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An increasing volume of patients presenting for acute care can create a need for more ICU beds and intensivists and lead to longer wait times and boarding of critically ill patients in the emergency department (ED).¹ Data suggest that boarding of critically ill patients for more than 6 hours in the emergency department leads to poorer outcomes and increased mortality.^2,3 To address this issue, University of Michigan Health, part of Michigan Medicine, developed an ED-based ICU, the first of its kind, in its 1,000-bed adult hospital. The University of Michigan Emergency Critical Care Center (EC3) opened on February 16, 2015, as a 7,800-square-foot unit with five resuscitation or trauma bays and nine critical care patient rooms immediately adjacent to the main ED.4 The goal of EC3 is to deliver early, aggressive, evidence-based critical care to the most acutely ill and injured patients arriving to the ED.

Prior to opening EC3, all ED patients requiring ongoing critical care were evaluated and treated by the ED team in resuscitation bays or regular ED rooms until an inpatient ICU bed became available or the patient no longer required critical care and was admitted to a non-ICU level of care.

Studies of the EC3 initiative have found promising outcomes, including modest but significant decreases in mortality (14.1% reduction in adjusted 30-day mortality for ED patients in the post-EC3 cohort; number needed to treat [NNT]=220 patients to reduce 1 death at 30 days),⁵ reduced ICU utilization (12.9% reduction in the post-EC3 cohort; NNT=179 patients to reduce 1 ICU admission), quicker patient turnover, and shorter hospital stays.^5,6

The EC3 care team is comprised of emergency medicine (EM) physicians (with or without critical care fellowship training), house staff (primarily EM residents and critical care fellows), physician assistants (with critical care training), ED nurses (with additional ICU training), respiratory therapists, and pharmacists. The patient-to-nurse ratio is the same as most traditional inpatient ICUs at 2:1.⁷ EC3 has treated over 16,000 patients to date.

For this type of innovation to ultimately be successful, EC3 leadership recommend that care be evidenced-based and protocol-driven, yet the care team remain flexible and nimble enough to adapt to the constantly changing conditions inherent within the world of emergency medicine. Further, EC3 leadership emphasize that all care providers need to remain well-versed in the knowledge and skillsets needed to provide both EM-centric resuscitation and stabilization as well as the early and continuing critical care knowledge and skillsets more traditionally found in inpatient ICUs. Obtaining these knowledge and skills requires the innovating organization to provide continual training and evaluation and feedback to the care team. Additionally, since the initiative requires significant resources, it is important to keep thorough data pre- and post-implementation to demonstrate impact on patient-centric outcomes.

Checklists are used in many clinical settings to improve patient safety. This pediatric intensive care unit updated a static checklist, eSIMPLE, to a dynamic, decision-support enhanced checklist, eSIMPLER.