Care Of Complex Patients Research Articles

Noise in the Postanesthesia Care Unit: Identifying Potential Causes for Increased Noise Levels

PurposeWith increasingly complex care, monitor alarms, and high patient traffic, the postanesthesia care unit (PACU) is one of the loudest patient care areas in the hospital. High noise levels lead to worse outcomes and impede recovery. The objective of this study is to measure the sound levels in the PACU and identify potential causes for increased sound levels. DesignAn observational study in the 24-unit PACU in the Ghent University Hospital was conducted. MethodsSound levels were measured every second continuously at 3 separate locations using noise dosimeters over a period of 11 days. During the sound measurements, the patient and nurse census in the PACU was measured. FindingsThe mean A weighted equivalent sound level pressure (LAeq) was 59.0 A-weighted decibel (dBA) (standard deviation 6.5), exceeded the noise levels recommended by the World Health Organization (40 dBA LAEQ). With an average LAEQ of 62.4 dBA (6.1), the morning shift is the noisiest. We evaluated the effect of patient census and nurse census on LAEQ. The overall regression was statistically significant (P < .001). Nurse census and patient census significantly predicted noise levels (P < .001). ConclusionsNoise levels in the PACU were consistently above the levels recommended by the World Health Organization. Nurse census and patient census seemed to significantly impact the mean noise levels. Our results suggest that the most important sources of ambient noise are consistently present sources such as computers, ventilation systems, air-conditioning. These factors, along with the architectural design and nurse and patient census, might play a very important role in noise control.

Motivasi dan Tantangan Tamatan Perawat Dalam Mencapai Kelulusan NCLEX-RN di California

Introduction: Significant factors in influencing students' ability to pass the competency test include academic, cognitive, and individual aspects. Several factors that influence the success of the competency test from the perspective of student preparation in learning include motivation, reading ability, record management, time management, and critical thinking skills. Objective: This study aims to analyze the motivation and challenges of nurse graduates from Universitas Advent Indonesia in achieving graduation on the NCLEX-RN exam in California. Method: This study is a qualitative study with a phenomenological study that collects research data through in-depth interviews consisting of six UNAI alumni participants in California. Results: the results of the study in the form of research themes, namely: preparing for and requirements for the NCLEX exam, factors causing failure to pass the NCLEX exam, and motivation to take and pass the NCLEX exam. Conclusion: Nurses’ motivations in achieving NCLEX RN graduation in California are to improve finances, flexible working hours, make family happy, and be involved in complex patient care. Nurses’ challenges in achieving NCLEX RN graduation in California are meeting the administrative requirements for registering for the NCLEX RN exam, managing study time, understanding the material and the purpose of the exam questions, and adapting to the CAT exam system

Streamlining Radiology Reporting: A Hands-Free Approach With Voice to Text and Generative Artificial Intelligence

ObjectiveIn radiology, report generation is critical for patient management, though can be time-consuming and labor-intensive. This study aims to investigate the feasibility of a hands-free radiology reporting system, leveraging voice-to-text technology and generative AI to improve time efficiency, report standardization, and reduce radiologist workload. Methods100 chest and musculoskeletal radiographs reports were generated using both traditional methods and an automated process using generative AI. To use generative AI, a radiologist dictated their findings into a voice-to-text software (Dragon), creating a raw text transcript. GPT-4 was then used to develop a report based on our institution’s template. Completion time for each traditional report and voice-to-text transcript was recorded. All reports were then evaluated for comprehensiveness, clarity, factual accuracy, and conciseness on a 5-point Likert scale. ResultsThe AI-driven system demonstrated considerable proficiency in transcribing and generating radiology reports, albeit with occasional inaccuracies. While it achieved a high level of precision in standard scenarios, its performance varied in more complex cases. Notably, the system significantly reduced the time taken to generate reports by 38% (p < 0.0001), signifying a potential increase in overall radiological workflow efficiency. ConclusionThis study highlights the potential of voice-to-text and generative AI integration in radiology reporting. Increased time efficiency, even in standard scenarios, can allow radiologists to focus more on complex cases and patient care. However, further development and refinement are required to address comprehensiveness and occasional inaccuracies. Ongoing advancements in AI and speech recognition technologies suggest a positive outlook for future implementations in medical reporting.

An Improvised External Ventricular Drain Fixation Technique to Avoid Pullout-Related Complications in a Low-Resource Setting: A Descriptive Cross-Sectional Study in a Single Center of Nepal.

