A new model to mitigate boarding of critical ill and injured patients in an italian second level emergency department
Boarding of critically ill patients in the Emergency Department (ED) is an emerging problem and increases their morbidity and mortality. Many institutions have developed strategies to mitigate the impact of ED boarding. In Europe an intensive care unit (ICU) based model, called "ICU without walls" has become widespread. Our institution is a second-tier community hospital in Turin, Italy. We have developed a critical emergency medicine (CREM) Unit led by an anesthesiologist that manages critical patients in the ED. This work aims to assess whether the CREM Unit is an effective and efficient resource for mitigating the boarding of critical patients in our ED.
This is a retrospective observational study. We collected all patients assigned directly to the CREM Unit at arrival, from January 1st, 2019 to December 31th, 2021.
Boarding was defined as more than 6 hours in ED from arrival or time spent in ED after the decision to admit to ICU is made, whichever comes first. We calculated ED boarding time as the primary end-point and Simplified Acute Physiology Score (SAPS II) and the 28-day mortality as secondary outcomes.
Patients managed by the CREM unit were 127 in 2019, 181 in 2020, and 206 in 2021, with a clear upward trend, for a total of 514 patients (p<0.001). 295 were managed entirely by the CREM Unit and admitted to our hospital while 45 were transferred to other hospitals to complete treatment. Overall boarding rate was 13.9%. The median value of SAPS II for inpatients was 54. While the predicted mortality was 55.3%, the observed mortality was 36.8%.
Over the years, the number of patients assigned to the CREM Unit has steadily increased. These data suggest that the CREM Unit cares for a significant number of patients, has a well-defined role to keep limited boarding times for acute critical patients and is effective in providing care for critically ill patients, reducing mortality.
F. Urso (1), E. Boero (1), I. Suprina Petrovic (1).
1. Department of Anesthesia, Intensive care and critical emergency medicine, San Giovanni Bosco Hospital, Turin, Italy