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The Cost of a Learner in the Pediatric Emergency Department: A Comparison Across Two Pediatric Emergency Departments. Pediatr Emerg Care 2022; 38:e1688-e1691. [PMID: 35353800 DOI: 10.1097/pec.0000000000002668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Experimental learning is a foundation of medical education, but a learner in the pediatric emergency department impacts utilization, time and disposition metrics. Our study sought to compare the effect of a resident learner on metrics between 2 pediatric emergency departments. METHODS This retrospective study was conducted in 2019 in 2 pediatric emergency departments of tertiary care hospitals. We compared various time, utilization, and disposition metrics between resident-covered and nonresident-covered patients. RESULTS A total of 62,548 patient encounters were included in our analysis, with 8102 (13%) encounters were resident-managed. Residents were consistently found to see higher-acuity patients, which led to increased relative value unit generation. Residents used more diagnostic testing consistently across both sites. However, we found significant differences between time and disposition metrics between the 2 sites. CONCLUSIONS Residents see sicker patients and tend to order more ancillary tests, which ultimately leads to increased relative value unit generation. We hypothesize that the difference in metrics seen could be explained by the training background of residents, as well as efficiencies of the department as a whole.
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Michael SS, Church RJ, Michael SH, Clark RT, Reznek MA. Effect of resident complement on timeliness of stroke team activation in an academic emergency department. J Am Coll Emerg Physicians Open 2022; 3:e12643. [PMID: 35079732 PMCID: PMC8769070 DOI: 10.1002/emp2.12643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 12/07/2021] [Accepted: 12/20/2021] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVES Investigations of the impact of residents on emergency department (ED) timeliness of care typically focus only on global ED flow metrics. We sought to describe the association between resident complement/supervisory ratios and timeliness of ED care of a specific time-sensitive condition, acute stroke. METHODS We matched ED stroke patient arrivals at 1 academic stroke center against resident and attending staffing and constructed a Cox proportional hazards model of door-to-activation (DTA) time (ie, ED arrival ["door"] to stroke team activation). We considered multiple predictors, including calculated ratios of residents supervised by each attending physician. RESULTS Among 462 stroke activation patients in 2014-2015, DTA ranged from 1 to 217 minutes, 72% within 15 minutes. The median number of emergency and off-service residents supervised per attending were 1.7 (interquartile range [IQR], 1.3-2.3) and 0.7 (IQR, 0-1), respectively. A 1-resident increase in off-service residents was associated with a 24% decrease (hazard ratio [HR], 0.76; 95% confidence interval [CI], 0.64-0.90) in the probability of stroke team activation at any given time. An independent 1-resident increase in the number of emergency residents was associated with a 13% increase (HR, 1.13; 95% CI, 1.01-1.25) in timely activation. CONCLUSION Timeliness of care for acute stroke may be impacted by how academic EDs configure the complement and supervisory structures of residents. Higher supervisory demands imposed by increasing the proportion of rotating off-service residents may be associated with slower stroke recognition and DTA times, but this effect may be offset when more emergency residents are present.
