Emergency department crowding: the effect on resident education

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.

Understanding junior doctors' experiences of teaching on the acute take: a qualitative study

BACKGROUND

New medical graduates are significantly unprepared to manage acutely unwell patients due to limited first-hand clinical exposure in the undergraduate curriculum. Supporting undergraduate learning in the acute setting can be challenging for junior doctors when balancing teaching and clinical responsibilities. Our aim was to explore junior doctors' first-hand experiences of supporting undergraduate education in the acute admissions environment(take).

METHODS

Fourteen junior doctors in one teaching hospital in South West England took part in semi-structured focus groups (4-6 participants in each) which were audio-recorded, transcribed, and thematically analysed.

RESULTS

Junior doctors described their educational role as comprising: teaching, demonstrating, coaching, and supervising. They perceived the acute take as a highly variable, unpredictable setting that offered a broad scope for learning. Tensions between doctors' clinical and educational roles were described, influenced by internal and external factors. Clinical work was prioritised over teaching and participants lacked confidence in supervisory and clinical skills. Doctors felt pressured to meet students' expectations and lacked understanding of their educational needs. Senior colleagues were highly influential in establishing an educational culture and were often a source of pressure to deliver timely clinical care. Organisations were perceived not to value teaching due to the lack of provision of dedicated teaching time and prioritisation of limited resources towards patient care. Participants managed tensions by attempting to formally separate roles, demoting students to passive observers, and they sought greater continuity in placements to better understand students' abilities and expectations.

CONCLUSIONS

Educational opportunities for undergraduate students on the acute take are varied and highly valuable. This study provides insight into the provision of workplace education and its challenges from junior doctors' perspectives. We highlight areas for improvement of relevance to educational providers.

Narrative Review of Clinical Productivity and Teaching in Emergency Medicine

Emergency medicine educators are subject to external pressures to increase clinical productivity while maintaining quality teaching. Strategies to mitigate this perceived conflict include alterations in staffing and incentive compensation with educational value units. There is a paucity of information describing the effect of clinical demands on teaching metrics in emergency medicine. We performed a narrative review of the literature describing the relationship between clinical productivity and teaching evaluations of emergency medicine faculty and residents. We searched PubMed and Google Scholar for peer-reviewed articles describing emergency medicine clinical productivity metrics, teaching metrics, and the relationship between them. Seven articles met inclusion criteria. While most articles utilized relative value units (RVUs) per hour, other outcomes metrics were heterogeneous. Almost all studies utilized retrospective data and took place at academic teaching hospitals. Despite variability in statistical analysis, no studies found a relationship between clinical productivity and teaching metrics. Multiple articles identified characteristics of faculty that were associated with improved teaching metrics independent of clinical demands. The available literature does not support the concept that increased clinical productivity conflicts with quality teaching. A subset of faculty was identified who excelled at both. Next research steps should include developing shared standards for assessment of clinical productivity and educational quality that can be used to collect data at multiple sites at academic and community clinical settings; a secondary outcome includes measuring the effects of additional teaching attendings and educational value units.

Innovating Pediatric Emergency Care and Learning Through Interprofessional Briefing and Workplace-Based Assessment: A Qualitative Study

BACKGROUND

Managing pediatric emergencies can be both clinically and educationally challenging with little existing research on how to improve resident involvement. Moreover, nursing input is frequently ignored. We report here on an innovation using interprofessional briefing (iB) and workplace-based assessment (iWBA) to improve the delivery of care, the involvement of residents, and their assessment.

METHODS

Over a period of 3 months, we implement an innovation using iB and iWBA for residents providing emergency pediatric care. A constructivist thematic analysis approach was used to collect and analyze data from 4 focus groups (N = 18) with nurses (4), supervisors (5), and 2 groups of residents (4 + 5).

RESULTS

Residents, supervisors, and nurses all felt that iB had positive impacts on learning, teamwork, and patient care. Moreover, when used, iB seemed to play an important role in enhancing the impact of iWBA. Although iB and iWBA seemed to be accepted and participants described important impacts on emergency department culture, conducting of both iB and iWBA could be sometimes challenging as opposed to iB alone mainly because of time constraints.

CONCLUSIONS

Interprofessional briefing and iWBA are promising approaches for not only resident involvement and learning during pediatric emergencies but also enhancing team function and patient care. Nursing involvement was pivotal in the success of the innovation enhancing both care and resident learning.

The Parallel Encounter: An Alternative to the Traditional Serial Trainee-Attending Patient Evaluation Model

BACKGROUND

The emergency department environment requires the clinician-educator to use adaptive teaching strategies to balance education with efficiency and patient care. Recently, alternative approaches to the traditional serial trainee-attending patient evaluation model have emerged in the literature.

METHODS

The parallel encounter involves the attending physician and resident seeing the patient independently. Instead of the trainee delivering a traditional oral case presentation, the trainee does not present the history and examination to the attending physician. Rather, the attending and trainee come together following their independent evaluations to jointly discuss and formulate the assessment and plan.

RESULTS

The parallel encounter has the potential to enhance the teaching encounter by emphasizing clinical reasoning, reduce cognitive bias by integrating two independent assessments of the same patient, increase attending workflow flexibility and efficiency, and improve patient satisfaction and outcomes by reducing time to initial provider contact. The attending must be mindful of protecting resident autonomy. This model tends to work better for more senior learners.

CONCLUSIONS

The parallel encounter represents a novel approach to the traditional serial trainee-attending patient evaluation model that may enhance the teaching encounter and improve patient care.

