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  • The care or intervention provided during the ED

    2019-06-05

    The care or intervention provided during the ED stay for critically ill patients significantly impacts the progression of hospital outcomes. Svenson and colleagues reported that hiv protease inhibitor critically ill patients received critical care procedures commonly performed in the ED while waiting for ICU admission. A significant proportion of critical care and typical ICU procedures were performed in the ED for critically ill patients. For patients with acute cardiogenic pulmonary edema, hypoxia, and severe respiratory distress or failure, noninvasive positive pressure ventilation may not only improve outcomes but also help to avoid intubation and ICU admission. However, there still remains a high risk of clinical deterioration in patients with acute cardiovascular emergency, with few if any signs of improvement during their short stay in the ED. Having a continuously monitoring system and interventions for acute critically ill patients has become imperative, especially for patients with acute cardiovascular emergency. The main purpose for establishing an ICU in the ED (EICU) was to meet the need of quality care for critically ill patients, who might deteriorate rapidly or progressively in an overcrowded ED with prolonged boarding time. In addition, a lack of specialty ICU beds for acute critically ill patients, either from inpatient units or ED, would be associated with increased ED LOS and a delay of quality care. Thirdly, to improve acute critically ill patient outcome by reconstructing an observation unit into an EICU setting that were equipped by a monitoring and intervention system, and intensivists, including reasonable collaboration with other specialists to be responsible for the care of all critically ill patients while waiting admission. In a previous report on patients with cardiovascular diseases, the leading diagnoses of patients staying at an observation unit are described. Early implementation of intensive monitoring and therapies, such as short-term noninvasive positive pressure ventilation for ED patients with acute cardiogenic pulmonary edema may improve outcome. Our previous article demonstrated that cardiovascular emergency patients occupied approximately 13.3% of EICU admissions in a 1-year study period. However, the detailed clinical characteristics and outcomes of patients admission to the EICU as compared to those admissions to the coronary care unit (CCU) still require elucidation. Few articles have aimed to investigate the care model of ICU settings in ED, especially focusing on cardiovascular emergency patients. The hypothesis addressed by this study was that providing continuous EICU for patients with acute critical cardiovascular emergencies had a similar quality of care compared with those patients admitted to the CCU.
    Methods
    Results
    Discussion In Taiwan, overcrowding and prolonged ED LOS are very common in tertiary medical centers, especially those in larger public and university-affiliated hospitals, which is detrimental to ED patients\' quality of care. Undoubtedly, the admission priority for patients with acute cardiovascular emergencies was first in the CCU, but alternatively the EICU if no CCU bed was available in the hospital admission system. The average boarding time for those ED patients waiting for hospital admission was approximately 21 hours in our ED. To intensify care quality for relatively high-risk patients with a compulsory longer waiting and boarding time, we immediately set up the EICU for critical patients who cannot be admitted to special critical care. In this study, we highlighted that patients admitted to EICU were associated with more complicated clinical diagnosis, severity (evaluated by APACHE II score), and multiple comorbidities accompanied with patients being more elderly (Table 1). A recent study demonstrated that in a third of hospitals surveyed, care for critically ill cardiovascular patients is provided in a general ICU, and only 16% of the cardiac ICUs had an attending cardiologist of record with a critical care focus. An updated meta-analysis study demonstrated high-intensity staffing is associated with reduced ICU and hospital mortality in critically ill patients. However, within high-intensity staffing models, 24-hour in-hospital intensivist coverage did not reduce hospital or ICU mortality compared with day-time-only intensivist coverage. Our operative system and strategy of EICU would be more likely found in a general ICU that was staffed with 24-hour EPs in close collaboration with the cardiologist and can continuously provide both diagnostic studies and therapeutic interventions for multiple varieties and complexities patients.