Triage physicians in an academic emergency department: Impact on resident education

Effects of opening a vertical care area on emergency medicine resident clinical experience

Background

Challenging clinical environments faced by emergency departments (EDs) have led to operational changes including implementation of vertical care units and fast-track units. Little is known regarding the impact of such units on resident physician clinical education.

Methods

A retrospective, observational study was performed at an urban quaternary care ED evaluating the effect of opening a vertical care unit with a triage physician directing lower acuity patients to be seen by physician associates (PAs)/advanced practice registered nurses (APRNs) on the following parameters: (1) percentage of patients seen by residents, (2) Emergency Severity Index (ESI) of patients seen by residents, (3) number of procedures performed by residents, (4) number of patients per shift seen by residents, (5) percentage of critical care patients seen by residents, and (6) percentage of behavioral health patients seen by residents.

Results

Comparing the implementation of the vertical care unit to the prior 3 months, postgraduate year (PGY)-1 residents had greater exposure to ESI Levels 1 and 2 (odds ratio [OR] 2.15) and more critical care (OR 2.58). PGY-2 and PGY-3 residents had a lower exposure to ESI 1 and 2 patients (PGY-2 OR 0.63, PGY-3 OR 0.61) and less critical care exposure (OR 0.64 for PGY-2 and OR 0.62 for PGY-3) after implementation. PGY-1 residents saw fewer behavioral health patients (OR 0.65) while the other two classes saw more (PGY-2 OR 1.64, PGY-3 OR 2.74). ESI 4 and 5 exposure decreased for all classes (PGY-1 OR 0.15, PGY-2 OR 0.86, PGY-3 OR 0.72). No significant difference was found in the proportion of patients treated by residents (p = 0.85) or the number of procedures performed by residents (p = 0.25) comparing the implementation of a vertical care unit to the prior 3 months.

Conclusions

This study suggests no detrimental effects of vertical care unit implementation on multiple resident education outcomes including the number and acuity level of patients seen as well as procedure numbers of resident trainees. While the outcomes measured did not show significant negative effect for the resident compliment as a whole, we noted changes to the distribution of patient acuity based on PGY level. Similar assessments are recommended to determine the educational impact of comparable operational changes in other EDs.

Development and implementation of just-in-time curricula for on-shift teaching during times of boarding

Background

Overcrowded emergency departments (EDs) due to boarding of inpatients can lead to fewer patients seen by residents and may negatively impact their education. The existing literature recommends providing educational resource banks to augment teaching during overcrowding. We aimed to develop and evaluate the use of an educational curriculum during times of boarding.

Methods

Using Kern's model of curriculum development, we conducted local and national needs assessments to identify existing curricula. The final curriculum consisted of electrocardiogram (ECG) cases, procedural resources, journal articles, and oral boards style cases. The derived curriculum was implemented at the study site, where content was released weekly via email or Slack and via our departmental educational blog. Residents were asked to fill out a survey assessing their satisfaction with the resource, their current patient load, and current National Emergency Department Overcrowding Study score (NEDOCS). We compared clinician educator satisfaction with teaching before implementation and at 3 months after implementation using Wilcoxon rank-sum test.

Results

The national needs assessment was sent to the Council of Residency Directors (CORD) listserv. There were 36 unique program responses with only one program with resources for teaching during overcrowding. The derived curriculum was used seven times during the study period. The mean (±SD) NEDOCS at the time of resource use was 238.7 (±23.6). The median (range) number of active patients while using the resource was 4 (0-7). ECG cases were the most used resource. Mean (±SD) satisfaction with teaching before implementation was 2.8 (±0.9; Likert-type item scale 1 to 6 from not at all to a great deal satisfied). Satisfaction with teaching improved after implementation of the curriculum, with the mean (±SD) increasing to 3.5 (±1.0; p = 0.01).

Conclusions

We report the development and implementation of a local educational curriculum for use during times of boarding. The curriculum was lightly used during the study period, but the availability of a curriculum may have increased satisfaction with teaching during boarding.

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.