Factors Affecting Emergency Department Crowding

Emergency department crowding is a multifactorial issue with causes intrinsic to the emergency department and to the health care system. Understanding that the causes of emergency department crowding span this continuum allows for a more accurate analysis of its effects and a more global consideration of potential solutions. Within the emergency department, boarding of inpatients is the most appreciable effect of hospital-wide crowding, and leads to further emergency department crowding. We explore the concept of emergency department crowding, and its causes, effects, and potential strategies to overcome this problem.

Resident Supervision and Patient Care: A Comparative Time Study in a Community-Academic Versus a Community Emergency Department

OBJECTIVE

The objective was to compare attending emergency physician (EP) time spent on direct and indirect patient care activities in emergency departments (EDs) with and without emergency medicine (EM) residents.

METHODS

We performed an observational, time-motion study on 25 EPs who worked in a community-academic ED and a nonacademic community ED. Two observations of each EP were performed at each site. Average time spent per 240-minute observation on main-category activities are illustrated in percentages. We report descriptive statistics (median and interquartile ranges) for the number of minutes EPs spent per subcategory activity, in total and per patient. We performed a Wilcoxon two-sample test to assess differences between time spent across two EDs.

RESULTS

The 25 observed EPs executed 34,358 tasks in the two EDs. At the community-academic ED, EPs spent 14.2% of their time supervising EM residents. Supervision activities included data presentation, medical decision making, and treatment. The time spent on supervision was offset by a decrease in time spent by EPs on indirect patient care (specifically communication and electronic health record work) at the community academic ED compared to the nonacademic community ED. There was no statistical difference with respect to direct patient care time expenditure between the two EDs. There was a nonstatistically significant difference in attending patient load between sites.

CONCLUSIONS

EPs in our study spent 14.2% of their time (8.5 minutes/hour) supervising residents. The time spent supervising residents was largely offset by time savings related to indirect patient care activities rather than compromising direct patient care.

Entrustment Checkpoint: Clinical Supervisors' Perceptions of the Emergency Department Oral Case Presentation

Phenomenon: The oral case presentation represents a unique method of communication and forms the foundation for trainee-supervisor interactions in the clinical setting. Recently, entrustment has been highlighted as an essential element of trainee-supervisor interactions. Despite the growing body of knowledge concerning entrustment in medical education, how supervisors conceptualize the oral case presentation as a contributor to entrustment decision making during clinical supervision remains unknown. Given their widespread use, oral case presentations may represent a potential tool for future frameworks of workplace-based assessment. This study sought to explore what factors influence supervisors' expectations of oral case presentation content and how the oral case presentation may contribute to entrustment decision making. Approach: Using qualitative methodology, semistructured interviews were conducted from a purposive sample of attending emergency medicine physicians at an academic medical center from 2015 to 2016. Thematic analysis of the semistructured interview transcripts was conducted by 2 investigators using line-by-line coding and constant comparative analysis. Key themes were identified through consensus. Theoretical sampling occurred until thematic saturation was reached. Findings: Twenty-one attending physicians were interviewed. Four factors were found to influence supervisor expectations pertaining to oral case presentation content (trainee level, trainee familiarity, clinical context, and clinical task). Further, the oral case presentation was found to serve as a means of indirect observation and an entrustment check point informing future decisions relating to trainee supervision. Insights: The oral case presentation represents a core activity within the trainee-supervisor relationship in which entrustment plays a central role. Given the numerous factors influencing oral case presentation content, we caution supervisors against relying solely on the oral case presentation as an entrustment check point, as this may lead to inaccurate judgments of trainee competence. We recommend that the oral case presentation be used in conjunction with other means of direct and indirect observation to assist with entrustment decisions relating to trainee supervision.

Emergency Medicine Resident Self-assessment of Clinical Teaching Compared to Student Evaluation Using a Previously Validated Rubric

PURPOSE

The quality of clinical teaching in the emergency department from the students' perspective has not been previously described in the literature. Our goals were to assess senior residents' teaching ability from the resident/teacher and student/learner viewpoints for any correlation, and to explore any gender association. The secondary goal was to evaluate the possible impact of gender on the resident/student dyad, an interaction that has previously been studied only in the faculty/student pairing.

METHODS

After approval by an institutional review board, a 1-year, grant-funded, single-site, prospective study was implemented at a regional medical campus that sponsors a 4-year dually approved emergency medicine residency. The residency hosts both medical school students (MSs) and physician's assistant students (PAs). Each student and senior resident working concurrently completed a previously validated ER Scale, which measured residents' teaching performance in 4 categories: Didactic, Clinical, Approachable, and Helpful. Students evaluated residents' teaching, while residents self-assessed their performance. The participants' demographic characteristics gathered included prior knowledge of or exposure to clinical teaching models. Gender was self-reported by participants. The analysis accounted for multiple observations by comparing participants' mean scores.

FINDINGS

Ninety-nine subjects were enrolled; none withdrew consent. Thirty-seven residents (11 women) and 62 students (39 women) from 25 MSs and 6 PA schools were enrolled, completing 517 teaching assessments. Students evaluated residents more favorably in all ER Scale categories than did residents on self-assessments (P < 0.0001). This difference was significant in all subgroup comparisons (types of school versus postgraduate years [PGYs]). Residents' evaluations by type of student (MS vs PA) did not show a significant difference. PGY 3 residents assessed themselves higher in all categories than did PGY 4 residents, with Approachability reaching significance (P = 0.0105). Male residents self-assessed their teaching consistently higher than did female residents, significantly so on Clinical (P = 0.0300). Students' evaluations of the residents' teaching skills by residents' gender did not reveal gender differences.

