Goyal – Intensive Care Outside of the ICU

Dr. Munish Goyal is an Emergency Medicine trained Intensivist who has been a leader in resuscitation science over the past decade.  Dr. Goyal is returning to the University of Maryland where he did his fellowship at the Shock Trauma Center to discuss the importance of early, aggressive resuscitation and why he believes our current system needs to improve in order  to meet the rising demand for critical care outside of the traditional walls of the ICU.

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Written Summary by Dr. Nikki Naderi

Intensive Care Delivery Outside the ICU

• The number of patients being admitted to the intensive care unit (ICU) from the emergency department (ED) has significantly increased
  • In a study, between 2002-03 there were 2.79 million ICU admissions from the ED to the ICU and between 2008-09 the number increased to 4.14 million
  • Overall, the total number of ED visits increased by 18% during that time frame, but the number of ICU admissions increased by 48%
  • Nationwide 2.1% of ED patients are admitted to the ICU

Mortality Effects

• Multiple factors have been studied in patients with sepsis to understand their effect on mortality
  • Antibiotics delivery within 1 hour of presentation
    • If the patient is hypotensive, for every hour antibiotics are not given, mortality increases by 7.6%
    • This effect is not seen in non-hypotensive patients

• Colloid vs. Crystalloid: no difference in 28-day mortality with resuscitation with 4% albumin vs. crystalloids 

• MAP target: no difference in mortality when MAP goal was 65-70 vs. 80-85, normally hypertensive patients had decreased need for RRT with the higher MAP goal

• Length of time spent in the ED:
  • Retrospective cross-sectional study of project IMPACT: ICU mortality increased by 2% in patients whose ER length of stay (LOS) was 6 hours or greater before transfer to the ICU, in hospital mortality increased by 4%
  • In a study of blunt trauma patients, for those patients intubated in the ER, for each 1 hour stay in the ER the risk of pneumonia increased by 20%’

• Case volume: the number of cases seen, directly correlated with in patient mortality

Models Adapting to Increase in Volume of Critically Ill

• Increasing the focus on phase of critical illness over the patient’s physical location
• Improving the ED’s ability to manage critically ill patients
  • University of Michigan Model (EC3): Resuscitation rooms proximal to transitional ICU beds – paradigm shift away from traditional ED to ICU transfer model.
• Resuscitation Units – University of Maryland Critical Care Resuscitation Unit