Emergency Departments (EDs) are vital for providing immediate diagnostic and resuscitative care for a wide spectrum of critically ill patients around the clock. However, unlike Intensive Care Units (ICUs), EDs are not designed for prolonged critical care. When ICU beds are unavailable, EDs often become holding areas for critically ill patients needing extended monitoring and complex interventions. This situation, especially during peak hours with multiple ICU-level patients boarding in the ED, can strain resources and compromise the quality of critical care delivered, diverting attention from other patients needing emergency services. Even when ICU teams are officially responsible for boarding patients, their capacity for continuous bedside care in the ED is limited by their responsibilities to patients elsewhere in the hospital. This divided attention can lead to suboptimal care, particularly during the critical early hours of severe illness, potentially impacting patient outcomes negatively. Recognizing this critical challenge, the Stanford Emergency Critical Care Program (ECCP) was established in August 2017. Staffed by dual-board certified emergency intensivists, the ECCP provides dedicated specialty critical care to patients within the ED, irrespective of ICU bed availability, significantly enhancing patient care and offering unique training opportunities, including for nurses involved in critical care.
Targeted Patients for the ECCP and the Role of Nursing
The Stanford ECCP is strategically designed to benefit specific patient populations within the ED, each presenting unique critical care needs where specialized nursing plays a crucial role:
- ED Boarding ICU Patients: Patients held in the ED due to ICU bed shortages directly benefit from the ECCP’s dedicated critical care, ensuring they receive ICU-level attention while awaiting transfer. ECC nurses are integral in delivering this continuous care.
- Undifferentiated Critical Care Patients: For ED patients requiring critical care without an immediate clear ICU designation (e.g., medical, surgical, cardiac), the ECCP provides rapid assessment and tailored care pathways. ECC nurses are essential in the initial stabilization and diagnostic phases.
- Borderline Stability Patients: Patients whose condition falls between ward and ICU admission criteria receive focused evaluation and management within the ECCP, preventing potential deterioration. ECC nursing expertise is vital in monitoring these patients closely.
- High-Likelihood Stabilization Patients: Critically ill patients expected to stabilize with intensive short-term ED treatment (e.g., diabetic ketoacidosis) are managed within the ECCP, avoiding unnecessary ICU admissions. ECC nurses are key in delivering this intensive, time-sensitive care.
- Patients with Complex Goals of Care: For critically ill patients whose care goals may not align with ICU admission, the ECCP facilitates early, nuanced discussions and tailored care plans, respecting patient wishes and optimizing resource utilization. ECC nurses are crucial in providing compassionate care and supporting these sensitive conversations.
Program Description and Nursing Integration
Hours of Operation and Nursing Presence
The ECCP operates from 2:00 pm to midnight, Monday through Friday, including holidays. These hours are strategically aligned with peak ED volume and the typical influx of critically ill patients. Importantly, the program is supported by dedicated Emergency Critical Care Registered Nurses (ECC RNs) who provide 24/7 coverage. These specialized nurses, with dual ED/ICU expertise, are central to overseeing the care of critically ill patients in the ED around the clock, highlighting the program’s commitment to continuous, high-quality nursing care.
Providers: A Collaborative Physician-Nurse Model
All ECC physicians are board-certified in both Emergency Medicine (EM) and Critical Care Medicine (CCM). The program includes full-time and per diem faculty, fostering a robust team of experts. Crucially, ECC RNs are integral members of this interdisciplinary team. These nurses are not only highly skilled clinicians but also partners in delivering exceptional patient care. The close collaboration between ECC physicians and ECC nurses is a defining feature of the Stanford ECCP, emphasizing a team-based approach to critical care in the emergency setting. This collaborative model provides rich learning and professional growth opportunities for nurses seeking advanced critical care expertise.
Responsibilities: Shared Expertise in Patient Care and Training
During ECCP shifts, ECC physicians function as intensivists within the ED, providing immediate evaluation and specialized care for critically ill patients upon ED attending physician request. Beyond direct patient care, ECC physicians also evaluate newly admitted patients to the Medical ICU (MICU) in the evenings, regardless of their origin, supervise MICU procedures, and are available to assist with ICU emergencies. A significant responsibility of the ECCP team, encompassing both physicians and nurses, is providing support and education to trainees in both the ED and MICU. This commitment to education underscores the program’s role as a vital training ground for future generations of critical care professionals, including nurses who benefit from the expertise of the ECC RNs and the interdisciplinary learning environment.
Logistics in the ED and the Nursing Workflow
Terminology for Streamlined Care
To ensure clear communication and efficient workflow, the ECCP utilizes a tiered patient classification system:
- Level 1 Patients: ED patients with clear ICU admission needs, irrespective of initial management. These patients require immediate ICU-level nursing care and monitoring.
- Level 2 Patients: ED patients currently needing ICU-level care but likely to be downgraded to ward status within 6 hours (e.g., asthma exacerbation, DKA). These patients benefit from focused, intensive nursing care in the ED, potentially avoiding ICU admission.
- Consult-Only Patients: ED patients for whom intensivist consultation is requested, but the ECC physician determines ICU-level care is not immediately required. ECC nurses may still be involved in implementing recommended care plans and monitoring.