An external ventricular drain (EVD) placement is a commonly performed life-saving procedure. Its accidental pullout can occur in complex environments, patient care, and positioning, which leads to significant morbidity. The method of EVD fixation and pullout rates is sparsely described in the literature, and there exists a wide variation among the techniques practiced for fixation. However, some techniques require additional tools, which are expensive and unavailable in low-resource settings. We describe an improvised method of securely fixing the EVD to the scalp applicable in low-resources and describe the EVD pullout rate with the use of this technique. A retrospective review of pullout-related complications in 107 consecutive patients was performed. The EVD was fixed to the scalp using an improvised technique to loop the catheter around a soft flange and secure it with sutures. Pullout occurred in 1 patient (0.93%), who was in an alcohol withdrawal state and deliberately pulled out the catheter. There were zero nondeliberate pullouts. EVD fixation by coiling the catheter around a soft flange has a low pullout rate. Because it is secure and requires only a flange, it is suitable for low-resource settings.

Complex primary care for multimorbid patients in the Netherlands: Interprofessional perspectives within and beyond general practice

Many consultations in general practice concern patients with multimorbidity, pressuring our healthcare systems with complex care needs. The number of people affected from multimorbidity is still increasing, as is the average number of co-occurring diseases per patient. The resulting complexity of care needs cannot be managed by health professionals from a single discipline, but requires interprofessional collaborative practice.This paper describes best practices from the Netherlands to facilitate interprofessional caretaking of patients with multimorbidity in primary care. The focus here is on collaborations within general practice and at community level.

Improving Endoscopy Nursing Staff's Patient Management Through the Implementation of an Education Initiative.

Endoscopic procedure areas have high-volume, fast-paced work environments. This practice requires a diverse range of knowledge and skills that are continuously changing with the evolution of high-acuity procedures and the shift toward routine use of anesthesia services. Endoscopy nursing staff have recently shown higher levels of stress and emotional exhaustion than their colleagues in similar practice settings. Patient management and recovery from anesthesia are identified by this group of nurses as a perceived stressor with high priority for improvement in competencies. Standardized education in collaboration with anesthesia services regarding these topics does not exist. As an improvement initiative, a standardized education guide was developed and implemented in an urban endoscopy unit situated within a Level 1 trauma center to improve nursing staff's patient management, knowledge, and readiness. Nursing knowledge was evaluated before and after the delivery of an educational presentation. Results demonstrated a substantial improvement in nursing knowledge and preparedness for complex procedures and high-acuity patients. Implementation of a similar standardized endoscopy nursing education guide has the potential to positively impact endoscopy nursing staff's knowledge and preparedness related to complex endoscopy patient care delivery, possibly relieving a source of stress for endoscopy staff and improving patient safety.

Quo Vadis, ECMO? Multidisciplinary Hybrid Extra Corporeal Membrane Oxygenation Rounds During the COVID-19 Pandemic

The complex care of patients on ECMO requires a high level of collaboration between multiple medical specialties and allied health professionals. Effective and timely communication between team members is imperative in ensuring patient safety. The COVID-19 pandemic posed unique challenges in the care of patients on ECMO. Communication between team members was complicated by social distancing recommendations, increased patient volume, and staff turnover. In this article, we describe a hybrid approach to rounds that allowed team members to attend virtually or in-person to improve team communication. Weekly hybrid ECMO rounds were held to discuss patient cases and work collectively to establish patient centered goals for the following week. Critical care and surgical consultants, RN ECMO specialists, RNs, perfusionists, respiratory therapists, physical and occupational therapists, pharmacists, ethics committee members, and patient family members were invited to attend hybrid ECMO rounds. After eight months of rounds, medical care team members were asked to provide feedback regarding the rounds format, strengths, and weaknesses. The most frequently identified strengths were improved multidisciplinary communication and continuity of care. This article demonstrates that hybrid virtual and in-person patient rounds are a feasible way for ECMO programs to improve team communication and overall patient care.

Ensuring comprehensive access to care for frail and complex patients, but not just through the ED.

Ensuring comprehensive access to care for frail and complex patients, but not just through the ED.

Beyond the business-to-client model: how the business-to-business model can transform the complex patient care

Beyond the business-to-client model: how the business-to-business model can transform the complex patient care

Impact of Preoperative Multidisciplinary Conference on Head and Neck Reconstruction Outcomes.