IMPLICATIONS

MS and PA students evaluated teaching by EM senior residents statistically significantly higher than did EM residents on self-evaluation when using the ER Scale. Students did not evaluate residents' teaching with any difference by gender, although male residents routinely self-assessed their teaching abilities more positively than did female residents. These findings suggest that, if residency programs utilize resident self-evaluation for programmatic evaluation, the gender of the resident may impact self-scoring. This cohort may inform future study of resident teaching in the emergency department, such as the design of future resident-as-teacher curricula.

The educational value of emergency department teaching: it is about time

There is a paucity of research on the quality and quantity of clinical teaching in the emergency department (ED) setting. While many factors impact residents' perceptions of attending physicians' educational skill, the authors hypothesized that the amount of time residents spend with attending in direct teaching is a determinant of residents' perception of their shift's educational value. Researchers shadowed emergency medicine (EM) attendings during ED shifts, and recorded teaching time with each resident. Residents were surveyed on their assessment of the educational value (EV) of the shift and potential confounders, as well as the attending physician's teaching quality using the ER Scale. The study was performed in the EDs of two urban teaching hospitals affiliated with an EM residency program. Subjects were EM residents and rotators from other specialties. The main outcome measure was the regression of impact of teaching time on EV. Researchers observed 20 attendings supervising 47 residents (mean 2.35 residents per attending, range 2-3). The correlation between teaching time in minutes (mean 60.8, st.dev 25.6, range 7.6-128.1) and EV (mean 3.45 out of 5, st. dev 0.75, range 2-5) was significant (r = 0.302, r ² = 0.091, p < 0.05). No confounders had a significant effect. The study shows a moderate correlation between the total time attendings spend directly teaching residents and the residents' perception of educational value over a single ED shift. The authors suggest that mechanisms to increase the time attending physicians spend teaching during clinical shifts may result in improved resident education.

Social Workers as Workplace-Based Instructors of Alcohol and Drug Screening, Brief Intervention, and Referral to Treatment (SBIRT) for Emergency Medicine Residents

PROBLEM

Residency education is challenged by a shortage of personnel and time, particularly for teaching behavioral interventions such as screening, brief intervention, and referral to treatment (SBIRT) to reduce hazardous drinking and drug use. However, social workers may be well placed to teach SBIRT in clinical training settings.

INTERVENTION

We describe a curriculum with social workers as SBIRT trainers of emergency medicine (EM) residents during actual clinical shifts in an EM residency training program. The curriculum required 1 EM faculty member working with social workers and 1 additional hour of formal residency conference teaching time.

CONTEXT

We implemented the curriculum at both a university tertiary care hospital emergency department and a county trauma center. We trained 8 social workers at both sites as SBIRT superusers to teach and assess EM resident SBIRT performance with actual patients. We measured the length and number of sessions to attain SBIRT competence, residents' satisfaction, and resident comments (coded by authors).

OUTCOME

Five of the 8 social workers trained residents between June 2013 and May 2014, 31 EM residents trained to a level indicating SBIRT competence with 114 patients. Each patient interaction averaged 8.8 minutes and residents averaged 3.13 patients. Twenty-four (77%) residents gave ratings of 1.58 (SD = .58) for the quality of teaching, 2.33 (SD = .87) for recommending the training to a colleague, 1.38 (SD = .49) for superusers' knowledge, 1.88 (SD = .95) for usefulness of instruction, 1.54 (SD = .72) for workplace learning, and 1.58 (SD = .78) for valuing learning from social workers (on a scale of 1 [very satisfied/strongly agree] to 5 [very dissatisfied/strongly disagree]). Residents preferred learning SBIRT during the 1st and 2nd training years and in the workplace.

LESSONS LEARNED

Social work colleagues can be effective in teaching SBIRT to residents in the workplace, and our residents highly valued learning from social workers, who all had prior training in motivational interviewing. In the implementation of this curriculum, the clinical demands of residents must be taken into account when teaching occurs, and having multiple social worker instructors was instrumental.

Reducing length of stay and satisfying learner needs

A complicated relationship exists between emergency department (ED) learner needs and patient flow with solutions to one issue often negatively affecting the other. Teaching shifts that allow clinical teachers and learners to interact without the pressure of patient care may offer a mutually beneficial solution. This study investigated the relationship between teaching shifts on ED length of stay, student self-efficacy and knowledge application.In 2012-2013, a prospective, cohort study was undertaken in a large Canadian acute-care teaching centre. All 132 clinical clerks completing their mandatory two-week emergency medicine rotation participated in three teaching shifts supervised by one faculty member without patient care responsibilities. The curriculum emphasized advanced clinical skills and included low fidelity simulation exercises, a suturing lab, image interpretation modules and discussion about psychosocial issues in emergency medicine. The clerks then completed seven clinical shifts in the traditional manner caring for patients under the supervision of an ED attending physician. Length of stay was compared during and one week following teaching shifts. A self-efficacy questionnaire was validated through exploratory factor analysis. Pre/post knowledge application was assessed using a paper-based clinical case activity.Across 40.998 patient visits, median length of stay was shortened overall by 5 minutes (95 % CI:1.2, 8.8) when clerks were involved in their teaching shifts. In the first academic block, median length of stay was reduced by 20 minutes per patient (95 % CI:12.7, 27.3). Self-efficacy showed significant improvement post teaching shifts (p < 0.001) with large effect sizes (d > 1.25) on dimensions of knowledge base, suturing, trauma and team efficacy. Students' knowledge application scores improved from pre to post (p < 0.01), with notable gains in the generation of differential diagnoses.Teaching shifts are an effective educational intervention that has a positive relation to ED patient flow while successfully attending to learner needs. Teaching shifts for the most naïve clerks in the first academic block appear to maximally benefit length of stay. Students demonstrated improved self-efficacy and knowledge application after their teaching shifts.

