Shock Trauma model for critically ill patients cuts transfer time in half
Baltimore, February 23, 2016–A novel unit to care for critically ill patients significantly speeds access to specialized care, according to a new study by physician scientists at the University of Maryland School of Medicine (UMSOM) and the University of Maryland Medical Center (UMMC).
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 such as UMMC are known for. 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. During its first full year of operation, for the subset of adult patients admitted for critical care, transfers increased 64.5 percent compared to a previous year (2,228 vs. 1,354) and patients arrived in nearly half the time (129 vs. 234 minutes), according to data published online today in the Journal of the American College of Surgeons.
"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," said lead author Thomas M. Scalea, MD, FACS, 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. "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 6-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.
"We've discovered a new niche for resuscitation medicine," said co-author Lewis Rubinson, MD, PhD, an Associate Professor of Medicine at UMSOM and Director of the CCRU. "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 percent to 14 percent in this subset of transfer patients requiring critical care. Significantly more transfer patients required an operation during their hospital stay (46 percent vs. 31.1 percent) and a higher percentage were in the operating room within 12 hours of arriving (41 percent vs. 21.4 percent).
"We admitted nearly 1,000 additional transfer patients in the first year alone since opening the CCRU," said senior author James O'Connor, MD, Professor of Surgery at UMSOM and Critical Care Chief at UMMC. "Adding just six beds and borrowing practices we had honed in the Shock Trauma Center made our entire system more efficient."
"We built the CCRU to address the inefficiencies inherent in relying on a particular ICU to accept a transfer," added Dr. Scalea. "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.
"This is a major advance in clinical science akin to a fundamental discovery," said UMSOM Dean E. Albert Reece, MD, PhD, MBA, the John Z. and Akiko Bowers Distinguished Professor at UMSOM and Vice President of Medical Affairs at the University of Maryland. "It is exciting to see another example of our faculty's commitment to discovery-based medicine."
About the University of Maryland Medical Center
The University of Maryland Medical Center (UMMC) is comprised of two hospitals in Baltimore: an 800-bed teaching hospital — the flagship institution of the 12-hospital University of Maryland Medical System (UMMS) — and a 200-bed community teaching hospital, UMMC Midtown Campus. UMMC is a national and regional referral center for trauma, cancer care, neurocare, cardiac care, diabetes and endocrinology, women's and children's health, and has one of the largest solid organ transplant programs in the country. All physicians on staff at the flagship hospital are faculty physicians of the University of Maryland School of Medicine. At UMMC Midtown Campus, faculty physicians work alongside community physicians to provide patients with the highest quality care. UMMC Midtown Campus was founded in 1881 and is located one mile away from the University Campus hospital. For more information, visit http://www.umm.edu.
About the R Adams Cowley Shock Trauma Center
The R Adams Cowley Shock Trauma Center at the University of Maryland Medical Center was the first fully integrated trauma center in the world, and remains at the epicenter for trauma research, patient care, and teaching, both nationally and internationally today. Shock Trauma is where the "golden hour" concept of trauma was born and where many of the life-saving practices in modern trauma medicine were pioneered. Shock Trauma is also at the heart of Maryland's unparalleled Emergency Medical Service System.
About the University of Maryland School of Medicine
The University of Maryland School of Medicine, chartered in 1807 as the first public medical school in the United States, continues today as a leader in accelerating innovation and discovery in medicine. The School of Medicine is the founding school of the University of Maryland, and is an integral part of the 11-campus University System of Maryland. Located on the University of Maryland's Baltimore campus, the School of Medicine works closely with the University of Maryland Medical Center and Medical System to provide a research-intensive, academic and clinically based education. With 43 academic departments, centers and institutes and a faculty of more than 3,000 physicians and research scientists, plus more than $400 million in extramural funding, the School is regarded as one of the leading biomedical research institutions in the U.S.A., with top-tier faculty and programs in vaccine development, cancer, brain science, surgery and transplantation, trauma and emergency medicine, and human genomics, among other centers of excellence. The School is not only concerned with the health of the citizens of Maryland and the U.S.A., but also has a global presence, with research and treatment facilities in more than 35 countries around the world. For more information, visit http://medschool.umaryland.edu.