Measurement of Cost of Boarding in the Emergency Department Using Time-Driven Activity-Based Costing.

STUDY OBJECTIVE: Boarding admitted patients in emergency departments (EDs) is a national crisis that is worsening despite potential financial disadvantages. The objective of this study was to assess costs associated with boarding. METHODS: We conducted a prospective, observational investigation of patients admitted through an ED for management of acute stroke at a large, urban, academic, comprehensive stroke center hospital. We employed time-driven activity-based costing methodology to estimate cost for patient care activities during admission and aggregated results to estimate the total cost of boarding versus inpatient care. Primary outcomes were total daily costs per patient for medical-surgical (med/surg) boarding, med/surg inpatient care, ICU boarding, and ICU inpatient care. RESULTS: The total daily cost per patient with acute stroke was US$1856, for med/surg boarding versus US$993 for med/surg inpatient care and US$2267, for ICU boarding versus US$2165, for ICU inpatient care. These differences were even greater when accounting for costs associated with traveler nurses. ED nurses spent 293 min/d (mean) caring for each med/surg boarder; inpatient nurses spent 313 min/d for each med/surg inpatient. ED nurses spent 419 min/d caring for each ICU boarder; inpatient nurses spent 787 min/d for each ICU inpatient. Neurology attendings and residents spent 25 and 52 min/d caring for each med/surg boarder versus 62 minutes and 90 minutes for each med/surg inpatient, respectively. CONCLUSION: Using advanced cost-accounting methods, our investigation provides novel evidence that boarding of admitted patients is financially costly, adding greater urgency for elimination of this practice.

A Granular View of Emergency Department Length of Stay: Improving Predictive Power and Extracting Real-Time, Actionable Insights.

STUDY OBJECTIVE: Improved understanding of factors affecting prolonged emergency department (ED) length of stay is crucial to improving patient outcomes. Our investigation builds on prior work by considering ED length of stay in operationally distinct time periods and using benchmark and novel machine learning techniques applied only to data that would be available to ED operators in real time. METHODS: This study was a retrospective review of patient visits over 1 year at 2 urban EDs, including 1 academic and 1 academically affiliated ED, and 2 suburban, community EDs. ED length of stay was partitioned into 3 components: arrival-to-room, room-to-disposition, and admit disposition to departure. Prolonged length of stay for each component was considered beyond 1, 3, and 2 hours, respectively. Classification models (logistic regression, random forest, and XGBoost) were applied, and important features were evaluated. RESULTS: In total, 135,044 unique patient encounters were evaluated for the arrival-to-room, room-to-disposition, and admit disposition-to-departure models, which had accuracy ranges of 84% to 96%, 66% to 77%, and 62% to 72%, respectively. Waiting room and ED volumes were important features in all arrival-to-room models. Room-to-disposition results identified patient characteristics and ED volume as the most important features for prediction. Boarder volume was an important feature of the admit disposition-to-departure models for all sites. Academic site models noted nurse staffing ratios as important, whereas community site models noted hospital capacity and surgical volume as important for admit disposition-to-departure prediction. CONCLUSION: This study identified granular capacity, flow, and nurse staffing predictors of ED length of stay not previously reported in the literature. Our novel methodology allowed for more accurate and operationally meaningful findings compared to prior modeling methods.

A Fast-Track Pathway for Emergency General Surgery at an Academic Medical Center.

