The provision of critical care in emergency departments at Canada.

INTRODUCTION: Critically ill patients are common in emergency medicine, and require expert care to maximize patient outcomes. However, little data is available on the provision of critical care in the ED. The goal of this study is to describe the management of critically ill patients in the ED via a survey of Canadian emergency physicians.
MATERIALS AND METHODS: A survey of attending physician members of CAEP was conducted by email. The survey was developed by the authors and internal validity was established prior to survey deployment. Data on physician demographics, hospital resources, use of invasive procedures, vasopressor/inotropic medications, length of stay in the ED and patient responsibility were assessed.
RESULTS: The survey response rate was 22.9%, with the majority of respondents possessing speciality training in EM (73.5%). Respondents indicated that critically ill patients were commonly managed in the ED, with 68.5% reporting >6 critically ill patients per month, and 12.4% indicating > 20 patients per month. Respondents indicated that the majority of critically ill patients remained in the ED for 1-4 hours (70%) after resuscitation, yet 18% remained in the ED for >5 hours. Patients with a "respiratory" etiology were the most common critically ill patient population reported, followed by "cardiovascular", "infectious" and "traumatic illness". Direct laryngoscopy was frequently performed (66.9%> 11 in the year prior to the survey) in the year prior to the survey, while other invasive procedures and vasopressor/inotropic medications were utilized less often. EM physicians were responsible for the management of critically ill patients in the ED, even after consultation to an inpatient service, and were often required to provided acute care to critically ill patients admitted to an ICU, yet remaining in the ED prior to transfer (20% reported > 50% of the time).
CONCLUSION: Our survey demonstrates that critically ill patients are common in Canadian ED's, and that EMP's are often responsible to provide care for prolonged period of time. In addition, the use of invasive procedures other then direct laryngoscopy was variable. Further research is warranted to determine the impact of delayed transfer and ED physician management of critically ill patients in the ED.

INTRODUCTION

Patients with a wide spectrum of acuity present to emergency departments (ED) in Canada, ranging from relatively minor in nature to life threatening illness.[12] Emergency physicians simultaneously manage the resuscitation of critically ill patients while balancing the needs of other patients in the ED. Unfortunately, data indicates that patient acuity in the ED is increasing and, combined with the lack of available acute care in-hospital beds, may result in critically ill patients remaining in the ED for extended periods of time prior to transfer.[3-10]

The care provided in the initial phase of critical illness dramatically impacts on their survival, with rapid diagnosis and stabilization improving both morbidity and mortality in this patient population.[11-14] Emergency physicians are often challenged to recognize, diagnose, and institute life-saving therapy in a simultaneous fashion. However, timely and expert resuscitation in the ED may be the most important care these patients receive in terms of impact on patient survival.[15-17] Alternatively, delayed resuscitation may allow progressive and irreversible physiologic instability, which results in increased organ dysfunction and mortality.

In addition to resuscitation and stabilization, emergency physicians may be charged with the provision of post-resuscitation care, as acute care in-patient beds are often unavailable in the current heath care environment.[7-9] This presents unique challenges to emergency physicians and other healthcare members, as some management principles in the post-resuscitation phase, including ventilation strategies, vasopressor use and invasive procedures may be beyond the training and skill set of many emergency physicians.

Despite this, little data is available on the provision of critical care in the ED. The objective of this study was to describe the management of critically ill patients in the ED via a survey of Canadian emergency physicians. Specifically, we sought to determine the frequency of critically ill patients in the ED; the length of ED stay; responsibility of critically ill patients in the ED; and the frequency of use of invasive procedures and vasopressor medications by emergency medicine (EM) physicians.

MATERIALS AND METHODS

Design and survey methods

We conducted an e-mail-based survey of all attending physician members of the Canadian Association of Emergency Physicians (CAEP). An invitation to participate in an electronic web- based survey (SurveyMonkey®) was distributed utilizing the CAEP official email list on 3 separate occasions over a 10 week period commencing in August of 2005. Residents, medical students and non-practicing physicians were not eligible for this survey, and any responses by one of these groups were removed prior to analysis. The survey was deployed in a blinded fashion to 1328 physician members of CAEP, and quality control mechanisms were in place to only allow respondents to complete the survey on a single occasion.

The study protocol was approved by the Capital Health Research Ethics Board, Queen Elizabeth II Health Sciences Center, Halifax, NS.

Survey instrument

The survey was developed through an iterative process among the investigative team, with input from other experts in EM, critical care medicine (CCM), and research methodology. We asked respondents to answer questions with reference to their primary ED practice over the year prior to the survey. Survey data included respondent demographic data, hospital resources availability, physician experience with various invasive procedures and vasopressor/inotropic medications, patient length of stay in the ED, and who was responsible for critically ill patients while in the ED. The frequency of use of invasive procedures and vasopressor/inotropic medications were categorized into “never”, “1-5,” “6-10,” “11-15,” “16-20,” and “>20” per year. The survey was piloted in a test/re-test fashion with 15 attending physician members of the Queen Elizabeth II, Department of Emergency Medicine.

