressed after 5PM.

In other words, students who wish the be a doctor to really sick people for most of their careers need to realize that the price of admission is a minimum of FIVE, not three, years of post-graduate training. That is a minimum of 5; most of us who do this **** for a living spent a good bit more doing research years in addition to fellowship. Three years gets you a nice paycheck in the community (for now) seeing a few sick people among an ocean of ankle sprains, back pain, and functional abdominal pain.

I see a similar dynamic playing out in the peds world, although kind of in the reverse way. Good peds residents who are capable of handling sick patients and would be good intensivists or neonatologists end up going Peds EM because it's mostly healthy kids with a few sick ones sprinkled in.

 

[DrGasPasser]

I see a similar dynamic playing out in the peds world, although kind of in the reverse way. Good peds residents who are capable of handling sick patients and would be good intensivists or neonatologists end up going Peds EM because it's mostly healthy kids with a few sick ones sprinkled in.

I think that pediatricians entertaining Peds EM need to think long and hard about their ability to deliver a customer service model of EM. I say that because well over 50% of our department’s complaints were generated in the Peds ED despite that section seeing less than 1/3 of our total Department’s volume. Simply put, parents complain about their kid’s doctor at an astonishingly high rate when there is no long-term relationship.

To put it in perspective, my last institution used the Patient Advocacy Reporting System (PARS), and I think that all of our Peds EM faculty were on performance improvement plans - including the medical director for the Peds ED. Listening to these faculty discuss their treatment at the hands of demanding parents and the institution was sobering. A couple said they would have never considered the speciality had they known - the things that you don’t see as a resident can bite you.

 

[engineeredout]

Just out of curiosity, and maybe no one can answer this question but:

Do EM/IM dual-residency trained physicians perform better with intensive care patients despite not having done an intensive care fellowship directly? Does the basic IM training perhaps just open their eyes to a bit more of chronic conditions and how to treat them in a critical patient?

Does EM/IM do better on the inpatient ICU side than EM trained? Maybe. My particular residency was structured to be very critical care heavy, and we had a great deal of independence. We were well prepared to transition into critical care fellowships, and this is evidenced by how many of us did decide to go into CCM, despite the fact that we were already pursuing extended residency programs.

Still, as good as my EM/IM training was (I firmly believe it was superior to many others), it is not a substitute for critical care fellowship training. Even if you get a position somewhere, acting as a half-intensivist is a disservice to your patients, and I suspect if you are really interested in critical care, you will not be satisfied without going the distance.

As my PD likes to say, "You are here to learn how to be an intensivist, not to be a hospitalist who can intubate"

 

[KeikoTanaka]

Does EM/IM do better on the inpatient ICU side than EM trained? Maybe. My particular residency was structured to be very critical care heavy, and we had a great deal of independence. We were well prepared to transition into critical care fellowships, and this is evidenced by how many of us did decide to go into CCM, despite the fact that we were already pursuing extended residency programs.

Still, as good as my EM/IM training was (I firmly believe it was superior to many others), it is not a substitute for critical care fellowship training. Even if you get a position somewhere, acting as a half-intensivist is a disservice to your patients, and I suspect if you are really interested in critical care, you will not be satisfied without going the distance.

As my PD likes to say, "You are here to learn how to be an intensivist, not to be a hospitalist who can intubate"

Can you speak as to what other graduates of your residency went on to do with a dual EM/IM certification?

My dream would be to work in EM for a while, and transition as I age to a primary care outpatient clinic, but I'm not sure how to go about maintaining skills in both. Has anyone else expressed interest in such a thing that you went through residency with?

Maybe it would be better to work OP and moonlight in EDs, but ik ED would make more $$ up front to pay off loans and for ultimately saving money for the transition to OP PCP work where the income will be slower coming in until well established.

 

[BigRedBeta]

I think that pediatricians entertaining Peds EM need to think long and hard about their ability to deliver a customer service model of EM. I say that because well over 50% of our department’s complaints were generated in the Peds ED despite that section seeing less than 1/3 of our total Department’s volume. Simply put, parents complain about their kid’s doctor at an astonishingly high rate when there is no long-term relationship.

To put it in perspective, my last institution used the Patient Advocacy Reporting System (PARS), and I think that all of our Peds EM faculty were on performance improvement plans - including the medical director for the Peds ED. Listening to these faculty discuss their treatment at the hands of demanding parents and the institution was sobering. A couple said they would have never considered the speciality had they known - the things that you don’t see as a resident can bite you.

Interesting numbers.

I wonder how being at a freestanding children's hospital changes those things - so often they get viewed as the Mecca of pediatric care in their communities and have a better reputation.

