The effects of the absence of emergency medicine residents in an academic emergency department

Intensivists' Direct Management without Residents May Improve the Survival Rate Compared to High-Intensity Intensivist Staffing in Academic Intensive Care Units: Retrospective and Crossover Study Design

BACKGROUND

Medical staff members are concentrated in the intensive care unit (ICU), and medical residents are essentially needed to operate the ICU. However, the recent trend has been to restrict resident working hours. This restriction may lead to a shortage of ICU staff, and there is a chance that regional academic hospitals will face running ICUs without residents in the near future.

METHODS

We performed a retrospective observational study (intensivist crossover design) of medical patients who were transferred to two ICUs from general wards between September 2017 and February 2019 at one academic hospital. We compared the ICU outcomes according to the ICU type (ICU with resident management under high-intensity intensivist staffing vs. ICU with direct management by intensivists without residents).

RESULTS

Of 314 enrolled patients, 70 were primarily managed by residents, and 244 were directly managed by intensivists. The latter patients showed better ICU mortality (29.9% vs. 42.9%, P = 0.042), lower cardiopulmonary resuscitation (CPR) (10.2% vs. 21.4%, P = 0.013), lower continuous renal replacement therapy (CRRT) (24.2% vs. 40.0%, P = 0.009), and more advanced care planning decisions before death (87.3% vs. 66.7%, P = 0.013) than the former patients. The better ICU mortality (hazard ratio, 1.641; P = 0.035), lower CPR (odds ratio [OR], 2.891; P = 0.009), lower CRRT (OR, 2.602; P = 0.005), and more advanced care planning decisions before death (OR, 4.978; P = 0.007) were also associated with intensivist direct management in the multivariate cox and logistic regression analysis.

CONCLUSION

Intensivist direct management might be associated with better ICU outcomes than resident management under the supervision of an intensivist. Further large-scale prospective randomized trials are required to draw a definitive conclusion.

Cost of a learner in pediatric ED

Background: Experiential learning in a cornerstone of medical education, but impacts throughput, utilization of resources and patient outcomes.

Objectives: Our study sought to determine the cost of a resident across various throughput, utilization, and patient outcome measures.

Methods: This retrospective study was conducted in 2016 in the pediatric emergency department of an urban tertiary care hospital. . We compared various throughput, utilization and patient outcome measures between resident-covered and nonresident–covered patients. A subgroup analysis was performed based on complexity as determined by CPT codes.

Results: 33,278 patient encounters occurred between 1 January 2016, and 31 December 2016. Of these, 8,434 (25.42%) were resident-covered patients. Across all encounters, throughput, utilization and patient experience measures were unfavorable for the resident covered group. In subgroup analysis based on complexity of patients, throughput measures were either unfavorable or there was a trend towards unfavorability across all complexities for the resident covered group. Overall utilization and patient outcome measures were unfavorable in low and moderate complexity patients for the resident covered group. In high complexity patients, most of the utilization and patient outcome measures were similar in both groups.

Conclusion: Presence of a resident led to unfavorable increases in many throughput, utilization and outcome measures, a difference which disappeared in most cases with higher complexity patients. Therefore, the cost of a resident may actually decrease with increasing patient complexity.

Does Intradisciplinary Conflict Influence to Outcomes of Emergency Medicine Residency Program? A Mixed Methods Study

Objective

To explore impact of emergency medicine residency program on patient waiting times in emergency department (ED) and determine the associated factors.

Methods

A two-phased sequential exploratory mixed-methods approach was used. The first phase was comprised of retrospective before-after design of ED encounters for a 3-month period, six months before and six months after the introduction of an emergency medicine residency program in an Iranian teaching hospital. The second phase included semi-structured interviews with five individuals which purposively selected to participate in qualitative design. Quantitative data were analysed descriptively and qualitative data were analysed using an iterative framework approach.

Results

The most patients were admitted to the hospital in night shift, both before and after the resident EMS. No statistically significant differences were found among all of the waiting times during the two time periods except for the average time interval between admission and physician start time (p<0.0001), which increased (instead of reducing), and the average time interval between physician start time and first treatment measure (p<0.0001), which decreased during the year the residents began. The interviewees revealed the intradisciplinary conflicts and interferences existing between ED and other specialist departments, are main important factor to delayed processing of patients visits.

