Education
The Impact of Emergency Department Overcrowding on Resident Education

Presented at the Society of Academic Emergency Medicine Annual Meeting, Phoenix, Arizona, June 2010.
https://doi.org/10.1016/j.jemermed.2011.03.022Get rights and content

Abstract

Background

Few studies have evaluated the effect of Emergency Department (ED) overcrowding on resident education.

Objectives

To determine the impact of ED overcrowding on Emergency Medicine (EM) resident education.

Materials and Methods

A prospective cross-sectional study was performed from March to May 2009. Second- and third-year EM residents, blinded to the research objective, completed a questionnaire at the end of each shift. Residents were asked to evaluate the educational quality of each shift using a 10-point Likert scale. Number of patients seen and procedures completed were recorded. Responses were divided into ED overcrowding (group O) and non-ED overcrowding (group N) groups. ED overcrowding was defined as >2 h of ambulance diversion per shift. Questionnaire responses were compared using Mann–Whitney U tests. Number of patients and procedures were compared using unpaired T-tests.

Results

During the study period, 125 questionnaires were completed; 54 in group O and 71 in group N. For group O, the median educational value score was 8 (interquartile range [IQR] 7–10), compared to 8 (IQR 8–10) for group N (p = 0.24). Mean number of patients seen in group O was 12.3 (95% confidence interval [CI] 11.4–13.2), compared to 13.9 (95% CI 12.7–15) in group N (p = 0.034). In group O, mean number of procedures was 0.9 (95% CI 0.6–1.2), compared to 1.3 (95% CI 1–1.6) in group N (p = 0.047).

Conclusions

During overcrowding, EM residents saw fewer patients and performed fewer procedures. However, there was no significant difference in resident perception of educational value during times of overcrowding vs. non-overcrowding.

Introduction

Emergency Department (ED) overcrowding has been called a crisis in Emergency Medicine (EM) (1). ED overcrowding occurs when the demand for services overwhelms available resources. Symptoms of ED overcrowding include boarding admitted patients, diverting ambulances, and caring for patients on stretchers in hallways. As evidence to the magnitude of this problem, the Institute of Medicine has estimated that over 90% of EDs are affected by overcrowding (1). However, overcrowding is most severe in academic centers and urban hospitals, many of which support EM residency training programs 1, 2, 3.

Several studies have demonstrated that ED overcrowding is associated with increased morbidity and mortality 4, 5, 6, 7, 8, 9, 10, 11, 12, 13. However, the impact of ED overcrowding on EM resident education is largely unknown. Several authors have hypothesized that overcrowding increases ED attendings’ clinical and administrative workload, resulting in decreased quality and time available for teaching 14, 15, 16.

At present, only one published peer-reviewed study assessing the relationship between overcrowding and EM resident education exists. Pines et al. assessed the quality of teaching for residents and medical students during individual patient encounters (17). This study failed to find a correlation between the quality of education and ED overcrowding. Unfortunately, the study was powered to detect only very large differences in educational quality and did not measure the number of patients seen or number of procedures completed. Smaller, possibly important educational differences may have been detected if the study had been adequately powered. Therefore, the objective of this study is to determine the impact of ED overcrowding on EM resident education as measured by number of patients seen, number of procedures completed, and resident perception.

Section snippets

Materials and Methods

A prospective cross-sectional study was performed over a 3-month period from March to May 2009 at Louisiana State University Health Sciences Center Shreveport (LSUHSC-S). LSUHSC-S is a tertiary care, level I trauma center, and an academic center. The ED has an annual volume of 60,000 patient visits per year and treats primarily uninsured or underinsured patients. It is also home to a 1- to 3-year EM residency program with 7 residents per year.

Second- and third-year EM residents, blinded to the

Results

During the 3-month study period from March 2009 to May 2009, second- and third-year residents worked a total of 236 shifts. Questionnaires were completed for 125 shifts, a response rate of 53% (125/236). Group O had 54 questionnaires and group N had 71. Second-year residents completed 75 questionnaires, compared to 50 by third-year residents (Table 1).

The median ambulance diversion time per shift for Group O was 5 h (interquartile range [IQR] 3–7) compared to 0 h (IQR 0) for group N (p <

Discussion

Due to a high prevalence of overcrowding in academic centers and urban hospitals with EM residency training programs, several authors have hypothesized that overcrowding decreases the quality and time available for teaching in the ED 1, 2, 3, 14, 15, 16. In this study, the residents’ perception of the overall educational value of each shift did not differ significantly based on overcrowding. However, during times of overcrowding, residents cared for fewer patients and completed fewer

Conclusions

During shifts with ED overcrowding, EM residents saw fewer patients and performed fewer procedures. However, residents’ opinion of the educational value of shifts did not differ significantly based on overcrowding. The long-term effects of overcrowding on EM resident education remain unknown. Future studies should assess educational value, number of patients cared for, and number of procedures completed over a longer time period. In addition, future studies should measure educational value

References (20)

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