The ICU (intensive care unit) is easily one of a hospital’s highest value resources. A scarcity of intensive care beds means patients require prioritization when demand exceeds supply.  As a result, there are frequent delays in admission to an ICU. Though it is accepted that such delays adversely impact patient outcomes, there has been little data on the relationship between bed availability in an ICU and processes of care for patients who develop sudden clinical deterioration – especially in the context of an emergency department (ED). Recently, studies seeking to address this gap have provided renewed momentum to such discussions. They have also dovetailed with other efforts, such as specialist training in critical care for emergency medicine students and residents. However, the area generating maximum interest is a dedicated ICU within an emergency department.
Balancing needs, finding beds
Critically ill patients are commonplace in emergency medicine. They require aggressive and timely care, but emergency medicine clinicians have to balance their needs with those of other patients in their facility. In addition, due to constraints in beds in the ICU, increasing numbers of critically ill patients require to be boarded for prolonged periods of time in the ED. Adding to this problem is a shortage of beds in EDs too.
One of the most vexed questions is whether ED physicians consider bed availability in an ICU as part of their triage decisions, thereby impacting, in a potentially profound manner, on patient outcomes and resource utilization in both the ED and ICU. In effect, does a high availability of ICU beds lead to a bias in admission of patients who are either too well or too ill to benefit ? On the other side, does a low availability then lead to denying admission to ED patients, who would otherwise have been accepted to the ICU?

ED-ICU interface demands attention
In 2013, a study by the George Washington University School of Public Health and Health Sciences in Washington, DC, found that the volume of ICU admissions from EDs in the US had increased sharply, by almost 50 percent, in the period 2001-2009.¹ During this period, another study found that the number of ICU beds across the country had increased only 15%, from 67,579 to 77,809.²
In other words, it is clear that ICU admissions from EDs have been increasing at a faster rate than ED visits. The George Washington University study found that though lengths of mean ED and hospital stays had not changed significantly, the mean ICU admission spends over 5 hours in the ED prior to transfer to an ICU bed. As a result, its authors concluded, there was a need for more emphasis on the ED-ICU interface and for critical care delivered in the ED.

Training emergency physicians in the ICU
The roots of this complex combination of challenges go back several decades. One good example is a time-based study, published in 1993 in the peer-reviewed journal ‘Critical Care Medicine’.³  The authors, from Houston, Texas-based Methodist Hospital’s Department of Emergency Services, noted that not only did critically ill patients “constitute an important proportion of emergency department practice”, but also needed treatment in the ED “for significant periods of time.”  One of the solutions they proposed was for emergency medicine practitioners to “receive training in the continuing management of critically ill patients.”
The above approach was also witnessed in Europe. In Belgium, for example, an official paper from 1995, titled ‘How to become an intensivist’, proposes that a candidate with an “agreement in Emergency medicine has to make another year of ICU formation.”⁴

Pathways remained unclear
In subsequent years, there was significant growth in emergency medicine residents pursuing critical care fellowship training, and a reconsideration of the role played by the ED in caring for the critically ill. Nevertheless, there still was a lack of clarity in ways to acquire advanced training in critical care for emergency medicine residents.
In December 2002, an article in ‘Current Opinion in Critical Care’ complained that although ED care for critically ill patients was shown to significantly impact mortality, “formal critical care training for emergency physicians” was still “limited.”⁵
Less than three years later, another peer-reviewed journal, ‘Annals of Emergency Medicine’, noted that in spite of growing demand for critical care services, most critical care medicine fellowships did not accept emergency medicine residents, “and those who do successfully complete a fellowship do not have access to a US certification examination in critical care medicine.”⁶  The authors proposed “expansion of the J-1 visa waiver program for foreign medical graduates,” but said the only sensible long-term approach was to strengthen the relationship between emergency medicine and critical care medicine.

Critical care medicine as emergency medicine sub-specialty
In the US, the Accreditation Council for Graduate Medical Education (ACGME) approved critical care medicine as a sub-specialty for emergency medicine physicians in 2011. The following year, the surgical critical care fellowship pathway was approved for emergency physicians interested in becoming board-eligible intensivists.
Currently, the most common training pathways are via combinations of critical care medicine with internal medicine and anaesthesiology, and alongside surgical critical care and neurocritical care. Career pathways for physicians trained in emergency and critical care medicine are also evolving, with options in both community and academic settings.

