Does ED crowding decrease the number of procedures a physician in training performs? A prospective observational study

The impact of emergency department crowding and patient boarding on resident point-of-care ultrasound education

Objectives

Emergency department (ED) crowding negatively affects patient care, but the effect on resident education has been difficult to quantify. We aimed to describe the relationship between ED crowding and residents' ability to meet point-of-care ultrasound (POCUS) education goals.

Methods

We retrospectively reviewed medical records from November 2021 to June 2023 at an academic level 1 trauma center, where emergency medicine residents complete longitudinal POCUS scanning shifts throughout 3 years of training. Residents are expected to complete ≥14 scans per scanning shift. We assessed whether completing the goal POCUS scans on a scanning shift (success: ≥14 scans, near-success: 10‒13, failure: <10) was associated with the average National Emergency Department Overcrowding Scale (NEDOCS) score or patient boarding hours during each scanning shift. Ordinal logistic regression was performed, controlling for the type of POCUS device available and the presence of medical students, interns, ultrasound faculty, and multiple residents.

Results

Over 125 scanning shifts, 1340 scans were performed. Residents met the expected number of POCUS scans for 26.4% of scanning shifts, with 34.4% near-success and 39.2% failure. The average NEDOCS was 157.4 ± 31.9. POCUS success was associated with a lower mean NEDOCS (142 vs. 169, p < 0.001). After controlling for covariates, every 10-point increase in NEDOCS was associated with 17% lower odds of achieving the goal (odds ratio [OR] = 0.83, 95% confidence interval [CI] 0.73‒0.94, p = 0.003). Other significant factors were having only one resident on a scanning shift, which was associated with lower odds of success (OR = 0.41, 95% CI 0.18‒0.97, p = 0.043), and having a cart-based POCUS device available in addition to a handheld POCUS device, which was associated with higher odds of success (OR = 13.58, 95% CI 5.53‒33.38, p < 0.001).

Conclusion

As ED crowding increased, residents were increasingly likely to fail to meet their POCUS education goals.

Is boarding compromising our residents' education? A national survey of emergency medicine program directors

Background

Boarding patients in the emergency department (ED) potentially affects resident education. Program director (PD) perceptions of the impact of boarding on their trainees have not been previously described.

Methods

We surveyed a cross-sectional convenience sample of emergency medicine PDs using a mixed-methods approach to explore their perceptions of how boarding has affected their residents' training. Descriptive data were reported as percentages and differences were calculated using Pearson's chi-square test, with p < 0.05 considered significant. A framework model was used to qualitatively analyze free-text responses.

Results

A total of 170 responses were collected, for a response rate of 63%. Most respondents felt that boarding had at least some effect on resident education with 29%, 35%, 18%, and 12% noting "a little," "a moderate amount," "a lot," and "a great deal," respectively, and 5% noting "no effect at all." Respondents perceived a negative impact of boarding on resident education and training, with 80% reporting a "somewhat" or "extremely negative" effect, 18% feeling neutral, and 2% noting a "somewhat positive" effect. Most noted a "somewhat" or "extremely negative" effect on resident education in managing ED throughput (70%) and high patient volumes (66%). Fifty-four percent noted a "somewhat" or "extremely negative" impact on being involved in the initial workup of undifferentiated patients. Thirty-two percent saw a "somewhat" or "extremely positive" effect on learning the management of critically ill patients. Qualitative analysis of challenges, mitigation strategies, and resident feedback emphasized the lack of exposure to managing departmental patient flow, impact on bedside teaching, and need for flexibility in resident staffing.

Conclusions

Most PDs agree that boarding negatively affects resident education and identify several strategies to mitigate the impact. These findings can help inform future interventions to optimize resident learning in the complex educational landscape of high ED boarding.

Critical appraisal of emergency medicine education research: the best publications of 2012

OBJECTIVES

The objective was to critically appraise and highlight medical education research published in 2012 that was methodologically superior and whose outcomes were pertinent to teaching and education in emergency medicine (EM).

METHODS

A search of the English language literature in 2012 querying Education Resources Information Center (ERIC), PsychInfo, PubMed, and Scopus identified EM studies using hypothesis-testing or observational investigations of educational interventions. Two reviewers independently screened all of the publications and removed articles using established exclusion criteria. This year, publications limited to a single-site survey design that measured satisfaction or self-assessment on unvalidated instruments were not formally reviewed. Six reviewers then independently ranked all remaining publications using one of two scoring systems depending on whether the study methodology was primarily qualitative or quantitative. Each scoring system had nine criteria, including four related to methodology, that were chosen a priori, to standardize evaluation by reviewers. The quantitative study scoring system was used previously to appraise medical education published annually in 2008 through 2011, while a separate, new qualitative study scoring system was derived and implemented consisting of parallel metrics.

RESULTS

Forty-eight medical education research papers met the a priori criteria for inclusion, and 33 (30 quantitative and three qualitative studies) were reviewed. Seven quantitative and two qualitative studies met the criteria for inclusion as exemplary and are summarized in this article.

CONCLUSIONS

This critical appraisal series aims to promote superior education research by reviewing and highlighting nine of the 48 major education research studies with relevance to EM published in 2012. Current trends and common methodologic pitfalls in the 2012 papers are noted.