Emergency Department Critical Care

I had the pleasure of speaking with Dr. Angela Barskaya about Critical Care Fellowship and Emergency Medicine (EM) Critical Care. Dr. Barskaya currently divides her time between working in the Emergency Department (ED) and in the Medical Intensive Care Unit at Columbia University Irving Medical Center (CUIMC). She recently completed her fellowship in Anesthesia-Critical Care Medicine at NYP-Columbia and established the Emergency Department’s new Critical Care Resuscitation (CCR) Unit. I learned a lot from our conversation and hope you will too. Thank you, Dr. Barskaya, for taking the time to speak with us!

Curato: Would you share with us how and when you developed an interest in EM-Critical Care and your path to fellowship?

Barskaya: When I was in medical school at the University of Buffalo, I did a few Critical Care rotations and discovered I really enjoyed taking care of sick patients. I chose Emergency Medicine because we see everything and I really think we as EM doctors should be the best doctors in the hospital and I wanted to be that.

My residency training at the University of Rochester really solidified that for me; it was excellent! Rochester is a Level I Trauma, Burn, STEMI and Stroke Center with cardiac and liver transplant programs and because of this, I felt like I got to see everything as a resident. I stayed on and worked as an attending at the University of Rochester and found my favorite part of the job was when I would take care of patients in the Critical Care Bay. I certainly liked it as a resident but even more so as an attending. I wanted to be the best at the medicine and the procedures; if I didn’t know something the first time around, I would never allow that to happen the next time around. I wanted to be the best at taking care of critical patients and whatever was associated with that, including teaching the residents and just being that person for the department. That was when I started to think about a Critical Care fellowship, not because I wanted to work ‘upstairs’ in the ICU specifically, but because I wanted to bring that depth of care down to the ED.

Curato: You worked as an attending for two years before going back and starting fellowship, could you speak a little about what that transition was like and how you were received in the ICU?

Barskaya: It was an interesting ride, for a variety of reasons; one of which is that I started fellowship during the pandemic. Challenging times are excellent for learning. In some ways it was an adjustment, no longer being the one to call the shots and make the final decisions but I remembered to have perspective and to stay humble. I recognized I was in someone else’s arena and there is a ton to learn. I also appreciated the opportunity to demonstrate what we as EM docs are capable of and tried to be a good ambassador for our specialty. I learned a ton, but I also think they learned from having the EM perspective upstairs, a perspective they don’t typically have since we don’t otherwise interact with one another a tremendous amount as specialties. The interdisciplinary environment was key in fostering open learning spaces and excellent collaborative care.

Curato: Now, getting into that idea of ICU care in the ED, what are the advantages of having a designated ED Critical Care space and what does that look like?

Barskaya: Critical care spaces in EDs can run the full spectrum, from a designated Resuscitation Bay that an ED doc and team manage (and once the patient is stabilized, moved out of) to a full-fledged ICU staffed by doctors boarded in Critical Care Medicine, to everything in between. Some places with a more intermediate framework have designated areas of the ED that are for patients as a “pit stop” to the Operating Room or upstairs ICU or perhaps to stabilize completely before going to the floor. The ability to have one of these areas will depend on the available resources, which will depend on a huge number of factors, including community vs. academic practice setting. Some departments may ask the ED attendings to have further certifications in critical care such as FCCS (Fundamental Critical Care Support) from the Society of Critical Care Medicine which trains non-intensivists to manage critically ill patients for the first 24 hours.

You also have opportunities and may be asked to lead committees or serve in roles for the hospital or the medical school. For example, I am currently the Vice Chair of our health system medical board and I chair the operations committee for our faculty practice organization.

There are many advantages to having some version of an ED-ICU. Overall, the goal is that having a designated space enables the creation of an environment, with a cohesive team, that is fully dedicated to caring for the sickest patients in the department. Different EDs will have differing abilities to define that space, but it’s important to offload the distractions. It’s a challenging mental switch, for all members of the team, to pivot from an ankle sprain to a crashing acute pulmonary edema. I think cognitive offloading really optimizes care and can help mitigate bias. Having a specific resuscitation area enables you to be in the appropriate mindset to care for each of those patients in the best possible way.

