Background: Increased Emergency Department (ED) boarding times have been associated with delays in care, longer length of stay, lower patient satisfaction, increased adverse events, and increased mortality. Kobayashi et. al., coined the term “dead time” to describe the time spent awaiting admission during which meaningful contribution to the advancement of care is limited. In the current state, the demand for medicine services exceeds the capacity, and since 2022, UNC Hospitals has seen a marked increase in dead time – the time between ED decision to admit and the admitting team placing admission orders – due to a bottleneck phenomenon driven by a multitude of reasons such as inadequate hospital bed availability, limited inpatient team capacity, and inpatient throughput challenges. This has negatively impacted patient care due to prolonged delays in handoff between the emergency medicine and inpatient medicine teams.
Purpose: To bridge this gap, our Department of Medicine restructured resident and hospitalist teams to create a new team, the Medicine Care Advancement Team (MCAT), to deliver care toward this vulnerable patient population. This team is staffed by one senior resident and one attending and operates using a consult model with the emergency medicine physician functioning as the primary team. For patients selected for admission but for whom inpatient space is not immediately available, MCAT evaluates the patient and performs the tasks needed to advance their care.
Description: This team was implemented July 2024 and to date has provided direct care for 502 patients in the first 4 months (3.7 patients per day). Most patient encounters occur between the hours of 2000 and 0700 with 80% of patients evaluated by internal medicine physicians within 13 hours from ED arrival, compared to 19.5 hours in prior state (~33% reduction in delay). Patients followed by the MCAT team were subsequently routed to one of three dispositions: inpatient admission, observation, or discharge from the emergency department. Of these patients, approximately 11% (56/502) were able to be discharged directly, an increase from a discharge rate of 5.9% across other services.
Conclusions: While this does not address the cause for delays in admission, this does provide earlier access to and advancement of care and helps to allocate limited inpatient bed space to those who need it most. Additionally, increased discharge rate could be an indication of an avoided unnecessary inpatient admission, which would allow for improved access to care for those truly needing hospital admission. A unique feature of the MCAT model is the inclusion of resident house staff as part of the care team which provides multiple beneficial educational experiences. This provides senior residents opportunities to receive direct feedback and work one-on-one with an attending. This role provides experience in and education around triage, allocation of scarce resources, inpatient versus observation status, and outpatient care pathways, topics that are rarely taught directly in the current state of resident education.