BACKGROUND: Fast Track Pathways (FTP) directed at reducing length of stay (LOS) and overall costs are being increasingly implemented for emergency surgeries. The purpose of this study is to evaluate implementation of a FTP for Emergency General Surgery (EGS) at an academic medical center (AMC). METHODS: The study included 165 patients at an AMC between 2016 and 2018 who underwent laparoscopic appendectomy (LA), laparoscopic cholecystectomy (LC), or laparoscopic inguinal hernia repair (LI). The FTP group enrolled 89 patients, and 76 controls prior to FTP implementation were evaluated. Time to surgery (TTS), LOS, and post-operative LOS between groups were compared. Direct costs, reimbursements, and patient reported satisfaction (satisfaction 1 = never, 4 = always) were also studied. RESULTS: The sample was 60.6% female, with a median age of 40 years. Case distribution differed slightly (56.2% versus 42.1% LA, 40.4% versus 57.9% LC, FTP versus control), but TTS was similar between groups (11h39min versus 10h02min, P = 0.633). LOS was significantly shorter in the FTP group (15h17min versus 29h09min, P < 0.001), reflected by shorter post-operative LOS (3h11min versus 20h10min, P< 0.001), fewer patients requiring a hospital bed and overnight stay (P < 0.001). Direct costs were significantly lower in the FTP group, reimbursements were similar (P < 0.001 and P = 0.999 respectively), and average patient reported satisfaction was good (3.3/4). CONCLUSION: In an era focused on decreasing cost, optimizing resources, and ensuring patient satisfaction, a FTP can play a significant role in EGS. At an AMC, an EGS FTP significantly decreased LOS, hospital bed utilization while not impacting reimbursement or patient satisfaction.

2017 AAAEM Benchmarking Survey: Comparing Pediatric and Adult Academic Emergency Departments.

OBJECTIVES: The Academy of Administrators in Academic Emergency Medicine Benchmark Survey of academic emergency departments (EDs) was conducted in 2017. We compared operational measures between pediatric and adult (defined as fewer than 5% pediatric visits) EDs based on survey data. Emergency departments in dedicated pediatric hospitals were not represented. METHODS: Measures included: (1) patient volumes, length of stay, and acuity; and 2) faculty staffing, productivity, and percent effort in academics. t Tests were used to compare continuous measures and inferences for categorical variables were made using Pearson χ2 test. RESULTS: The analysis included 17 pediatric and 52 adult EDs. We found a difference in the number of annual visits between adult (median, 66,275; interquartile range [IQR], 56,184-77,702) and pediatric EDs (median, 25,416; IQR, 19,840-29,349) (P < 0.0001). Mean "arrivals per faculty clinical hour" and "total arrivals per treatment space" showed no differences. The proportion of visits (1) arriving by emergency medical services and (2) for behavioral health were significantly higher in adult EDs (both P < 0.0001). The mean length of stay in hours for "all" patients was significantly longer in adult (5.4; IQR, 5.0-6.6) than in pediatric EDs (3.5; IQR, 2.9-4.3; P = 0.017). A similar difference was found for "discharged" patients (P = 0.004). Emergency severity indices, professional evaluation and management codes, and hospitalization rates all suggest higher acuity in adult EDs (all P < 0.0001). There were no differences in mean work relative value units per patient or in the distribution of full time equivalent effort dedicated to academics. CONCLUSIONS: In this cohort, significant differences in operational measures exist between academic adult and pediatric EDs. No differences were found when considering per unit measures, such as arrivals per faculty clinical hour or per treatment space.

Clinical operations of academic versus non-academic emergency departments: a descriptive comparison of two large emergency department operations surveys.

BACKGROUND: Academic and non-academic emergency departments (EDs) are regularly compared in clinical operations benchmarking despite suggestion that the two groups may differ in their clinical operations characteristics. and outcomes. We sought to describe and compare clinical operations characteristics of academic versus non-academic EDs. METHODS: We performed a descriptive, comparative analysis of academic and non-academic adult and general EDs with 40,000+ annual encounters, using the Academy of Academic Administrators of Emergency Medicine (AAAEM)/Association of Academic Chairs of Emergency Medicine (AACEM) and Emergency Department Benchmarking Alliance (EDBA) survey results. We defined academic EDs as primary teaching sites for emergency medicine (EM) residencies and non-academic EDs as sites with minimal resident involvement. We constructed the academic and non-academic cohorts from the AAAEM/AACEM and EDBA surveys, respectively, and analyzed metrics common to both surveys. RESULTS: Eighty and 454 EDs met inclusion criteria for academic and non-academic EDs, respectively. Academic EDs had more median annual patient encounters (73,001 vs 54,393), lower median proportion of pediatric patients (6.3% vs 14.5%), higher median proportion of EMS patients (27% vs 19%), and were more commonly designated as Level I or II Trauma Centers (94% vs 24%). Median patient arrival-to-provider times did not differ (26 vs 25 min). Median length-of-stay was longer (277 vs 190 min) for academic EDs, and left-before-treatment-complete was higher (5.7% vs 2.9%). MRI utilization was higher for academic EDs (2.2% patients with at least one MRI vs 1.0 MRIs performed per 100 patients). Patients-per-hour of provider coverage was lower for academic EDs with and without consideration for advanced practice providers and residents. CONCLUSIONS: Demographic and operational performance measures differ between academic and non-academic EDs, suggesting that the two groups may be inappropriate operational performance comparators. Causes for the differences remain unclear but the differences appear not to be attributed solely to the academic mission.

