(408) Escalating Care of Critically Ill ED-Boarded Patients: A Framework for Developing an ED-ICU

Introduction: Emergency department (ED) boarding, where admitted patients stay in the ED after hospital admission,1 is a growing concern. Singer et al found that patients boarded for less than 2 hours have a 2.5% in-hospital mortality rate, increasing to 4.5% after 12 hours.2 Despite this, there is limited focus on managing the critical care needs of this population beyond the initial 2 hours of boarding. To address this, ED-Intensive Care Units (ED-ICUs) have been established to provide earlier critical care access. However, there remains a need for further research to develop a comprehensive framework for implementing ED-ICUs effectively.

Methods: We implemented a four-tier approach to establish an ED-ICU at our center, focusing on: ED-boarding time statistics, financial considerations, logistical setup, and strategies to gain support from staff and corporate leaders. For ED-boarding statistics, a retrospective chart review was conducted of ICU admissions boarding in the ED at a large academic center from January 2016 to August 2023 and categorized boarding times accordingly. We also surveyed ED residents and attending physicians using a 5-point Likert scale to gauge interest in developing an ED-ICU. Data analysis was performed using Epic Slicer Dicer and managed in the RedCap database.

Results: Of 19,630 ICU patients who were boarded in the ED for more than 2 hours (94.6% of all boarded patients), 54.1% were in the 2-6-hour group, 32.1% in the 6-12-hour group, and 8.4% in the over 12-hour group. Thirty ED residents and attendings provided overwhelmingly positive feedback, indicating an ED-ICU would alleviate boarding issues (median Likert score 5/5) and relieve the strain on general ED providers balancing critically ill and non-critically ill patients (median Likert score 5/5). Based on this, we advocated for establishing an ED-ICU. This prompted further consideration of the remaining tiers for ED-ICU implementation.

Conclusions: Boarding critically ill patients in the ED is associated with poorer outcomes. While efforts have focused on mitigating boarding, there remains a need to extend ICU-driven care beyond the initial 2-hours of boarding. We proposed a novel ED-ICU at our center and advocated for establishing a comprehensive framework using a four-tiered approach to support its implementation.