Also curious about the payer mix for your particular site. I know when I interviewed at Children's Medical Center Dallas, they made a lot out about how time spent at their Legacy Campus in Plano was pretty frustrating because of all the handholding of the uptight suburban parents that was required there.

 

[ShockIndex]

Interesting numbers.

I wonder how being at a freestanding children's hospital changes those things - so often they get viewed as the Mecca of pediatric care in their communities and have a better reputation.

Also curious about the payer mix for your particular site. I know when I interviewed at Children's Medical Center Dallas, they made a lot out about how time spent at their Legacy Campus in Plano was pretty frustrating because of all the handholding of the uptight suburban parents that was required there.

There are several factors working against the Peds-EM faculty. First, they see a ton of relatively low acuity patients and turn their beds over fairly quickly. Thus, a Peds-EM attending has about 25% more patient contacts (pts/hr) than their adult attending colleagues during a shift. This is especially true in the viral seasons. Second, our Peds EM faculty tend to have more clinical responsibilities and less protected time for research or education. This adds to the disproportionate patient contact. Keep in mind that PARS is all about raw numbers of complaints and is not adjusted for numbs of patients seen.

I’m not sure that payer mix is a huge factor as the Medicaid/CHIPs mothers seem to have our Patient Relations Office on speed dial.

As the cost of medical education goes up and reimbursement goes down, the academic community needs to take a long, hard look a the lengths of some of our training programs. I’d argue that peds EM could be taught to pediatricians and EPs in 4 total years of training, not 5 or 6.

 

[deleted547339]

There are several factors working against the Peds-EM faculty. First, they see a ton of relatively low acuity patients and turn their beds over fairly quickly. Thus, a Peds-EM attending has about 25% more patient contacts (pts/hr) than their adult attending colleagues during a shift. This is especially true in the viral seasons. Second, our Peds EM faculty tend to have more clinical responsibilities and less protected time for research or education. This adds to the disproportionate patient contact. Keep in mind that PARS is all about raw numbers of complaints and is not adjusted for numbs of patients seen.

I’m not sure that payer mix is a huge factor as the Medicaid/CHIPs mothers seem to have our Patient Relations Office on speed dial.

As the cost of medical education goes up and reimbursement goes down, the academic community needs to take a long, hard look a the lengths of some of our training programs. I’d argue that peds EM could be taught to pediatricians and EPs in 4 total years of training, not 5 or 6.

Lol. Our PGY2s are so much faster than the PEM attendings it’s comical. There is no way they see 25% more volume than our adult ED on a pph/faculty rate.

 

[ShockIndex]

Lol. Our PGY2s are so much faster than the PEM attendings it’s comical. There is no way they see 25% more volume than our adult ED on a pph/faculty rate.

Hmm, so your PGY2s (who must staff patients with an attending) are faster than your Peds-EM attendings who presumably have residents under them? If so, your shop has issues. Or, perhaps your EM residents are better than any I’ve ever heard of because ours see about 1.4 pph.

Our ped-EM attendings will see 4-5 pph during Winter months. They typically have a upper level resident, intern, +/- a fellow feeding them charts (fellows operate independently in their last year). Our adult attendings typically see 3/hr with boarding being a significant limiter. Our adult admission rate is 20%; peds is closer to 10%.

 

[deleted547339]

Hmm, so your PGY2s (who must staff patients with an attending) are faster than your Peds-EM attendings who presumably have residents under them? If so, your shop has issues. Or, perhaps your EM residents are better than any I’ve ever heard of because ours see about 1.4 pph.

Our ped-EM attendings will see 4-5 pph during Winter months. They typically have a upper level resident, intern, +/- a fellow feeding them charts (fellows operate independently in their last year). Our adult attendings typically see 3/hr with boarding being a significant limiter. Our adult admission rate is 20%; peds is closer to 10%.

Our PGY2s will see ~2pph. Our PEM attendings are peds->EM and slow as molasses. The attending is and always has been the rate limiting factor. Yes, the attending is getting sign out from >1 resident, but I don’t see how an academic attending can’t at least staff 2:1 for a resident comfortably.

 

[alpinism]

There are several factors working against the Peds-EM faculty. First, they see a ton of relatively low acuity patients and turn their beds over fairly quickly. Thus, a Peds-EM attending has about 25% more patient contacts (pts/hr) than their adult attending colleagues during a shift. This is especially true in the viral seasons. Second, our Peds EM faculty tend to have more clinical responsibilities and less protected time for research or education. This adds to the disproportionate patient contact. Keep in mind that PARS is all about raw numbers of complaints and is not adjusted for numbs of patients seen.

I’m not sure that payer mix is a huge factor as the Medicaid/CHIPs mothers seem to have our Patient Relations Office on speed dial.