Faculty perceptions and practice impact of a faculty development workshop on emergency medicine teaching

Background:

Faculty development initiatives to improve emergency department (ED) teaching are compromised by the paucity of information about what behaviours and characteristics are desirable in an emergency medicine (EM) teacher.

Objectives:

To design and evaluate a learner-centred, interactive faculty development workshop based on original ED teaching research.

Methods:

Registrants for a university-based faculty development workshop on ED teaching completed a needs assessment and pre-workshop self-reflection exercise. Responses were grouped into 3 themes derived from the ambulatory teaching literature and a recent survey of expert clinical EM teachers and learners. Participants underwent a half-day workshop consisting of 1 large group interactive session and 3 small group sessions using role playing, practice reflection, real time review of hard copy resources, and brainstorming. Evaluation included a post-event ordinal scale questionnaire and a 4-month follow-up short answer survey, both measuring participants' perceptions of workshop effectiveness.

Results:

Fifteen faculty participated. The needs assessment identified “Common mistakes,” “Teaching efficiently” and “Dealing with the difficult learner” as themes. All 15 completed evaluations, rating the workshop as relevant (4.6/5), specific to their needs (4.4/5) and useful (4.5/5). At 4 months, 10 out of 10 respondents reported success at implementing new techniques and 8 reported greater confidence in teaching. The most common new techniques were: setting better learning objectives, giving better feedback, actively seeking teaching opportunities, and identifying a teaching point.

Conclusions:

Learner-centred faculty development meets perceived needs of faculty and can result in participants trying new teaching strategies.

Education scholarship in emergency medicine part 2: supporting and developing scholars

Emergency medicine (EM) is defined, in part, by clinical excellence across an immense breadth of content and the provision of exemplary bedside teaching to a wide variety of learners. The specialty is also well-suited to a number of emerging areas of education scholarship, particularly in relation to team-based learning, clinical reasoning, acute care response, and simulation-based teaching. The success of EM education scholarship will be predicated on systematic, collective attention to providing the infrastructure for this to occur. Specifically, as a new generation of emergency physicians prepares for education careers, academic organizations need to develop means not only to identify potential scholars but also to mentor, support, and encourage their careers. This paper summarizes the supporting literature and presents related recommendations from a 2013 consensus conference on EM education scholarship led by the Academic Section of the Canadian Association of Emergency Physicians.

Medical student perceptions on the instruction of the emergency medicine oral case presentation

BACKGROUND

The emergency medicine oral case presentation (EM OCP) is the clinician's communication tool to justify whether urgent intervention is required, to argue for ruling out emergent disease states, and to propose safe disposition plans in the context of triaging patients for medical care and prioritization of resources. The EM OCP provides the representation of the practice of emergency medicine, yet we do not know the current level of effectiveness of its instruction.

OBJECTIVES

We aimed to document medical student perceptions and expectations of the instruction of the EM OCP.

METHODS

We surveyed medical students from five institutions after their emergency medicine clerkship on their instruction of the EM OCP. Analysis included univariate descriptive statistics and chi-squared analyses for interactions.

RESULTS

One hundred fifty-five medical students (82%) completed the survey. Most medical students reported the EM OCP to be unique compared to that of other disciplines (86%), integral to their clerkship evaluation (77%), and felt that additional teaching was required beyond their current medical school instruction (78%). A minority report being specifically taught the EM OCP (37%), that their instruction was consistent (29%), or that expectations of the EM OCP were clear (21%). Respondents felt that brief instruction during their orientation (65%) and reading with a portable summary card (45%) would improve their EM OCP skills, whereas other modalities would be less helpful.

CONCLUSION

This study identifies a need for additional specific and consistent teaching of the EM OCP to medical students and their preference on how to receive this instruction.

Exploring the value of technology to stimulate interprofessional discussion and education: a needs assessment of emergency medicine professionals

BACKGROUND

The emergency department (ED) is an environment fraught with increasing patient volumes, competing priorities, fluctuating information, and ad hoc interprofessional clinical teams. Limited time is available to reflect on and discuss clinical experiences, policies, or research with others on the involved team. Online resources, such as webcasts and blogs, offer an accessible platform for emergency shift workers to engage in interprofessional discussion and education.

OBJECTIVE

Our objective was to explore the current opportunities for shared learning and discussion and to discover the potential of online resources to foster and facilitate interprofessional education within an academic tertiary emergency department community.

METHODS

A qualitative study using semistructured interviews was conducted to solicit participants' views of the current culture of IPE in the ED, the potential value of introducing new online resources and technology in support of IPE, and possible barriers to uptake. Participation was voluntary and participants provided verbal informed consent.

RESULTS

Online resources discussed included webcasts, interactive discussion forums, websites, and dashboard with links to central repositories. Identified barriers to uptake of new online resources were an unwillingness to "work" off-shift, a dislike of static one-directional communication, concerns with confidentiality, and the suggestion that new resources would be used by only a select few.

CONCLUSIONS

Owing to the sensitive dynamics of emergency medicine-and the preference among its professional staff to foster interprofessional discussion and education through personal engagement, in an unhurried, non-stressful environment-introducing and investing in online resources should be undertaken with caution.

Influence of clinical experience and productivity on emergency medicine faculty teaching scores

BACKGROUND

Commonly cited barriers to effective teaching in emergency medicine include lack of time, competing demands for patient care, and a lack of formal teaching experience. Teaching may be negatively affected by demands for increased clinical productivity, or positively influenced by clinical experience.

