1. Introduction Methods Objectives Results Conclusions Figures/Graphs Implementation of clinical innovations are often evaluated at the operational and patient level, but rarely on the impact of educational outcomes. Our institution developed a novel Emergency Critical Care Center (EC3) to optimize the care of critically ill patients presenting to the ED. EC3 has potential to impact Emergency Medicine (EM) and Internal Medicine (IM) resident critical care training. Introduction Click headings to further view content The Impact of an ED-Based Critical Care Unit on the Procedural Training Experience for Residents Purpose: To assess the impact of a novel Emergency Critical Care Center’s (EC3) implementation on: Medical Intensive Care Unit admissions Resident procedural experience Resident perceptions of critical care learning experience Retrospective analysis of procedural notes and billing data from two quarters of an academic year, one prior to EC3 implementation and one after implementation. Anonymous survey of EM and IM residents on perceptions of the impact of EC3 on training. Implementation of a novel Emergency Critical Care Center can lead to significant trainee anxiety on its impact on training. EC3 implementation leads to increased procedural experience for EM trainees while IM trainees may see small decreases in procedural opportunities. Matthew J. Stull, MD, Laura Hopson, MD, Benjamin Bassin, MD, Lauren Heidemann, MD, Sarah Hartley, MD, Sarah Tochman, MD, Kyle Gunnerson, MD University of Michigan Medical School ED – Before EC3 ED – After EC3 % Change MICU – Before EC3 MICU – After EC3 % Change Central Line1625+56.3%5051+2.0% Intubations71101+42.3%2318-21.7% Arterial Line3147+51.6%6958-15.9% Thoracentesis79+28.6%83-62.5% Paracentesis5751-10.5%109-10% In February 2015, our institution initiated a novel Emergency Department ICU, or Emergency Critical Care Center (EC3) EC3’s goal is to enhance timely resuscitation and management of critically ill patients prior to admission. Care in EC3 may reverse certain conditions rapidly in some cases, and those patients may meet floor status admission criteria instead of being admitted to the ICU (e.g., diabetic ketoacidosis or severe sepsis). Implementation of ED-ICU has potential to impact Emergency Medicine (EM) and Internal Medicine (IM) resident critical care training by altering where care is provided, where procedures are performed and by whom. Despite significant anxiety expressed by both EM and IM trainees regarding EC3’s impact on training, overall procedural experience is not significantly changed for either group

2. Objectives To assess the impact of a novel Emergency Department-based Critical Care Unit’s (EC3) implementation on the training experience for both Emergency Medicine and Internal Medicine trainees Impact will be assess on the resident procedural experience, admission volume and case mix, and resident perceptions regarding the impact on learning critical care Matthew J. Stull, MD, Laura Hopson, MD, Benjamin Bassin, MD, Lauren Heidemann, MD, Sarah Hartley, MD, Sarah Tochman, MD, Kyle Gunnerson, MD University of Michigan Medical School Conclusions Implementation of a novel Emergency Critical Care Center can lead to significant trainee anxiety on its impact on training. EC3 implementation leads to increased procedural experience for EM trainees while IM trainees may see small decreases in procedural opportunities. Results Figures/Graphs ED – Before EC3 ED – After EC3 % Change MICU – Before EC3 MICU – After EC3 % Change Central Line1625+56.3%5051+2.0% Intubations71101+42.3%2318-21.7% Arterial Line3147+51.6%6958-15.9% Thoracentesis79+28.6%83-62.5% Paracentesis5751-10.5%109-10% Introduction Methods Objectives Implementation of clinical innovations are often evaluated at the operational and patient level, but rarely on the impact of educational outcomes. Our institution developed a novel Emergency Critical Care Center (EC3) to optimize the care of critically ill patients presenting to the ED. EC3 has potential to impact Emergency Medicine (EM) and Internal Medicine (IM) resident critical care training. Purpose: To assess the impact of a novel Emergency Critical Care Center’s (EC3) implementation on: Medical Intensive Care Unit admissions Resident procedural experience Resident perceptions of critical care learning experience Retrospective analysis of procedural notes and billing data from two quarters of an academic year, one prior to EC3 implementation and one after implementation. Anonymous survey of EM and IM residents on perceptions of the impact of EC3 on training. Click headings to further view content Despite significant anxiety expressed by both EM and IM trainees regarding EC3’s impact on training, overall procedural experience is not significantly changed for either group The Impact of an ED-Based Critical Care Unit on the Procedural Training Experience for Residents

