Features and perceptions of a critical care outreach physician role

OBJECTIVE: To describe the tasks completed by the critical care outreach physician (CCOP) and staff perceptions of the CCOP role. DESIGN: Prospective observational study and survey of intensive care unit (ICU) staff. SETTING: University-affiliated teaching hospital in Australia. PARTICIPANTS: ICU consultants, registrars and nurses. INTERVENTIONS: Implementing a dedicated ICU consultant to review deteriorating patients outside the ICU. MAIN OUTCOME MEASURES: Prospective collection of CCOP tasks and survey of ICU staff. RESULTS: During 101 clinical shifts, the CCOP had 1524 encounters (mean, 15.1 [standard deviation, 6.1]; median, 14 [interquartile range, 10–19] per day). The three commonest interventions were emergency department visits, direct consultant communication, and coordinating ICU admissions. Involvement in Medical Emergency Team (MET) calls, expediting patient care, and goals of care discussions were also relatively common. Survey responses were obtained from 55/84 (66%) eligible participants. Most respondents thought the CCOP would improve the predefined processes of care and patient-centred outcomes. The areas of greatest perceived benefit included supporting the MET registrar and coordinating simultaneous emergencies outside the ICU. Areas where the role was perceived to be less beneficial included improving handover, identifying patients at clinical risk outside the ICU, and reducing repeat MET calls. CONCLUSIONS: The tasks of a CCOP involved high level communication, coordination of care, and supervision of ICU staff. The effect of this role on patient-centred outcomes requires further research.

Reforming the paramedic profession? Two weeks with paramedics in Germany

While paramedics in Anglo-American emergency medical services enjoy relative autonomy, paramedic practice in the Franco-German model deployed in Germany depends heavily on emergency physician input. Increasing demand, especially from low-acuity incidents, causes challenges in these countries. To address this, German politicians plan to implement extensive emergency care reforms and consider an update of regulations around paramedic practice. A 2-week placement allowed for practice observation, discussions with stakeholders and a review of various resources to identify current issues in Germany. These include legal discrepancies, significant local differences in scope of practice, limited career opportunities and influence on clinical guidelines. Although the update and reforms are intended to resolve some of these problems, a groundbreaking evolution of the profession from its current restrictions is not expected. Possible development of the emergency physician role and associated specialities as a response to emergency care challenges is less debated.

Redesigning the Clinical Learning Environment to Improve Interprofessional Care and Education: Multi-Method Program Evaluation of the iPACE Pilot Unit

ABSTRACT Background In 2016, Maine Medical Center received an Accreditation Council for Graduate Medical Education Pursuing Excellence in Innovation grant to redesign the clinical learning environment to promote interprofessional care and education. The Interprofessional Partnership to Advance Care and Education (iPACE) model was developed and piloted on an adult inpatient medicine unit as an attempt achieve these aims. Objective We describe the iPACE model and associated outcomes. Methods Surveys and focus groups were employed as part of a multimethod pragmatic observational strategy. Team surveys included relational coordination (RC): a validated proprietary measure of interpersonal communication and relationships within teams. Pre-iPACE respondents were a representative historical sample from comparable inpatient medical units surveyed from March to April 2017. iPACE respondents were model participants surveyed March to August 2018 to allow for adequate sample size. Results Surveys were administered to pre-iPACE (N = 113, response rate 74%) and iPACE (N = 32, 54%) teams. Summary RC scores were significantly higher for iPACE respondents (iPACE 4.26 [SD 0.37] vs 3.72 [SD 0.44], P < .0001), and these respondents were also more likely to report a professionally rewarding experience (iPACE 4.4 [SD 0.6] vs 3.5 [SD 1.0], P < .0001). Learners felt the model was successful in teaching interprofessional best practices but were concerned it may hinder physician role development. Patient experience was positive. Conclusions This pilot may have a positive effect on team functioning and team member professional experience and patient experience. Learner acceptance may be improved by increasing autonomy and preserving traditional learning venues.

Unexpected Intimacies

Anthropologists examining the relationship between physician and patient in Western biomedicine have observed an inherent power discrepancy between the physician, assumed to hold scientific knowledge, and the patient, the recipient of this knowledge. COVID-19 presents a unique challenge to that dynamic, as physicians, scientists and medical experts possess limited understanding of the pathophysiology, interventions and treatment of the disease. Drawing on my experience as a resident physician on the frontlines of the COVID-19 pandemic, I contend that the absence of knowledge surrounding COVID-19 fosters a new form of intimacy between physician and patient through greater emphasis on subjective patient experience, increased transparency between physician and patient, and an expanding physician role beyond management of the physical disease state.

