Collaborative process clarifies ICU admissions from ED

From the emergency department (ED) to the intensive care unit (ICU), a clear, collaborative admission process at a Tennessee hospital cut in half the time newly admitted critically ill patients waited to receive specialized care, even as they waited in the ED for an ICU bed to become available.

Nurse practitioners at Ascension Saint Thomas West Hospital in Nashville, Tennessee, developed a multipronged interdepartmental care model that prioritized rapid assessment and treatment of patients admitted to the 28-bed medical intensive care unit (MICU) from the ED and awaiting an assigned bed.

As part of the hospital’s transition to a closed ICU model, an intensivist-led team began to fully manage the care of critically ill patients from admission to discharge, instead of being called in for a consulting role when requested by an attending hospitalist. The shift in clinician roles required changing the long-standing admission process and provided an opportunity to clarify responsibilities and resolve variations between departments and among clinicians.

“Critical Care Consultations for Patients Boarding in the Emergency Department” details the development and implementation of the new MICU Admission Management Process (MAMP) for patients admitted to the MICU directly from the ED. The article is published in AACN Advanced Critical Care.

Co-authors Whitney Haley, DNP, APRN, AGACNP-BC, and Rachel Smith, DNP, APRN, AGACNP-BC, CCRN, are pulmonary critical care nurse practitioners at the hospital. They led the quality improvement project as part of the Doctor of Nursing Practice degree program at the University of Alabama at Birmingham School of Nursing and were mentored by Assistant Professor Dana Mitchell, DNP, ACNP-BC, CHFN.

“The updated admissions process alleviates any uncertainty about which medical team is managing a patient’s care and ensures that definitive care and assessment by the critical care team aren’t hampered by delays in transfer to the MICU,” Haley said. “In essence, it brings MICU-level expertise to the patient during a high-risk transition period.”

As part of the new admissions process, the MICU and ED teams collaborated to ensure that patients who were not promptly transferred to the MICU did not experience delays in care. Critical care consultations and initial assessments occurred before the patient’s arrival in the MICU and enabled triage of patients being boarded in the ED.

After the MAMP protocol was implemented, patients spent less time waiting for critical care team involvement, from a preintervention mean of 113.9 minutes to a postintervention mean of 56 minutes (a 50.8% reduction).

The study also examined ICU length of stay and the number of patients who spent fewer than 24 hours in the MICU after being admitted from the ED. Although ICU length of stay increased from a mean of 2.8 days before implementation to 3.4 days afterward, short-stay admissions decreased slightly from 23.3% before implementation to 19.2% afterward. The combination signaled an unanticipated benefit of the MAMP protocol—by providing critical care expertise while patients were in the ED, the team was able to improve allocation of MICU resources and prioritize transfer for the most critically ill patients.

MAMP also led to ongoing interactions and greater collaboration between ED and ICU nursing staff and providers, which improved the patient care experience.

The study involved 275 adult patients who met established inclusion criteria and were admitted directly from the ED to the MICU. Retrospective data from medical records were used to establish the preintervention sample, which included 150 patients admitted between Feb. 1 and April 30, 2024. During the intervention period, from Aug. 15 to Oct. 20, 2024, 125 patients who met the inclusion criteria were admitted to the MICU from the ED.

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Gaby Clark

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