Best practices for critically ill patients boarding in the emergency department: A Delphi study

Boarding of critically ill patients in the emergency department is common and associated with worse outcomes due to delays in time-sensitive interventions. This study used a Delphi process to develop a checklist of best practices for managing these patients during this vulnerable period.

Study personnel recruited a representative Delphi panel of 18 intensivists who are board certified in emergency medicine and critical care. We used a structured literature review to identify candidate items for a best practices checklist. This included a PubMed search of English language articles from 2011 to 2021 using terms like "critical illness," "emergency ward," "ICU," and "boarding." We scrutinized existing best practice checklists and specialty society guidelines. Panel members rated interventions using a seven-point Likert scale via web-based surveys and submitted comments, which were visible to co-panelists in subsequent rounds. Consensus for inclusion was defined a priori as ≥80% of panelists rating the item 5-7 on the Likert scale.

An initial list of 92 candidate checklist items was evaluated by 18 expert panelists across three Delphi rounds, with response rates exceeding 85% in each round. The modified Delphi process identified 101 items that achieved consensus for inclusion in the final checklist. Consensus items addressed management of post-cardiac arrest syndrome, increased intracranial pressure, intracerebral hemorrhage, respiratory failure, and shock. Examples of highly rated items included vasopressor selection in shock, lung-protective ventilation strategies for mechanically ventilated patients, and protocolized sedation and analgesia after intubation. Additional consensus items addressed management of gastrointestinal hemorrhage, electrolyte imbalances, renal and liver failure, coagulopathy, endocrine abnormalities, infectious diseases, and considerations for devices and logistics.

A Delphi process identified 101 expert consensus items for a checklist designed to support the care of critically ill patients boarding in the ED. Future studies are needed to evaluate implementation and potential effects on care processes and patient outcomes.