Mortality Associated With Emergency Department Boarding Exposure: Are There Differences Between Patients Admitted to ICU and Non-ICU Settings?

BACKGROUND: Emergency Department (ED) boarding threatens patient safety. It is unclear whether boarding differentially affects patients admitted to intensive care units (ICUs) versus non-ICU settings. RESEARCH DESIGN AND SUBJECTS: We performed a 2-hospital, 18-month, cross-sectional, observational, descriptive study of adult patients admitted from the ED. We used Kaplan-Meier estimation and Cox Proportional Hazards regression to describe differences in boarding time among patients who died during hospitalization versus those who survived, controlling for covariates that could affect mortality risk or boarding exposure, and separately evaluating patients admitted to ICUs versus non-ICU settings. MEASURES: We extracted age, race, sex, time variables, admission unit, hospital disposition, and Elixhauser comorbidity measures and calculated boarding time for each admitted patient. RESULTS: Among 39,781 admissions from the EDs (21.3% to ICUs), non-ICU patients who died in-hospital had a 1.2-fold risk (95% confidence interval, 1.03-1.36; P=0.016) of having experienced longer boarding times than survivors, accounting for covariates. We did not observe a difference among patients admitted to ICUs. CONCLUSIONS: Among non-ICU patients, those who died during hospitalization were more likely to have had incrementally longer boarding exposure than those who survived. This difference was not observed for ICU patients. Boarding risk mitigation strategies focused on ICU patients may have accounted for this difference, but we caution against interpreting that boarding can be safe. Segmentation by patients admitted to ICU versus non-ICU settings in boarding research may be valuable in ensuring that the safety of both groups is considered in hospital flow and boarding care improvements.

Door-to-Imaging Time for Acute Stroke Patients Is Adversely Affected by Emergency Department Crowding.

BACKGROUND AND PURPOSE: National guidelines call for door-to-imaging time (DIT) within 25 minutes for suspected acute stroke patients. Studies examining factors that affect DIT have focused primarily on stroke-specific care processes and patient-specific factors. We hypothesized that emergency department (ED) crowding is associated with longer DIT. METHODS: We conducted a retrospective investigation of 1 year of consecutive patients in our prospective Code Stroke registry, which included all ED stroke team activations. The registry and electronic health records were abstracted for 27 potential predictors of DIT, including patient, stroke care process, and ED operational factors. We fit a multivariate logistic regression model and calculated odds ratios and 95% confidence intervals. Second, we constructed a random forest recursive partitioning model to cross-validate our findings and explore the proportional importance of each category of predictor. Our primary outcome was the binary variable of DIT within the 25-minute goal. RESULTS: A total of 463 patients met inclusion criteria. In the regression model, ED occupancy rate emerged as a predictor of DIT, with odds ratio of 0.83 (95% confidence interval, 0.75-0.91) of DIT within 25 minutes per 10% absolute increase in ED occupancy rate. The secondary analysis estimated that ED operational factors accounted for nearly 14% of the algorithm's prediction of DIT. CONCLUSIONS: ED crowding is associated with reduced odds of meeting DIT goals for acute stroke. In addition to improving stroke-specific processes of care, efforts to reduce ED overcrowding should be considered central to optimizing the timeliness of acute stroke care.