3. Methods Retrospective pre- and post-intervention analysis. Patient data was evaluated prior to the the implementation of EC3 (first quarter of 2014) and after implementation (first quarter of 2015). Source of MICU admissions (e.g., ED, outside institution) Procedure billing data for a single unit that houses most of the MICU patients All PGY-2 through PGY-4 IM and EM residents were surveyed electronically evaluating: Perceptions regarding ICU training and experience Expectations of ICU training Perceptions regarding impact of ED-ICU implementation on ICU experience Statistical comparisons were completed using chi-square test or Fisher’s exact test, as appropriate. Matthew J. Stull, MD, Laura Hopson, MD, Benjamin Bassin, MD, Lauren Heidemann, MD, Sarah Hartley, MD, Sarah Tochman, MD, Kyle Gunnerson, MD University of Michigan Medical School Conclusions Implementation of a novel Emergency Critical Care Center can lead to significant trainee anxiety on its impact on training. EC3 implementation leads to increased procedural experience for EM trainees while IM trainees may see small decreases in procedural opportunities. Results Figures/Graphs ED – Before EC3 ED – After EC3 % Change MICU – Before EC3 MICU – After EC3 % Change Central Line1625+56.3%5051+2.0% Intubations71101+42.3%2318-21.7% Arterial Line3147+51.6%6958-15.9% Thoracentesis79+28.6%83-62.5% Paracentesis5751-10.5%109-10% Introduction Methods Objectives Implementation of clinical innovations are often evaluated at the operational and patient level, but rarely on the impact of educational outcomes. Our institution developed a novel Emergency Critical Care Center (EC3) to optimize the care of critically ill patients presenting to the ED. EC3 has potential to impact Emergency Medicine (EM) and Internal Medicine (IM) resident critical care training. Purpose: To assess the impact of a novel Emergency Critical Care Center’s (EC3) implementation on: Medical Intensive Care Unit admissions Resident procedural experience Resident perceptions of critical care learning experience Retrospective analysis of procedural notes and billing data from two quarters of an academic year, one prior to EC3 implementation and one after implementation. Anonymous survey of EM and IM residents on perceptions of the impact of EC3 on training. Click headings to further view content Despite significant anxiety expressed by both EM and IM trainees regarding EC3’s impact on training, overall procedural experience is not significantly changed for either group The Impact of an ED-Based Critical Care Unit on the Procedural Training Experience for Residents

4. Figures Matthew J. Stull, MD, Laura Hopson, MD, Benjamin Bassin, MD, Lauren Heidemann, MD, Sarah Hartley, MD, Sarah Tochman, MD, Kyle Gunnerson, MD University of Michigan Medical School Conclusions Implementation of a novel Emergency Critical Care Center can lead to significant trainee anxiety on its impact on training. EC3 implementation leads to increased procedural experience for EM trainees while IM trainees may see small decreases in procedural opportunities. Results Figures/Graphs ED – Before EC3 ED – After EC3 % Change MICU – Before EC3 MICU – After EC3 % Change Central Line1625+56.3%5051+2.0% Intubations71101+42.3%2318-21.7% Arterial Line3147+51.6%6958-15.9% Thoracentesis79+28.6%83-62.5% Paracentesis5751-10.5%109-10% Introduction Methods Objectives Implementation of clinical innovations are often evaluated at the operational and patient level, but rarely on the impact of educational outcomes. Our institution developed a novel Emergency Critical Care Center (EC3) to optimize the care of critically ill patients presenting to the ED. EC3 has potential to impact Emergency Medicine (EM) and Internal Medicine (IM) resident critical care training. Purpose: To assess the impact of a novel Emergency Critical Care Center’s (EC3) implementation on: Medical Intensive Care Unit admissions Resident procedural experience Resident perceptions of critical care learning experience Retrospective analysis of procedural notes and billing data from two quarters of an academic year, one prior to EC3 implementation and one after implementation. Anonymous survey of EM and IM residents on perceptions of the impact of EC3 on training. Click headings to further view content ED – Before EC3 ED – After EC3 % Change MICU – Before EC3 MICU – After EC3 % Change Central Line1625+56.3%5051+2.0% Intubations71101+42.3%2318-21.7% Arterial Line3147+51.6%6958-15.9% Thoracentesis79+28.6%83-62.5% Paracentesis5751-10.5%109-10% Table 1: Procedures Performed Pre/Post-EC3 Implementation Figure 1: Resident Perceptions of EC3 Implementation on Training EM RESIDENT COMMENTS: “I’m concerned ED-ICU has whisked patients away too quickly and taken away from managing critically ill patients…[this] doesn’t reflect real-world practice in the vast majority of other places.” “This is a perfect rotation for ED residents.” IM RESIDENT COMMENTS: “Fewer lines, not seeing patients early in their critical care course, receiving septic patients that have been inadequately resuscitated. On the flip side, we have gotten fewer ‘quick turnaround’ admissions so censuses have been lower.” “Almost all of my admissions arrived to the unit with central lines and arterial lines in place, so I've had extremely limited practice” Sample Resident Comments on EC3 Impact on Training Despite significant anxiety expressed by both EM and IM trainees regarding EC3’s impact on training, overall procedural experience is not significantly changed for either group The Impact of an ED-Based Critical Care Unit on the Procedural Training Experience for Residents