Head and neck oncologic resections with microvascular reconstruction are lengthy and complex procedures with inefficiencies in the operating room (OR) associated with increased complications and higher costs. Multidisciplinary care has become increasingly used to provide improved care for complex patients; however, the potential role of this has not yet been studied in head and neck microvascular free flap procedures. Patients between 2016 and 2022 treated before and after implementation of the conference were included. Primary outcome was total procedure time (TPT). Demographics, operative details, and postoperative complications were also collected. 233 patients were included in the preconference group and 330 in the post-conference group. Preconference mean (SD) age was 61.6 (12) years versus 62.9 (12) years in the post-conference group. The post-conference group was associated with shorter mean (SD) TPT (629 [117] vs. 719 [134] minutes), less mean (SD) estimated blood loss (ESD) (230 [201] mL vs. 306 [211] mL), fewer prolonged lCU stays (>1 day), and fewer returns to the operating room (RTOR). The post-conference group was associated with TPT ≤9 h (p < 0.001) on multivariate analysis. Factors associated with TPT greater than 9 h include history of head and neck radiation (p = 0.003), bony reconstruction (p = 0.05), stage IVa (p = 0.009), and stage IVb cancer (p < 0.001). Implementation of the multidisciplinary conference in head and neck surgery was associated with reduced TPT and reduced OR return. Our study suggests preoperative planning conferences may improve surgical efficiency and outcomes in head and neck oncologic resections with microvascular free flap reconstruction. 3 Laryngoscope, 2024.

Multidisciplinary Collaboration in Hospitals via Patient- and Process-Oriented Units: A Longitudinal Study.

The complexity of healthcare is increasing, mainly due to the prevalence of multimorbidity in an ageing population. Complex care for patients with multimorbidity requires a multidisciplinary approach. Traditional physician-centered hospital structures do not facilitate the necessary multidisciplinary collaboration. European hospitals are implementing process-based hospital designs with patient- and process-oriented units to stimulate multidisciplinary collaboration. Patient-oriented units are formed based on shared patient groups and focus on care trajectories, while process-oriented units are formed based on having similar processes and focus on efficiency. This study has two aims. First, to study the effect of introduction of these units on multidisciplinary collaboration and perceived impact (efficiency, innovation, and effectiveness). Second, to study whether there are differences between patient- and process-oriented units. A survey-based longitudinal evaluation study was conducted in 2020 and 2022 among physicians in a Dutch hospital to measure multidisciplinary collaboration (relational coordination) and perceived impact (efficiency, innovation, and effectiveness). In addition, open questions were used to enrich the data. Quantitative and qualitative data together suggest that physicians in patient-oriented units notice benefits from the redesign to multidisciplinary units, they perceive higher impact over time. Physicians in process-oriented units achieve a better relationship with the physicians in their unit over time, but they do not perceive impact as high as physicians in patient-oriented units. A process-based design with patient- and process-oriented units is supportive of multidisciplinary collaboration and perceived impact, especially for physicians in patient-oriented units. Physicians in patient-oriented units are positive about the introduction of these units as they feel it contributes to better multidisciplinary patient care. As the results for physicians in process-oriented units may be less directly visible in terms of quality of care, they are less likely to see positive effects, even though their relationships are improving.

Challenges of care coordination for complex patients among family medicine residents in a community ambulatory clinic: a qualitative study

BackgroundCare coordination has been identified as one of five focuses of HealthierSG. Family medicine residents are expected to collaborate with other healthcare professionals for complex patients by the end of residency. However, many residents felt that it was challenging to coordinate care effectively among healthcare stakeholders. However, to date, no qualitative studies have explored these challenges. Therefore, this study aimed to understand the challenges encountered by family medicine residents when coordinating care for complex patients.MethodsThis was a qualitative descriptive study in which semi structured in-depth interviews were conducted and guided by a topic guide. Total population sampling of 15 third-year family medicine residents in the National Healthcare Group Polyclinics was performed. The interviews were performed over Zoom and were transcribed. Thematic analysis was subsequently performed to analyse the transcripts. Coding was performed iteratively by two independent researchers. Disagreements were adjudicated by a third coder. A coding framework was agreed upon. Potential themes were then independently developed based on the coding framework.ResultsSix themes emerged from the data, namely, interprofessional communications, accessibility, personal knowledge, time constraints, patient factors and caregiver dissent.ConclusionChallenges faced by family medicine residents are multifaceted. While a few are systemic and pertain to the broader healthcare framework, others, such as issues of unfamiliarity with institutional workflows, community resources, and confidentiality, pertain to the microcosm of residency itself. These are reversible areas for improvement. These challenges can be addressed during planning of residency curricula to better equip family medicine residents with coordinating care for complex patients in the future.