Patient safety incident capture resulting from incident reports: a comparative observational analysis.

BACKGROUND: Patient safety incident (PSI) discovery is an essential component of quality improvement. When submitted, incident reports may provide valuable opportunities for PSI discovery. However, little objective information is available to date to quantify or demonstrate this value. The objective of this investigation was to assess how often Emergency Department (ED) incident reports submitted by different sources led to the discovery of PSIs. METHODS: A standardized peer review process was implemented to evaluate all incident reports submitted to the ED. Findings of the peer review analysis were recorded prospectively in a quality improvement database. A retrospective analysis of the quality improvement database was performed to calculate the PSI capture rates for incident reports submitted by different source groups. RESULTS: 363 incident reports were analyzed over a period of 18 months; 211 were submitted by healthcare providers (HCPs) and 126 by non-HCPs. PSIs were identified in 108 resulting in an overall capture rate of 31%. HCP-generated reports resulted in a 44% capture rate compared to 10% for non-HCPs (p < 0.001). There was no difference in PSI capture between sub-groups of HCPs and non-HCPs. CONCLUSION: HCP-generated ED incident reports were much more likely to capture PSIs than reports submitted by non-HCPs. However, HCP reports still led to PSI discovery less than half the time. Further research is warranted to develop effective strategies to improve the utility of incident reports from both HCPs and non-HCPs.

Improved incident reporting following the implementation of a standardized emergency department peer review process.

OBJECTIVE: Incident reporting is an important component of health care quality improvement. The objective of this investigation was to evaluate the effectiveness of an emergency department (ED) peer review process in promoting incident reporting. DESIGN: An observational, interrupted time-series analysis of health care provider (HCP) incident reporting to the ED during a 30-month study period prior to and following the peer review process implementation and a survey-based assessment of physician perceptions of the peer review process' educational value and its effectiveness in identifying errors. SETTING: Large, urban, academic ED. PARTICIPANTS AND INTERVENTIONS: HCPs were invited to participate in a standardized, non-punitive, non-anonymous peer review process that involved analysis and structured discussion of incident reports submitted to ED physician leadership. MAIN OUTCOME MEASURES: Monthly frequency of incident reporting by HCPs and physician perceptions of the peer review process. RESULTS: HCPs submitted 314 incident reports to the ED over the study period. Following the intervention, frequency of reporting by HCPs within the hospital increased over time. The frequencies of self-reporting, reporting by other ED practitioners and reporting by non-ED practitioners within the hospital increased compared with a control group of outside HCPs (P = 0.0019, P = 0.0025 and P < 0.0001). Physicians perceived the peer review process to be educational and highly effective in identifying errors. CONCLUSIONS: The implementation of a non-punitive peer review process that provides timely feedback and is perceived as being valuable for error identification and education can lead to increased incident reporting by HCPs.

Emergency department patient safety incident characterization: an observational analysis of the findings of a standardized peer review process.

BACKGROUND: Emergency Department (ED) care has been reported to be prone to patient safety incidents (PSIs). Improving our understanding of PSIs is essential to prevent them. A standardized, peer review process was implemented to identify and analyze ED PSIs. The primary objective of this investigation was to characterize ED PSIs identified by the peer review process. A secondary objective was to characterize PSIs that led to patient harm. In addition, we sought to provide a detailed description of the peer review process for others to consider as they conduct their own quality improvement initiatives. METHODS: An observational study was conducted in a large, urban, tertiary-care ED. Over a two-year period, all ED incident reports were investigated via a standardized, peer review process. PSIs were identified and analyzed for contributing factors including systems failures and practitioner-based errors. The classification system for factors contributing to PSIs was developed based on systems previously reported in the emergency medicine literature as well as the investigators' experience in quality improvement and peer review. All cases in which a PSI was discovered were further adjudicated to determine if patient harm resulted. RESULTS: In 24 months, 469 cases were investigated, identifying 152 PSIs. In total, 188 systems failures and 96 practitioner-based errors were found to have contributed to the PSIs. In twelve cases, patient harm was determined to have resulted from PSIs. Systems failures were identified in eleven of the twelve cases in which a PSI resulted in patient harm. CONCLUSION: Systems failures were almost twice as likely as practitioner-based errors to contribute to PSIs, and systems failures were present in the majority of cases resulting in patient harm. To effectively reduce PSIs, ED quality improvement initiatives should focus on systems failure reduction.

