Integrated Emergency Department and General Intensive Care Unit Management on Health Outcomes
The integration of emergency department (ED) and general intensive care unit (ICU) management has been shown to significantly improve health outcomes for critically ill patients. This approach addresses the challenges faced by EDs, particularly in China, where overcrowding and the inability to deny patients access to medical resources have made it difficult to prioritize care for those in critical condition. By implementing a unified management strategy, hospitals can ensure that critically ill patients receive timely and consistent treatment, ultimately improving survival rates and overall care quality.
The ED is a critical component of the healthcare system, responsible for providing immediate medical treatment to patients in emergency or critical conditions. However, in China, the ED faces unique challenges. There are no limitations on the medical resources that ED patients can access, and healthcare providers are not allowed to deny treatment to anyone. This has led to severe overcrowding in EDs, making it difficult to distinguish between critically ill patients and those who require non-emergency care. This situation underscores the need for an effective triage system and a more integrated approach to patient management.
Critically ill patients require a team-based approach to care to ensure they receive sequential and consistent treatments. However, in many cases, emergency physicians are only responsible for patients during their shifts, which can lead to fragmented care. Previous research has demonstrated that critically ill patients benefit greatly when the management of the ED and ICU is effectively integrated, incorporating advanced theories and techniques of critical care medicine during the emergent stages of the disease. This integrated approach ensures that patients receive continuous care from the moment they enter the ED until they are stabilized or transferred to the ICU.
To address these issues, a five-level adult emergency triage standard was developed based on the “Emergency classification guidelines” issued by the National Health Commission of the People’s Republic of China. These guidelines combine 10 objective quantitative indicators, such as body temperature, systolic blood pressure, pulse rate, mean arterial pressure, shock index, respiration rate, peripheral oxygen saturation, peripheral blood glucose, state of consciousness, and pain score, with 48 common complaints or symptoms seen in priority general patients and 25 in trauma patients. Additionally, computer-aided patient triage software was developed to identify patients in need of emergency care. Emergency patients were triaged according to disease severity and classified as level I (fatal, red), level II (critical, orange), level III (emergency, yellow), level IV (not urgent, green), and level V (non-emergency, blue). Critically ill patients were defined as those with unstable vital signs classified as level I, requiring immediate treatment.
The primary outcomes of this integrated management approach included ED length of stay, cardiopulmonary resuscitation success rate, the resuscitation success rate in emergency and critical patients, time to emergency electrocardiogram (ECG) examination in patients with acute ST-segment elevation myocardial infarction (MI), time to antiplatelet drug administration, the rate of goal time compliance, and treatment success rate. Secondary outcomes included the average daily number of critically ill patients, the number of hospitalizations, the number of central venous catheterization cases, the average daily cost, and the outcomes of patients with acute ST-segment elevation MI. Time to emergency ECG examination was defined as the time from ED entry to completion of the ECG examination, and time to antiplatelet drug administration was defined as the time from ED entry to the administration of oral antiplatelet drugs.
The results of the integrated management model were significant. The resuscitation rate of critically ill patients increased from 73.58% (401 in 545) to 85.32% (1244 in 1458). The percentage of patients requiring resuscitation was higher in the observational group than in the control group: 6.60% (1458 in 22,017) vs. 5.40% (545 in 10,008). The ED length of stay decreased due to the rapid transfer of patients to the general ICU or specialty wards. The percentage of general ICU admissions increased sixfold to 0.48% (105 in 22,017) after the implementation of the integrated management model. Access for patients with key diseases was unimpeded in the observation group, the wait time was significantly shortened, and the medical quality of the treatment process and the total successful rescue rate were significantly improved by effectively standardizing emergency medical staffs’ clinical decision-making in the observation group.
The successful rescue rate of acute trauma patients and acute respiratory failure patients was significantly improved. Among the MI patients with acute ST-segment elevation, the times to ECG examination and administration of antiplatelet drugs were significantly reduced. The average door-to-balloon (DTB) time and the rate of reaching the standard of the DTB time were comparable. Critically ill patients received decisive treatments sooner, leading to an increased success rate of cardiopulmonary resuscitation and return of spontaneous circulation (ROSC). This progress is the result of several factors, including yearly training of staff in first aid and critical care medicine, and standardized rescue treatment. By developing reliable triage tools, standardizing care procedures for emergency patients, and conserving medical resources for critically ill patients, critically ill patients’ wait times were significantly shortened.
The rescue team shares some responsibilities with the Rapid Response team in critical care medicine and can effectively respond to all kinds of emergencies. In a previous study, emergency treatment and medical safety were improved by formulating standardized clinical management guidelines based on the best available evidence. Therefore, standardized emergency care procedures for key diseases were created, which significantly improved the successful rescue rate of acute trauma, acute respiratory failure, and acute ST-segment elevation MI patients, and the DTB time met the DTB Alliance requirements. However, the rate of emergency percutaneous coronary intervention (PCI) was lower than that reported in a previous study, which may be due to the lack of adequate healthcare human resources needed to implement an emergent PCI. Overall, the standardized care procedures for key diseases effectively simplified the intermediate link and effectively shortened the treatment duration. This ensured the continuity and standardization of treatment and provided quick, efficient, and safe medical services.
Through triaging, most critically ill patients can be screened, and treatment priority can be fairly determined. However, some emergency patients are not well informed about their condition or are dishonest and misreport their main symptoms or complaints, leading to over-triage or under-triage. Undoubtedly, standardized training can help improve the comprehensive first aid skills of emergency physicians. Unfortunately, not every emergency physician is willing to engage in this continued education outside of work. The learning process is long and boring and may dissuade physicians from completing the training. Ensuring this training is completed requires the active coordination of the management department as well as policies, job qualifications, and income distributions that promote emergency physicians to actively engage in learning. In addition, the implementation of the intervention also requires emergency patients to be compliant with reasonable requests from medical staff. Some patients may be reluctant to cooperate for various reasons, which may lead to inadequate intervention. This can be circumvented through continuous health education that is coordinated by the management department.
In conclusion, the integration of ED and general ICU management has proven to be an effective strategy for improving health outcomes for critically ill patients. By developing reliable triage tools, standardizing care procedures, and ensuring continuous training for emergency physicians, hospitals can significantly reduce wait times, improve the quality of care, and increase the successful rescue rate of critically ill patients. This integrated approach not only addresses the challenges faced by overcrowded EDs but also ensures that critically ill patients receive the timely and consistent care they need.
doi.org/10.1097/CM9.0000000000001794
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