Triaging Inpatient Admissions: an Opportunity for Resident Education

Rapid implementation of a medical student rotation in health systems operations and remote patient care in response to COVID-19

Medical schools initially removed students from clinical rotations at the outset of COVID-19 for safety reasons when students were eager to help and health systems needed personnel. In response, we rapidly implemented an innovative 2-week rotation for medical students to participate in health systems operations and care through remote efforts including triage and resource allocation. The curriculum also contained online self-paced educational modules covering topics including ethics, crisis standards of care, and modeling. As the health system needs shifted, so too did learners' work. One hundred and twenty-five 3rd and 4th-year students completed the experience over 10 months. Learner satisfaction, confidence, and knowledge assessed through pre- and post-rotation surveys showed statistically significant and educationally meaningful improvement. A near uniform change greater than 1 point (on a 5-point scale) was demonstrated upon rotation completion. Blending health systems and educational structures to meet the needs of both creates unique opportunities to educate students in new ways.

Utilization of an Internal Medicine Triaging Resident in the Emergency Department Reduces Preventable Admissions and Improves Trainee Experiences

OBJECTIVE

Increasing patient care requirements and suboptimal communication between emergency department (ED) and Internal Medicine (IM) services may lead to inefficient hospital utilization, lapses in transitions of care, and reduced trainee satisfaction in the inpatient setting. Furthermore, a lack of triaging roles for IM trainees has been a common limitation in graduate medical education. We aimed to demonstrate that the addition of an IM triaging resident (TR) in the ED may represent an innovative solution to these problems.

METHODS

A single-center pilot study was performed. An IM trainee served as the TR at a tertiary Veterans Affairs hospital for 2 weeks. The TR evaluated medical patients in a parallel manner with ED physicians and assisted in the initial management, disposition, and transitions of care under the supervision of an IM attending physician. Hospital utilization and patient safety were tracked using electronic records, and trainee satisfaction was measured using daily surveys administered to IM resident teams.

RESULTS

Of the 62 cases evaluated by the TR for medical admission, 26 (42%) represented preventable admissions; 12 (46%) of those patients were discharged from the ED, representing a 19% overall reduction. There were statistically significant improvements in trainee experiences relating to patient flow (P < 0.01) and initial patient management (P < 0.02), and our intervention did not have a negative impact on ED performance metrics or patient safety.

CONCLUSIONS

Expansion of this model in select integrated health systems may improve graduate medical education and healthcare system performance. Future iterations of this study can aim to improve transitions of care between ambulatory and inpatient providers and limit the overuse of antimicrobial agents, radiography, and consultative services.

When Duty Calls, Resident Physicians Answer: Learning to Take Transfer Calls

BACKGROUND AND OBJECTIVE

Transitions of care are error-prone. Standardized handoffs at transitions improve safety. There are limited published curricula teaching residents to perform interfacility transfer calls or providing a framework for performance evaluation. The objective of this study was to measure the impact of a workshop utilizing a standardized handoff tool on resident-reported confidence in taking transfer calls and observed behavioral change in a simulated environment.

METHODS

A pre- and posteducational intervention trial was performed at a large children's hospital in March 2021. A 1-hour session highlighting the importance of phone communication, outlining an evidence-based handoff tool, and reviewing cases was delivered to 44 of 75 residents who attended scheduled didactics. The workshop's effectiveness was measured by rating behavioral change in a simulated environment. Calls were scored by using a 0 to 24 summative score checklist created from the handoff tool. A paired t test was used to analyze the differences in pre- and postintervention scores. Resident confidence, knowledge of the call process, and perceived importance of skill were measured with an internally developed retrospective pre- and postsurvey. The survey results were analyzed with a Wilcoxon rank test and Kruskal-Wallis test.

RESULTS

Behaviors in a simulated environment, measured by an average score on the grading checklist, had a mean score increase of 6.52 points (P <.0001). Of the participants, 95% completed the survey, which revealed that reported confidence, knowledge of the transfer call process, and importance of transfer call skills increased significantly (P <.0001).

CONCLUSIONS

This workshop improved resident behaviors in a simulated environment, confidence, and knowledge of the transfer call process, demonstrating the utility of providing a standardized tool and education to improve transitions of care.