OBJECTIVE

To examine the association between faculty teaching scores and clinical productivity, years of clinical experience, and amount of clinical contact with resident physicians.

METHODS

We conducted a retrospective, observational study with existing data on full-time faculty at a high-volume, urban emergency medicine residency training program for academic year 2008-2009. Residents rated faculty on 9 domains of teaching, including willingness to teach, enthusiasm for teaching, medical knowledge, preparation, and communication. Clinical productivity data for relative value units per hour and number of patients per hour, years of clinical experience, and annual clinical hours were obtained from existing databases.

RESULTS

For the 25 core faculty members included in the study, there was no relationship between faculty teaching scores and clinical productivity measures (relative value units per hour: r (2)  =  0.01, P  =  .96, patients per hour: r (2)  =  0.00, P  =  .76), or between teaching scores and total clinical hours with residents (r (2)  =  0.07, P  =  .19). There was a significant negative relationship between years of experience and teaching scores (r (2)  =  0.27, P < .01).

CONCLUSIONS

Our study demonstrated that teaching scores for core emergency medicine faculty did not correlate with clinical productivity or amount of clinical contact with residents. Teaching scores were inversely related to number of years of clinical experience, with more experienced faculty earning the lowest teaching scores. Further study is necessary to determine if there are clinical measures that identify good educators.

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

PURPOSE

The aim of the study was to determine whether the number of procedures performed by residents and medical students in the emergency department (ED) is affected by ED crowding.

METHODS

In this single-center, prospective, observational study, standardized data collection forms were completed by both trainees and supervising emergency physicians (EPs) at the end of each ED shift from August 2009 to March 2010. Shifts with no trainees were excluded. All procedures that were offered to a trainee were recorded as well as the number of potential ED procedures that were, instead, referred to a consulting service. Emergency department crowding was measured in 2 ways: ED length of stay (LOS) and the EP's assessment of crowding during the shift. Poisson regression was used to assess the adjusted effect of ED crowding on the number of trainee procedures performed as well as on the number of procedures given away.

RESULTS

There were 804 procedures performed by 113 trainees during 647 trainee shifts. Medical students comprised 51% of trainees. Median number of procedures performed per shift was 1.0 (Fine interquartile range, 0-2.0). Emergency department crowding was not associated with the adjusted number of procedures trainees performed using either the EP's assessment of crowding (P = .52) or ED LOS (P = .84). Emergency department crowding was associated with an adjusted 256% increase in the mean number of procedures given away (P = .02) when measured using physician assessment but was not associated with crowding when assessed using ED LOS (P = .06).

CONCLUSIONS

Crowding was not significantly associated with the number of procedures availed to ED trainees. In patients being considered for admission, however, when the managing EP felt that it was crowded, there was an association with giving procedures to consulting services.

Clinical decision-making by the emergency department resident physicians for critically ill patients

The application of main methodologies for clinical decision-making by residents in emergency medical practice was assessed, and issues in this area were investigated. The treatments provided to 2 611 critical patients by the Emergency Department of Peking Union Medical College Hospital were analyzed by independent investigators who evaluated the main clinical decision-making processes applied by the hospital residents. The application of decision-making strategies by PG1 and PG3 groups, which means the residents in first year and the third year, were compared. The patients were treated according to pattern recognition (43.0%), hypothetico-deductive reasoning (23.4%), event-driven models (19.3%), and rule-using algorithms (5.9%). A significant difference was found between PG1 and PG3 groups (χ(2)= 498.01, P < 0.001). Pattern recognition and hypothetic-deductive methods were the most common techniques applied by emergency physicians in evaluating critically ill patients. The decision-making processes applied by junior and senior residents were significantly different, although neither group adequately applied rule-using algorithms. Inclusion of clinical decision-making in medical curricula is needed to improve decision-making in critical care.

Emergency department crowding: time for interventions and policy evaluations

This paper summarises the consequences of emergency department crowding. It provides a comparison of the scales used to measure emergency department crowding. We discuss the multiple causes of crowding and present an up-to-date literature review of the interventions that reduce the adverse consequences of crowding. We consider interventions at the level of an individual hospital and a policy level.

Impact of a teaching attending physician on medical student, resident, and faculty perceptions and satisfaction

OBJECTIVES

To determine if a dedicated teaching attending for medical student education improves medical student, attending physician, and resident perceptions and satisfaction.

METHODS

Two dedicated teaching attending physician shifts were added to the clinical schedule each week. A before-after trial compared medical student evaluations from 2000 to 2004 (preteaching attending physician) to medical student evaluations from 2005 to 2006 (teaching attending physician). Attending physician and resident perceptions and satisfaction with the teaching attending physician shifts using a 5-point Likert-type scale (1  =  poor to 5  =  excellent) were also assessed.

RESULTS

Eighty-nine (100%) medical students participated, with 63 preteaching attending physician and 26 teaching attending physician rotation evaluations. The addition of teaching attending physician shifts improved mean medical student satisfaction with bedside teaching (4.1 to 4.5), lecture satisfaction (4.2 to 4.8), preceptor scores (4.3 to 4.8), and perceived usefulness of the rotation (4.5 to 5.0) (all p < 0.05). Thirteen attending physicians (93%) participated in the cross-sectional questionnaire. The addition of teaching attending physician shifts improved faculty ratings of their medical student interactions by ≥ 1.5 points for all items (p ≤ 0.001). Faculty perceptions of their resident interactions improved for quality of bedside teaching (3.1 to 4.0), their availability to hear resident presentations (3.4 to 4.2), and their supervision of residents (3.4 to 4.1) (p ≤ 0.01). Residents (n  =  35) noted minor improvements with the timeliness of patient dispositions, faculty bedside teaching, and attending physician availability.