Another advantage of a dedicated critical care space is the ability of the physician team to be physically co-located with nursing, techs and ideally, pharmacy. This truly allows everybody to become fully invested members of the team. Everybody takes on more responsibility and grows from it. We realize we cannot do our jobs without one another. Good team cohesion becomes paramount for good performance and allows team members to truly excel and really work at the top of their degrees.

Interestingly, dedicated critical care spaces have also been shown to be cost neutral and improve value. This is in part because it is a restructuring of preexisting resources. There are also increasing numbers of ICU patients boarding in the ED and we know boarding is associated with increased morbidity and mortality. Existing ED ICU models have shown both improved survival and decreased ICU admission rates and all of this is without any increase in cost.

Curato: How did you go about implementing the Critical Care Resuscitation Unit in your ED? And what recommendations would you have for someone wanting to set this up in their shop?

Barskaya: Start with an overarching goal. For us, it was to provide excellent team-based care to the department’s sickest patients. Then, identify the stakeholders. In most EDs, the key players will be the departmental operations leadership, nursing leadership and residency leadership. While it can be challenging to meet all these entities’ individual needs, having a common mental model really helps facilitate everything from conception through to implementation. The primary driver is patient care, but resident education is going to improve. Nursing and attending job satisfaction is going to improve. Overall, this took quite a bit of work over about the course of a year. We did a lot of modeling, diagramed work flows, identified roles and responsibilities and ran simulations. We thought about every player’s responsibility and what it would look like.

Geographically, most ED’s are tight on space and may need to work within the confines of an already established floorplan. This was the case for us, and we had to implement a lot of space saving measures. For example, using rolling carts for intubation and difficult airway equipment, a procedure cart for commonly performed procedures including central line kits, IO’s, chest tube equipment, as well as a nursing cart for common nursing needs including IV starts and monitoring equipment and of course a code cart. We even had to think about what outlets would be designated for our dedicated video laryngoscope and ultrasound in this area.

In running simulations prior to the opening of our Critical Care Resuscitation Area, we made sure to try to account for the work flow every step of the way, from how registration first engages new patients to how equipment is physically housed and moved through the space. We thought about how existing ED patients would be upgraded to the space in the event of deterioration and similarly, how patients would be moved out of the space depending on their disposition.

When the space first opened in our department, it was really rewarding to be able to observe our designed workflow in real time and to witness excellent bidirectional communication and shared learning between the ED residents and nurses, as well as with the consulting teams coming into the space.

It certainly took some persistence, but time spent up front delineating a common goal and shared mental model very much helped facilitate transitioning a potential space into a physical one.

Curato: There are several paths one could take to a critical care fellowship, what are they and what advice would you give to someone exploring this as a potential fellowship?

Barskaya: Board certification in Critical Care Medicine is available to EM trained physicians via four different pathways: Internal Medicine, Anesthesia, Surgery and Neurocritical Care. Not every program in the country admits EM graduates so potential applicants will need to do some research, both for specific programs and whether those programs participate in the standard NRMP match, San Francisco match or possibly a paper application. My advice would be to think about what type of ICU and what types of patients you want to be working with and learning from going forward. Think of what kind of specialty ICU you may want to work in and whether you’d want to be in academics or in the community. For example, if you want to be working with trauma patients then surgical critical care would be the best route. IM/CCM is going to set you up well for working in a Medical ICU, but there will likely be flexibility to extend to other ICUs depending on your specific location. Anesthesia CCM will expose you to a post-surgical and post-cardiac surgical patient population, with significant overlap with cardiology critical care and mechanical circulatory support, which can enable you to work in a variety of ICUs. There are different strengths to each of these fellowships.

Curato: What does the future look like for someone who has completed a fellowship in critical care?

Barskaya: I really think EM docs are very well suited for this space. When you combine the breadth of what we do in emergency medicine and the depth of what is done in critical care, out comes an excellent clinician who is both flexible and well-versed and can work in either or both environments.

EM is still rather new to critical care and the beauty of that is it’s still rather unchartered (something I didn’t realize at first!) so you can create your own path. Some choose to work entirely in the ED and be the Critical Care person for their department, others split their time between working ‘upstairs’ in the ICU and ‘downstairs’ in the ED, and some go on to work 100% in an ICU. While the numbers are growing, right now only about 1.2% of EM physicians are also board certified in Critical Care Medicine. Carving out a new space can be challenging but it can also be tremendously rewarding.