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Affiliation(s)
- Sean S. Michael
- Department of Emergency MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
- Department of Emergency MedicineUniversity of Massachusetts Medical SchoolWorcesterMassachusettsUSA
| | - Richard J. Church
- Department of Emergency MedicineUniversity of Massachusetts Medical SchoolWorcesterMassachusettsUSA
| | - Sarah H. Michael
- Department of Emergency MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
- Department of Emergency MedicineBrown UniversityProvidenceRhode IslandUSA
| | - Richard T. Clark
- Department of Emergency MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Martin A. Reznek
- Department of Emergency MedicineUniversity of Massachusetts Medical SchoolWorcesterMassachusettsUSA
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Kraut AS, Sheehy L, Schnapp BH, Patterson B. Effect of Resident Physicians in a Supervisory Role on Efficiency in the Emergency Department. West J Emerg Med 2020; 21:1266-1269. [PMID: 32970584 PMCID: PMC7514401 DOI: 10.5811/westjem.2020.7.46587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 06/27/2020] [Accepted: 07/02/2020] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION While patient throughput and emergency department (ED) length of stay (LOS) are recognized as important metrics in the delivery of efficient care, they must be balanced with the educational mission of academic centers. Prior studies examining the impact of learners on throughput and LOS when staffing directly with attending physicians have yielded mixed results. Herein we sought to examine the impact of a staffing model involving a supervisory resident "pre-attending" (PAT) on ED throughput and LOS, as this model offers a valuable educational experience for residents, but may do so at the expense of operational efficiency. METHODS We retrospectively analyzed 26,702 unique patient encounters at a university-affiliated community ED between July 1, 2017-January 1,2019. The experimental group was comprised of patients seen primarily by midlevel providers, who staffed with a PAT, who subsequently staffed with an attending physician. The control group was comprised of patients seen by midlevel providers and staffed directly with attendings without a PAT. We used a parametric hazard model to analyze the effect of the presence of a PAT on service time, controlling for potential confounders including timing of presentation and patient demographics. RESULTS The presence of a PAT is associated with a statistically significant increase in service time of five minutes (p = 0.006). Holding other variables equal, predicted service time in the experimental group was 173 minutes (95% confidence interval (CI), 171-176), while that for controls was 168 minutes (95% CI, 165-171). CONCLUSION The presence of a PAT is associated with a statistically significant increase in service time, but the magnitude (five minutes) is likely operationally insignificant. The negligible increase in service time is offset by the benefit to residents' training. The results of this study may be helpful for residency programs considering the addition of a PAT shift structure.
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Affiliation(s)
- Aaron S. Kraut
- University of Wisconsin School of Medicine and Public Health-BerbeeWalsh, Department of Emergency Medicine, Madison, Wisconsin
| | - Lauren Sheehy
- University of Wisconsin School of Medicine and Public Health-BerbeeWalsh, Department of Emergency Medicine, Madison, Wisconsin
| | - Benjamin H. Schnapp
- University of Wisconsin School of Medicine and Public Health-BerbeeWalsh, Department of Emergency Medicine, Madison, Wisconsin
| | - Brian Patterson
- University of Wisconsin School of Medicine and Public Health-BerbeeWalsh, Department of Emergency Medicine, Madison, Wisconsin
- University of Wisconsin-Madison, Department of Industrial and Systems Engineering and Department of Biostatistics and Medical Informatics, Madison, Wisconsin
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Kim JH, Kim J, Bae S, Lee T, Ahn JJ, Kang BJ. 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. J Korean Med Sci 2020; 35:e19. [PMID: 31950776 PMCID: PMC6970079 DOI: 10.3346/jkms.2020.35.e19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 12/02/2019] [Indexed: 11/20/2022] Open
Abstract
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.
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Affiliation(s)
- Jin Hyoung Kim
- Department of Internal Medicine, Ulsan University Hospital, Ulsan, Korea
| | - Jihye Kim
- Intensive Care Nursing Team, Ulsan University Hospital, Ulsan, Korea
| | - SooHyun Bae
- Department of Internal Medicine, Ulsan University Hospital, Ulsan, Korea
| | - Taehoon Lee
- Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Jong Joon Ahn
- Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Byung Ju Kang
- Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea.
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Jadhav N, Grams K, Alweis R. Cost of a learner in pediatric ED. J Community Hosp Intern Med Perspect 2019; 9:80-85. [PMID: 31044036 PMCID: PMC6484465 DOI: 10.1080/20009666.2019.1581045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 02/05/2019] [Indexed: 11/28/2022] Open
Abstract
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.