Conclusion

This study has shown that intradisciplinary conflict would affect the outcomes of emergency medicine residency program and ED process. These new findings enhance the understanding of the nature of conflicts and will persuade policy makers that design a set of clinical practice guidelines to clarify the duties and responsibilities of parties involved in ED.

Does Intradisciplinary Conflict Influence to Outcomes of Emergency Medicine Residency Program? A Mixed Methods Study

OBJECTIVE

To explore impact of emergency medicine residency program on patient waiting times in emergency department (ED) and determine the associated factors.

METHODS

A two-phased sequential exploratory mixed-methods approach was used. The first phase was comprised of retrospective before-after design of ED encounters for a 3-month period, six months before and six months after the introduction of an emergency medicine residency program in an Iranian teaching hospital. The second phase included semi-structured interviews with five individuals which purposively selected to participate in qualitative design. Quantitative data were analysed descriptively and qualitative data were analysed using an iterative framework approach.

RESULTS

The most patients were admitted to the hospital in night shift, both before and after the resident EMS. No statistically significant differences were found among all of the waiting times during the two time periods except for the average time interval between admission and physician start time (p<0.0001), which increased (instead of reducing), and the average time interval between physician start time and first treatment measure (p<0.0001), which decreased during the year the residents began. The interviewees revealed the intradisciplinary conflicts and interferences existing between ED and other specialist departments, are main important factor to delayed processing of patients visits.

CONCLUSION

This study has shown that intradisciplinary conflict would affect the outcomes of emergency medicine residency program and ED process. These new findings enhance the understanding of the nature of conflicts and will persuade policy makers that design a set of clinical practice guidelines to clarify the duties and responsibilities of parties involved in ED.

The Effect of Emergency Medicine Residents on Clinical Efficiency and Staffing Requirements

OBJECTIVES

The effect of emergency medicine (EM) residents on the clinical efficiency of attending physicians is controversial. The authors hypothesized that implementing a new EM residency program would result in an increase in relative value units (RVUs) generated per hour by attending physicians and decrease staffing requirements.

METHODS

This was a retrospective observational analysis of an emergency department before, during, and after the establishment of a new EM residency program. We analyzed the change in RVUs billed, patients seen, and hours worked by attending physicians, midlevel providers (MLPs), and residents, and addressed potential confounding factors.

RESULTS

The clinical efficiency of attending physicians increased by 70%, or 4.98 RVUs/hour (from 7.12 [SD ± 1.4] RVUs/hour to 12.1 [SD ± 2.2] RVUs/hour, p < 0.001) with the implementation of an EM residency program. Overall, net department RVU generation rose by 32%, even as attending physician coverage decreased by 6.3% (p < 0.05), and MLP coverage dropped by 60% (p < 0.05). We estimated that the implementation of the residency saved 4,860 hours of attending physician coverage and 5,828 hours of MLP coverage per year. This represents an estimated $1,741,265 in annual staffing savings, comparable to the residency program's annual operating cost of $1,821,108.

CONCLUSIONS

The implementation of an EM residency program had a positive effect on the clinical efficiency of attending physicians and decreased staffing requirements.

Impact of a teaching service on emergency department throughput

INTRODUCTION

There are 161 emergency medicine residency programs in the United States, many of which have medical students rotating through the emergency department (ED). Medical students are typically supervised by senior residents or attendings while working a regular shift. Many believe that having students see and present patients prolongs length of stay (LOS), as care can be delayed. Our institution implemented a unique method of educating medical students while in the ED with the creation of a teaching service, whose primary goal is education in the setting of clinical care. The objective of this study was to explore the effect of the teaching service on efficiency by describing LOS and number of patients seen on shifts with and without a teaching service.

METHODS

This was a retrospective chart review performed over a 12-month period of visits to an urban academic ED. We collected data on all patients placed in a room between 14:00 and 19:59, as these were the hours that the teaching shift worked in the department. We categorized shifts as 1) a teaching service with students (TWS); 2) a teaching service without students (TWOS); and 3) no teaching service (NTS). LOS and median number of patients seen on days with a teaching service, both with and without students (TWS and TWOS), was compared to LOS on days without a teaching service (NTS).

