Tsyrulnik Alina, Rothenberg Craig, Sun Wendy W, Venkatesh Arjun, Coughlin Ryan F, Goldflam Katja, Sangal Rohit B
Yale University School of Medicine New Haven Connecticut USA.
AEM Educ Train. 2024 Nov 20;8(6):e11040. doi: 10.1002/aet2.11040. eCollection 2024 Dec.
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.
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.
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 ( = 0.85) or the number of procedures performed by residents ( = 0.25) comparing the implementation of a vertical care unit to the prior 3 months.
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.
急诊科面临的具有挑战性的临床环境已导致运营变革，包括实施垂直护理单元和快速通道单元。关于此类单元对住院医师临床教育的影响知之甚少。
在一家城市四级护理急诊科进行了一项回顾性观察研究，评估开设一个垂直护理单元的效果，该单元由一名分诊医师指导将病情较轻的患者交由医师助理（PAs）/高级执业注册护士（APRNs）诊治，观察以下参数：（1）住院医师诊治的患者百分比；（2）住院医师诊治患者的急诊严重程度指数（ESI）；（3）住院医师执行的操作数量；（4）住院医师每班诊治的患者数量；（5）住院医师诊治的重症监护患者百分比；（6）住院医师诊治的行为健康患者百分比。
将垂直护理单元实施后的情况与前3个月进行比较，一年级住院医师（PGY-1）接触ESI 1级和2级患者的机会更多（优势比[OR]为2.15），接触重症监护的机会也更多（OR为2.58）。实施后，二年级住院医师（PGY-2）和三年级住院医师（PGY-3）接触ESI 1级和2级患者的机会减少（PGY-2的OR为0.63，PGY-3的OR为0.61），接触重症监护的机会也减少（PGY-2的OR为0.64，PGY-3的OR为0.62）。PGY-1住院医师诊治的行为健康患者较少（OR为0.65），而其他两个年级诊治的行为健康患者较多（PGY-2的OR为1.64，PGY-3的OR为2.74）。所有年级接触ESI 4级和5级患者的机会均减少（PGY-1的OR为0.15，PGY-2的OR为0.86，PGY-3的OR为0.72）。将垂直护理单元实施后的情况与前3个月进行比较，住院医师治疗的患者比例（P = 0.85）或住院医师执行的操作数量（P = 0.25）没有显著差异。
本研究表明，实施垂直护理单元对多项住院医师教育成果没有不利影响，包括住院医师诊治的患者数量和病情严重程度水平以及住院医师培训生的操作数量。虽然所测量的结果并未对整个住院医师群体显示出显著的负面影响，但我们注意到基于PGY水平的患者病情严重程度分布发生了变化。建议进行类似评估，以确定其他急诊科类似运营变革的教育影响。
