ICU diagnoses associated with increased early emergency department downgrades by a novel emergency critical care program.

BACKGROUND: The Emergency Critical Care Program (ECCP) utilizes an ECC attending with dual board certification in Emergency Medicine and Critical Care Medicine providing longitudinal care for MICU patients in the ED after initial resuscitation by the ED team during ECCP hours (2 pm to midnight, weekdays). It is unclear which admission diagnoses of critically ill ED patients are most responsive to the ECCP regarding timely ED downgrades to mitigate ICU overcrowding.

METHODS: This single-center retrospective cohort study included adult ED patients with initial admission orders to the MICU or ECC service between 2015 and 2019. Our primary outcome was the proportion of patients who received a transfer order to a non-ICU service within six hours of their critical care admission order while still in the ED ("Early ED Downgrades"), stratified by admission diagnosis category and adjusted by illness severity. A difference-in-differences analysis compared the change in proportion of "Early ED Downgrades" between the preintervention period (2015-2017) and the intervention period (2017-2019) relative to non-ECCP hours.

RESULTS: Our cohort included 1882 patients (mean age 63 years, 53.2% male). The ECCP was associated with a 19.0% (95% CI, 13.0% - 25.0%) increase in severity-adjusted Early ED Downgrades. By diagnosis, significant increases were seen in Respiratory (22.9%; 95% CI, 11.0% - 34.9%), Sepsis (14.2%; 95% CI, 3.0% - 25.5%), and Renal (43.0%; 95% CI, 7.4% - 78.5%) categories. No increases in mortality or transfers to the MICU within 24 h of the downgrades were observed.

CONCLUSIONS: The ECCP significantly increased Early ED Downgrades, particularly for Respiratory, Sepsis and Renal diagnosis categories, optimizing ICU resources without compromising patient safety.