Risk Versus Reward: Hospitals Incentivized More Than Surgeons to Care for Riskier Arthroplasty Patients

BackgroundThe purpose of this study was to assess the relationship between risk and reimbursement for both surgeons and hospitals among Medicare patients undergoing primary total joint arthroplasty (TJA). MethodsThe “2021 Medicare Physician and Other Provider” and “2021 Medicare Inpatient Hospitals” files were used. Patient comorbidity profiles were collected, including the mean patient hierarchal condition category (HCC) risk score. Surgeon data included all primary TJA procedures (inpatient and outpatient) billed to Medicare in 2021, while hospital data included all such inpatient episodes. Surgeon and hospital reimbursements were collected. All episodes were split into a “sicker cohort” with an HCC risk score of 1.5 or more and a “healthier cohort” with HCC risk scores less than 1.5. Variables were compared across cohorts. ResultsIn 2021, 386,355 primary total hip and knee arthroplasty procedures were billed to Medicare and were included. The mean surgeon reimbursement among the sicker cohort was $1,021.91, which was less than for the healthier cohort of $1,060.13 (P < .001). Meanwhile, for the hospital analysis, 112,012 Medicare TJA patients were admitted as inpatients and included. The mean reimbursement to hospitals was significantly greater for the sicker cohort at $13,950.66, compared to the healthier cohort of $8,430.46. For both analyses, the sicker patient cohorts had a significantly higher rate of all comorbidities assessed (P < .001). ConclusionsThis study demonstrates that mean surgeon reimbursement was lower for primary TJA among sicker patients in comparison to their healthier counterparts, while hospital reimbursement was higher for sicker patients. This represents a discrepancy in the incentivization of care for complex patients, as hospitals receive increased remuneration for taking on extra risk, while surgeons get paid less on average for performing TJA on sicker patients. Such data should inform future policy to assure continued access to arthroplasty care among complex patients.

Intensive care nurses’ and nurse anaesthetists’ motivation to enrol in an academic master’s program: A qualitative study

Background: Nurses worldwide are increasingly working in environments characterized by healthcare reforms, complex patient care and technological advancements that require the integration of evidence-based practice. There is also a growing need for continuous education, systematic competence research and competence assessment instruments to meet the rapid changes in critical and anaesthesia care settings. Aim: The aim of this study was to explore and describe anaesthetists’ (NAs) and intensive care nurses’ (ICNs) motivation for enrolling in an academic master’s program. Method: A qualitative study was carried out, using focus groups. Data were analysed by means of qualitative content analyses. The participants were 11 students from an academic master’s program at a Norwegian university. Findings: The participants’ motivation was linked to the theme “improving patient care through continuous learning” and supported by three categories: understanding research; learning to argue within an intraprofessional team; improving and further developing the NAs and ICNs professions. Conclusion: Continuous learning to improve patient care for the critically ill was the main motivating factor for NAs and ICNs to enrol in an academic master’s program. NAs and ICNs enrolled in the academic master’s program with little or no support from the hospitals, and they reported that, in a busy ward, the time available for learning is scarce. The finding that NAs and ICNs desire continuous learning is relevant for hospital leaders who struggle to achieve patient safety goals and retain/recruit highly competent advanced nurses.

Integration of an online application to optimise multi-disciplinary meetings: a retrospective analysis.

Multi-disciplinary Meetings (MDM) play a crucial role in complex patient care, involving input from various specialties to formulate evidence-based management plans. However, traditional unidirectional approaches and reliance on manual processes have led to inefficiencies in the MDM pathway. This study identified and aimed to improve four critical moments where Information Communication Technologies (ICTs) could enhance the MDM process. Initial referral, information synthesis, meeting presentation and the creation of actionable/auditable items. Microsoft Office Forms, a customisable survey platform, was implemented to streamline MDM processes. Forms were created to gather patient information, develop agendas, and track outcomes. Automation through Excel scripting further optimised data organisation and agenda creation. Referrals using Forms takes an average of 7min and 21s. Over 15months the submission time has reduced and is trending towards under 5min for each referral. The system's scalability has allowed 1744 cases to be discussed over a 15-month period. Active departments using Forms is expanding to seven from two prior to the pilot. Microsoft Office Forms proved to be a valuable and adaptable tool for MDMs, offering benefits such as streamlined information gathering, real-time collaboration, and scalability. The study highlights the potential of existing tools within Microsoft licenses for healthcare process optimisation, providing a cost-effective and customisable solution for MDM agendas. While recognising some limitations, the study concludes that leveraging Microsoft Office Forms can significantly improve system efficiency in a multi-disciplinary setting.

