Emergency critical care: closing the gap between onset of critical illness and intensive care unit admission

Abstract

Critical illness is an exquisitely time-sensitive condition and follows a disease continuum, which always starts before admission to the intensive care unit (ICU), in the majority of cases even before hospital admission. Reflecting the common practice in many healthcare systems that critical care is mainly provided in the confined areas of an ICU, any delay in ICU admission of critically ill patients is associated with increased morbidity and mortality. However, if appropriate critical care interventions are provided before ICU admission, this association is not observed. Emergency critical care refers to critical care provided outside of the ICU. It encompasses the delivery of critical care interventions to and monitoring of patients at the place and time closest to the onset of critical illness as well as during transfer to the ICU. Thus, emergency critical care covers the most time-sensitive phase of critical illness and constitutes one missing link in the chain of survival of the critically ill patient. Emergency critical care is delivered whenever and wherever critical illness occurs such as in the pre-hospital setting, before and during inter-hospital transfers of critically ill patients, in the emergency department, in the operating theatres, and on hospital wards. By closing the management gap between onset of critical illness and ICU admission, emergency critical care improves patient safety and can avoid early deaths, reverse mild-to-moderate critical illness, avoid ICU admission, attenuate the severity of organ dysfunction, shorten ICU length of stay, and reduce short- and long-term mortality of critically ill patients. Future research is needed to identify effective models to implement emergency critical care systems in different healthcare systems.

Keywords: Critical illness; Emergency critical care; Emergency department; Medical emergency team; Prehospital.

Fig. 1

The chain of survival of critically ill patients illustrating the link of emergency critical care as well as pathways to recovery from critical illness. (ICU intensive care unit). (Images by flaticon.com)

Fig. 2

Spectrum of the settings in which emergency critical care interventions are delivered to critically ill patients outside of the ICU. (a pre-hospital critical care, b critical care in the emergency department, c retrieval and interhospital transfer of critically ill patients, d intraoperative critical care, e critical care provided by medical emergency or rapid response teams on hospital wards; ER emergency room, ICU intensive care unit). (Images by flaticon.com)

Fig. 3

Schematic presentation of the potential effects of early vs. delayed critical care interventions in patients with acute critical illness, critical illness complicating acute disease and critical illness complicating chronic disease. (Black lines represent the natural disease course, green lines represent the disease course when critical care interventions are delivered early (e.g., at the closest time point and location of the onset of critical illness), and red lines represent the disease course when critical care interventions are delayed (e.g., initiated only after intensive care unit admission). The figure schematically summarizes scientific evidence summarized in the section “Scientific Evidence”; ICU intensive care unit)

Fig. 4

Schematic description of a medical emergency or rapid response system consisting of an afferent (e.g., ward team recognizing critical illness using clinical acumen and validated scores) and efferent loop (e.g., medical emergency or rapid response team providing critical care support). (ICU intensive care unit, MET medical emergency team, RRT rapid response system). (Images by flaticon.com)