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Affiliation(s)
- Nagesh Jadhav
- Internal medicine residency program, Rochester General Hospital, Rochester, NY, USA
| | - Keith Grams
- Emergency Medicine, Rochester Regional Health, Rochester, NY, USA
| | - Richard Alweis
- Internal Medicine, Rochester Regional Health, Rochester, NY, USA
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Abstract
Virtual medicine is growing in importance as the cost of medical care rises and the potential for Internet applications expands. The purpose of this study was to evaluate the impact of e-consults (ECs) (also known as virtual specialty consultations) on the frequency of return visits for family medicine patients. Two groups of patients were compared: those for whom an EC was requested (n = 228) and a comparison group for whom face-to-face referrals occurred (n = 500). Two types of early return office visits were used as dependent variables: those within 2 weeks for any reason and those for the same reason. No significant difference was found in rates of early return visits for the same reason. The percent of return visits for any reason within 2 weeks was 38.2% for EC patients and 27.6% for patients receiving face-to-face specialist visits (p < .01). After adjusting for comorbidity, age, sex, and marital status, the odds of an early return visit for any reason after an EC were elevated (odds ratio, 1.88; confidence interval, 1.33-2.66; P < .01). E-consults by referral specialists were associated with increased odds of early return visits for primary care patients with a primary care provider.
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James C, Harper M, Johnston P, Sanders B, Shannon M. Effect of trainees on length of stay in the pediatric emergency department. Acad Emerg Med 2009; 16:859-65. [PMID: 19673709 DOI: 10.1111/j.1553-2712.2009.00480.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Emergency departments (EDs) in teaching hospitals have competing goals of timely patient care and supervised trainee education. Previous investigations have indicated that trainees add time to the length of ED patient encounters. However, no studies have quantified the effect of trainees on pediatric ED length of stay (LOS). OBJECTIVES The objectives were to measure the effect of trainees on pediatric ED LOS by comparing LOS for patients managed by a pediatric emergency physician (PEP) alone to LOS for patients seen by a trainee and a precepting PEP (Trainee+PEP). A secondary objective was to identify factors other than provider type associated with LOS differences observed in teaching hospital pediatric EDs. METHODS Data were extracted from a computerized ED tracking system in an urban tertiary care children's hospital with approximately 52,000 visits annually. All patients were seen by a PEP alone, an urgent care physician, or a trainee (a pediatric emergency medicine fellow; a pediatric, emergency medicine, or combined internal medicine/pediatrics resident; or a medical student) plus a precepting PEP. The primary comparison was the ratio of median LOS for the PEP group versus the Trainee+PEP group. RESULTS There were 92,193 visits eligible for inclusion over a 2-year period. Median patient age was 5.75 years (interquartile range [IQR] = 21 months to 12.9 years). The PEP group managed 9,141 patients (10%), while the Trainee+PEP group treated 72,135 patients (78%). Overall LOS for an ED visit was 221 minutes. The median LOS was 192 minutes for PEP patients and 225 minutes for Trainee+PEP patients (difference of means = 17%, p < 0.001). Laboratory and imaging studies were associated with LOS increases of 111 and 74 minutes, respectively; both were performed more frequently in Trainee+PEP patients (44% vs. 33% for laboratory studies and 41% vs. 39% for imaging studies, both comparisons p < 0.001). When LOS was analyzed after adjusting for confounding factors including patient acuity, laboratory or radiologic testing, and trainee year, LOS for Trainee+PEP was higher by 17 minutes, or 9% (95% confidence interval [CI] = 6% to 12%, p < 0.001). When LOS was examined for four specific diagnoses (asthma, gastroenteritis, appendicitis, foot/ankle sprain), there were no significant differences in LOS between the PEP and Trainee+PEP groups. CONCLUSIONS In the pediatric ED of a teaching hospital, ED LOS is on average 9% higher in patients seen by trainees. In an era of increasing efforts to accelerate throughput while training future providers, these findings provide an important metric for the delivery of pediatric emergency care.
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Affiliation(s)
- Catherine James
- Division of Pediatric Emergency Medicine, UMass Memorial Medical Center, USA.