5. Results Matthew J. Stull, MD, Laura Hopson, MD, Benjamin Bassin, MD, Lauren Heidemann, MD, Sarah Hartley, MD, Sarah Tochman, MD, Kyle Gunnerson, MD University of Michigan Medical School Conclusions Implementation of a novel Emergency Critical Care Center can lead to significant trainee anxiety on its impact on training. EC3 implementation leads to increased procedural experience for EM trainees while IM trainees may see small decreases in procedural opportunities. Results Figures/Graphs ED – Before EC3 ED – After EC3 % Change MICU – Before EC3 MICU – After EC3 % Change Central Line1625+56.3%5051+2.0% Intubations71101+42.3%2318-21.7% Arterial Line3147+51.6%6958-15.9% Thoracentesis79+28.6%83-62.5% Paracentesis5751-10.5%109-10% Introduction Methods Objectives Implementation of clinical innovations are often evaluated at the operational and patient level, but rarely on the impact of educational outcomes. Our institution developed a novel Emergency Critical Care Center (EC3) to optimize the care of critically ill patients presenting to the ED. EC3 has potential to impact Emergency Medicine (EM) and Internal Medicine (IM) resident critical care training. Purpose: To assess the impact of a novel Emergency Critical Care Center’s (EC3) implementation on: Medical Intensive Care Unit admissions Resident procedural experience Resident perceptions of critical care learning experience Retrospective analysis of procedural notes and billing data from two quarters of an academic year, one prior to EC3 implementation and one after implementation. Anonymous survey of EM and IM residents on perceptions of the impact of EC3 on training. Click headings to further view content The majority of EM trainees reported increases (50%) or unchanged (40%) comfort caring for critically ill patients after the implementation of EC3. The majority of IM trainees (79.1%) felt that EC3 had lead to a negative impact on their comfort caring for the critically ill. Comments revealed significant anxiety in both groups regarding the change in learning environment by the implementation of EC3. EM comments were focused on the concern of applicability to other practice environments. IM comments were focused on the impact of procedural experience. Billing data revealed no change in the overall number of procedures performed in the MICU after opening EC3, despite the perceived concerns by trainees. Procedural experience for EM trainees was enhanced with slight increases in the number of intubations, central lines, and arterial lines performed by EM trainees as a result of EC3 implementation. EC3 implementation resulted in an increase in the number of admissions to the MICU from outside institutions and direct admissions with slight decreases in ED or inpatient admissions to the MICU. Despite significant anxiety expressed by both EM and IM trainees regarding EC3’s impact on training, overall procedural experience is not significantly changed for either group The Impact of an ED-Based Critical Care Unit on the Procedural Training Experience for Residents

6. Conclusions Matthew J. Stull, MD, Laura Hopson, MD, Benjamin Bassin, MD, Lauren Heidemann, MD, Sarah Hartley, MD, Sarah Tochman, MD, Kyle Gunnerson, MD University of Michigan Medical School The changes in admitting sources to the MICU should be explored further. Our findings suggest that EC3 may be a potential option for facilities who struggle to meet patient demand with their currently available MICU beds. While both EM and IM residents report concern over procedural volume after implementation of EC3, this is discordant with billing data. Institutions considering implementation of an ED-ICU should carefully plan for potential changes in the educational environment including procedural experience for trainees. Conclusions Implementation of a novel Emergency Critical Care Center can lead to significant trainee anxiety on its impact on training. EC3 implementation leads to increased procedural experience for EM trainees while IM trainees may see small decreases in procedural opportunities. Results Figures/Graphs ED – Before EC3 ED – After EC3 % Change MICU – Before EC3 MICU – After EC3 % Change Central Line1625+56.3%5051+2.0% Intubations71101+42.3%2318-21.7% Arterial Line3147+51.6%6958-15.9% Thoracentesis79+28.6%83-62.5% Paracentesis5751-10.5%109-10% Introduction Methods Objectives Implementation of clinical innovations are often evaluated at the operational and patient level, but rarely on the impact of educational outcomes. Our institution developed a novel Emergency Critical Care Center (EC3) to optimize the care of critically ill patients presenting to the ED. EC3 has potential to impact Emergency Medicine (EM) and Internal Medicine (IM) resident critical care training. Purpose: To assess the impact of a novel Emergency Critical Care Center’s (EC3) implementation on: Medical Intensive Care Unit admissions Resident procedural experience Resident perceptions of critical care learning experience Retrospective analysis of procedural notes and billing data from two quarters of an academic year, one prior to EC3 implementation and one after implementation. Anonymous survey of EM and IM residents on perceptions of the impact of EC3 on training. Click headings to further view content Despite significant anxiety expressed by both EM and IM trainees regarding EC3’s impact on training, overall procedural experience is not significantly changed for either group The Impact of an ED-Based Critical Care Unit on the Procedural Training Experience for Residents