A Pilot Randomized Controlled Trial of Augmented Reality Just-in-Time Guidance for the Performance of Rugged Field Procedures.

INTRODUCTION: Medical resuscitations in rugged prehospital settings require emergency personnel to perform high-risk procedures in low-resource conditions. Just-in-Time Guidance (JITG) utilizing augmented reality (AR) guidance may be a solution. There is little literature on the utility of AR-mediated JITG tools for facilitating the performance of emergent field care. STUDY OBJECTIVE: The objective of this study was to investigate the feasibility and efficacy of a novel AR-mediated JITG tool for emergency field procedures. METHODS: Emergency medical technician-basic (EMT-B) and paramedic cohorts were randomized to either video training (control) or JITG-AR guidance (intervention) groups for performing bag-valve-mask (BVM) ventilation, intraosseous (IO) line placement, and needle-decompression (Needle-d) in a medium-fidelity simulation environment. For the interventional condition, subjects used an AR technology platform to perform the tasks. The primary outcome was participant task performance; the secondary outcomes were participant-reported acceptability. Participant task score, task time, and acceptability ratings were reported descriptively and compared between the control and intervention groups using chi-square analysis for binary variables and unpaired t-testing for continuous variables. RESULTS: Sixty participants were enrolled (mean age 34.8 years; 72% male). In the EMT-B cohort, there was no difference in average task performance score between the control and JITG groups for the BVM and IO tasks; however, the control group had higher performance scores for the Needle-d task (mean score difference 22%; P = .01). In the paramedic cohort, there was no difference in performance scores between the control and JITG group for the BVM and Needle-d tasks, but the control group had higher task scores for the IO task (mean score difference 23%; P = .01). For all task and participant types, the control group performed tasks more quickly than in the JITG group. There was no difference in participant usability or usefulness ratings between the JITG or control conditions for any of the tasks, although paramedics reported they were less likely to use the JITG equipment again (mean difference 1.96 rating points; P = .02). CONCLUSIONS: This study demonstrated preliminary evidence that AR-mediated guidance for emergency medical procedures is feasible and acceptable. These observations, coupled with AR's promise for real-time interaction and on-going technological advancements, suggest the potential for this modality in training and practice that justifies future investigation.

Operations Factors Associated with Emergency Department Length of Stay: Analysis of a National Operations Database.

INTRODUCTION: Prolonged emergency department (ED) length of stay (LOS) has been shown to adversely affect patient care. We sought to determine factors associated with ED LOS via analysis of a large, national, ED operations database. METHODS: We performed retrospective, multivariable, linear regression modeling using the 2019 Emergency Department Benchmarking Alliance survey results to identify associated factors of ED LOS for admitted and discharged patients. RESULTS: A total of 1,052 general and adult-only EDs responded to the survey. Median annual volume was 40,946. The median admit and discharge LOS were 289 minutes and 147 minutes, respectively. R-squared values for the admit and discharge models were 0.63 and 0.56 with out-of-sample R-squared values of 0.54 and 0.59, respectively. Both admit and discharge LOS were associated with academic designation, trauma level designation, annual volume, proportion of ED arrivals occurring via emergency medical services, median boarding, and use of a fast track. Additionally, admit LOS was associated with transfer-out percentage, and discharge LOS was associated with percentage of high Current Procedural Terminology, percentage of patients <18 years old, use of radiographs and computed tomography, and use of an intake physician. CONCLUSION: Models derived from a large, nationally representative cohort identified diverse associated factors of ED length of stay, several of which were not previously reported. Dominant within the LOS modeling were patient population characteristics and other factors extrinsic to ED operations, including boarding of admitted patients, which was associated with both admitted and discharged LOS. The results of the modeling have significant implications for ED process improvement and appropriate benchmarking.