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Sucov A, Sidman R, Valente J. A cost-efficiency analysis to increase clinician staffing in an academic emergency department. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2009; 84:1211-1216. [PMID: 19707059 DOI: 10.1097/acm.0b013e3181b187fc] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
PURPOSE To develop a software-based model to determine which combination of attendings working with/without residents and/or midlevel providers (MLP) was most cost-efficient for incremental staffing in an academic emergency department (ED). METHOD A decision tree model using standard decision analysis software was created to compare different staffing configurations for the Rhode Island Hospital ED. The productivity, salary, and working hour data of different staffing configurations were determined using data from the ED, reported productivity data, and assumptions based on the authors' experience. Attending physician productivity alone was assumed to be 2.1 patients per hour, and each additional resident and/or MLP was assumed to add smaller net productivity gains (the first one adds 0.75 patients/hour; the second, 0.5 patients/hour; the third, 0.33 patients/hour). Resident and MLP productivity were assumed to be equivalent in the base case and varied during subsequent analysis. Noneconomic variables were not included in the model. RESULTS The lowest base case cost option is to pair one attending with one resident; all other approaches are more expensive. The difference between most options is less than $5/patient. Only at extremes of variables do overall choices differ. CONCLUSIONS Incrementally staffing an academic ED with a ratio of one attending per resident achieves the lowest cost, but other models are minimally more expensive. The model allows an ED administrator to determine the costs of different models.
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Affiliation(s)
- Andrew Sucov
- Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island 02903, USA.
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Impact of retail walk-in care on early return visits by adult primary care patients: evaluation via triangulation. Qual Manag Health Care 2009; 18:19-24. [PMID: 19148026 DOI: 10.1097/01.qmh.0000344590.61971.97] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Retail medicine clinics have become widely available. However, few studies have been published reporting on the outcomes of care from these clinics. The purpose of this study was to assess the risk of early return visits for patients using a retail walk-in clinic. DESIGN Medical records of patients seen in a large group practice in Minnesota in the first 2 months of 2008 were analyzed for this study. Three groups of patients were studied: those using the retail walk-in clinic (n = 300), a comparison group using regular office care in the previous year (n = 373), and a same-day acute care clinic in a medical office (n = 204). The dependent variable was a return office visit within 2 weeks. Multiple logistic regression analysis was used to adjust for case-mix differences between groups. RESULTS The percentage of office visits within 2 weeks for these groups was 31.7 for retail walk-in patients, 38.9 for office visit patients, and 37.1 for same-day acute care clinic patients, respectively (P = .13). The corresponding percentages of return office visits within 2 weeks for the same reasons were 14.0, 24.4, and 20.6 (P < .01). After adjustment for age, sex, marital status, acuity, and number of office visits in the previous 6 months, no significant differences in risk of early return visits were found among clinic types. CONCLUSION Our retail walk-in clinic appeared to increase access without increasing early return visits.
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Abstract
PURPOSE OF REVIEW Being critical in terms of time and complexity, emergency medicine is exposed to an emerging imperative for quality improvement strategies. We review current concepts and recent advances in the management of quality in emergency medicine. RECENT FINDINGS There is a strong interdependence between quality of emergency healthcare provision and the education of emergency healthcare providers. Introduction of emergency medical residencies and highly qualified triage liaison physicians helps prevent the overcrowding of emergency departments, accelerate access to emergency medical care and improve patient satisfaction. New advances in detecting and reducing patient management errors include the collection of healthcare provider complaints and the classification of unpreventable and preventable deaths of patients within 1 week of admission via the emergency department. Medical record review and video recording have revealed that frequent patient management problems relate to shortcomings in the diagnostic process, clinical tasks, patient factors, and poor teamwork. Communication skills and patient data/documentation systems may effectively resolve these problems. SUMMARY According to the available evidence, more performance improvement strategies need to be tested to delineate which process changes would be most effective in improving patient outcome in emergency medicine.
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