Ordinarily when we bring a Journal Club post, it’s because we want to present some form of data that can make a difference to your clinical practice. This week it’s slightly different as we’ve picked up more of a concept paper on the use of resuscitative care units or RCUs.
I think this is on my mind as I’ve recently had shifts in the ED that have been extremely busy with critical care cases. In my typical 8-hour shift there will inevitably be an RSI, often more than one, arterial lines, central lines and other procedures in the resus room that blur the boundaries between the tribes and geographies of emergency and critical care. It’s made me reflect on how we deliver critical care in the ED and how in Virchester I believe we have an excellent relationship between the various teams. In large part this is because five of my consultant colleagues are dual trained in emergency medicine (EM) and intensive care medicine (ICM). Most of my ED consultant colleagues and senior trainees are comfortable in airway management and critical care interventions (but clearly know when to get help and are not scared or embarrassed to do so). It’s a team effort all and certainly not an area of practice for egos IMHO (remember that the airway belongs to the patient and not to any particular tribe or speciality). We are not unique in this across the UK and there’s another good example of interspeciality working in Edinburgh as described in this blog on teaching and maintaining RSI skills1,2.
Anyway, back to the paper. It’s an opinion piece published in the EMJ on the anatomy of RCUs. These are departments or in many cases ‘areas’ that sit outside of the main ICU and which are designed to provide short term critical care interventions to either avoid a full ICU admission and/or to specifically focus on the first few hours of critical care which are focused on resuscitation agility and diagnostics. The paper is open access on the EMJ3 site so follow the link and read it for yourself. You might notice a few familiar authors from the #FOAMed and #SMACC world.
Our department has a reputation for lots of patients requiring critical care and that often means that our resus room feels like an extension of the ICU/CCU. That leads to crowding and significant pressures on patient flow and staff workload which will be familiar to many readers. Whilst we believe that we offer great care there are very real concerns that critical care patients who have extended stays in the ED may have worse outcomes 4–6.
The RCUs described in the paper vary in size, scope and staffing but there are some common themes.
- ED led (usually with crit care fellowship training)
- Geographically separate from main ICU
- Close/adjacent to ED
- Admission from host ED and for transfer in from other EDs
- High level procedures e.g. ECMO, REBOA, VAD management
The authors suggest that by focusing the care of the critically ill patients on a smaller area and staffing model the outcomes may improve. No data is given to support this, but at face value there is some sense in this.
Is this a model for the UK?
The paper is largely US based and we must remember that this changes how we view the opinions. Staffing, training and finances are very different in the US and these do not easily translate to the UK. Most of the units described are staffed by critical care enthusiasts who have either undergone an addition critical care fellowship or are in the process of doing one. Nurses too often have additional critical care qualifications. This is not the case in the UK, where the engagement with critical care and resuscitation activity varies between departments and individuals. I suspect that in any UK model there would likely be a closer link with anaesthetics and critical care and that might be a concern to many emergency physicians who would be somewhat upset if those tribes came and took away the critically ill and injured aspects of our workload. My personal opinions on this are reasonably well known, in that I do think that the consultant emergency physician of the future should be competent in the resus room and my understanding is that the new college curriculum will emphasise this (though it’s not finalised yet so I don’t really know). It will also be interesting to see how the current cohort of EM trainees going through PHEM training will impact on the ability for EM consultants to maintain and develop their critical care skills. A lot of PHEM training involves the development and appraisal of critical care interventions and I cant see that skill set being constrained by where that individual happens to be working that day.
There is perhaps a paradox in this paper in that the authors quote Peter Safar7,8, one of the founding fathers of critical care who described it as a speciality without geography. In some health economies the opposite has happened with critical care being focused within the intensive care unit, whereas in the UK critical care outreach is now a common and effective tool to project critical care beyond the walls of the unit. Whether the development of a new geography in the guise of an RCU is a way forward remains to be seen, but if anyone wants to build one in Virchester then I’d almost certainly welcome it with open arms. Staffed by critical care and EM clinicians, based in the ED and offering high level care to patients combined with great training it might be the future.
Until then, we will cope in resus with a team of ED clinicians interested in critical care, and a team of critical care clinicians interested in working with EM.
My belief is that there probably is data out there from this group. A simple description of a novel concept is unlikely to change that many people no matter how good it may seem. We really need data and I hope that we might see that sometime soon. UPDATE – Cindy Hsu has been in touch to point out that there is data out there in this paper from JAMA showing better survival and decreased ICU usage9. I think that paper may be worth a review in itself. Headline figures from the paper are that implementation of an ED-based ICU was associated with reductions in risk-adjusted 30-day mortality among ED patients, from 2.13% to 1.83%, and ICU admissions, from 3.2% to 2.7% of all ED visits. One for a closer critical appraisal I think…..
- 1.Carley S. JC: ED RSI. St Emlyn’s. http://www.stemlynsblog.org/jc-ed-rsi-can-st-emlyns/. Published 2016. Accessed 2019.
- 2.Kerslake D, Oglesby A, Di R, et al. Tracheal intubation in an urban emergency department in Scotland: a prospective, observational study of 3738 intubations. Resuscitation. 2015;89:20-24. https://www.ncbi.nlm.nih.gov/pubmed/25613360.
- 3.Leibner E, Spiegel R, Hsu CH, et al. Anatomy of resuscitative care unit: expanding the borders of traditional intensive care units. Emerg Med J. April 2019:364-368. doi:10.1136/emermed-2019-208455
- 4.Cavallazzi R, Marik PE, Hirani A, Pachinburavan M, Vasu TS, Leiby BE. Association Between Time of Admission to the ICU and Mortality. Chest. July 2010:68-75. doi:10.1378/chest.09-3018
- 5.Cardoso LT, Grion CM, Matsuo T, et al. Impact of delayed admission to intensive care units on mortality of critically ill patients: a cohort study. Critical Care. 2011:R28. doi:10.1186/cc9975
- 6.Chalfin DB, Trzeciak S, Likourezos A, Baumann BM, Dellinger RP. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit*. Critical Care Medicine. June 2007:1477-1483. doi:10.1097/01.ccm.0000266585.74905.5a
- 7.Safar P, Grenvik A. Critical Care Medicine. Chest. May 1971:535-547. doi:10.1378/chest.59.5.535
- 8.Safar P. Critical care medicine—quo vadis? Crit Care Med. 1974;2(1):1-5. https://www.ncbi.nlm.nih.gov/pubmed/4815738.
- 9.Gunnerson KJ, Bassin BS, Havey RA, et al. Association of an Emergency Department–Based Intensive Care Unit With Survival and Inpatient Intensive Care Unit Admissions. JAMA Netw Open. July 2019:e197584. doi:10.1001/jamanetworkopen.2019.7584