Qualitative analysis of disposition decision making for patients referred for admission from the emergency department without definite medical acuity

OBJECTIVE

To map the physician approach when determining disposition for a patient who presents without the level of definite medical acuity that would generally warrant hospitalisation.

DATA SOURCES/STUDY SETTING

Since 2018, our US academic county hospital/trauma centre has maintained a database in which hospitalists ('triage physicians') document the rationale and outcomes of requests for admission to the acute care medical ward during each shift.

STUDY DESIGN

Narrative text from the database was analysed using a grounded theory approach to identify major themes and subthemes, and a conceptual model of the admission decision-making process was constructed.

PARTICIPANTS

Database entries were included (n=300) if the admission call originated from the emergency department and if the triage physician characterised the request as potentially inappropriate because the patient did not have definite medical acuity.

RESULTS

Admission decision making occurs in three main phases: evaluation of unmet needs, assessment of risk and re-evaluation. Importantly, admission decision making is not solely based on medical acuity or clinical algorithms, and patients without a definite medical need for admission are hospitalised when physicians believe a potential issue exists if discharged. In this way, factors such as homelessness, substance use disorder, frailty, etc, contribute to admission because they raise concern about patient safety and/or barriers to appropriate treatment. Physician decision making can be altered by activities such as care coordination, advocacy by the patient or surrogate, interactions with other physicians or a change in clinical trajectory.

CONCLUSIONS

The decision to admit ultimately remains a clinical determination constructed between physician and patient. Physicians use a holistic process that incorporates broad consideration of the patient's medical and social needs with emphasis on risk assessment; thus, any analysis of hospitalisation trends or efforts to impact such should seek to understand this individual-level decision making.

Letting Residents Lead: Implementing Resident Admission Triage Call Curriculum and Practice

BACKGROUND AND OBJECTIVES

Graduating residents are expected to be competent in triaging patients to appropriate resources. Before 2017, pediatric residents were not involved in admission triage decisions. In 2017, after implementing an admission triage curriculum (ATC), residents had opportunities to be involved in overnight admission calls with the emergency department (ED), which were initially supervised (joint calls), and as skills progressed, residents conducted calls and admitted patients independently. We implemented and evaluated the impact of a graduated ATC intervention bundle on pediatric resident opportunities to participate in admission triage, while monitoring resident confidence, the ED experience, and patient safety.

METHODS

We evaluated the impact of our ATC using quality improvement methodology. The primary outcome was the frequency of resident participation in joint and independent triage calls. Other measures included resident confidence, the ED clinician experience, and patient safety. Resident confidence and the ED clinician experience were rated via surveys. Safety was monitored with daytime hospitalist morning assessments and postadmission complications documented in the medical record.

RESULTS

The percent of joint calls with the hospitalist increased from 7% to 88%, and 125 patients were admitted independently. Residents reported significant increases in adequacy of triage training and confidence in 3 triage skills (P < .001) after ATC. There were no complications or safety concerns on patients admitted by residents. ED clinicians reported increased admitting process efficiency and satisfaction.

CONCLUSIONS

Our ATC intervention bundle increased the number of admission decision opportunities for pediatric residents, while increasing resident triage confidence, maintaining safety, and improving ED clinician experience.

Hospitalists as Triagists: Description of the Triagist Role across Academic Medical Centers

From the hospitalist perspective, triaging involves the evaluation of a patient for potential admission to an inpatient service. Although traditionally done by residents, many academic hospitalist groups have assumed the responsibility for triaging. We conducted a cross-sectional survey of 235 adult hospitalists at 10 academic medical centers (AMCs) to describe the similarities and differences in the triagist role and assess the activities and skills associated with the role. Eight AMCs have a defined triagist role; at the others, hospitalists supervise residents/advanced practice providers. The triagist role is generally filled by a faculty physician and shared by all hospitalists.We found significant variability in verbal communication practices (P = .02) and electronic communication practices (P < .0001) between the triagist and the current provider (eg, emergency department, clinic provider), and in the percentage of patients evaluated in person (P < .0001). Communication skills, personal efficiency, and systems knowledge are dominant themes of attributes of an effective triagist.