CONCLUSIONS

The addition of select teaching attending physician shifts had the greatest effect on medical student and faculty perceptions and satisfaction, with some improvements for residents.

Feedback in the emergency medicine clerkship

OBJECTIVE

Feedback is a technique used in medical education to help develop and improve clinical skills. A comprehensive review article specifically intended for the emergency medicine (EM) educator is lacking, and it is the intent of this article to provide the reader with an in-depth, up-to-date, and evidence-based review of feedback in the context of the EM clerkship.

METHODS

The review article is organized in a progressive manner, beginning with the definition of feedback, the importance of feedback in medical education, the obstacles limiting the effective delivery of feedback, and the techniques to overcome these obstacles then follows. The article concludes with practical recommendations to implement feedback in the EM clerkship. To advance the literature on feedback, the concept of receiving feedback is introduced.

RESULTS

The published literature regarding feedback is limited but generally supportive of its importance and effectiveness. Obstacles in the way of feedback include time constraints, lack of direct observation, and fear of negative emotional responses from students. Feedback should be timely, expected, focused, based on first-hand data, and limited to behaviors that are remediable. Faculty development and course structure can improve feedback in the EM clerkship. Teaching students to receive feedback is a novel educational technique that can improve the feedback process.

CONCLUSION

Feedback is an important educational technique necessary to improve clinical skills. Feedback can be delivered effectively in the EM clerkship.

The impact of emergency department overcrowding on resident education

BACKGROUND

Few studies have evaluated the effect of Emergency Department (ED) overcrowding on resident education.

OBJECTIVES

To determine the impact of ED overcrowding on Emergency Medicine (EM) resident education.

MATERIALS AND METHODS

A prospective cross-sectional study was performed from March to May 2009. Second- and third-year EM residents, blinded to the research objective, completed a questionnaire at the end of each shift. Residents were asked to evaluate the educational quality of each shift using a 10-point Likert scale. Number of patients seen and procedures completed were recorded. Responses were divided into ED overcrowding (group O) and non-ED overcrowding (group N) groups. ED overcrowding was defined as >2 h of ambulance diversion per shift. Questionnaire responses were compared using Mann-Whitney U tests. Number of patients and procedures were compared using unpaired T-tests.

RESULTS

During the study period, 125 questionnaires were completed; 54 in group O and 71 in group N. For group O, the median educational value score was 8 (interquartile range [IQR] 7-10), compared to 8 (IQR 8-10) for group N (p = 0.24). Mean number of patients seen in group O was 12.3 (95% confidence interval [CI] 11.4-13.2), compared to 13.9 (95% CI 12.7-15) in group N (p = 0.034). In group O, mean number of procedures was 0.9 (95% CI 0.6-1.2), compared to 1.3 (95% CI 1-1.6) in group N (p = 0.047).

CONCLUSIONS

During overcrowding, EM residents saw fewer patients and performed fewer procedures. However, there was no significant difference in resident perception of educational value during times of overcrowding vs. non-overcrowding.

Effect of an educational intervention on faculty and resident satisfaction with real-time feedback in the emergency department

OBJECTIVES

Effective real-time feedback is critical to medical education. This study tested the hypothesis that an educational intervention related to feedback would improve emergency medicine (EM) faculty and resident physician satisfaction with feedback.

METHODS

This was a cluster-randomized, controlled study of 15 EM residency programs in 2007-2008. An educational intervention was created that combined a feedback curriculum with a card system designed to promote timely, effective feedback. Sites were randomized either to receive the intervention or to continue their current feedback method. All participants completed a Web-based survey before and after the intervention period. The primary outcome was overall feedback satisfaction on a 10-point scale. Additional items addressed specific aspects of feedback. Responses were compared using a generalized estimating equations model, adjusting for confounders and baseline differences between groups. The study was designed to achieve at least 80% power to detect a one-point difference in overall satisfaction (α = 0.05).

RESULTS

Response rates for pre- and postintervention surveys were 65.9 and 47.3% (faculty) and 64.7 and 56.9% (residents). Residents in the intervention group reported a mean overall increase in feedback satisfaction scores compared to those in the control group (mean increase 0.96 points, standard error [SE] ± 0.44, p = 0.03) and significantly higher satisfaction with the quality, amount, and timeliness of feedback. There were no significant differences in mean scores for overall and specific aspects of satisfaction between the faculty physician intervention and control groups.

CONCLUSIONS

An intervention designed to improve real-time feedback in the ED resulted in higher resident satisfaction with feedback received, but did not affect faculty satisfaction with the feedback given.

Optimizing resident training: results and recommendations of the 2009 Council of Residency Directors consensus conference

This paper reports the results of a consensus conference of the Council of Emergency Medicine Residency Directors (CORD) to discuss the experiential training component of residency education in the emergency department (ED) and to make recommendations on structuring clinical training. Self-selected emergency medicine (EM) educators discussed experiential training focusing on three topic areas: 1) methods to optimize training in the clinical setting, 2) identification of goals and objectives by training year, and 3) determination of measurable behaviors demonstrating achievement of goals and objectives by residents. Topic areas were organized into the following questions: 1) what is the optimal number and evolution of ED shifts for EM residents during their residency training, 2) what clinical skills are expected of a resident at each level of training, and 3) what objective measures should be used to provide evidence of resident competency? Participants attended a lecture on the goals of the conference, the questions to be answered, and the role and implementation of deliberate practice into experiential training. Attendees were divided into three groups, each discussing one question. Each group had two discussion leaders. All discussions were digitally recorded for accuracy. After discussion all groups reconvened and reported summaries of discussions and recommendations to ensure group agreement. There were 59 participants representing 42 training programs. Educators agree that essential features of designing the ED clinical experience include the need to: 1) structure and tailor the clinical experience to optimize learning, 2) establish expectations for clinical performance based on year of training, and 3) provide feedback that is explicit to year-specific performance expectations.