LO28: Innovating for overcrowding: analyzing the impact of a novel emergency physician role on patient flow

Introduction: Overcrowding in the Emergency Department (ED) results in delays in care, and increased patient morbidity and mortality. Innovative departmental approaches have the potential to make patient flow through the ED more efficient and reduce overcrowding by improving patient throughput. The Calgary zone ED recently piloted a new physician role, the Emergency Physician Lead (EPL), a senior physician working closely with the charge nurse and consulting services to provide physician leadership, and to troubleshoot flow issues and safety breeches such as EMS offload delays and long emergency inpatient (EIP) stays. The objective of this study was to evaluate the efficacy of the EPL by determining its effect on key metrics of patient flow, and by identifying which specific EPL interventions were most effective at improving patient throughput. Methods: A retrospective cohort design was used to compare Foothills Medical Centre (FMC) ED patients seen by the EPL from March-June 2019 (n = 1343 patients) with a control group from the same period in 2018 (n = 5530). An EMR search was used to collect patient data and generate descriptive statistics, which were compared between groups by Mann-Whitney U-test. Patient handover notes left by the EPL were also collected and analyzed by two independent assessors to develop a list of actions taken by the EPL. Each patient was then coded based on the actions in the handover note, and means for each coded group were compared to control to find correlations between action and changes in key flow metrics. Results: Patients whose care involved the EPL had a 40% shorter average ED length of stay (ELOS) compared to control (515 vs 865 min, p < 0.001). The EPL was especially effective for patients with ELOS above the 90th percentile, with a 58% relative reduction. EPL patients also had lower average times from first contact with the department to first order being placed (79 vs 143 min, p < 0.001), and spent less time as EIPs after being admitted (390 vs 515 mins, p < 0.001). EPL actions aimed at early ordering of investigations or early management showed the largest relative reductions in ELOS, followed by actions related to resolving issues with consulting services (56% and 48% respectively, p < 0.001). Conclusion: The EPL role appears to be associated with improvements in several key metrics of patient flow. Specific EPL actions were correlated with marked decreases in length of stay. The EPL may be an effective strategy to improve patient throughput and combat ED overcrowding.

Percepção dos estudantes de medicina sobre medicina de família e comunidade

Avaliar a influência de uma matriz curricular na percepção dos discentes de medicina sobre medicina de família e comunidade e na escolha por essa especialidade. Estudo qualitativo-quantitativo de cunho exploratório e transversal, efetuado por meio de questionário semiestruturado com acadêmicos do primeiro e do décimo-segundo semestres de medicina de um centro universitário brasileiro. Foram realizadas as análises descritivas e não paramétricas, com um nível de significância de 5%. Egressos conheciam bem a especialidade medicina de família e comunidade, ao contrário dos que estavam iniciando o curso. Dentre os fatores curriculares estudados, apenas o contato com um profissional modelo médico de família e comunidade foi estatisticamente significante para a escolha pela carreira (p-valor de 0,02). Este estudo sugere que o contato com médicos de família e comunidade e a inserção precoce e contínua na atenção básica durante a graduação contribuem para o interesse por essa especialidade.Descritores: Educação Médica, Medicina de Família e Comunidade, Currículo. Medical students’ perceptions on family medicineAbstract: To evaluate the influence of a medical program in medical students’ perceptions towards family medicine and in choosing a career in this field. A cross-sectional exploratory and qualitative-quantitative survey accomplished by the application of a semi-structured questionnaire. This research encompasses first and twelfth semesters medical students from a Brazilian university center. We performed a descriptive and a non-parametric analysis, with a significance level of 5%. Family Medicine was not well known by medical students who were beginning their graduation and very well known by those finishing medical school. Among the curriculum aspects studied, only the contact with a family medicine physician role model was statistically significant to affect the graduates’ career choice in family medicine (p-value 0.02). This study suggests that the contact with family physicians and the early and continued insertion in primary care during graduation contribute to a greater interest in this specialty.Descriptors: Medical Education, Family Practice, Curriculum. Percepción de los estudiantes de medicina sobre medicina de família y comunidadResumen: Evaluar la influencia de una matriz curricular en la percepción de los estudiantes de medicina con foco en la medicina de família y comunidade. Estudio cualitativo-cuantitativo de cuño exploratório trabajando la transversalidad, efectuado por medio de cuestionários semi estructurado aplicado a academicos de medicina de una institución universitária brasileña. Fueron realizadas los análisis descriptivas y no paramétricas, con un nível de significancia de un 5%. Egresos conocian bien la especialidad, En oposición a los que estaban iniciando el curso. Entre los factores curriculares estudiados, fué registrado como importante el contacto con un profisional modelo médico de família y comunidad que resultó estadísticamente significante para la elección de esta carrera (p-valor 0,02). Este Estudio sugiere que el contacto con médicos de família y comunidade, la inserción precoz y contínua em los servicios de atención básica durante la graduação contribuyen para despertar el interés por esa especialidad.Descriptores: Educación Médica, Medicina de Família y Comunidad, Currículum.