Impact of Quality Improvement Curriculum on Intensive Care Unit Upgrades by Resident Physicians




Bohman, Seth Reid

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BACKGROUND: Patients admitted to the hospital ward from the emergency department (ED) can decompensate rapidly and require transfer to the intensive care unit (ICU). These patients may benefit from identification of critical illness in the ED and earlier admission to the ICU. This could reduce delays in care, improve patient outcomes, and reduce healthcare expenses. The 66 emergency medicine (EM) residents at a single academic medical center are part of a quality improvement curriculum known as Residents Enhancing Safety and Quality (RES-Q). The "ICU upgrades" group in the curriculum evaluates patients who require transfer from the inpatient floor to the ICU within 12 hours of admission from the ED. For a period of 6 months, residents participate in structured case review of qualifying patient encounters and attempt to determine the root causes for ICU upgrades. LOCAL PROBLEM: The Parkland Hospital ED has one of the largest patient volumes in the country.1 Given the busy nature of the department, learning and following-up on patient visits by the EM residents can take the backburner. A dedicated quality analysis curriculum, called RES-Q, was enacted in 2014 to help improve the residents' education. RES-Q consists of four major groups for review: ICU upgrades, 72-hour patient return visits, intubations, ED mortalities. Two additional groups are added on a year-to-year basis depending on resident interest. Residents evaluate patient cases in these groups each month and determine if there were any issues or learning points. These analyses are then presented during the monthly EM resident conference. Participation in each group is rotated every six months over three-year span of the residents' training to allow involvement in all groups. The ICU upgrades group evaluates patients that are dispositioned to the floor but decompensate within 12 hours and subsequently get "upgraded" to an ICU bed. METHODS: A retrospective analysis was performed to determine the effectiveness of this quality improvement program in reducing the number of clinical ICU upgrades. This took place at a large, urban, county hospital with over 200,000 ED visits per year. The initial analysis compared second-year EM residents who participated in the ICU upgrades curriculum during their first year to second-year EM residents who did not participate in the curriculum during their first year. The method of maximum likelihood was estimated by fitting a generalized Poisson linear regression model to the data. INTERVENTIONS: The primary intervention consisted of a quality improvement curriculum that involved structured case review of qualifying patient encounters, focusing on resident education and exposure to common causes of intensive care unit upgrades. This was complemented by a survey of the resident physicians that participated in the program, providing insight into their perceived value of the program and the general time commitment required to complete the program. RESULTS: Analysis of the 242 qualifying ICU upgrade cases from July 2019 - December 2021 showed 19 second-year EM residents who completed the curriculum were responsible for 19 ICU upgrades, and 26 second-year EM residents who had not yet completed the curriculum were responsible for 40 ICU upgrades. The incidence rate ratio of ICU upgrade cases for second-year residents who didn't complete the curriculum was 1.54 (95% CI: 0.89-2.66; p=0.122) compared to second-year residents who completed the curriculum. CONCLUSION: Initial analysis suggests that completion of the RES-Q ICU upgrades curriculum may improve resident proficiency in recognizing and appropriately dispositioning critical patients from the ED. This is associated with reduced number of patients requiring transfer from the inpatient floor to the ICU within 12 hours of admission. A limitation to this study is that all residents participated in the monthly RES-Q conference which presents data and learning points of all groups. Additional time periods and residency classes are currently under review to better determine the effect of the RES-Q ICU upgrades curriculum.

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