The effect of ED crowding on education

OBJECTIVE

We studied if emergency department (ED) crowding affects the quality of resident and medical student education on individual patient encounters.

METHODS

We performed a cross-sectional study of a ED faculty-learner interactions over a 5-week period in an academic ED. Research assistants administered surveys to residents and senior medical students assessing attending physicians on 4 domains (teaching, clinical care, approachability, and helpfulness) using a scale (ER score for teaching on individual patients) validated for use during ED rotations. Each domain was assessed on a 5-point scale with a highest score of 20 representing superb/outstanding. We tested the association between measures of ED crowding (waiting room number, occupancy, number of admitted patients, and patient-hours) at the time of assessment with the ER score and individual domain scores using correlation coefficients and regression analysis with clustering on the attending physician.

RESULTS

Forty-three residents (22 ED, 21 non-ED) and 3 medical students assessed 34 attending physicians in 352 separate encounters. Median ER score was 16/20 (interquartile range, 12-16). Emergency department crowding levels and ER scores on individual patients were not significantly correlated, nor were ED crowding and individual domains. In the adjusted analysis, ED crowding was not associated with an ER score of 16 or higher, nor was any ED crowding measure associated individual assessments of teaching, clinical care, approachability, or helpfulness.

CONCLUSION

Emergency department crowding is not associated with the quality of education on individual patients.

Attending and resident satisfaction with feedback in the emergency department

OBJECTIVES

Effective feedback is critical to medical education. Little is known about emergency medicine (EM) attending and resident physician perceptions of feedback. The focus of this study was to examine perceptions of the educational feedback that attending physicians give to residents in the clinical environment of the emergency department (ED). The authors compared attending and resident satisfaction with real-time feedback and hypothesized that the two groups would report different overall satisfaction with the feedback they currently give and receive in the ED.

METHODS

This observational study surveyed attending and resident physicians at 17 EM residency programs through web-based surveys. The primary outcome was overall satisfaction with feedback in the ED, ranked on a 10-point scale. Additional survey items addressed specific aspects of feedback. Responses were compared using a linear generalized estimating equation (GEE) model for overall satisfaction, a logistic GEE model for dichotomized responses, and an ordinal logistic GEE model for ordinal responses.

RESULTS

Three hundred seventy-three of 525 (71%) attending physicians and 356 of 596 (60%) residents completed the survey. Attending physicians were more satisfied with overall feedback (mean score 5.97 vs. 5.29, p < 0.001) and with timeliness of feedback (odds ratio [OR] = 1.56, 95% confidence interval [CI] = 1.23 to 2.00; p < 0.001) than residents. Attending physicians were also more likely to rate the quality of feedback as very good or excellent for positive feedback, constructive feedback, feedback on procedures, documentation, management of ED flow, and evidence-based decision-making. Attending physicians reported time constraints as the top obstacle to giving feedback and were more likely than residents to report that feedback is usually attending initiated (OR = 7.09, 95% CI = 3.53 to 14.31; p < 0.001).

CONCLUSIONS

Attending physician satisfaction with the quality, timeliness, and frequency of feedback given is higher than resident physician satisfaction with feedback received. Attending and resident physicians have differing perceptions of who initiates feedback and how long it takes to provide effective feedback. Knowledge of these differences in perceptions about feedback may be used to direct future educational efforts to improve feedback in the ED.

A novel diversion protocol dramatically reduces diversion hours

INTRODUCTION

Ambulance diversion is a problem in many communities. When patients are diverted prompt and appropriate medical care may be delayed.

OBJECTIVE

Compare diversion hours and drop-off times before and after a dramatic change in diversion policy restricting each hospital to 1 hour out of every 8.

METHODS

This study was a retrospective study in a county of 600,000 people and 10 hospitals from September 2004 to February 2006. A countywide diversion protocol was implemented in March 2005 that limited diversion hours to 1 hour out of every 8 (maximum of 90 h/mo). No other changes were implemented during the study period. Pretrial (9/04-2/05), interim (3/05-8/05), and posttrial (9/05-2/06) periods were compared. The main outcome measures were ambulance diversion hours and emergency medical service (EMS) drop-off times. Results were compared using analysis of variance and a Tukey post hoc analysis. P < .05 was considered significant.

RESULTS

There was no significant difference in the number of monthly transports comparing the posttrial vs pretrial periods; however, a significant decrease in monthly ambulance diversion hours (difference, 251 hours; 95% CI, 136-368) and significant increase in additional time that EMS crews required to transport patients (drop-off times) (difference, 178 hours; 95% CI, 74-283) were observed. Posttrial diversion hours decreased to 18% of the pretrial values (from 305 to 54).

CONCLUSION

This novel ambulance diversion protocol dramatically reduced diversion hours at the cost of increasing EMS drop-off times in a large community.

Daily encounter cards facilitate competency-based feedback while leniency bias persists

OBJECTIVE

We sought to determine if a novel competency-based daily encounter card (DEC) that was designed to minimize leniency bias and maximize independent competency assessments could address the limitations of existing feedback mechanisms when applied to an emergency medicine rotation.

