ABSTRACT
Study Objectives: Delays in intensive care unit (ICU) admission for critically ill patients are associated with worse outcomes, but the effect of “boarding” during the COVID-19 pandemic has not been well characterized. This study describes the emergency department (ED)-based care for patients presenting with COVID-19-related acute hypoxemic respiratory failure (AHRF) to five hospitals in a large, academic health system during the initial surge in New York City, examining both respiratory modality choice and settings. For those managed with noninvasive respiratory support, we also aimed to explore the association between ED boarding time and patient morbidity and mortality. Methods: We conducted a retrospective cohort study of ED patients presenting from 3/1/2020 to 7/10/2020 with COVID-19-related AHRF and requiring ICU admission at any time during their hospitalization. Patient demographics, comorbidities, severity of illness (Mortality Probability Model III on admission), clinical course, including the use, settings (initial and changes), and duration of respiratory support modalities (ie, noninvasive ventilation [NIV], high flow nasal cannula [HFNC], invasive mechanical ventilation [IMV]), as well as hospital site, were collected through validated electronic query and standardized manual chart abstraction. AHRF severity was defined using a PaO2/FiO2 ratio (PF): 200-300 (mild), 100-199 (moderate), and <100 (severe). For patients without a PaO2, the PF was imputed using SpO2/FiO2 ratio using previously validated non-linear conversion. Boarding was defined as the time interval from ED request for admission to ED departure. The primary outcome was a composite outcome of ICU admission, intubation, or mortality within 48 hours of ED arrival. Descriptive analyses stratified by boarding duration and AHRF were completed. Multivariable logistic regression modelling was used to determine the association between ED boarding and the primary outcome. Results: A total of 679 ED patients with COVID-19 AHRF required ICU admission during the study period. They were managed with low flow oxygen only (261, 38.4%), or with NIV (120, 17.7%), HF (51, 7.5%), and/or IMV (99, 14.6%), with setting ranges detailed in Table 1. Of the patients with a known PF ratio (N=418), 110 (26.35%) had mild, 34 (5.0%) had moderate, and 274 (40.4%) had severe AHRF. Of these patients, 279 (41.1%) had a change documented to their settings, with increased likelihood of adjustments with longer boarding time (p<0.001) and higher AHRF severity (p<0.001). Median boarding duration across all site was 9.5 hours (IQR 5.3-16.9 hours) with site variation. AHRF severity and support modality were not associated with differences of boarding time (p = 0.77 and p=0.54). Controlling for age, sex, race, and severity of illness, boarding time was not associated with worse patient outcomes in 48 hours (OR 0.85, 95% CI 0.67-1.08, p=0.17) Conclusion: During the COVID-19 pandemic, critically ill patients presented to the ED and boarded for long periods of time, requiring prolonged ventilatory management. Despite the surge state and resource limitations, boarding times did not worsen post-ED outcomes for patients managed with non-invasive modalities. [Formula presented]
ABSTRACT
INTRODUCTION: The COVID-19 pandemic mandated rapid, flexible solutions to meet the anticipated surge in both patient acuity and volume. This paper describes one institution's Emergency Department innovation at the center of the COVID crisis, including the creation of a temporary ED-ICU and development of interdisciplinary COVID-specific care delivery models to care for critically ill patients. METHODS: Mount Sinai Hospital, an urban quaternary academic medical center, had an existing five-bed resuscitation area insufficiently resourced due to its size and lack of negative pressure (NP) rooms. The ED-based Observation Unit, which has four NP rooms, was deemed to be the ideal spot for a new ED-ICU. An interdisciplinary and intradepartmental task force was critical to this development. This task force worked to ensure the physical supplies, medications, staffing, and clinical protocols were appropriate to allow for the proper functioning of the ED-ICU. RESULTS: Within one week, the ED-based Observation Unit was quickly converted into a COVID-specific unit, split between a 14-bed stepdown unit and a 13-bed ED-ICU unit. The ED-ICU had all the functional and staffing capacities of an ICU, and was able to efficiently care for large numbers of critically ill patients. All critically ill patients in the ED were treated in the ED-ICU. Further, all intubations and non-invasive ventilation were able to occur in the negative pressure rooms. CONCLUSIONS: The Mount Sinai Hospital Emergency Department rapidly adapted the delivery of care and treatment models to meet the challenges of the COVID-19 pandemic. An ED-ICU was rapidly built by converting the prior observation area (a 27-bed zone). A redesign of a new space in a large U.S. academic hospital often requires months, if not years, of planning and negotiations with the varying hospital interests involved. With the pressure of high COVID demand, this conversion was executed in approximately 1 week, from the initial decision to full activation. Moreover, the unit functioned during the peak of the NYC COVID-19 epidemic largely as envisioned and required surprisingly few space or workflow modifications mid-course. Its success was due to the hard work of the leadership team and front-line providers and the collaboration across the institution.