The role of professional societies
Leading professional societies in emergency medicine and critical care have set up focused sections on the interface between the two areas to stimulate interest as well as provide support to medical students and residents.
Examples from the US include the Emergency Medicine Residents’ Association (EMRA), whose Critical Care Division maintains a comprehensive database of training opportunities across the country,⁷  and regularly publishes alerts on key developments in critical care. Another interesting initiative is the Coalition for Critical Care Medicine in the Emergency Department (C3MED), which was set up in 2003 and hosts an active email discussion forum.⁸
Similar efforts have been undertaken by the American College of Emergency Physicians (ACEP),⁹  the Society of Critical Care Medicine (SCCM),¹⁰  the American Association of Emergency Medicine¹¹  and the Society for Academic Emergency Medicine (SAEM).¹²
In Europe, one of the best-known initiatives to harmonize convergence of the ED and the ICU is ISICEM, the International Symposium on Intensive Care and Emergency Medicine. This non-profit organization, headquartered in Brussels, was set up in 1980. It currently runs a series of eight annual events, covering different aspects of intensive care and emergency medicine. Over the years, participation has grown from about 200 to over 6,000 from more than 100 countries.
 
Impact of ED on ICU: US and European studies
There have also been concerted efforts to assess the impact of emergency department volume and boarding times on ICU admission and patient outcomes. Two recent studies have catalysed considerable new attention in the topic.
The first is a retrospective cohort study on critically-ill ED patients for whom a consult for medical ICU admission had been requested over a 21-month period. It was published in ‘Critical Care Medicine’ last year by a US-based team from the Icahn School of Medicine at Mount Sinai, New York, and titled ‘Effect of Emergency Department and ICU Occupancy on Admission Decisions and Outcomes for Critically Ill Patients’.
The authors conclude that ICU admission decisions for critically ill ED patients were affected by ICU bed availability. However, higher ED volume and other ICU occupancy did not play a role. They also found that prolonged ED boarding times were associated with worse patient outcomes, suggesting a need for improved throughput and targeted care for patients awaiting ICU admission.
In August 2019, ‘Critical Care Medicine’ published findings online from another study on this topic, this one by a Dutch team from  six University Medical Centres at Amsterdam, Groningen, Leiden, Nijmegen, Rotterdam and Utrecht, along with the country’s National Intensive Care Evaluation (NICE) foundation.¹³  The retrospective observational cohort study conducted a registry analysis of 14,788 patients from the six hospitals, and found an association between emergency department to ICU time greater than 2.4 hours and increased hospital mortality after ICU admission

Ad-hoc and hybrid models
At present, there are two approaches to the challenge of intensive care in the ED. The more common is to have an emergency physician intensivist working standard ED shifts, and lending expertise on an ad-hoc basis to critically ill patients. A recent development is a ‘hybrid’ model. This earmarks a dedicated area of the emergency department for ramping up care to critically ill patients, with a dedicated physician providing intensive care only to such patients, typically for periods longer than an hour.
Supporters of the hybrid model state that it is easier and less expensive to establish with extra costs involving only the dedicated ED-ICU physician.

The ED-ICU
One of the most watched developments in recent years in care for critically ill patients in an ED is the development of ED-ICUs (emergency department intensive care units).
Two such facilities in the US, Stony Brook Resuscitation and Acute Critical Care Unit (RACC) in New York and Emergency Critical Care Center (EC3) in Michigan are considered as being both ED-ICU pioneers and best-of-class references for the concept.
EC3 is considered to be among the world’s most advanced emergency critical care centres. It was opened in February 2015 and has five resuscitation trauma bays and nine patient rooms, located adjacent to the main adult emergency department.
Due to this reputation, the case for ED-ICUs was strengthened after a recent study by EC3 found convincing improvements in survival as well as reduced inpatient ICU admissions.¹⁴  In effect, an ED-ICU can improve care and survival rates for the entire emergency department population.¹⁵
The EC3 study covered 350,000 ED patient encounters, and found that implementation of an ED-based ICU was associated with significant reductions in risk-adjusted 30-day mortality among patients, from 2.13 to 1.83 percent. The median time to ICU-level care for critically ill patients decreased from 5.3 hours to 3.4 hours, while the hospital ICU admission rate from the ED dropped from 3.2 percent to 2.8 percent.

