6
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WINTER 2018
WINTER 2018
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7
Patients Benefit from Collaboration
between ICU and ED
Breaking down the barriers between two departments has a direct impact on improving the
quality of critical care.
By Steven Clark
S
tudies have shown that collaboration
between clinical teams from the
emergency department and ICU
can help counteract the silo effect of
specialists working in isolation by
breaking down communication barriers
and providing better cooperation. This
has been found to improve patient
outcomes, limit adverse events (e.g.
morbidity/mortality), decrease length of
stay and increase patient satisfaction.
With this in mind, ED and ICU teams at
SBH have been working collaboratively
over the past year to improve the quality
of critical care. In addition, a monthly
conference attended by residents in
both specialties has been established,
with patient cases discussed to improve
care and educate.
“There’s a fair amount of overlap in
the care of critically ill patients between
the emergency department and the ICU,
and our goal was to work together as
a team, and also to use our experience
to highlight cases where we think there
are opportunities to learn more and
improve care on both ends,” says
Dr. Jeffrey Lazar, vice chair and medical
director of Emergency Medicine.
“So the thought was to take advantage
of experts in both departments and
for us to meet on a monthly basis,
where we’d have both teams together
to provide overview of a particular
pathology or topic.”
Dr. Lazar worked with Dr. Raghu
Loganathan, divisional director,
Pulmonary and Critical Care Medicine,
to develop the program shortly after
both physicians arrived at SBH in 2015.
“I would say about 80 to 90 percent
of patients admitted to the critical
care areas enter the hospital through the
emergency room,” says Dr. Loganathan.
“The ICU team works very closely with
the ER team while the patient is still
in the emergency room. In addition
to establishing resilient triage systems
where patients are referred in an
appropriate and timely manner, patients
are co-managed with the emergency
room physicians where there is a very
close integration of services in terms
of how care is rendered. We strongly
believe in the concept of ‘Critical Care
without Walls.’”
At these conferences, attendings and
residents from IM and EM review the
management and treatment of common
cases, which recently have included
patients presenting with multiple organ
shutdowns as a result of sickle cell and
severe hypoglycemia crises.
“In a situation such as this, if we have
a patient who may require admission
to the ICU, we place a consult to a
member of the critical care team
requesting their involvement in the case,”
says Dr. Lazar. “There is a 30-minute
window where the critical care
doctor comes down to the emergency
department to evaluate the patient and
makes a rapid decision if they think the
patient warrants their involvement. Once
the patient is admitted to the ICU, the
ICU is managing that patient while they
are physically still in the ED, with the
ED team interacting with the care of that
patient. This emphasizes the need for
teamwork and optimal care. Medicine is
getting more complex, but especially for
critically ill patients. With these patients
there is less room for error and we really
want to make sure we’re giving them the
best, most seamless possible care from
the emergency room to the ICU.”
Drs. Lazar and Loganathan describe
the relationship between the two
departments as very healthy and
productive, breaking down barriers
between them, while providing a safety
net for patients. This apparently is not
the case at many hospitals.
The monthly ED-ICU interdisciplinary
conference is another example of the
close collaboration between the two
departments. “In other places I’ve
worked there’s been more of an M&M
approach, where if something went
wrong it’s ‘Why was a mistake made?’
as opposed to a ‘Hey, look, we did this
right. Let’s talk about why and how
we can continue to do things like
this,’” says Dr. Howard Greller, director,
Research and Medical Toxicology,
who mentors SBH’s emergency
medicine residents.
“This program works well because
it really complements things that we
don’t commonly encounter. From the
emergency medicine perspective, it
really gives us an opportunity to see how
our thought process and management
impacted the patient’s course going
forward. And, it’s valuable from the
ICU’s perspective to understand why a
certain path or therapeutic intervention
was started and get the perspective on
what they inherited from us.”
It simply makes plenty of sense, the
doctors agree. “You can make the
argument that on some days the ICU
attendings could be on the emergency
department or faculty lists because they
are present in the ED and involved in
the care,” says Dr. Lazar. “Recently, we
had a very busy night in the ED with
many very sick patients and the next
morning our attending who worked the
overnight wrote an email recognizing
the ICU attending who assisted in the
management of these patients. So, it’s
really like having another doctor in the
ED, but it’s a doctor from ICU providing
expert, critical care.
“For a lot of emergency medicine
doctors, it’s actually the most exciting
and important form of emergency
medicine. Personally, when I was
graduating residency, I had considered
doing a critical care fellowship after
emergency medicine residency. However,
at the time, they were not credentialing
emergency medicine physicians as ICU
attendings. That has since changed
and there is now an acknowledgement
for critical care fellowship emergency
medicine physicians. I think what we are
doing in this hospital is along the latest
wave in medicine in that there is such
an important role for critical care in the
field of emergency medicine.”
“I WOULD SAY ABOUT 80 TO 90 PERCENT OF PATIENTS
ADMITTED TO THE CRITICAL CARE AREAS ENTER THE
HOSPITAL THROUGH THE EMERGENCY ROOM.”
DOC TO DOC