RESULTS

The median LOS on shifts with a dedicated teaching service without students (TWOS) was 206 minutes, while the median LOS on shifts with a teaching service with students (TWS) was 220 minutes. In comparison, the median LOS on shifts when no teaching service was present (NTS) was 202.5 minutes. The median number of patients seen on shifts with the teaching service with students (TWS) was 44, identical to the number seen on shifts when the teaching service was present without students (TWOS). When the teaching service was absent (NTS), the median number of patients seen was 40.

CONCLUSION

A teaching service in the ED is a novel educational model for medical student and resident instruction that increases total ED patient throughput and has only a modest effect on increased median length of stay for patients.

The effect of medical trainees on pediatric emergency department flow: a discrete event simulation modeling study

BACKGROUND

Providing patient care and medical education are both important missions of teaching hospital emergency departments (EDs). With medical school enrollment rising, and ED crowding becoming an increasing prevalent issue, it is important for both pediatric EDs (PEDs) and general EDs to find a balance between these two potentially competing goals.

OBJECTIVES

The objective was to determine how the number of trainees in a PED affects patient wait time, total ED length of stay (LOS), and rates of patients leaving without being seen (LWBS) for PED patients overall and stratified by acuity level as defined by the Pediatric Canadian Triage and Acuity Scale (CTAS) using discrete event simulation (DES) modeling.

METHODS

A DES model of an urban tertiary care PED, which receives approximately 40,000 visits annually, was created and validated. Thirteen different trainee schedules, which ranged from averaging zero to six trainees per shift, were input into the DES model and the outcome measures were determined using the combined output of five model iterations.

RESULTS

An increase in LOS of approximately 7 minutes was noted to be associated with each additional trainee per attending emergency physician working in the PED. The relationship between the number of trainees and wait time varied with patients' level of acuity and with the degree of PED utilization. Patient wait time decreased as the number of trainees increased for low-acuity visits and when the PED was not operating at full capacity. With rising numbers of trainees, the PED LWBS rate decreased in the whole department and in the CTAS 4 and 5 patient groups, but it rose in patients triaged CTAS 3 or higher. A rising numbers of trainees was not associated with any change to flow outcomes for CTAS 1 patients.

CONCLUSIONS

The results of this study demonstrate that trainees in PEDs have an impact mainly on patient LOS and that the effect on wait time differs between patients presenting with varying degrees of acuity. These findings will assist PEDs in finding a balance between providing high-quality medical education and timely patient care.

The effect of medical students and residents on measures of efficiency and timeliness in an academic medical center emergency department

PURPOSE

Research regarding the effect of trainees on emergency department (ED) operations has demonstrated mixed results. In this study, the authors evaluated the effect of trainees on ED length of stay (LOS), door to medical provider (DTMP) time, and door to disposition decision (DTDD) time while accounting for covariates known to influence ED efficiency and timeliness.

METHOD

The authors used retrospective cohort data for ED visits to Maine Medical Center's mixed adult and pediatric ED for the calendar years 2005 through 2009. Each visit was coded indicating the type of provider conducting the visit (student-attending, resident-attending, midlevel provider, or attending group). Ordinary least squares regression analyses were performed to examine the relationships between provider groups and ED LOS, DTMP time, and DTDD time. Hierarchical regression models were constructed to control for the confounding effects of triage acuity, time of year, laboratory testing, radiographic testing, and patient characteristics.

RESULTS

The analysis of 246,142 visits found significant intergroup differences across provider groups for each outcome (P < .001). Multiple regression modeling revealed that treatment by trainees was a significant predictor of longer LOS (medical students and residents), shorter DTMP time (residents), and longer DTDD time (medical students and residents), after controlling for covariates.

CONCLUSIONS

Laboratory and radiographic testing accounted for a much larger proportion of variation in outcomes than did trainees. The small increases in LOS and DTDD time are balanced by the decrease in DTMP time and the intangible benefits of educating trainees.

Family medicine patients who use retail clinics have lower continuity of care

PURPOSE

The purpose of this study was to compare continuity of care for family medicine patients using retail medicine clinics to continuity for patients not using retail clinics. Retail medicine clinics have become popular in some markets. However, their impact on continuity of care has not been studied.

METHODS

Electronic medical records of adult primary care patients seen in a large group practice in Minnesota in 2011 were analyzed for this study. Two randomly chosen groups of patients were selected (N = 400): those using 1 of 3 retail walk-in clinics staffed by nurse practitioners in addition to standard office care and a comparison group that only used standard office care. Continuity was measured as the percentage of visits that involved the primary care provider. We also compared patients who made zero visits to their primary care providers with those who made some visits to their primary care providers.

