Enhancing Care for Critically Ill Patients Boarding in the Emergency Department: A 360° Evaluation of an Emergency Medicine Critical Care Fellow Model.

Objectives: Evaluate the impact of an emergency medicine-trained anesthesiology critical care (EM ACC) fellow on the delivery of critical care to patients admitted to the intensive care unit (ICU) and boarding in the emergency department (ED). Methods: This is a mixed methods observational study at a single urban tertiary care center. A second year EM ACC fellow was deployed to the ED for 2 months. We performed a 360° analysis of this pilot program using a cross-sectional staff survey, an analysis of fellow productivity, and a secondary retrospective cohort analysis of patient outcomes. Results: Fellows worked a total of 26 shifts and encountered 101 ICU boarding patients. Surveys were completed by 71 medical professionals: 22 emergency medicine (EM) physicians, 44 EM nurses, and 5 critical care (CC) physicians (n = 107, response rate 66.4%). On a 5-point Likert scale, the EM ACC fellow was reported to be invaluable or very helpful by 91.5% of all respondents. Qualitative analysis of open feedback emphasized improved team communication, coordination of care, timely interventions, and enhanced CC education. Fellows generated 3.1 work relative value unit (wRVU) per hour and 4.9 wRVU per patient while facilitating 11 (10.8%) ICU downgrades and 4 (3.9%) ICU upgrades. There were no significant differences in patient outcomes (ICU length of stay [LOS], hospital LOS, and discharge disposition). Conclusion: This model, using an EM ACC fellow, offers an approach to improve the delivery of CC to ICU patients boarding in the ED and may be modified to fit the resources, needs, and models available at different institutions. At the study institution, integrating EM ACC fellows into the ED garnered widespread support and demonstrated billing feasibility, but did not show difference in patient outcomes.