Comparison of Emergency Department Boarders Managed by a Critical Care Consult Service versus Standard Care

Emergency department (ED) boarding of critically ill patients awaiting intensive care unit (ICU) admission has been associated with delays in time-sensitive interventions, prolonged lengths of stay (LOS), increased crowding, and higher incidence of morbidity and mortality. To address this, our institution implemented an ED critical care consult team in 2020 and established a resuscitation and emergency critical care fellowship in 2022. The critical care consult team, staffed by emergency physicians with additional resuscitation or critical care training, provides consultative support for resuscitations and the management of boarding critically ill patients 10 hours per day, with the dual goals of improving clinical care and optimizing patient flow. The primary outcome of this study was to evaluate the rate of patients downgraded from their initial admission level of care (ICU, Intermediate care) to a lesser intensity of care (intermediate, ward, home). Secondary outcomes included ED, ICU, and hospital LOS.

We conducted a retrospective chart review of all patients ≥ 18 years old with ICU or intermediate care admission orders placed between November 1-30, 2024. Patients were sequentially identified via the electronic health record, and clinical and quality assurance data were collected in a REDCap database.

During the study period, the ED critical care consult team was active on 73% of days, staffed primarily by resuscitation and emergency critical care fellows. Of 372 eligible patients, 18% (68/372) were managed by the critical care consult team after initial assessment by primary emergency physician staff, while 82% (304/372) served as controls and did not have involvement with the critical care consult team. Patients evaluated by the team had higher acuity, with 30.9% presenting with an Emergency Severity Index (ESI) score 1 compared to 4.6% in the control group. Despite this, the downgrade rate was significantly higher in the ED3CT cohort (29.4% vs 11.8%, p=0.001). No differences were observed in ED (0.62 days vs 0.60 days, P = .80), ICU (5.1 days vs. 5.2 days, P = .93), or hospital LOS (9.7 days vs 10.8 days, P = .68).

These findings suggest that ED-based critical care physicians, including fellows in training, may facilitate earlier identification of patients suitable for lower levels of care despite initially higher acuity. While there was no change in ED, ICU, and hospital length of stay, it is possible that this is related to systemic problems with hospital bed availability. The high rate of downgrades highlights the benefits of ED-based critical care physicians advancing care of critically ill patients boarding in the ED.