An Interdepartmental Care Model to Expedite Admission from the Emergency Department to the Medical ICU.

BACKGROUND: Early evidence suggests that multidisciplinary programs designed to expedite transfer from the emergency department (ED) may decrease boarding times. However, few models exist that provide effective ways to improve the ED- to-ICU transition process. In 2012 Christiana Care Health System (Newark, Delaware) created and implemented an interdepartmental program designed to expedite the transition of care from the ED to the medical ICU (MICU). METHODS: This quasi-experimental study compared ED length of stay (LOS), MICU LOS, and overall hospital LOS before and after the MICU Alert Team (MAT) intervention program. The MAT consisted of a MICU nurse and physician assistant, with oversight by a MICU attending physician. The ED triggered the MAT after patients were stabilized and determined to require MICU admission. Following bedside face-to-face hand off, the MAT providers then assumed responsibly of a patient's care. If no MICU bed was available, the MAT cared for patients in the ED until they were transferred to the MICU. RESULTS: ED LOS was reduced by 30% (2.6 hours) from baseline (p < .001). There were no significant differences in MICU LOS (p = .26), overall hospital LOS (p = .43), or mortality (p = .59). ED LOS was shortened (p < .001) at each increasing level of MICU bed availability (31% when 0 MICU beds available; 26% when 1 or more MICU beds available). Time series analysis identified a 1.5-hour drop in ED LOS (p = .02) for patients transferred from the MICU immediately following intervention implementation and was sustained over time. CONCLUSION: Early outcomes demonstrate that the MAT intervention can reduce ED LOS for critically ill patients. Additional studies should determine optimal approaches to improve clinical outcomes.

Improving Resident Performance Through a Simulated Rapid Response Team: A Pilot Study.

BACKGROUND: The Joint Commission requires hospitals to develop systems in which a team of clinicians can rapidly recognize and respond to changes in a patient's condition. The rapid response team (RRT) concept has been widely adopted as the solution to this mandate. The role of house staff in RRTs and the impact on resident education has been controversial. At Christiana Care Health System, eligible residents in their second through final years lead the RRTs. OBJECTIVE: To evaluate the use of a team-based, interdisciplinary RRT training program for educating and training first-year residents in an effort to improve global RRT performance before residents start their second year. METHODS: This pilot study was administered in 3 phases. Phase 1 provided residents with classroom-based didactic sessions using case-based RRT scenarios. Multiple choice examinations were administered, as well as a confidence survey based on a Likert scale before and after phase 1 of the program. Phase 2 involved experiential training in which residents engaged as mentored participants in actual RRT calls. A qualitative survey was used to measure perceived program effectiveness after phase 2. In phase 3, led by senior residents, simulated RRTs using medical mannequins were conducted. Participants were divided into 5 teams, in which each resident would rotate in the roles of leader, nurse, and respiratory therapist. This phase measured resident performance with regard to medical decision making, data gathering, and team behaviors during the simulated RRT scenarios. Performance was scored by an attending and a senior resident. RESULTS: A total of 18 residents were eligible (N=18) for participation. The average multiple choice test score improved by 20% after didactic training. The average confidence survey score before training was 3.44 out of 5 (69%) and after training was 4.13 (83%), indicating a 14% improvement. High-quality team behaviors correlated with medical decision making (0.92) more closely than did high-quality data gathering (0.11). This difference narrowed during high-pressure scenarios (0.84 and 0.72, respectively). CONCLUSION: Our data suggest that resident training using a team-based, interdisciplinary RRT training program may improve resident education, interdisciplinary team-based dynamics, and global RRT performance. In turn, data gathering and medical decision making may be enhanced, which may result in better patient outcomes during RRT scenarios.

On Latent Growth Models for Composites and Their Constituents.

Over the last decade and a half, latent growth modeling has become an extremely popular and versatile technique for evaluating longitudinal change and its determinants. Most common among the models applied are those for a single measured variable over time. This model has been extended in a variety of ways, most relevant for the current work being the multidomain and the second-order latent growth models. Whereas the former allows for growth function characteristics to be modeled for multiple outcomes simultaneously, with the degree of growth characteristics' relations assessed within the model (e.g., cross-domain slope factor correlations), the latter models growth in latent outcomes, each of which has effect indicators repeated over time. But what if one has an outcome that is believed to be formative relative to its indicator variables rather than latent? In this case, where the outcome is a composite of multiple constituents, modeling change over time is less straightforward. This article provides analytical and applied details for simultaneously modeling growth in composites and their constituent elements, including a real data example using a general computer self-efficacy questionnaire.