References
1.https://www.sciencedaily.com/releases/2013/05/130514212946.htm2.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4351597/3.https://www.ncbi.nlm.nih.gov/pubmed/8319477/4.http://www.siz.be/education/training-in-critical-care/5.https://www.ncbi.nlm.nih.gov/pubmed/124545496.https://pdfs.semanticscholar.org/4f1b/5cea333174e599784e6a2d80c9b55b868b2e.pdf7.https://www.emra.org/fellowships/critical-care-fellowships/8.c3med@yahoogroups.com9.https://www.acep.org/criticalcaresection/10.http://www.sccm.org/Member-Center/Sections/Pages/Emergency-Medicine.aspx11.http://www.aaem.org/membership/critical-care-section12.https://community.saem.org/communities/community-home?CommunityKey=5dc206d8-d248-4f71-aecd-e0490cdc3ba913.https://insights.ovid.com/pubmed?pmid=3139332114.https://jamanetwork.com/journals/jamanetworkopen/fullarticle/273862515.https://medicalxpress.com/news/2019-07-department-based-intensive-patient-survival.html

Point-of-care testing (POCT) is typically described as a clinical test which is done at, or close to, the physical location of a patient. This could be at a patient’s home, in a pharmacy, a GP’s office or an in-hospital bed site. POCT typically consists of portable devices and instruments, which return results quickly. As a result, POCT permits immediate intervention or treatment.
POCT can also be defined usefully by specifying what it is not. In this case, a POCT is simply a test that is not analysed in a laboratory. POCT short circuits many steps involved in the latter. It eliminates the need to collect a specimen, transfer it to the lab, perform the test, and transmit results back to the provider.
POCT is increasingly used to diagnose and manage a range of diseases, from chronic conditions such as diabetes to acute coronary syndrome (ACS). Recent additions include genetic tests.

Driven by miniaturisation
The POCT era is considered to have begun in the 1970s, with a test to measure blood glucose levels during cardiovascular surgery. In 1977, a rapid pregnancy test called ‘epf’ became the first POCT for use wholly outside a hospital.
Since the late 1980s, one of the key drivers of POCT has been product miniaturization, with increasingly sophisticated and ever-smaller mechanical and electrical components integrated onto chips that can analyse biological objects at the microscale. The pace of miniaturization has accelerated at a breakneck speed in recent years, to mobile handheld and wearable POCT devices. These can be inte-
grated with other applications within a healthcare facility, or aid patients in monitoring and self-management of chronic conditions.

Wide product range, but handful of tests dominate
The most widely-used POCTs include “blood glucose testing, blood gas and electro-
lytes analysis, rapid coagulation testing, rapid cardiac markers diagnostics, drugs of abuse screening, urine strips testing, pregnancy testing, faecal occult blood analysis, food pathogens screening, haemoglobin diagnostics, infectious disease testing and cholesterol screening.” Nevertheless, just three tests – urinalysis by dipstick, blood glucose and urine pregnancy – are believed to account for the majority of POCT.

Comparisons with the lab
Beyond definition, the relationship of POCT to a laboratory is close for a very good reason. Most clinical cases for POCT use lab testing as a comparator. In other words, the first question that comes to many people when using POCT is whether its results match those of a laboratory. Although evidently quicker to obtain, is POCT as reliable? Another topic for comparison consists of the cost of POCT versus lab tests.

Costs: a vexed question
Even in the heady early days of POCT, there was awareness about potential cost downsides. One of the first efforts to address this question was a US study, published in 1994 in ‘Clinical Therapeutics’. [1] The study, by the Office of Health Policy and Clinical Outcomes at the Thomas Jefferson University Hospital in Philadelphia, sought to determine time and labour costs for POCT versus central laboratory testing on a cohort of 210 patients presenting to the emergency department.
The patients had blood drawn for a Chem-7 profile (sodium, potassium, chloride, carbon dioxide, blood urea nitrogen, glucose, and creatinine), or for cell blood count (CBC). Largely due to much quicker turnaround time (TAT), physicians reported that POCT would have resulted in earlier therapeutic action for 40 of 210, or 19 percent of patients. Costs for POCT were, however, over 50 percent higher, and also showed significant variability, depending on test volume. The authors speculated that increasing volumes of POCT would reduce costs “substantially.”

Volumes lower cost
The perception that POCT is much more expensive than a centralized laboratory persists. There are several reasons for this. Consumables generally cost more than tests done with automated laboratory instruments. On its part, POCT simply cannot achieve the scale economy associated with the latter. It also requires more staff downtime.
However, right from the early stages of POCT use, it seemed likely that unit costs could be reduced by increasing test volumes, as anticipated in the 1994 study by Jefferson University Hospital.
POCT was also to quickly demonstrate enhanced utility for certain kinds of tests. In 1997, a study at an Indiana hospital reported a near-halving in unit costs of panels, from USD 15.33 to USD 8.03, following POCT implementation for blood gases and electrolytes [2].