As the cost of medical education goes up and reimbursement goes down, the academic community needs to take a long, hard look a the lengths of some of our training programs. I’d argue that peds EM could be taught to pediatricians and EPs in 4 total years of training, not 5 or 6.

Maybe in the community but at least in academics I had the opposite experience.

When I was a senior resident at our adult ED we'd commonly see 20 pts a shift while at our peds ED it was rare to even see 10 pts a shift.

The peds EM faculty by in large were very slow and inefficient and also loved to consult multiple specialists for even the simplest complaints.

 

[ShockIndex]

The peds EM faculty by in large were very slow and inefficient and also loved to consult multiple specialists for even the simplest complaints.

Our PGY2s will see ~2pph. Our PEM attendings are peds->EM and slow as molasses. The attending is and always has been the rate limiting factor. Yes, the attending is getting sign out from >1 resident, but I don’t see how an academic attending can’t at least staff 2:1 for a resident comfortably.

I feel fortunate that I’ve never encountered a shop where that would be tolerated in the faculty.

 

[BigRedBeta]

There are several factors working against the Peds-EM faculty. First, they see a ton of relatively low acuity patients and turn their beds over fairly quickly. Thus, a Peds-EM attending has about 25% more patient contacts (pts/hr) than their adult attending colleagues during a shift. This is especially true in the viral seasons. Second, our Peds EM faculty tend to have more clinical responsibilities and less protected time for research or education. This adds to the disproportionate patient contact. Keep in mind that PARS is all about raw numbers of complaints and is not adjusted for numbs of patients seen.

I’m not sure that payer mix is a huge factor as the Medicaid/CHIPs mothers seem to have our Patient Relations Office on speed dial.

As the cost of medical education goes up and reimbursement goes down, the academic community needs to take a long, hard look a the lengths of some of our training programs. I’d argue that peds EM could be taught to pediatricians and EPs in 4 total years of training, not 5 or 6.

I'm not surprised about your reaction to the payer mix, some places it doesn't make an iota of difference

Unfortunately the Peds ED exposure is so highly variable from the peds residencies that I think there is a significant portion of first year fellows who really need time to just learn to be competent clinically in the ED before they even get into the next level skills and expertise to make them useful attendings (ultrasound, trauma, resuscitation, how to manage an ED when it's busy...which based on the comments above they aren't even producing good enough graduates as it stands now). For example, at my Peds residency program, I did something like 56 twelve hour ED shifts as an intern. There was at least another 10-14 shifts as a second year and then a final month in third year with around 23ish shifts depending on how the weekends fell. I'd be surprised to find a residency program anywhere in the country that does that many shifts. Where I did medical school they only did 1 rotation in the second and third years, each with only 14 shifts.

As far as the overconsultation problem many of you are seeing, that's unfortunately a large byproduct of the quintenary referral centers that the top children's hospitals represent in 2019. The esoteric and rare diagnoses in the patient populations that these big name places support make it painfully unfair for the typical PEM faculty member or fellow to try to manage a significant chunk of their board without some expert guidance. Just impossible to know all the nuances. Most of the parents have been burned by their community ED's that they will preferentially drive 3+ hours with a sick kid in the car than go to any old ED (or they show up and say, "call children's!"). Unfortunately, if you're a PEM fellow and aren't being pushed towards independence on stuff that makes sense for you to manage, then it becomes very easy to just consult everyone else and have that be your practice style forever and ever. The lack of independence for trainees in Peds residencies is extremely problematic and getting worse. The "thought leaders" are all at these top children's hospitals where the peds residents come out unprepared to do bread and butter peds and so the thought is they need more training. So now there is a peds hospitalist fellowship that is trying to gain traction which is just asinine. But that's a whole other discussion

 

[jdh71]

Most of the parents have been burned by their community ED's that they will preferentially drive 3+ hours with a sick kid in the car than go to any old ED (or they show up and say, "call children's!").

very true

 

[engineeredout]

Can you speak as to what other graduates of your residency went on to do with a dual EM/IM certification?

My dream would be to work in EM for a while, and transition as I age to a primary care outpatient clinic, but I'm not sure how to go about maintaining skills in both. Has anyone else expressed interest in such a thing that you went through residency with?

Maybe it would be better to work OP and moonlight in EDs, but ik ED would make more $$ up front to pay off loans and for ultimately saving money for the transition to OP PCP work where the income will be slower coming in until well established.

Majority does EM only. Some do EM and hospitalist time, some do CCM fellowships. I have not known a single person who has done outpatient medicine. Its just not what we're well trained for, and nobody is interested in it anyway.

 

[KeikoTanaka]

Majority does EM only. Some do EM and hospitalist time, some do CCM fellowships. I have not known a single person who has done outpatient medicine. Its just not what we're well trained for, and nobody is interested in it anyway.

