How to Implement an Effective Critical Care Resuscitation Unit

University of Maryland Medical Center shares its recipe for critical care resuscitation unit success.

Critical care resuscitation units (CCRUs) can improve the transfer of critically ill patients from emergency departments to tertiary care hospitals, a recent research article indicates.

Critically ill patients are often transferred from a hospital when the facility lacks the capabilities at tertiary care centers. Transfers of trauma patients are well established, but transfers of critically ill, time-sensitive patients such as stroke patients who need clot retrieval can be impromptu and fragmented. Critically ill emergency department (ED) patients who do not receive timely treatment tend to have negative outcomes.

To rise to this challenge, University of Maryland Medical Center established a CCRU at its R Adams Cowley Shock Trauma Center. The recent research article, which was published in The Journal of Emergency Medicine, examined the impact of the CCRU in its first year—July 2013 to June 2014.

A co-author of the research who is the medical director of the CCRU, Daniel Haase, MD, says there are several differences between a CCRU and a traditional intensive care unit (ICU).

"The CCRU focuses on the acute resuscitation and time-sensitive care of critically ill patients. Our physicians are primarily emergency physicians, and all of them have specialized fellowship training in critical care. Our advanced practice providers and nursing staff are all specially trained and highly experienced," Haase recently told HealthLeaders.

The CCRU has capabilities that are not found in many ICUs, he said.

"Unlike most ICUs at tertiary care, academic hospitals, we are equipped to take care of nearly every kind of patient requiring one of the myriad of mechanical support devices, including extracorporeal membrane oxygenation for respiratory or cardiac failure, extraventricular drain for brain injury, resuscitative endovascular balloon occlusion of the aorta for massive hemorrhage, transesophageal echocardiography for advanced cardiac imaging, and hemodynamic monitoring."

The CCRU also has an elaborate process to help manage the transfer of ED patients, the research article says.

"The initial phone call from the ED provider is to the University of Maryland ExpressCare, which manages all transfer requests from another hospital to our academic hospital. University of Maryland Medical Center specialists immediately organize a conference call with the referring physician, the CCRU attending physician, and UMMC specialty consulting attending simultaneously on the phone call. This allows a single high-level discussion of the patient's clinical condition and appropriateness for transfer," the research article's co-authors wrote.

"The CCRU team then determines the appropriate mode of transport and, based on clinical information, anticipates patient needs, including imaging studies, medication, infusions, vascular access, and monitoring. The CCRU attending also directs medical care during transport. As a result, it took less time for ED-transferred patients with time-sensitive diseases to receive diagnostic studies or to go to the OR compared with ED patients who were admitted to traditional ICUs," the researchers wrote.

CCRU impact data

The research examined data from 1,565 critically ill patients—644 who were transferred to the CCRU and 574 in a 2011 control group who were transferred to ICUs and 347 in a 2013 control group. The research generated three key data points.

• Transfers to the CCRU were faster than transfers to ICUs. The median time from a transfer request to arrival at the CCRU was 108 minutes, compared to 158 minutes for the 2011 control group and 185 minutes for the 2013 control group.
   
• After arrival at the CCRU or ICUs, CCRU patients had faster times to undergo surgical interventions in an operating room. The median time for CCRU patients to get into an OR was 220 minutes, compared to 429 minutes for the 2011 control group and 356 minutes for the 2013 control group.
   
• CCRU patients also had lower mortality compared to the ICU patients, with an odds ratio of 0.64.

"This study demonstrated that the CCRU expedited transfer of patients from referring EDs and provided earlier interventions. Patients admitted to the CCRU were associated with lower mortality likelihood compared with patients admitted to other traditional ICUs at our academic quaternary center," the research co-authors wrote.

Keys to CCRU success

The CCRU model at University of Maryland Medical Center will not fit every tertiary care facility, Haase said.

"We were created to focus on the transfer and resuscitation of critically ill patients from outside hospitals because we were seeing delays in transfer and lost admissions for patients that needed tertiary care quickly. Other 'ED-ICU' models exist to focus on boarding issues in the emergency department, while still others focus on prevention of ICU admission of emergency department patients," he said.

Several factors have contributed to the effectiveness of the University of Maryland Medical Center CCRU, Haase said.

"Our creation and success have been predicated on support from hospital administration and supporting specialty services—particularly surgical services and other critical care units—that recognized the need for and supported the idea of the CCRU. We depend on collaboration with our specialty services for training of our physicians, advanced practice providers, and nursing staff as well as the care of our patients. Success of a CCRU is dependent on far more than just the skilled providers that staff the CCRU," he said.