Improving Accessibility in the Emergency Department for Patients with Disabilities: A Qualitative Study.

INTRODUCTION: The emergency department (ED) is a critical service area for patients living with disabilities in the United States. Despite this, there is limited research on best practices from the patient experience regarding accommodation and accessibility for those with disabilities. In this study we investigate the ED experience from the perspective of patients living with physical and cognitive disability, as well as visual impairment and blindness, to better understand the barriers to accessibility in the ED for these populations. METHODS: Twelve individuals with either physical or cognitive disabilities, visual impairments or blindness were interviewed regarding their ED experiences, particularly related to accessibility. Interviews were transcribed and coded for qualitative analysis with generation of significant themes relating to accessibility in the ED. RESULTS: Major themes from coded analysis were as follows: 1) inadequate communication between staff and patients with visual impairments and physical disabilities; 2) the need for electronic delivery for after-visit summaries for individuals with cognitive and visual disabilities; 3) the importance of mindful listening and patience by healthcare staff; 4) the role of increased hospital support including greeters and volunteers; and 5) comprehensive training with both prehospital and hospital staff around assistive devices and services. CONCLUSION: This study serves as an important first step toward improving the ED environment to ensure accessibility and inclusivity for patients presenting with various types of disabilities. Implementing specific training, policies, and infrastructure changes may improve the experiences and healthcare of this population.

Factors Associated with Overutilization of Computed Tomography of the Cervical Spine.

Introduction: Despite the wide availability of clinical decision rules for imaging of the cervical spine after a traumatic injury (eg, NEXUS C-spine rule and Canadian C-spine rule), there is significant overutilization of computed tomography (CT) imaging in patients who are deemed to be at low risk for a clinically significant cervical spine injury by these clinical decision rules. The purpose of this study was to identify the major factors associated with the overuse of CT cervical spine imaging using a logistic regression model. Methods: This was a retrospective review of all adult patients who underwent CT cervical spine imaging for evaluation of a traumatic injury at a tertiary academic emergency department (ED) and three affiliate community EDs in January and February 2019. We performed multivariable logistic regression to identify factors associated with obtaining CT cervical spine imaging despite low-risk classification by the NEXUS C-spine Rule. Results: A total of 1,051 patients underwent CT cervical spine imaging for traumatic indications during the study period, and 889 patients were included in the analysis. Of these patients, 376 (42.3%) were negative by the NEXUS C-spine rule. Variables that were associated with increased likelihood of unnecessary imaging included age over 65, Emergency Severity Index (ESI) score 2 and 3, arrival as a walk-in, and anticoagulation status. Patients who presented to the tertiary academic ED had a significantly lower likelihood of unnecessary imaging. Twenty-one patients (2.4%) were found to have cervical spine fractures on imaging, two of whom were negative by the NEXUS C-spine rule, but neither had a clinically significant fracture. Conclusion: Cervical spine imaging is vastly overused in patients presenting to the ED with traumatic injuries, as adjudicated using the NEXUS C-spine rule as a reference standard. Older age, ESI level, arrival as a walk-in, and taking anticoagulation drugs were associated with overutilization of CT imaging. Conversely, presenting to the tertiary academic ED was associated with a lower likelihood of undergoing unnecessary imaging. This model can guide future interventions to optimize ED CT utilization and minimize unnecessary testing.

A mobile integrated health program for the management of undifferentiated acute complaints in older adults is safe and feasible.