Statistical analysis

Descriptive statistics was carried out using SPSS 15.0 statistical software (SPSS Inc) to describe the survey respondent population characteristics and institution characteristics. Descriptive statistics were used to determine percentages based on only questions answered by respondents. Unanswered questions were not included in the analysis of that question. Ranking of categories of critical illness and consultant assessments were calculated by the use of a weighted average (percent x rank).

RESULTS

The respondent rate for this survey was 22.9%. Physician demographic data reported by respondents is outlined in Table 1. The majority of respondents were less than 45 years of age (67.7%), and 73.5% were male. Most reported EM speciality training [79.7%, Certificant of the College of Family Physicians with Emergency Medicine specialization (CCFPEM) 49.5%, Fellow of the Royal College of Physicians and Surgeons of Canada with Emergency Medicine specialization (FRCPC) 27.9%, American Board of Emergency Medicine (ABEM) 2.0%, Pediatric Emergency Medicine specialization (PedsEM) 0.3%, and a median of 14.5 years since completion of their training. Respondents also reported that critically ill patients were common, with 44.9% indicating that they manage >11 critically ill patients per month.

Table 1

Physician demographic data

Table 2 summarizes the reported ED characteristics and hospital resources. The majority of physicians worked in an ED with a census of >40 000 patients per year (68.1%), and had an intensive care unit (ICU; 94.0%) and Coronary Care Unit (CCU; 73.2%) located in their hospital. Respiratory therapist coverage (24 hour/day, in-hospital coverage) was common (78.5%), as was the presence of an ED training program (49.7%).

Table 2

Respondent emergency department characteristics and hospital resources

The survey asked respondents to rank categories of critically ill patients which they had managed over the previous year in the ED [Table 3]. Patients with a “respiratory” etiology was the most common critically ill population in the ED, followed by those with “cardiovascular”, “infectious” and “trauma” illness.

Table 3

Categories of critically ill patients in the emergency department

The frequency of various invasive procedures and vasopressors/inotrope medications used by respondents in the year prior to the survey are outlined in Tables 4 and 5. Emergent airway management with direct laryngoscopy (DL) was reported being frequently performed (66.9% >11 DL per year; 31% reporting >20 DL per year), compared to other intubation procedures. Central venous cannulation (CVC) was performed less frequently (26.5-48.9% reported “never” inserting a CVC in either the internal jugular, subclavian, or femoral veins); with the femoral vein the most common site utilized when this procedure was performed. Similarly, arterial cannulation was reported as being infrequently performed by emergency physicians in our survey.

Table 4

Frequency of procedures performed in the last year, as reported

Table 5

Frequency of vasopressor/inotrope use in the last year, as reported

When asked about the frequency of vasopressor and inotropic use in the previous year, dopamine was the most commonly utilized vasopressor [Table 5]. However overall, vasopressor and inotropic medications were not reported as being frequently used. When asked about colloid administration in the ED, synthetic colloids (hydroxyethyl starch solutions) were reported as being more frequently used compared with albumin.

After consultation by the EM physician, critically ill patients were most commonly assessed by attending intensive care physicians, followed by ICU residents and clinical associates. [Table 6] Respondents indicated that most critically ill patients remained in the ED for 1-4 hours after resuscitation (75.1%), with 18.2% of respondents reporting that patients remain in the ED for >5 hours. EM physicians were responsible for patient care in the majority of cases, either solely (21.3%) or in combination with another service (49.8%). In addition, EM physicians frequently provided acute care to critically ill patients admitted to an ICU, yet remaining in the ED prior to transfer (20.5% >50% of the time).

Table 6

Consultation and beyond

DISCUSSION

We have found that Canadian emergency physicians provide a substantial amount of care to critically ill patients. Based on the data provided by our respondents the majority of these patients remain in the ED for 1-4 hours awaiting intensive care unit admission, with EM physicians often providing ongoing care after consultation. Respondents also indicated that some invasive procedures, such as direct laryngoscopy, were frequently performed in the past year, while others such as central venous and arterial catheters were utilized less often.

The management of critically ill patients is an integral part of emergency medicine and to some extent is viewed synonymously with the speciality. In contrast to most other specialties, resuscitation and stabilization of acute physiologic derangements in the face of little information is inherent in EM. Traditionally, other consultant services, such as CCM, assume responsibility for post-resuscitation care and expedite transfer of these patients to an intensive care unit rapidly from ED. However, ED overcrowding has impeded on the ability of this practice to continue.[781018]

