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Is there a CRITER in your hospital Interaction between the ED and ICU

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I do not have an affiliation (financial or otherwise) with any commercial ... ER and ICU evolution: Brothers from different mothers? ... – PowerPoint PPT presentation

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Title: Is there a CRITER in your hospital Interaction between the ED and ICU


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Exploring the ER/ICU interface
  • Dennis Djogovic MD, FRCPC
  • Emergency Medicine and Critical Care
  • University of Alberta

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Disclosure
  • I do not have an affiliation (financial or
    otherwise) with any commercial organization that
    may have a direct or indirect connection to the
    content of my presentation.

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Objectives
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Objectives
  • History
  • Benefits of interactions
  • Shared problems
  • Shared solutions
  • Setting up your own CRITER team

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Life in the ER? Life in the ICU?
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ER and ICU evolution Brothers from different
mothers?
  • 1960s explosion of research in resuscitation
  • 1961 first full time ER group
  • ACEP
  • 1968 two week course in EM and CCM at Mass
    General
  • 1970 first EM residency U. Cincinatti

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  • 1970 SCCM founded by Dr. Peter Safar
    (anesthesia)
  • Saw the field of critical care as a seamless
    continuum from prehospital to ER to ICU
  • Liaison with EM should be an initial step
  • 1972 ACEP and SCCM formed Federation for
    Emergency and Critical Care Medicine (FECCM)
  • Later dissolved as both specialties underwent
    separate paths for specialty certification

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  • ABEM experienced challenges (from ABIM) to its
    efforts at board status
  • Bargaining chip July 1988
  • withdraw its application for added
    qualifications in Critical Care Medicine
  • ABEM granted primary board status Sept 21 1989
  • Two decades of effort, struggle, and compromise

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Current state of events for training and
credentials
  • USA
  • EM residents can enter critical care fellowships,
    but are not allowed to become board certified
  • 6 yr EM/IM/CCM certification guidelines
    approved
  • Europe
  • Those with EM certification are eligible for
    training and certification by the European
    Society of Intensive Care Medicine

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Current state of events for training and
credentials
  • Canada
  • critical care medicine 1986, first fellowship
    1990
  • 1993 Emergency medicine added as an entry
    specialty
  • Currently 25-35 dual certified ER/ICU physicians
    in Canada
  • Interest and acceptance continues to grow

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Training
  • Combination ER/ICU training
  • Vukmir R. Emergency medicine and critical care
    medicine the collaborative model. CJEM January
    2001 Vol 3, No. 1
  • Sinclair D. Subspecialization in emergency
    medicine Where do we go from here? editorial.
    Can J Emerg Med 2005 7 (5)344-6.
  • Huang et al. Critical Care Medicine Training and
    Certification for Emergency Physicians.  Annals
    of Emergency Medicine, Volume 46, Issue 3, Pages
    217-223.

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Current State of Events for Critically Ill
patients in EDs
  • ED overcrowding across Canada/US
  • AHA 2002
  • Average wait time for ICU bed 3 hrs
  • Wait time doubles (5.8hrs) when ED overcrowding
  • Provision of critical care in the ED is
    increasing (frequency and duration)

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What is the effect of having critical care
delivered in ED?
  • Studies are limited

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  • Statistically significant decrease in organ
    dysfunction and predicted mortality during ER
    stay
  • 5.9hr ED stay only represented 2 of total length
    of hospitalization

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  • We can reverse physiologic derangment in the ED
  • And we dont need a lot of time to achieve this
  • 11.1 avoidance of ICU admission for these
    patients
  • Preventative role in disease progression and ICU
    resource utilization

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What is the effect of having critical care
delivered in ED?
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What is the effect of having critical care
delivered in ED?
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  • SAEM 1999 ED should be given designation
    similar to trauma centers depending on levels of
    critical care treatment that can be provided

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Why is ICU care in the ED a problem?
  • Barrier to specialized inpatient care and 11
    nursing
  • Potential for medical error
  • Inability for ED MD to provide close care

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How to provide this care?
  • ICU centric
  • ED centric
  • Collaborative ED-ICU model
  • Use of protocols to facilitate uniformity of care

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Current areas of shared interest (whether we
like it or not)
  • Sepsis
  • Trauma
  • Diabetic ketoacidosis
  • toxicology
  • Bioterrorism/Disaster Medicine/Infectious
    Pandemic
  • Therapeutic hypothermia

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What Should ED-ICU interactions address?
Clinical
Education
Research
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Possible types of interactions
  • Protocols
  • Communication
  • Research collaboration
  • Shared residency educational objectives
  • Medical simulation
  • prehospital

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Protocols
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Protocols
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Protocols
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Protocols
  • For admission
  • For consultation
  • Lactategt4 in stable septic patient
  • Aduen et al, JAMA, 1994
  • Gryzboyski, CHEST, 1999

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Communication
  • Clinical
  • Staff to staff? Staff to resident??
  • Administration
  • Bed availability, incoming patients
  • Nursing
  • Shared skills, shared pools?

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Research Collaboration
  • Sepsis
  • resuscitation
  • Any time dependent therapy

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Educational Objectives
  • ER and Critical Care residencies are growing
  • Many shared educational objectives
  • Many shared clinical experts

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  • Shared educational objectives

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  • Shared procedures

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Medical Simulation
  • Acute Care and Events Simulation course
  • Yearly event for CCM trainees
  • Crisis Resource Management workshop
  • CAEP 2009
  • Hemodynamic Instability Course
  • CAEP 2009
  • Local experience

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Track record of ER/subspecialty interactions
  • ED/Cardiology
  • Numerous trials
  • Evolution of thrombolytic use
  • ED/Neurology
  • tPA for stroke
  • ED/General Surgery
  • Trauma teams

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Other areas we could potentially improve upon
  • Numerous
  • Do we wait for topic to be assigned, or do we
    choose for ourselves?

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Prehospital setting
  • Many patients are transferred directly from
    peripheral hospital to ICU
  • Prehospital transport period is a field of
    expertise of the ED MD
  • Participation of a consulting ED MD could be
    valuable in ensuring adequate preparation and
    safe transport during this dangerous period

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Patient handover
  • Formalized handover process from ED MD to ICU MD
    and from ED RN to ICU RN
  • Potential area of error or miscommunication
  • Standardized expectations

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Canadian Association of Emergency
Physicians -CAEP Critical Care Interest Group
  • Nationwide representation
  • Yearly meeting
  • Many with ER/ICU training

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CJEM200810(5)443-59
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Edmonton experience
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Electronic Clinical Practice Guideline for Severe
Sepsis/Septic Shock
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  • Edmontons CRIT/ER program
  • 2004
  • ER and ICU representatives
  • Residents and attending staff

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  • CRITER
  • Email educational newsletter
  • Many contributors
  • CRITER conference 2008
  • 80 rural ED MD attendance
  • Life threatening topics that present to the ER
  • CRITER 2009 booked

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How to get this to happen in your institution?
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How to start your own CRITER program
  • Commitment
  • Representation
  • Man on the ground
  • Identify common shared problem areas
  • Choose one topic to start collaboration
  • Plan, do, study, act

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In Summary
  • More patients are being shared between ED and ICU
  • Treatment protocols
  • Improve baseline care, improve time based
    therapies
  • Collaboration
  • how can it not be a good thing?

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Thank You! djogovic_at_ualberta.ca
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