Critical Care Anywhere: A Novel Emergency Critical Care Consult Service in a Rural Health Network

In areas with limited access to critical care services, the intensivist's reach can be expanded by removing the silo of the ICU and providing care wherever the patient is located. The University of Vermont Health Network includes a tertiary care center, two community hospitals, and three critical access hospitals, and often experiences limited ICU bed availability. The community hospitals have ICU services; however, only the tertiary site has consistent staffing for many subspeciality services. For example, the University of Vermont Medical Center is the only Vermont hospital to offer inpatient dialysis services or continuous electroencephalogram. The tertiary center ICU beds can be occupied by patients with brief ICU needs, but who remain in the ICU due to constraints in system throughput. The critical care transition (CCT) service was created in October 2022 to provide critical care consults for patients outside of the ICU. CCT serves the tertiary care ED and hospital wards, and provides peer-to-peer support for emergency physicians at the rural network EDs via telehealth. Dual-boarded emergency medicine/critical care medicine (EM/CCM) physicians provide the consults and offer procedural assistance within the tertiary care site. By increasing this access to critical care consults - independent of patient location - the long-term goals are to reduce short (<24-hour) ICU admissions, reduce the rates of transfer declines to the ICU due to capacity, decrease the time to evaluation by the intensivist for critically ill patients, and improve patient-centered measures of quality, such as inter-facility transfers and mortality. Short-term measures of success included demonstration of value and sustainability through either cost avoidance or revenue generation, favorable staff satisfaction evaluated via surveys, and successful deployment of telehealth to support rural network providers. The authors present the pilot phase of this care delivery model in a rural setting. Work is ongoing to expand and improve the ways in which critical care can be effectively delivered where and when needed. The initial 9 months of coverage, through August 2023, suggest improved access to ICU care, mitigation of avoidable high-cost services, and positive feedback from staff in the management of complex patients. The service, which started with just two EM/CCM physicians (limited, sporadic shifts, 60% full-time equivalent [FTE]) was approved in April 2023 for full-time staffing of one shift per day (2.3 FTEs) with a goal to continue data collection for evaluation of long-term objectives, continued rapid cycle improvement testing to increase patient volumes, and expanded use of telehealth opportunities throughout the network. This model of a peri-ICU consult service, focused on critical care anywhere, utilized the same physicians to concurrently support patients and providers outside of an ICU in multiple health care settings. The health system has demonstrated the feasibility of implementing a creative solution to complex health care delivery challenges.