RESULTS

Continuity of care was lower for patients who used retail clinics than for patients who did not use retail clinics (0.17 vs 0.44, mean difference 0.27). The percentage of patients who made zero visits to their primary care providers was 54.5 for users of retail clinics versus 31.0 for those who did not use retail clinics.

CONCLUSIONS

Continuity of care should be monitored as retail medicine continues to expand.

The efficacy and value of emergency medicine: a supportive literature review

Study objectives

The goal of this study was to identify publications in the medical literature that support the efficacy or value of Emergency Medicine (EM) as a medical specialty and of clinical care delivered by trained emergency physicians. In this study we use the term "value" to refer both to the "efficacy of clinical care" in terms of achieving desired patient outcomes, as well as "efficiency" in terms of effective and/or cost-effective utilization of healthcare resources in delivering emergency care. A comprehensive listing of publications describing the efficacy or value of EM has not been previously published. It is anticipated that the accumulated reference list generated by this study will serve to help promote awareness of the value of EM as a medical specialty, and acceptance and development of the specialty of EM in countries where EM is new or not yet fully established.

Methods

The January 1995 to October 2010 issues of selected journals, including the EM journals with the highest article impact factors, were reviewed to identify articles of studies or commentaries that evaluated efficacy, effectiveness, and/or value related to EM as a specialty or to clinical care delivered by EM practitioners. Articles were included if they found a positive or beneficial effect of EM or of EM physician-provided medical care. Additional articles that had been published prior to 1995 or in other non-EM journals already known to the authors were also included.

Results

A total of 282 articles were identified, and each was categorized into one of the following topics: efficacy of EM for critical care and procedures (31 articles), efficacy of EM for efficiency or cost of care (30 articles), efficacy of EM for public health or preventive medicine (34 articles), efficacy of EM for radiology (11 articles), efficacy of EM for trauma or airway management (27 articles), efficacy of EM for using ultrasound (56 articles), efficacy of EM faculty (34 articles), efficacy of EM residencies (24 articles), and overviews and editorials of EM efficacy and value (35 articles).

Conclusion

There is extensive medical literature that supports the efficacy and value for both EM as a medical specialty and for emergency patient care delivered by trained EM physicians.

Care without coverage: is there a relationship between insurance and ED care?

The Institute of Medicine (IOM) has concluded that differences in care exist for hospitalized patients on the basis of insurance; we attempted to determine if these differences begin in the emergency department (ED). We retrospectively studied high-acuity adult visits to one ED over 6 months, utilizing electronic databases. Uninsured patients were more often younger, male, and non-white (n = 3899 visits; 468 uninsured, 3431 insured). Fewer uninsured patients were admitted (9.8% vs. 27.2% insured; p < 0.001). Comparing patients by admission status, there was no evidence of difference for most measures, excepting radiographic studies (admitted patients: 78.3% uninsured vs. 90.5% insured, p = 0.007; treated-and-released patients: 62.3% uninsured vs. 69.4% insured, p = 0.004). In a subset of trauma patients for whom acuity could be evaluated with Injury Severity Scores (ISS), admission rates were similar. In this pilot study of high-acuity patients, there was limited evidence of differences in most measures of ED-based patient care on the basis of insurance status.

Emergency department performance indicators that encompass the patient journey

OBJECTIVE

The study aimed to provide a recommended list of performance indicators from routinely collected data that measure most aspects of the patient journey through the emergency department (ED).

METHODS

Data from a large tertiary ED were used to investigate the proposed performance indicators, which fell into 7 categories: background information, time from arrival to triage, time from triage to treatment, length of stay, readmission rate, left without being seen, and deaths in the ED.

MAIN RESULTS

Category 1 patients were triaged, treated, and discharged rapidly. For category 2 patients, the times from arrival to triage increased but times from triage to treatment were relatively stable. Patients in categories 3 and 4 were not triaged rapidly and both the arrival to triage and triage to treatment processes were unstable and deteriorating. The average time to treatment for patients treated outside recommended times was unstable and increasing for categories 2, 3, and 4. The number of patients who left without being seen was stable except for 2 periods, and the readmission rate was stable except for 1 period of increase.

CONCLUSION

The performance indicators use only routinely collected data and clearly identify the areas in which this ED performed poorly.