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Objective In response to concerns about patient care and safety, our urban, tertiary care, Level 1 trauma center adult emergency department (ED) created an advanced practice provider‐staffed critical care step‐down unit (CCSU). We conducted a comprehensive evaluation of the CCSU's impact on patient care, safety, and ED operations. Methods We compared ED length of stay, return visits to the ED within 72 hours, billing code assignments (current procedural terminology evaluation and management [CPT E&M] codes), and quality of electronic health record documentation per QNOTE for the 2 years after the CCSU was initiated (CCSU period) versus before its initiation (pre‐CCSU period). Results There were 31,418 critical care ED patient visits in the pre‐CCSU period and 33,396 in the CCSU period. Median ED length of stay did not change overall between the CCSU versus pre‐CCSU period (∆1 [95% confidence interval (CI) = −2.4, 4.4] minutes), but decreased for patients who remained in the critical care suites (∆‐4 [95% CI = −7.8, −0.2] minutes). 72‐hour return ED visits also did not change overall (∆0% [95% CI = −0.1, 0]), but decreased for patients who remained in the critical care suites (∆0.4% [95% CI = −0.05, −0.4]). CPT E&M billing increased for highest‐level visits (99,291: ∆1.3% [95% CI= 0.5, 2.0]). Quality of electronic health record documentation as measured by QNOTE also improved (∆11.5% [95% CI = 4.9, 18.1]). Conclusion This ED's CCSU performance metrics indicate at least moderate improvement in ED length of stay, 72‐hour return visits, critical care patient billing, and electronic health record documentation. EDs elsewhere can consider implementation of this advanced practice provider‐staffed solution to improvement in critical care in ED.

Background South Africa is marked by high rates of both HIV and alcohol use, and there is a detrimental synergistic relationship between these two epidemics. The Institute of Medicine recommends integrated care for alcohol use treatment and HIV, but implementation of integrated services remains a challenge in South Africa. This protocol describes a study designed to evaluate trainer, provider-, and patient encounter-level outcomes relating to the national rollout of a cascade train-the-trainer model of task-sharing to build capacity of the HIV workforce to deliver Screening, Brief Intervention, and Referral to Treatment (SBIRT) to address risky alcohol use. Methods This 5 year protocol consists of two phases. First, we will finalize development of a robust SBIRT train-the-trainer model, which will include an SBIRT Trainer Manual, Provider Resource Guide, fidelity observational coding system, case vignettes, and a curriculum for ongoing consultation sessions. Materials will be designed to build the capacity of novice trainers to train lay workers to deliver SBIRT with fidelity. Second, we will recruit 24–36 trainers and 900 providers in order to evaluate the effects of the SBIRT train-the-trainer model on trainer- (e.g., fidelity, knowledge), provider- (e.g., SBIRT attitudes, confidence, acceptability), and patient encounter- (e.g., proportion receiving screening, brief intervention, referral to treatment) level variables. Data on patient encounters will be tracked by providers on programmed tablets or scannable paper forms in real-time. Providers will report on SBIRT delivery on an ongoing basis over a 6-months period. Additionally, we will test the hypothesis that trainer-level factors will account for a substantial proportion of variability in provider-level factors which will, in turn, account for a substantial proportion of variability in patient encounter-level outcomes. Discussion This protocol will allow us to take advantage of a unique national training initiative to gather comprehensive data on multi-level factors associated with the implementation of SBIRT in HIV service settings. In the long-term, this research can help to advance the implementation of integrated alcohol-HIV services, providing lessons that can extend to other low-and-middle income countries confronting dual epidemics.

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