Levelling the field of play
One of the biggest hurdles in making cost comparisons of POCT with lab tests is the difficulty of levelling the playing field. It is also difficult to use such an exercise to draw generalised conclusions, since key conditions often vary significantly from one care facility to another. POCT is also complex to manage, and it is especially challenging to maintain regulatory compliance, especially in large institutions.
Though the cost of consumables is straightforward to determine, this is hardly so for labour.
Labour costs for a lab test are not limited to staff in the laboratory. They also include costs of staff in the pre-analysis phase, for phlebotomy, nursing and other services. Many of the latter entail administrative overheads. Typically, these would consist of formalities in the collection of phlebotomy supplies, the completion and submission of a test request, the labelling of tubes, specimen packaging and despatch.
In contrast, POCT eliminates most pre-analytic steps, along with associated staff costs and overheads. POCT can be undertaken by personnel who are not trained in clinical laboratory sciences.

Cost versus value
Although it seems to be common sense that POCT labour costs are significantly less than for a laboratory test, calculating this precisely requires a complex time-and-motion study which takes account of differences in wages and other costs for phlebotomists, nurses, administrative staff and medical technologists.
Unit product cost therefore reflects only a part of the overall equation, as far as justifying the case for a test is concerned. Indeed, many experts now urge for making assessments based on unit value rather than unit cost.
The role of TAT
With POCT, faster TAT promises better treatment, reduced patient stay, superior workflow and improved clinical outcomes. POCT is however less about reducing TAT than making results available in an optimal and clinically relevant time frame. This, in turn, is frequently dictated by conditions for which care is targeted as well as the setting in which it is delivered.
Delayed test results also impact upon cost in indirect ways. For instance, radiology departments use creatinine POCT before administering contrast agents, since patients with impaired renal function can develop contrast-induced kidney injury. This allows for quick decisions about patients and efficient use of costly CT scanners. If physicians had to wait for test results from a laboratory, the scanner would risk having to idle in a stand by status.

POCT can sometimes be only choice
Some tests have to be performed at point of care since there is no choice, in terms of time for transport to a lab.
One good example is an activated clotting-time test. This is used to monitor cardiac patients undergoing high-dose heparin therapy, whose blood immediately starts to clot after collection of a sample. Another is a POCT glucose test, where a quick result is crucial in determining insulin dosage for diabetic patients.
Elsewhere, whole blood cardiac-marker POCT tests in an A&E facility allow physicians to make rapid decisions on patients with acute coronary syndromes in terms of triage and disposition for observation, catheterization or transfer to a cardiac ICU.
Yet another example is a rapid flu test, used to identify patients who could benefit from antiviral therapy requiring administration as soon as possible after infection, in order to reduce symptomatic intervals. None of the above permit the wait times required for a lab test.

The grey zones
Still, there are grey zones where lab tests have advantages, which are non-negotiable under certain conditions.
One example is routine monitoring of international normalized ratios (INR) for patients on warfarin. The latter is used for prophylaxis against stroke and systemic embolism in patients with atrial fibrillation or mechanical heart valves. The goal of testing is to ensure that anticoagulant levels are appropriate. Over a certain threshold, there is a risk of bleeding, while below it, there is the danger of clotting.
While warfarin toxicity can result in life-threatening risk of bleeding, inappropriate warfarin dose reduction can lead to inadequate protection from a stroke or systemic embolism.
Lab-based testing entails the patient travelling to a GP, or having a caregiver come to take blood at the patient’s home, and doing this regularly. However, even a one-day TAT for the lab test can be a major problem in terms of warfarin dosage. The utility of POCT here seems clear. The GP can know the results and adjust the medication dosage immediately. In addition, POCTs can enable certain categories of patient to self-test and manage warfarin therapy.

Lab tests as gold standard
However, POCT tests can vary significantly from laboratory analysers. In the case of warfarin monitoring, this happens as INR values rise. Correction factors are also typically device- and institution-specific. They cannot be uniformly applied across institutions. Many clinicians therefore require POCT INRs which are greater than 5.0 to be confirmed with a venipuncture sample and a lab test.
Lab tests therefore remain a gold standard. Instrumentation in a laboratory provides robust analytics during a test, and includes a host of quality controls, from test strengths and timings to testing accuracy. These are incorporated into a laboratory information system (LIS) and stored in a patient case file. POCT simply cannot provide such a depth of information.