Whispers of Consciousness: the Interplay of Surgery, Internal Medicine, and Anesthesia

Introduction: the interplay between surgery, internal medicine, and anesthesia is fundamental to the comprehensive care of patients, particularly in complex clinical scenarios. Understanding the dynamics of these interactions is crucial for improving patient outcomes and advancing healthcare practices.Objective: to review the existing literature on the collaboration between surgery, internal medicine, and anesthesia, identifying key areas of synergy, challenges, technological impacts, and future directions for research and practice.Methods: An extensive literature search was conducted across multiple databases, including PubMed and Google Scholar, using a combination of keywords related to surgery, internal medicine, anesthesia, patient care, and interdisciplinary collaboration. 22 relevant articles were selected based on predefined inclusion and exclusion criteria, with a focus on those that explored the integration and outcomes of these medical disciplines. Data were synthesized through thematic analysis.Results: the review highlights the significance of interdisciplinary collaboration in optimizing patient care, the role of technological advancements in bridging gaps between disciplines, and the ethical and patient-centered considerations that underpin successful integration. Education and training emerge as critical components for fostering effective collaboration.Conclusions: effective interdisciplinary collaboration between surgery, internal medicine, and anesthesia is pivotal for enhancing patient outcomes. Future research should focus on addressing identified gaps, particularly in the integration of technology and the development of ethical guidelines for complex patient care

Mentoring medical students as a means to increase healthcare assistant status: A qualitative study.

To offer a practical way in which the status of healthcare assistants (HCAs) can be increased by drawing on their experience, knowledge and skillset, whilst mentoring medical students during an HCA project. Qualitative, reflexive thematic analysis. One-to-one semi-structured interviews were conducted between April and June 2019, with 13 participants. Participants included five healthcare assistants; three practice development nurses, two of whom were former HCAs; one registered general nurse and four clinical educators. Two themes were identified: HCAs as silent, invisible caregivers (theme 1) and the formation of an HCA identity through mentoring (theme 2). HCAs are often silent performers of complex patient care with limited opportunity to engage in the interprofessional team dialogue. Social perceptions of HCAs describe them as a marginalised, poorly understood, 'unqualified' group with 'lowly status'. Mentoring medical students allows HCAs to draw on their experience, knowledge and skillset by actively contributing to the learning and development of future doctors. The mentoring of medical students gave HCAs an active voice within the interprofessional team, instilling their confidence and self-worth. Mentoring allowed HCAs to move from a homogenous, group-based social identity to a role-based one that enabled HCAs to reveal the true extent of their work whilst negotiating their place and identity within the interprofessional team. Leaders in healthcare will see that a re-evaluation of HCAs as performers of basic, hands-on patient care is needed to breakdown ingrained beliefs, eliminating a 'us and them' mentality. Involving HCAs in the mentoring of medical students will impact on the personal development of both HCAs and medical students in the cultivation of a future, person-centred, inclusive and collaborative workforce. COREQ guidelines to enhance methodological rigour were strictly adhered to. There is no patient or public involvement.

Complexity of patients with mental healthcare needs cared for by mental health clinical pharmacist practitioners in Veterans Affairs.

