Searching for Staircases: Strengthening the Connections Between the Emergency Department and the Intensive Care Unit

A stair not worn hollow by footsteps is, regarded from its own point of view, only a boring something made of wood.

—Franz Kafka

On a fall day in Chicago, a middle-aged man stepped out of a northbound train, appeared to choke, and collapsed. Paramedics arrived within minutes and administered several rounds of defibrillation and intravenous epinephrine. The patient was rapidly transported to an academic medical center, resuscitated in the emergency department (ED) and was soon surrounded by a multidisciplinary team of doctors, nurses, and respiratory therapists in the intensive care unit (ICU).

Dr. Peter Safar, one of the pioneers of cardiopulmonary resuscitation, envisioned the provision of critical care as a continuum spanning the prehospital setting, the ED, and the ICU.¹ During the fast-paced initial hours of caring for a critically ill patient at a modern academic medical center, it is easy to feel that Dr. Safar’s vision has been realized. Indeed, between a speeding ambulance and a quick elevator ride up to the ICU, our patient spent less than 15 minutes transitioning between critical care providers. However, when it comes time to reflect on difficult cases and discuss ways to improve the care we provide to our sickest patients, this continuum often falls apart.

Despite our best efforts, the middle-aged man who suffered a cardiac arrest at the train station died shortly after admission with refractory cardiogenic shock. His case was presented several months later at a pulmonary and critical care medicine conference. In retrospect, each decision point in the patient’s course highlighted an opportunity for improvement: an opportunity to improve interservice communication, reach consensus on indications for advanced hemodynamic support, and streamline transitions in care. Unfortunately, the discussion that day involved only members of the division of pulmonary and critical care and a single interventional cardiologist. While much time was spent discussing “downstairs” care, there were no emergency medicine (EM) providers present to contribute to or learn from the conference.

This, sadly, happens far too often. At EM morbidity and mortality conferences, pulmonary and critical care didactics, and daily rounds in the ICU, EM and ICU providers frequently talk about but rarely with one another. Surprising evolutions in a patient’s case are rarely relayed back to the EM providers who guided the initial resuscitation. ICU providers on rounds are often unaware of the nuances of care provided in the ED; “the ED ordered x I’m not sure why,” is a disturbingly frequent part of an admitting resident’s morning presentation. While providers both “upstairs” and “downstairs” care for patients with shock and respiratory failure and read the same clinical trials, we usually do so in isolation.

Much of this lack of dialogue is driven by time constraints. Duty-hour restrictions, clinical responsibilities, and required didactics allow for few opportunities where both EM and ICU providers are free to sit in the same room. Indeed, efforts at one of our institutions to establish a joint critical care–emergency medicine conference, while met with enthusiasm, has been plagued by scheduling conflicts and limited attendance for precisely these reasons. This, however, is not the whole story. We practice in silos in part because we allow them to exist.² We prioritize other educational opportunities and undervalue the importance of multidisciplinary discussion.

This unfortunately comes at a time when collaboration between our specialties should be most valued.³ Crowded hospitals have led to the routine “boarding” of critically ill patients in the ED. A growing body of evidence suggests that for conditions like septic shock, care provided in the early hours of critical illness has a profound impact on patient outcomes.⁴ Acute respiratory distress syndrome (ARDS), traditionally viewed as a diagnosis encountered and managed in the ICU, is now the focus of multicenter preventative trials based in the ED.⁵ Advanced supportive and therapeutic options from extracorporeal membrane oxygenation (ECMO) to catheter-directed therapies are now frequently considered in the ED, highlighting the need for providers “upstairs” and “downstairs” to collaborate on hospital-specific protocols and establish mechanisms to learn from institutional experience.

These “staircases”—shared spaces between EM and critical care—hold tremendous value for trainees as well. From developing proficiency with focused critical care ultrasound to refining procedural skills, ensuring safe handoffs of critically ill patients, and navigating cognitive biases in the face of uncertainty, EM and critical care trainees work to develop many of the same skills during their residencies and fellowships. Additionally, the relationship between the ED and the ICU is too often framed as an antagonistic one for impressionable new students and residents. Improved interspecialty collaboration would go a long way to help break these tired stereotypes.

So what is the way forward? Recently, there has been an explosion in the number of EM and ICU educational Internet blogs.⁶ The institutions and individuals in charge of these sites often collaborate with subspecialty experts to share feedback on clinical topics. This is certainly a step in the right direction and provides a forum for EM and ICU providers to share ideas. However, this type of dialogue is limited by the need to frame advice and clinical approaches in a way that is generalizable to a broad audience. A blog post may provide helpful general information on ECMO for ARDS or interventions for right-heart failure, but what matters at an individual patient level is how well providers are able to utilize the expertise and systems of their specific institution to provide cutting-edge care.

To accomplish this, we need to find time to discuss difficult cases in a shared setting, establish mechanisms that allow for constructive bidirectional feedback, and create opportunities to ensure that providers agree on institution-specific approaches to complex clinical entities such as refractory hypoxemia, high-risk pulmonary embolism, and life-threatening hemoptysis. We need to vigilantly guard against talking in silos and embrace opportunities (whether simulation sessions, journal clubs, or case conferences) that bridge the divide between “upstairs” and “downstairs”. Perhaps most importantly for academic centers, faculty members from both specialties need to create a culture that emphasizes the value of this dialogue for trainees so that insularity and Monday-morning quarterbacking become things of the past.

These staircases are all around us; it is time we start using them more.