Overcrowding: harming the patients of tomorrow?

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.

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.

Recruitment and retention of patients into emergency medicine clinical trials

The emergency medicine (EM) and prehospital environments are unlike any other clinical environments and require special consideration to allow the successful implementation of clinical trials. This article reviews the specific issues involved in EM clinical trials and provides strategies from EM and non-EM trials to maximize recruitment and retention. While the evidence supporting some of these strategies is deficient, addressing recruitment and retention issues with specific strategies will help researchers deal with these issues in their funding applications and in turn develop the necessary infrastructure to participate in EM clinical trials.