The complexity of patients with mental healthcare needs cared for by clinical pharmacists is not well delineated. We evaluated the complexity of patients with schizophrenia, bipolar disorder, and major depressive disorder (MDD) in Veterans Affairs (VA) cared for by mental health clinical pharmacist practitioners (MH CPPs). Patients at 42 VA sites with schizophrenia, bipolar disorder, or MDD in 2016 through 2019 were classified by MH CPP visits into those with 2 or more visits ("ongoing MH CPP care"), those with 1 visit ("consultative MH CPP care"), and those with no visits ("no MH CPP care"). Patient complexity for each condition was defined by medication regimen and service utilization. For schizophrenia, more patients in ongoing MH CPP care were complex than those with no MH CPP care, based on all measures examined: the number of primary medications (15.3% vs 8.1%), inpatient (13.7% vs 9.1%) and outpatient (42.6% vs 29.7%) utilization, and receipt of long-acting injectable antipsychotics (36.7% vs 25.8%) and clozapine (20.5% vs 9.5%). For bipolar disorder, more patients receiving ongoing or consultative MH CPP care were complex than those with no MH CPP care based on the number of primary medications (27.9% vs 30.5% vs 17.7%) and overlapping mood stabilizers (10.1% vs 11.6% vs 6.2%). For MDD, more patients receiving ongoing or consultative MH CPP care were complex based on the number of primary medications (36.8% vs 35.5% vs 29.2%) and augmentation of antidepressants (56.1% vs 54.4% vs 47.0%) than patients without MH CPP care. All comparisons were significant (P < 0.01). MH CPPs provide care for complex patients with schizophrenia, bipolar disorder, and MDD in VA.

Interprofessional collaboration skills and motivation one year after an interprofessional educational intervention for undergraduate medical and nursing students

BackgroundThe increasingly complex patient care in the twenty-first century is delivered by interprofessional health care teams. Interprofessional collaboration can be taught during interprofessional education. However, whether a long-term change in collaborative competencies can be achieved by interprofessional education has not been studied sufficiently. Our research questions were: How does motivation for interprofessional collaboration and interprofessional collaborative skills change up to one year after an interprofessional educational intervention? How are they related to each other?MethodsDuring a one-year period, undergraduate medical and nursing students attended four interprofessional (intervention) or uniprofessional (control group) education sessions. Self-determination Theory was used as the theoretical framework. Autonomous and controlled motivation scores for interprofessional collaboration were calculated using the Academic Self-Regulation Questionnaire, before (T1), directly after (T2) and one year post-intervention (T3). At T3, the students also filled out the Interprofessional Collaborative Competencies Attainment Survey (ICCAS), which measured the perceived attainment of collaborative competencies by a retrospective pre-test/post-test design. We used linear mixed effects models to analyse the motivation scores and linear regression for the relation between motivation and competence.ResultsIn the interprofessional group, autonomous motivation scores of the participants were significantly lower at T2 vs. T1. Controlled motivation scores were significantly higher at T3 vs. T1. Controlled motivation scores for T2 were significantly higher in the uniprofessional group than in the interprofessional group. Perceived competence was related to higher autonomous motivation scores. At T3 the interprofessional collaborative competencies seemed to have grown more among students in the interprofessional group.ConclusionsThe perceived growth in interprofessional collaboration competence lasted at least up to one year after the intervention, and was measurable with the ICCAS. The growth was significantly more in the IPE students than in the UPE students. The few differences found in motivation scores for interprofessional collaboration were probably caused by an imbalance of nursing versus medical students over the different time points. This finding indicates that classroom based IPE can contribute to interprofessional collaboration skills of nursing and medical students at least up to one year after an intervention.

Improved tracheostomy-dependent patient outcomes after implementation of the Pediatric Resident Education in Pulmonary (PREP) Boot Camp.

Children with tracheostomies are high risk for morbidity and mortality. Pediatric resident physicians are not routinely taught skills to care for this vulnerable patient population. Few reports link educational interventions to improved patient outcomes. This study evaluates the impact of an intensive educational training program on pediatric residents' observed skills and tracheostomy-dependent patient outcomes. Pediatric post-graduate year 2 (PGY2) resident physicians rotating through the inpatient pediatric pulmonology month at Children's Hospital Colorado July 2018-2019 participated in the Pediatric Resident Education in Pulmonary (PREP) Boot Camp, an intensive educational program with an interactive lecture and simulation experience on patients with tracheostomy-dependence. PGY2s who partook in PREP and PGY3s who rotated before PREP initiation were invited to be studied. Primary outcomes included: (1) resident skills assessed by direct observation during simulation encounters and (2) rates of intensive care unit (ICU) transfers in tracheostomy-dependent patients following acute events before and after introduction of PREP. We hypothesized that increased education would enhance resident skills and improve patient outcomes by decreasing the rate of ICU transfers. PGY2 residents retained skills learned during PREP up to 11 months following initial participation, and significantly outperformed their PGY3 counterparts. There was a significant decrease in ICU transfer rate in patients with tracheostomies admitted to the pulmonary team during the 19 months following initiation of PREP. Enhanced early education may improve resident physicians' ability to care for complex patients with tracheostomies and could improve outcomes in this high-risk population.