Emergency Medicine Resident Efficiency and Emergency Department Crowding

Abstract

Objectives: Provider efficiency has been reported in the literature but there is a lack of efficiency analysis among emergency medicine (EM) residents. We aim to compare efficiency of EM residents of different training levels and determine if EM resident efficiency is affected by emergency department (ED) crowding. Methods:We conducted a single-center retrospective observation study from July 1, 2014, to June 30, 2017. The number of new patients per resident per hour and provider-to-disposition (PTD) time of each patient were used as resident efficiency markers. A crowding score was assigned to each patient upon the patient's arrival to the ED. We compared efficiency among EM residents of different training levels under different ED crowding statuses. Dynamic efficiency changes were compared monthly through the entire academic year (July to next June). Results:The study enrolled a total of 150,920 patients. A mean of 1.9 patients/hour was seen by PGY-1 EM residents in comparison to 2.6 patients/hour by PGY-2 and -3 EM residents. Median PTD was 2.8 hours in PGY-1 EM residents versus 2.6 hours in PGY-2 and -3 EM residents. There were no significant differences in acuity across all patients seen by EM residents. When crowded conditions existed, residency efficiency increased, but such changes were minimized when the ED became overcrowded. A linear increase of resident efficiency was observed only in PGY-1 EM residents throughout the entire academic year.

Is boarding compromising our residents' education? A national survey of emergency medicine program directors

“…The SAEM Taskforce conceptual model 14 suggests the number of patients a resident is exposed to on a shift has consequences: too many or too few may negatively affect education. It may similarly impact resident efficiency, 26 an essential learned skill for emergency physicians.…”

“…The SAEM Taskforce conceptual model 14 suggests the number of patients a resident is exposed to on a shift has consequences: too many or too few may negatively affect education. It may similarly impact resident efficiency, 26 an essential learned skill for emergency physicians. Stagnant ED flow may create a training gap for a specialty heavily reliant on managing high patient loads and optimizing patient flow, both often used as productivity measures.…”

A nationwide survey of emergency medicine resident workflow efficiency: Are training programs teaching residents to be efficient?

“…previous study also showed that efficiency improved with increased ED crowding, although decreased for ED overcrowding. 15 However, the ways in which EM training programs specifically teach and measure WFE to residents have not been studied previously. We believe that this cross-sectional survey provides an accurate snapshot of the educational practices of allopathic EM programs with regard to measuring and teaching WFE.…”

“…A number of studies have shown that resident efficiency measured with common metrics such as PPH, ED length of stay, and resident RVUs improves with each PGY level 6,7,13,14 . A previous study also showed that efficiency improved with increased ED crowding, although decreased for ED overcrowding 15 . However, the ways in which EM training programs specifically teach and measure WFE to residents have not been studied previously.…”

Turning lemons into lemonade: Teaching strategies in boarded emergency departments

“…Boarding of inpatients in emergency department (ED) beds presents unique challenges and opportunities for clinician educators 1 . Severe overcrowding of the ED and operational responses to boarding of inpatients leads to fewer ED patients seen per hour by residents in training, changes in acuity of patients seen by residents, and the potential for decreased learning 2–4 . Though the research to date on the educational impacts of boarding on ED residents has not shown decreases in In‐training Exam (ITE) performance, 1 the result of decreasing number of patient encounters and decreased opportunity to practice the rapid task‐switching skills that are required of attending ED physicians represents a significant threat to residency education.…”