Transferring patients with time-sensitive critical illness from community hospitals to academic medical centers is a common practice in American medicine. Not all hospitals are able to provide the highly specialized and complex critical care that tertiary or quaternary care facilities. A novel unit to care for critically ill patients significantly speeds access to specialized care, revealed a new study by physician scientists at the University of Maryland School of Medicine (UMSOM) and the University of Maryland Medical Center (UMMC).
While organized trauma systems are in place for transferring patients from the scene of an accident to a specialized trauma center, no formal systems have been in place for transferring non-trauma patients in need of often lifesaving critical care.
Patient access to specialty care in the academic medical center setting is largely dependent on the availability of intensive care unit (ICU) beds in the receiving hospital; without an open bed to receive the patient, wait times for transfers can mean the difference between life and death, or the necessity for the patient to go to another hospital. UMMC, recognizing these limitations, has seen success with a novel solution with the opening of the nation's first Critical Care Resuscitation Unit (CCRU), in July 2013.
Lead author Thomas M. Scalea, the Honorable Francis X. Kelly Distinguished Professor of Trauma Surgery, Director of the Program in Trauma at UMSOM and Physician-in-Chief of the R Adams Cowley Shock Trauma Center at UMMC, said, "When we built the CCRU, we envisioned a unit mid-way between an emergency department and intensive care unit, similar to our Trauma Resuscitation Unit but for non-trauma patients. It has been phenomenally successful in its intended mission to serve critically ill patients, and we believe it should serve as a model for other institutions."
Despite UMMC's operation of an inter-hospital call center for the transfer of critically ill patients for over 20 years, Dr. Scalea noted prior to the opening of the CCRU, patients needing immediate critical care were sometimes unable to be transferred if a specialized ICU bed was unavailable, or transfer times were longer than desired, delaying access to lifesaving diagnostics, specialty care and surgery.
The CCRU is a six-bed, short-stay ICU located within the Shock Trauma Critical Care Tower at UMMC. Because the unit must be able to provide services at any time across a wide spectrum of diseases, it is staffed 24/7 by physicians and nurses with broad and diverse critical care experience. Together with UMSOM sub-specialists, the CCRU team provides consultations to referring physicians.
Recommendations for patient management are provided even before the patient is transferred. Based on information provided by the referring physician, patient rooms are prepped in advance with the appropriate equipment and therapeutics needed for each arrival - a model historically used for incoming trauma patients and a departure from the average transfer procedure. After initial resuscitation and possible surgical care, patients are then moved to the appropriate sub-specialty ICU for ongoing care.
Co-author Lewis Rubinson, an Associate Professor of Medicine at UMSOM and Director of the CCRU, said, "We've discovered a new niche for resuscitation medicine. It's a paradigm change but easily adaptable for other academic medical centers. While we were fortunate to model the CCRU on a similar system already in place for our trauma patients, the fundamental principles are universal."
In addition to decreasing the time to arrival and increasing transfers, the CCRU also significantly decreased the percentage of lost admissions from 25.7% to 14% in this subset of transfer patients requiring critical care. Significantly more transfer patients required an operation during their hospital stay (46% vs. 31.1%) and a higher percentage were in the operating room within 12 hours of arriving (41% vs. 21.4%).
Senior author James O'Connor, Professor of Surgery at UMSOM and Critical Care Chief at UMMC, said, "We admitted nearly 1,000 additional transfer patients in the first year alone since opening the CCRU. Adding just six beds and borrowing practices we had honed in the Shock Trauma Center made our entire system more efficient."
Dr. Scalea said, "We built the CCRU to address the inefficiencies inherent in relying on a particular ICU to accept a transfer. ICUs are designed to manage patients for the entire course of their stay and they are highly specialized according to disease. The CCRU is for the immediate resuscitation, evaluation and disposition of all transfer patients. That is only part of what an ICU can do, but it's the only thing the CCRU does."
The authors are hopeful that continued research will produce definitive data showing that the CCRU lowers mortality for patients. Previous studies have shown that getting patients to the hospital faster improves outcomes, and data in this study did show a trend towards lower mortality, though not statistically significant. Of note, patients who were transferred to the CCRU and required surgery had a significantly shorter length of stay (13 vs. 17 days), demonstrating the value of expedited stabilization in the CCRU and admission to the appropriate subspecialty care unit.
UMSOM Dean E. Albert Reece, the John Z. and Akiko Bowers Distinguished Professor at UMSOM and Vice President of Medical Affairs at the University of Maryland, said, "This is a major advance in clinical science akin to a fundamental discovery. It is exciting to see another example of our faculty's commitment to discovery-based medicine."