Sorry to keep asking questions, but can you speak as to how EM/Hospitalist work is split?

 

[stillers]

To the best of my knowledge, Michigan’s financial data on the EC3 has yet to be published. Thus, the cost of starting and running an EC3 might or might not be equal to adding an identical number of ICU beds elsewhere in the hospital. A lot of factors such as an institution’s existing physical plant, plans for growth, CONs, etc. can impact this cost analysis. Having listened to Dr. Gunnerson speak, I get the impression that Michigan was constrained for inpatient space, but the ED could foot it in their old peds ED making the start-up much more affordable. Daily cost savings comes from an ability to more rapidly turnover select populations of critically ill patients compared to other ICUs. Conditions like DKA, CHF, and undifferentiated shock are dispositioned to the floor faster from the EC3 than other ICU beds for a host of reasons. I suspect that efficient use of care protocols and proximity to advanced imaging play a roll. That makes sense to me as it can take an hour for a STAT CT in my SICU; the EC3 is 20 yards from the scanner.

To your point, I believe that Univ Maryland’s outfit is actually located on the top floor of Shock Trauma’s physical plant and accepts inter-facility critical care transfers. They are supposedly very pleased with the space which also relies on care protocols and rapid access to imaging for undifferentiated patients. So, each institution is a little unique in how they want to meet their institution’s critical care needs, and an EC3 is not right for everyone.

On a related note, Bill Barsan also told me that the EC3 was a game changer for Michigan’s domination of NIH and industry funding for the ED.

I did part of my training at Michigan, but don't currently work there.
Michigan does not have enough adult ICU beds for the size of their hospital and ER. This problem has been ongoing for years and is unlikely to be resolved soon. When I worked there, we would go to the ER from the ICU to see patients waiting for ICU meds to make sure they were getting proper resuscitation (sound ridiculous, I know). Due to the physical position of the hospital on a hill, they are unable to expand further since buliding a new children's hospital several years ago. They are also not a high-volume trauma center. Their ED-ICU may be helpful for their hospital, but not necessarily a model applicable to other hospitals, particularly in a busy urban setting.
The hospital where I currently work has many more ICU beds (medical and surgical) - dispoing a sick medical or trauma patient from the ED to ICU isn't a problem, and an ED-ICU wouldn't be needed here to send patients. Whether it would save money or improve patient outcomes here, I can't say.

 

[ShockIndex]

I did part of my training at Michigan, but don't currently work there.
Michigan does not have enough adult ICU beds for the size of their hospital and ER. This problem has been ongoing for years and is unlikely to be resolved soon. When I worked there, we would go to the ER from the ICU to see patients waiting for ICU meds to make sure they were getting proper resuscitation (sound ridiculous, I know). Due to the physical position of the hospital on a hill, they are unable to expand further since buliding a new children's hospital several years ago. They are also not a high-volume trauma center. Their ED-ICU may be helpful for their hospital, but not necessarily a model applicable to other hospitals, particularly in a busy urban setting.
The hospital where I currently work has many more ICU beds (medical and surgical) - dispoing a sick medical or trauma patient from the ED to ICU isn't a problem, and an ED-ICU wouldn't be needed here to send patients. Whether it would save money or improve patient outcomes here, I can't say.

Michigan broke ground on a new, $1 billion, 12-story inpatient tower 2 months ago. It will add 264 ICU-capable beds to the campus, but you are correct that it will not help soon since occupancy will not occur until late 2023 - long after I’m done with fellowship (and my wife is itching to get back to the South). It will be located in the grassy field in front of Frankel. Just so people don’t think that I’m sock puppeting, I switched my account from DrGasPasser.

Michigan Medicine will build new 12-story adult inpatient hospital | The University Record

 

[ShockIndex]

Sorry to keep asking questions, but can you speak as to how EM/Hospitalist work is split?

I tend to see it by month - one month in the ED, another on the wards. Some do 50:50, but others do more months in the ED vs wards. You can also do 1 or2 week blocks. There are no hard rules. People with grants or educational buy-down may have different breakdown to accommodate their scholarly activities and every place is different.

 

[stillers]

Michigan broke ground on a new, $1 billion, 12-story inpatient tower 2 months ago. It will add 264 ICU-capable beds to the campus, but you are correct that it will not help soon since occupancy will not occur until late 2023 - long after I’m done with fellowship (and my wife is itching to get back to the South). It will be located in the grassy field in front of Frankel. Just so people don’t think that I’m sock puppeting, I switched my account from DrGasPasser.

Michigan Medicine will build new 12-story adult inpatient hospital | The University Record

Thanks for the update. It's been several years since I was there. They really need more ICU beds so that will definitely help them.