Novel critical care program speeds up transfer of critically ill surgical patients
BALTIMORE, USA: Critical surgical illnesses are often time-sensitive and patients affected require care at specialized centers. For critically injured trauma patients, trauma systems facilitate transport to and treatment in specialized centers. However, such formal systems do not exist for nontraumatic critical illness. Based on the model of its shock trauma center, a team of surgeons at the University of Maryland Medical Center (UMMC) in the U.S. has developed a program that effectively directs critically ill nontrauma patients to an appropriate treatment location.
As the population has aged and the nature of their illnesses has become more complex—often involving multiple diseases—the demand for referral centers such as UMMC to handle critically ill patients has increased. Community hospitals seek to transfer their most challenging cases to high-volume centers best equipped to provide urgent specialty care. “The demand for transfers has gone way up,” explained lead investigator Prof. Thomas Scalea, physician-in-chief at the R. Adams Cowley Shock Trauma Center at UMMC.
In July 2013, the hospital opened the Critical Care Resuscitation Unit (CCRU), a six-bed intensive care unit in the shock trauma center with the aim of increasing adult critical care transfers to UMMC and improving outcomes. The CCRU staff and subspecialists collaborate to rapidly evaluate and stabilize patients and then transfer them to the unit or operating room that will best serve their needs, Scalea explained.
“Time is a huge variable,” he stated. “There are a number of things—aortic dissection, acute vascular insufficiency, arguably stroke and sepsis—that are all time-related diseases. The clock starts ticking at the time the disease strikes. If you burn the time trying to get the patient to the hospital, you have less time to intervene. The more you can truncate the time, the better patients do.”
In the year after the CCRU opened, overall transfers increased by 64.5 percent, and those of critically ill surgical patients increased by 93.6 percent. For patients needing surgery, median arrival times at the CCRU decreased significantly, from 223 to 118 minutes, as did median time to surgery, from about 57 hours to about 18.5 hours. Likewise, the median length of hospital stay declined from 17 to 13 days, and even death rates declined from 16.5 percent to 14.6 percent.
Before implementing the program, UMMC had been losing admissions of critically ill patients because it did not have available beds in the hospital’s intensive care unit. “The referring hospitals, particularly if people are sick, do not want to wait for a bed; they want you to come right away and pick the patient up,” Scalea explained.
The challenge for UMMC was to develop a fast-intake strategy for critically ill patients that bypassed the emergency department. “Emergency departments are not good places to use for incoming critically ill transfers,” Scalea said. “It’s not what they do well.”
For its novel CCRU, the medical center recruited emergency physicians trained in critical care. Therefore, the CCRU is a hybrid of sorts, Scalea concluded, in that it brings together the rapid evaluation and stabilization of patients that an emergency department performs with the longitudinal care that an intensive care unit offers.
The study, titled “Critical Care Resuscitation Unit: An innovative solution to expedite transfer of patients with time-sensitive critical Illness,” was published online on Feb. 23 in the Journal of the American College of Surgeons.