BACKGROUND: Poor care access and lack of proper triage of medical complaints leads to inappropriate use of acute care resources. Mobile integrated health (MIH) programs may offer a solution by providing adaptable on-demand care. There is little information describing programs that manage undifferentiated complaints in the community. The objective of this study was to assess the safety and feasibility of an MIH program that responds to the community to manage medical complaints in older adults. METHODS: This was a prospective observational study examining a pilot MIH program. Seven ambulatory clinics and their affiliated patients aged 65 and older were oriented to the program and invited to use its services. Visit and follow-up data for all patients who underwent an MIH visit were abstracted, along with 30-day follow-up information. All demographic data and outcomes were reported descriptively. RESULTS: In 21 months, 153 MIH visits were completed, involving 91 patients (mean age 81 years, 60.4% female). The most common chief complaints were generalized weakness (28.8%) and shortness of breath (18.9%). Electrocardiogram (57.5%) and point-of-care bloodwork (34.6%) were the most common diagnostic tests performed. Sixteen visits (10.4%) were followed by an emergency department (ED) visit within 72 h. In 11 encounters, the patient was referred to the ED; in five cases, the ED visit was unforeseen. Fifteen patients (9.8%) were admitted to the hospital after an MIH visit. There were two deaths within 30 days following an index visit. CONCLUSIONS: An MIH program designed to address the acute complaints of community-dwelling older adults was feasible and safe, with low rates of unforeseen emergency services utilizations. MIH programs have valuable diagnostic and therapeutic capabilities and may serve to help triage the acute medical needs of patients. Further study is required to validate the efficacy and cost-effectiveness of MIH programs.

Accuracy of physician self-estimation of time spent during patient care in the emergency department.

Objective: Accurate measurement of physicians' time spent during patient care stands to inform emergency department (ED) improvement efforts. Direct observation is time consuming and cost prohibitive, so we sought to determine if physician self-estimation of time spent during patient care was accurate. Methods: We performed a prospective, convenience-sample study in which research assistants measured time spent by ED physicians in patient care. At the conclusion of each observed encounter, physicians estimated their time spent. Using Mann-Whitney U tests and Spearman's rho, we compared physician estimates to actual time spent and assessed for associations of encounter characteristics and physician estimation. Results: Among 214 encounters across 10 physicians, we observed a medium-sized correlation between actual and estimated time (Spearman's rho = 0.63, p < 0.001), and in aggregate, physicians underestimated time spent by a median of 0.1 min. An equal number of encounters were overestimated and underestimated. Underestimated encounters were underestimated by a median of 5.1 min (interquartile range [IQR] 2.5-9.8) and overestimated encounters were overestimated by a median of 4.3 min (IQR 2.5-11.6)-26.3% and 27.9% discrepancy, respectively. In terms of actual time spent, underestimated encounters (median 19.3 min, IQR 13.5-28.3) were significantly longer than overestimated encounters (median 15.3 min, IQR 11.3-20.5) (p < 0.001). Conclusions: Physician self-estimation of time spent was accurate in aggregate, providing evidence that it is a valid surrogate marker for larger-scale process improvement and research activities, but likely not at the encounter level. Investigations exploring mechanisms to augment physician self-estimation, including modeling and technological support, may yield pathways to make self-estimation valid also at the encounter level.

Effect of resident complement on timeliness of stroke team activation in an academic emergency department.

OBJECTIVES: Investigations of the impact of residents on emergency department (ED) timeliness of care typically focus only on global ED flow metrics. We sought to describe the association between resident complement/supervisory ratios and timeliness of ED care of a specific time-sensitive condition, acute stroke. METHODS: We matched ED stroke patient arrivals at 1 academic stroke center against resident and attending staffing and constructed a Cox proportional hazards model of door-to-activation (DTA) time (ie, ED arrival ["door"] to stroke team activation). We considered multiple predictors, including calculated ratios of residents supervised by each attending physician. RESULTS: Among 462 stroke activation patients in 2014-2015, DTA ranged from 1 to 217 minutes, 72% within 15 minutes. The median number of emergency and off-service residents supervised per attending were 1.7 (interquartile range [IQR], 1.3-2.3) and 0.7 (IQR, 0-1), respectively. A 1-resident increase in off-service residents was associated with a 24% decrease (hazard ratio [HR], 0.76; 95% confidence interval [CI], 0.64-0.90) in the probability of stroke team activation at any given time. An independent 1-resident increase in the number of emergency residents was associated with a 13% increase (HR, 1.13; 95% CI, 1.01-1.25) in timely activation. CONCLUSION: Timeliness of care for acute stroke may be impacted by how academic EDs configure the complement and supervisory structures of residents. Higher supervisory demands imposed by increasing the proportion of rotating off-service residents may be associated with slower stroke recognition and DTA times, but this effect may be offset when more emergency residents are present.