METHODS

Learners in 2 tertiary academic emergency departments (EDs) presented a DEC to their teachers after each shift. DECs included dichotomous categorical rating scales (i.e., "needs attention" or "area of strength") for each of the 7 CanMEDS roles or competencies and an overall global rating scale. Teachers were instructed to choose which of the 7 competencies they wished to evaluate on each shift. Results were analyzed using both staff and resident as the units of analysis.

RESULTS

Fifty-four learners submitted a total of 801 DECs that were then completed by 43 different teachers over 28 months. Teachers' patterns of selecting CanMEDS competencies to assess did not differ between the 2 sites. Teachers selected an average of 3 roles per DEC (range 0-7). Only 1.3% were rated as "needs further attention." The frequency with which each competency was selected ranged from 25% (Health Advocate) to 85% (Medical Expert).

CONCLUSION

Teachers chose to direct feedback toward a breadth of competencies. They provided feedback on all 7 CanMEDS roles in the ED, yet demonstrated a marked leniency bias.

The effects of clinical workload on teaching in the emergency department

BACKGROUND

Academic emergency physicians have expressed concern that increased clinical workload and overcrowding adversely affect clinical teaching.

OBJECTIVES

To evaluate the influence of clinical workload and attending physicians' teaching characteristics on clinical teaching in the emergency department (ED).

METHODS

This was a prospective observational study using learner satisfaction assessment tools to evaluate bedside teaching. On days when a research assistant was available, all ED residents and attending physicians were queried. A total of 335 resident surveys were administered over nine months (89% response). Clinical workload was measured by perception and patient volume. Teaching quality and characteristics were rated on ten-point scales. A linear mixed-effects model was used to obtain adjusted impact estimates of clinical workload and teaching attributes on teaching scores while controlling for individual attending physicians' teaching ability and residents' grading tendencies.

RESULTS

No clinical workload parameter had a significant effect on teaching scores: residents' workload perception (beta estimate, 0.024; p = 0.55), attending physicians' workload perception (beta estimate, -0.05; p = 0.28), patient volume in patients per hour (beta estimate, -0.010; p = 0.36), and shift type (beta estimate, -0.19; p = 0.28). The individual attending physician effect was significant (p < 0.001) and adjusted in each case. In another model, the attending physicians' learning environment established (beta estimate, 0.12; p = 0.005), clinical teaching skills (beta estimate, 0.36; p < 0.001), willingness to teach (beta estimate, 0.25; p < 0.001), and interpersonal skills (beta estimate, 0.19; p < 0.001) affected teaching scores, but the attending physicians' availability to teach had no significant effect (beta estimate, 0.007; p = 0.35).

CONCLUSIONS

Clinical workload and attending physicians' availability had little effect on teaching scores. Attending physicians' clinical teaching skills, willingness to teach, interpersonal skills, and learning environment established were the important determinants of overall scores. Skilled instructors received higher scores, regardless of how busy they were.

Evaluating "ED STAT!": a novel and effective faculty development program to improve emergency department teaching

OBJECTIVES

Effective clinical teaching in emergency departments (EDs) presents unique challenges. No validated approaches to enhancing ED teaching have been reported. The authors evaluated the effectiveness of a novel one-day evidence-based, skills-oriented faculty development course tailored to ED teachers (ED STAT!).

METHODS

The authors invited all inaugural course registrants to participate in this program evaluation study. The authors assessed participants' knowledge change and perceived change in teaching behavior using a multiple-choice and short-answer question examination, a teaching behaviors questionnaire, and a survey for satisfaction. Data were gathered before, immediately after, and one month after the course. Mean scores were compared using the Wilcoxon signed rank test, and qualitative results were analyzed via a grounded theory approach.

RESULTS

Thirty-one individuals from a variety of academic and community EDs completed the May 2005 course; 28 participated in the pre-evaluation and postevaluation, and 22 participated in the one-month postevaluation. Multiple-choice scores increased from pre-evaluation to one-month postcourse by 15.1% (p < 0.001, effect size large: d = 1.53). Short-answer scores increased by 17.2% (p = 0.001, effect size large: d = 0.90). After one month, 55% of participants reported an increased amount of teaching, 86% perceived this teaching to be of a greater quality, and 82% had shared new strategies with colleagues. The course would be recommended to a colleague by 96.3% of respondents.

CONCLUSIONS

ED STAT! improves participants' knowledge about ED-specific teaching strategies, and this improvement is maintained at one month. Participants reported high satisfaction and a positive effect on teaching behavior.

The relationship between hospital capacity characteristics and emergency department volumes in Korea

OBJECTIVE

To describe the level of emergency department (ED) volumes according to the hospital characteristics and to identify the relationship between hospital capacity characteristics and ED volumes in Korea.

METHOD

A survey was conducted to acquire information on the ED, its' hospital (facility, personnel, equipment), and the number of ED patients, as part of the National Emergency Medical Centers Assessment Program. Data from 106 nation-wide LEMCs were used. Multiple regression analysis was performed to determine the hospital capacity characteristics related with ED volumes.

RESULTS

The number of ED patients differed according to bed size, nurse staffing, residency training program, and the availability of emergency care-related equipment of the hospital. In the multiple regression analysis, the significant factors which explained the ED volumes were nurse staffing, inpatients per bed, and the population in the area where hospitals are located. The hospitals that were nurse staffing level 2, with more inpatients per bed and larger population of the service area, had more ED patients.

CONCLUSIONS

With the service area population, the ED volumes significantly related with nurse staffing and inpatients per bed. These could be used as one of criteria to designate a LEMC.