Workflow: Integrating Nursing Expertise at Every Stage
The ECCP workflow emphasizes a collaborative approach, starting with the primary ED team’s initial evaluation and resuscitation. The ED attending physician determines when to consult the ECCP. This respects the ED team’s autonomy and experience, crucial for maintaining physician satisfaction. Upon consultation request, the ECC physician promptly assesses the patient and categorizes them (Level 1, Level 2, or Consult-only). For Level 1 MICU patients with available ICU beds, the ECCP ensures a seamless care transition. For Level 1 patients without ICU beds, undifferentiated Level 1 patients, and all Level 2 patients, admission to the ECC service occurs directly within the ED, eliminating bed transfer delays. The ECC physician initiates orders and documents care comprehensively. Care for Level 1 and Level 2 patients (if not downgraded) transfers to the MICU team upon ICU bed availability or at midnight. Level 2 patients who stabilize are handed off to a ward team. Importantly, patient needs dictate bed requests, regardless of the 6-hour Level 2 timeframe. For Consult-only patients, recommendations are communicated to the ED team, facilitating timely patient disposition (Figure 1). Throughout this workflow, ECC nurses are actively involved in patient monitoring, intervention implementation, and communication, ensuring consistent, high-quality care.
Figure 1. Stanford ECCP workflow
Six Key Benefits of the ECCP: Elevating Patient Care and Professional Development
The Stanford ECCP delivers significant benefits across six core areas, enhancing patient care and offering unique professional development opportunities for both physicians and nurses:
Enhanced Quality of Care and Patient Safety:
Immediate and thorough evaluation by ECC attending physicians leads to prompt diagnostic testing, resuscitation, life-saving interventions, and adherence to quality measures, bridging any care gap between the ED and ICU. The dedicated ECC physician role allows for frequent re-evaluations, early detection of subtle changes, and timely interventions for decompensation. ECCP staff, including specialized nurses, accompany unstable patients during transport, ensuring safety. Close monitoring improves patient trajectory assessment and downgrading safety and timing. The ECCP also prioritizes addressing the emotional needs of critically ill patients and their families, providing holistic care. The ECC physician serves as a central communication hub, leveraging expertise in both ED and ICU environments to facilitate seamless communication among patients, families, ICU teams, ED teams, consultants, ward teams, and both ED and ECC nurses, enhancing care quality and safety. Timely and thorough ECC documentation further aids all providers in understanding the patient’s ED and ECC course.
Improved Educational Opportunities for Nurses and Medical Professionals:
The ECCP significantly enhances critical care education. While the original article focuses on EM residents and ICU residents/fellows, the presence of specialized ECC nurses within the program inherently creates valuable informal and formal learning opportunities for nurses in the ED. ECC nurses, with their dual ED/ICU expertise, serve as mentors and resources for other ED nurses, promoting best practices in critical care nursing. Furthermore, the collaborative environment within the ECCP, where nurses and physicians work side-by-side, fosters interprofessional learning and mutual respect. The ECCP model could also serve as a platform for developing formalized critical care training programs for nurses within the ED setting, leveraging the expertise of the ECC RNs and physicians.
Enhanced Research Opportunities in Emergency Critical Care Nursing:
The ECCP facilitates research focused on critically ill ED patients and the ED-ICU interface. This includes opportunities to study the impact of the ECCP model on patient outcomes and healthcare delivery. Furthermore, the ECCP creates a rich environment for research specific to emergency critical care nursing. ECC nurses are uniquely positioned to contribute to research on best nursing practices in the ED critical care setting, patient safety initiatives, and the impact of specialized nursing roles on patient outcomes. The program also facilitates the implementation of clinical trials requiring early enrollment of critically ill patients, offering further avenues for nursing research involvement.
Improved Departmental Throughput and Resource Allocation:
The ECCP directly improves throughput by enabling faster patient disposition. By managing Level 1 undifferentiated, Level 1 without ICU beds, and all Level 2 patients, including downstream handoffs, the ECCP allows the primary ED team to focus on other patients, improving overall ED flow. The ECCP’s strategy of managing Level 2 patients in the ED, even with available ICU beds, reduces unnecessary ICU admissions. Over 90% of Level 2 patients are successfully downgraded, preserving valuable ICU resources for patients with higher acuity needs. This efficient resource allocation not only benefits patient flow but also contributes to cost savings.
Desirable Cost Performance:
The ECCP’s staffing model is cost-effective, requiring no additional space, equipment, or ancillary staff. The operational cost is primarily the ECC faculty and ECC nursing staff, which is offset by generated revenue. Strategic staffing during peak hours optimizes cost performance, demonstrating a financially sustainable model for enhancing critical care in the ED.
Acknowledgement
The success of the Stanford ECCP is a testament to the dedication and collaborative spirit of many individuals. We acknowledge the foundational work of ECC nurses, Jason Nesbitt and Chris Cinkowski, and former EM-CCM fellows, Dr. Sara Crager and Dr. Julian Villar, who designed and piloted the program in 2016. The ECCP builds upon this pilot program, and their passion was instrumental in its creation. We also thank Dr. S.V. Mahadevan and Dr. Matt Strehlow for their leadership and mentorship during the planning and implementation phases. Grateful appreciation is extended to all ED and ICU colleagues for their understanding and support, essential during the program’s startup. Finally, we thank ECC faculty colleagues, Dr. Shawn Kaku, Dr. Chris Walker, Dr. Jenny Wilson, and Dr. Alfredo Urdaneta, as well as ECC nursing partners, Jim Mobley, Jennifer Kraft, Della Lau, and Claire Thomas. Special thanks to Dr. Jenny Wilson for her editorial assistance. The program’s success is a direct result of their dedication to patient care excellence, exceptional communication, and commitment to critical care education and research.
Tsuyoshi Mitarai, MD, FACEP
- Clinical Associate Professor, Director of Emergency Critical Care Program
- Assistant Director of Adult Emergency Medicine (Critical Care)
- Department of Emergency Medicine, Stanford University School of Medicine