In fact, little is known about the care of the critically ill provided in the ED in the current health care environment.[519-21] The mounting problem of ED overcrowding may result in critically ill patients remaining in the ED for an increased duration of time.[1822] Indeed, we have found that a substantial proportion of critically ill patients remain in the ED for >4 hours awaiting ICU admission (18.2%), and that EM physicians are responsible for their care either independently (21.3%) or in combination with a consultant in-patient service (49.8%). This may place both the patient and the ED staff in a difficult position, as ED's are infrequently resourced for the optimal care of patients for prolonged periods of time. In addition, physicians and nurses may not possess the required expertise in post-resuscitation care. Some studies have concluded that patients with delayed admission to the ICU from the ED are associated with poor outcomes.[182324]

Despite the location of resuscitation, critically ill patients often require the performance of invasive procedures and the use of vasopressors/inotropic medications to optimize patient outcomes.[1525] Specialists in EM and CCM share this knowledge base and skill set, yet little data exists of the use of invasive procedures in these two medical disciplines. Our survey suggests that relatively few Canadian EM physicians had performed invasive procedures or used vasopressor/inotropic mediations in the year prior to the survey. However, it is not possible to determine if the use of invasive procedures and/or vasopressor/inotropic medications was sub-optimal based on this survey. Regardless, it is somewhat surprising that respondents reported the use of relatively few of these management strategies given how common they reported managing critically patents. Further investigation in this area is warranted to clarify this issue.

The goal of this survey was to describe the frequency of critically ill patients in the ED, the length of ED stay, responsibility of critically ill patients in the ED, and the frequency of use of invasive procedures and vasopressor medications by EM physicians. As this patient population is becoming more common in the ED, and with ongoing reductions in access to inpatient beds, ED physicians will likely become increasingly responsible for the care of these patients for extended periods of time.[78] Strategies to improve both immediate resuscitation skills in addition to post-resuscitation management should be developed in an attempt to optimize patient outcomes. In addition, care pathways for the rapid transfer of critically ill patients from the ED to an ICU setting should be developed by all ED's by engaging hospital administrators and specialists in EM and CCM. Importantly, patient care needs were not evaluated by this survey, so we are unable to comment on the medical decisions in the care of critically ill patients in the ED by our respondents. It is possible that the provision of critical care indicated by our survey respondents were optimal, and that additional invasive procedures and vasopressor medications were not needed. However, based on comparative care provided in an ICU setting and in consideration with current evidence and clinical guidelines, it is possible that some patients did not receive care similar to the care they would have received had they been expediently admitted to an ICU. Indeed, current recommendations advocate the use of information which can only be obtained after invasive procedures are inserted, such as mixed venous oxygen saturation (SVO2).[26] Indeed, recommendations of resuscitation to physiologic endpoints that can only be obtained from invasive procedure related data is a pressing, although incompletely elucidated, strategy in the ED setting. We also did not assess any influence of EM physician billing, although it is possible that remuneration may play a role. Further research is warranted to determine the impact on critically ill patients of ED physician management and delayed transfer from the ED.

The limitations of this survey should be considered when interpreting our results. First, this survey was conducted in 2005, and therefore the responses may not reflect the current management of critically ill patients in Canada. In fact, it could be assumed that a similar survey performed in the present would yield differing results. However, our main findings of the frequency of critically ill patients in the ED, prolonged length of stay of these patients in the ED, and EM physicians sharing responsibly for post-resuscitation care is likely accurate and possibly underestimated when current health care pressures are considered. Nonetheless, we advocate caution in the interpretation of our results, and feel that a similar survey or other investigation is warranted to validate our findings. Secondly, this survey was not designed to determine the quality of the care provided by emergency physicians. At best, the use of invasive procedures and vasopressor/inotropic medications is a surrogate marker of optimal practices in the management of critically ill patients. Again, we caution readers, and support further research in this area. Thirdly, our response rate was lower than expected, at 22.9%. Despite our attempts to maximize survey response by distributing the survey multiple times, our response rate was likely affected by the close proximity of another EM survey, the timing of the survey during the summer season, and the use of an exclusive internet based survey.[27] It is possible that some Canadian Emergency Physicians did not receive the survey, or that the e-mail addresses that was obtained from the CAEP database was inaccurate, which may account for our response rate. We feel that the respondents of our survey appropriately reflect practicing EM in urban centers in Canada, although it is possible that rural based physicians are under-represented. Since this study was performed, strategies have been published to maximize survey responses, which should be considered in future surveys in this area.[28]

Despite the limitations of this survey, we report the first data available on the provision of critical care in Canadian ED. Based on our responses, EM plays a prominent role in the resuscitation of this patient population. Additional investigations on the impact of EM physicians on patient outcomes are warranted. Critical care should be viewed as a treatment paradigm, and should not be limited by geographic location. Indeed, future researchers may conclude that care in the ED is the most important determinate in the survival of the out-of-hospital critically ill.

CONCLUSION

We have found that critically ill patients are common in Canadian ED's, and remain under the care of emergency physician >4 hours while awaiting transfer to an ICU. In addition, emergent airway management was commonly performed by EM physicians, yet other invasive procedures and use of vasopressor/inotropic medications were not. Further research is warranted to determine the impact EM physician care on patient outcomes.