The Effect of Emergency Department Crowding on Education: Blessing or Curse?

Shayne, Philip; Lin, Michelle; Ufberg, Jacob W.; Ankel, Felix; Barringer, Kelly; Morgan-Edwards, Sarah; Deiorio, Nicole M.; Asplin, Brent R.

doi:10.1111/j.1553-2712.2008.00261.x

Cited by 16 publications

(21 citation statements)

References 30 publications

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“…[18] Regardless of the causes of crowding; the negative results include delays in treatment,[19] decreased quality of care for patients,[20] and medication errors[21] among others. [2223242526]…”

Section: Discussionmentioning

confidence: 99%

Further characterization of the influence of crowding on medication errors

Watts

Nasim

Sweis

et al. 2013

J Emerg Trauma Shock

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Study Objectives:Our prior analysis suggested that error frequency increases disproportionately with Emergency department (ED) crowding. To further characterize, we measured this association while controlling for the number of charts reviewed and the presence of ambulance diversion status. We hypothesized that errors would occur significantly more frequently as crowding increased, even after controlling for higher patient volumes.Materials and Methods:We performed a prospective, observational study in a large, community hospital ED from May to October of 2009. Our ED has full-time pharmacists who review orders of patients to help identify errors prior to their causing harm. Research volunteers shadowed our ED pharmacists over discrete 4- hour time periods during their reviews of orders on patients in the ED. The total numbers of charts reviewed and errors identified were documented along with details for each error type, severity, and category. We then measured the correlation between error rate (number of errors divided by total number of charts reviewed) and ED occupancy rate while controlling for diversion status during the observational period. We estimated a sample size requirement of at least 45 errors identified to allow detection of an effect size of 0.6 based on our historical data.Results:During 324 hours of surveillance, 1171 charts were reviewed and 87 errors were identified. Median error rate per 4-hour block was 5.8% of charts reviewed (IQR 0-13). No significant change was seen with ED occupancy rate (Spearman's rho = –.08, P = .49). Median error rate during times on ambulance diversion was almost twice as large (11%, IQR 0-17), but this rate did not reach statistical significance in univariate or multivariate analysis.Conclusions:Error frequency appears to remain relatively constant across the range of crowding in our ED when controlling for patient volume via the quantity of orders reviewed. Error quantity therefore increases with crowding, but not at a rate greater than the expected baseline error rate that occurs in uncrowded conditions. These findings suggest that crowding will increase error quantity in a linear fashion.

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Section: Discussionmentioning

confidence: 99%

Further characterization of the influence of crowding on medication errors

Watts

Nasim

Sweis

et al. 2013

J Emerg Trauma Shock

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“…Learners believe that bedside teaching is underutilized, with time constraints, faculty experience, and overreliance on technology cited as factors in the relative dearth of bedside instruction demonstrated in the literature (6,9). Emergency department (ED) overcrowding is also a potential barrier to teaching, though research exploring the impact of rising patient volume on graduate education is scarce (4,10,11). How these changes in patient volume specifically affect bedside instruction is unclear, though one could assume that attending physicians will have more administrative and direct patient care responsibilities (5,10).…”

Section: Introductionmentioning

confidence: 97%

Back to the Bedside: The 8-year Evolution of a Resident-as-Teacher Rotation

Ilgen

Takayesu

Bhatia

et al. 2011

The Journal of Emergency Medicine

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“…If included, trainees are often modeled similarly to physicians where the only difference exists in the assessment/treatment time [4-7]. However, previous research has found that the presence of trainees in the ED is positively associated with an increased patient length of stay (LOS) [8,9] and that trainees exhibit poor time management when faced with overcrowding [10,11]. Time and motion studies [12,13] have estimated that approximately 30% of a physician’s time is actually spent with the patient (e.g.…”

Section: Introductionmentioning

confidence: 99%

Simulating an emergency department: the importance of modeling the interactions between physicians and delegates in a discrete event simulation

Lim

Worster

Goeree

et al. 2013

BMC Med Inform Decis Mak

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BackgroundComputer simulation studies of the emergency department (ED) are often patient driven and consider the physician as a human resource whose primary activity is interacting directly with the patient. In many EDs, physicians supervise delegates such as residents, physician assistants and nurse practitioners each with different skill sets and levels of independence. The purpose of this study is to present an alternative approach where physicians and their delegates in the ED are modeled as interacting pseudo-agents in a discrete event simulation (DES) and to compare it with the traditional approach ignoring such interactions.MethodsThe new approach models a hierarchy of heterogeneous interacting pseudo-agents in a DES, where pseudo-agents are entities with embedded decision logic. The pseudo-agents represent a physician and delegate, where the physician plays a senior role to the delegate (i.e. treats high acuity patients and acts as a consult for the delegate). A simple model without the complexity of the ED is first created in order to validate the building blocks (programming) used to create the pseudo-agents and their interaction (i.e. consultation). Following validation, the new approach is implemented in an ED model using data from an Ontario hospital. Outputs from this model are compared with outputs from the ED model without the interacting pseudo-agents. They are compared based on physician and delegate utilization, patient waiting time for treatment, and average length of stay. Additionally, we conduct sensitivity analyses on key parameters in the model.ResultsIn the hospital ED model, comparisons between the approach with interaction and without showed physician utilization increase from 23% to 41% and delegate utilization increase from 56% to 71%. Results show statistically significant mean time differences for low acuity patients between models. Interaction time between physician and delegate results in increased ED length of stay and longer waits for beds.ConclusionThis example shows the importance of accurately modeling physician relationships and the roles in which they treat patients. Neglecting these relationships could lead to inefficient resource allocation due to inaccurate estimates of physician and delegate time spent on patient related activities and length of stay.

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The Effect of Emergency Department Crowding on Education: Blessing or Curse?

Cited by 16 publications

References 30 publications

Further characterization of the influence of crowding on medication errors

Further characterization of the influence of crowding on medication errors

Back to the Bedside: The 8-year Evolution of a Resident-as-Teacher Rotation

Simulating an emergency department: the importance of modeling the interactions between physicians and delegates in a discrete event simulation

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