Gaps being closed
In brief, both POCT and laboratory testing have pluses and minuses. POCT provides definite advantages and reduce risk in some situations.
However, laboratory testing is more advanced, more closely follows scientific process and is fully integrated with the kinds of technical redundancies necessary to ensure greater accuracy and validation of records.
Nevertheless, gaps between the two are being closed, especially through software technology.
Some hospitals now have dedicated satellite labs in emergency rooms and outpatient facilities equipped with POCT.

[1]  https://www.ncbi.nlm.nih.gov/pubmed/7859247
[2] Bailey TM, Topham TM, Wantz S, et al. Laboratory process improvement through point-of-care testing. Jt Comm J Qual Improv 1997;23(7):362–80

Doctors working in the eight-bed Pediatric Intensive Care Unit at the Ramón y Cajal University Hospital in Madrid use point-of-care ultrasound extensively to evaluate the condition of critically ill children, and find it essential to their work. Dr José Luis Vázquez Martínez, Head of UCIP at Hospital Ramón y Cajal, with over 25 years’ experience in pediatric intensive care medicine, explained.

Point-of-care ultrasound (POCUS) is used extensively in our unit, allowing comprehensive, head-to-toe assessment of critically ill children, including respiratory, oncology and post-operative cardiac patients, as well as those being treated for sepsis or multiple trauma. The POCUS approach allows not only an initial diagnosis, but also routine monitoring of treatment to see whether or not a patient’s condition changes, enabling alternative strategies to be implemented if there is no improvement.

POCUS helps pediatric doctors in many ways. For example, ultrasound scans enable evaluation of a patient’s hemodynamic state, looking at their heart function and blood volume to see if these factors are contributing to respiratory failure. Conversely, doctors can see if a lung problem, such as pneumonia, is affecting the heart. For a patient in a coma due to multiple trauma, ultrasound is used to look for signs of bleeding – a potential cause of unexplained anemia – and to assess the intracranial pressure. It is also used to monitor kidney function in children with blood pressure problems, and visualize intestinal indications of sepsis. In addition, ultrasound guidance can be used for endotracheal intubation. In short, broader applications that we did not anticipate until very recently.

We have used ultrasound in our PICU for more than a decade, and have always had SonoSite systems, upgrading them as new technology is introduced. In the beginning, when my knowledge was more limited, the aim was to perform clinical echocardiography but, when the SonoSite representative showed me the linear probe and the various techniques available, it was as if I was being shown electricity after using candles! It was amazing, a real turning point in the use of ultrasound, and everyone recognized it as a step forward in the pediatric intensive care world. For the patients, a major benefit of ultrasound is that exposure to radiation can be reduced. Before ultrasound, X-ray examinations were performed two or three times in the first few days after admission to try to establish the cause of the problem, often with limited success. With ultrasound, we can scan the patient as often as necessary, implementing treatment and monitoring its effect without exposing the child to more radiation.

In PICU, we consider an ultrasound system essential – there is nothing else that gives us so much information, so quickly and non-invasively – and today we have a dedicated Edge II ultrasound system with linear, including hockey stick, and adult and pediatric cardiac transducers. It is in constant demand and is a perfect fit for our work, fulfilling all our expectations. All my colleagues use it, and we are very satisfied with it. The system is high quality and ergonomic, and strikes a good balance between image quality and ease of use. It is also quick to boot up, which is crucial for an instrument that is frequently moved between different beds in the unit. Robustness is vital too; if a patient deteriorates, we may have to move any equipment surrounding the bed very quickly to create space to treat them. However careful you are, there is always the risk of unintentional knocks to the system.

A while ago someone said to me that they ‘sell ultrasound machines but don’t offer training’, but this view isn’t enough – it’s very short-sighted – training is very important. Ramón y Cajal pioneered the use of ultrasound in PICUs across Spain, and was the first hospital to offer external training courses for doctors from other facilities, initially focused on clinical echocardiography. Over time, this has expanded to include neuromonitoring, respiratory and abdominal monitoring. I acquired my ultrasound experience through a combination of external training in adult ultrasound and practical, hands-on learning, and am largely self-taught. If courses like these had been available when I started using ultrasound, I would have saved so much time.
FUJIFILM SonoSite is clearly committed to organising and supporting ultrasound training, and this is unquestionably a great benefit to the scientific community – long may it last!      

Today, we are seeing a boom in the use of ultrasound in pediatric care, as it non-invasively provides immediate information in situations where time is of the essence. Our advice to people attending our training courses who do not have – or have to share – an ultrasound system is to tell their hospital managers that, just like a ventilator, it is an essential piece of equipment for an intensive care unit.

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