Implementation of a Multidisciplinary Care Pathway via an Emergency Department-ICU to Improve Care of Emergency Department Patients Presenting With Leukostasis

Nathan L Haas; Abhinav Nafday; James A Cranford; Sarah E Yentz; Dale L Bixby; Benjamin S Bassin

doi:10.1097/CCE.0000000000000084

Implementation of a Multidisciplinary Care Pathway via an Emergency Department-ICU to Improve Care of Emergency Department Patients Presenting With Leukostasis

Crit Care Explor. 2020 Feb 24;2(2):e0084. doi: 10.1097/CCE.0000000000000084. eCollection 2020 Feb.

Authors

Nathan L Haas^{1

2}, Abhinav Nafday¹, James A Cranford¹, Sarah E Yentz³, Dale L Bixby³, Benjamin S Bassin^{1

2

4}

Affiliations

¹ Department of Emergency Medicine, University of Michigan, Ann Arbor, MI.
² Department of Emergency Medicine, Division of Critical Care, University of Michigan, Ann Arbor, MI.
³ Department of Internal Medicine, Division of Hematology and Medical Oncology, University of Michigan, Ann Arbor, MI.
⁴ Michigan Center for Integrative Research in Critical Care, University of Michigan, Ann Arbor, MI.

Abstract

Leukostasis is a life-threatening complication of acute hyperleukocytic leukemia, and is associated with substantial mortality. Management of leukostasis requires time-sensitive diagnostics and therapeutics, and leukapheresis remains a mainstay of treatment in select patients. Leukapheresis requires coordination of multi-disciplinary resources, which can prove challenging in the emergency department setting, and delays in treatment due to the complexity and coordination required are common. The objective of this study was to assess the effect of utilization of an emergency department-ICU and a multidisciplinary care pathway on outcomes of critically ill leukostasis patients presenting to the emergency department.

Design: Retrospective cohort study.

Setting: Single large academic medical center in the United States.

Patients: Adult emergency department patients with signs and symptoms of leukostasis requiring emergent leukapheresis from 2012-2019.

Interventions: Implementation of a hybrid emergency department-ICU setting (emergency critical care center) and a multidisciplinary care pathway with members from Emergency Medicine, Hematology, Blood Bank, and Clinical Pathology.

Measurements and main results: A total of 70 patients were identified and included for analysis: 14 preemergency critical care center; 32 postemergency critical care center, premultidisciplinary care pathway; and 24 postemergency critical care center, postmultidisciplinary care pathway. A statistically significant reduction in the time from emergency department presentation to initiation of leukapheresis was observed from preemergency critical care center to postemergency critical care center, premultidisciplinary care pathway and postemergency critical care center, postmultidisciplinary care pathway (11.5 vs 7.9 vs 7.7 hr; p = 0.004). Statistically significant reductions in in-hospital mortality were observed from preemergency critical care center to postemergency critical care center, premultidisciplinary care pathway and postemergency critical care center, postmultidisciplinary care pathway (64.3% vs 21.9% vs 25.0%; p = 0.01). A trend toward decreased inpatient ICU utilization was observed, although was not statistically significant (35.7% vs 12.5% vs 25.0%; p = 0.14.).

Conclusions and relevance: Implementation of a multidisciplinary care pathway via use of an emergency department-ICU for critically ill patients with leukostasis was associated with statistically significant reductions in time to leukapheresis and in-hospital mortality. These findings suggest an emergency department-ICU model may allow for maximal resource and care coordination at the point of contact with critically ill patients and improved clinical outcomes.

Keywords: blast crisis; emergency department; emergency department-intensive care unit; leukapheresis; leukemia; leukostasis.