From intern to "accepted": A guide to preparing for fellowship in emergency medicine.

Introduction: The number of fellowship options for emergency medicine (EM) physicians continues to expand. While guides exist to help residents explore individual fellowship pathways, we aimed to create a comprehensive guide for all residents considering fellowship. Methods: At the direction of the Society for Academic Emergency Medicine (SAEM) Board, 9 members of the Fellowship Guide Workgroup, including members of the Fellowship Approval Committee, and 2 members of SAEM Residents and Medical Students (RAMS) group collaboratively developed the guide using available evidence and expert opinion when high-quality evidence was unavailable. The guide was reviewed and approved by all members. Results: The guide offers advice to EM residents on how to conceptualize key aspects of their training with respect to preparation for fellowship, including scholarship, teaching, leadership, and electives. Additionally, it offers perspective on selecting a fellowship that matches the resident's interests and goals and successfully applying. Conclusion: This fellowship guide for EM residents considering fellowship summarizes the best currently available advice for residents considering fellowship training after residency.

From the ground up: Creating and leading fellowship programs in emergency medicine.

Background: A methodical and evidence-based approach to the creation and implementation of fellowship programs is not well described in the graduate medical education literature. The Society for Academic Emergency Medicine (SAEM) convened an expert panel to promote standardization and excellence in fellowship training. The purpose of the expert panel was to develop a fellowship guide to give prospective fellowship directors the necessary skills to successfully implement and maintain a fellowship program. Methods: Under direction of the SAEM Board of Directors, SAEM Education Committee, and SAEM Fellowship Approval Committee, a panel of content experts convened to develop a fellowship guide using an evidence-based approach and best practices content method. The resource guide was iteratively reviewed by all panel members. Results: Utilizing Kern's six-step model as a conceptual framework, the fellowship guide summarizes the construction, implementation, evaluation, and dissemination of a novel fellowship curriculum to meet the needs of trainees, educators, and sponsoring institutions. Other key areas addressed include Accreditation Council for Graduate Medical Education and nonaccredited fellowships, programmatic assessment, finances, and recruitment. Conclusions: The fellowship guide summarizes the conceptual framework, best practices, and strategies to create and implement a new fellowship program.

Advanced practice providers in academic emergency medicine: A national survey of chairs and program directors.

BACKGROUND: The Society for Academic Emergency Medicine Board of Directors convened a task force to elucidate the current state of workforce, operational, and educational issues being faced by academic medical centers related to advanced practice providers (APPs). The task force surveyed academic emergency department (ED) chairs and residency program directors (PDs). METHODS: The survey was distributed to the Association of Academic Chairs of Emergency Medicine (AACEM)-member chairs and their respective residency PDs in 2021. We surveyed 125 chairs with their self-identified PDs. The survey sampled hiring, state-independent practice laws, scope of practice, teaching and supervision, training opportunities, delegation of procedures between physician learners and APPs, and perceptions of the impact on resident and medical student education. RESULTS: Of the AACEM-member chairs identified, 73% responded and 47% of PDs responded. Most (98%) employ either physician assistants or nurse practitioners. Among responding departments, 86% report APPs working in fast-track settings, 80% work in the main ED, and 54% work in the waiting room. In 44% of departments, APPs and residents evaluate patients concurrently, and 2% of respondents reported that APPs manage high-acuity patients without attending involvement. Two-thirds of chairs believe that APPs contribute positively to the quality of patient care, while 44% believe that APPs contribute to the academic environment. One-third of PDs believe that the presence of APPs interferes with resident education. Although 75% of PDs believe that residents require training to work effectively with APPs in the ED, almost half (49%) report zero hours of training around APP supervision or collaborative skills. CONCLUSIONS: APPs are ubiquitous across academic EDs. Future research is required for academic ED leaders to balance physician and APP deployment across the academic ED within the context of patient care, resident education, institutional resources, professional development opportunities for APP staff, and standardization of APP EM training.