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Differences in outcomes between ICU attending and senior resident physician led medical emergency team responses.

ABSTRACT: Although rapid response systems (RRS) have been shown to decrease the incidence of cardiac arrest (CA), there are no studies evaluating optimal staffing. We hypothesize that there are no outcome differences between ICU physician and senior resident led events.A retrospective study of the RRS database at a single, academic hospital was performed from July 1, 2006 to May 31, 2010. Surgical patients and those in the ICU were excluded. Daytime (D) was defined as 7 am-5 pm Monday through Friday, and weekends were defined as 5 pm on Friday to 6:59 am on Monday. The nurse to patient ratio is constant during all shifts. An ICU physician leads daytime events on weekdays whereas night/weekend (NW) events are led by residents. NW events were compared against D events using chi square or Fischer's exact test. Significance was defined as p<0.05.A total of 1404 events were reviewed with 534 (38%) D and 870 (62%) NW events. Respiratory and staff concerns were more likely during NW compared to D (50% vs. 39% and 46% vs. 34%, p<0.001, respectively). Following RRS activation, no difference was noted between D and NW periods in the incidence of progression to CA, transfer to ICU, or hospital mortality. Invasive procedures were more common in the NW period.Resident-led RRS may have similar outcomes to attending intensivist led events. Prospective studies are needed to determine the ideal team composition.

SUBMITTER: Morris DS

PROVIDER: S-EPMC4037841 | biostudies-literature | 2012 Dec

REPOSITORIES: biostudies-literature

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Differences in outcomes between ICU attending and senior resident physician led medical emergency team responses.

Morris David S DS Schweickert William W Holena Daniel D Handzel Robert R Sims Carrie C Pascual Jose L JL Sarani Babak B

Resuscitation 20120724 12

<h4>Introduction</h4>Although rapid response systems (RRS) have been shown to decrease the incidence of cardiac arrest (CA), there are no studies evaluating optimal staffing. We hypothesize that there are no outcome differences between ICU physician and senior resident led events.<h4>Methods</h4>A retrospective study of the RRS database at a single, academic hospital was performed from July 1, 2006 to May 31, 2010. Surgical patients and those in the ICU were excluded. Daytime (D) was defined as ...[more]

PMID: 22841611

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Project description:BackgroundAccording to the rapid response system's team composition, responding teams were named as rapid response team (RRT), medical emergency team (MET), and critical care outreach. A RRT is often a nurse-led team, whereas a MET is a physician-led team that mainly plays the role of an efferent limb. As few multicenter studies have focused on physician-led METs, we comprehensively analyzed cases for which physician-led METs were activated.MethodsWe retrospectively analyzed cases for which METs were activated. The study population consisted of subjects over 18 years of age who were admitted in the general ward from January 2016 to December 2017 in 9 tertiary teaching hospitals in Korea. The data on subjects' characteristics, activation causes, activation methods, performed interventions, in-hospital mortality, and intensive care unit (ICU) transfer after MET activation were collected and analyzed.ResultsIn this study, 12,767 cases were analyzed, excluding those without in-hospital mortality data. The subjects' median age was 67 years, and 70.4% of them were admitted to the medical department. The most common cause of MET activation was respiratory distress (35.1%), followed by shock (11.8%), and the most common underlying disease was solid cancer (39%). In 7,561 subjects (59.2%), the MET was activated using the screening system. The commonly performed procedures were arterial line insertion (17.9%), intubation (13.3%), and portable ultrasonography (13.0%). Subsequently, 29.4% of the subjects were transferred to the ICU, and 27.2% died during hospitalization.ConclusionsThis physician-led MET cohort showed relatively high rates of intervention, including arterial line insertion and portable ultrasonography, and low ICU transfer rates. We presume that MET detects deteriorating patients earlier using a screening system and begins ICU-level management at the patient's bedside without delay, eventually preventing the patient's condition from worsening and transfer to the ICU.

Project description:ImportanceWhile the relationship between resident work hours and patient safety has been extensively studied, little research has evaluated the role of attending physician supervision on patient safety.ObjectiveTo determine the effect of increased attending physician supervision on an inpatient resident general medical service on patient safety and educational outcomes.Design, setting, and participantsThis 9-month randomized clinical trial performed on an inpatient general medical service of a large academic medical center used a crossover design. Participants were clinical teaching attending physicians and residents in an internal medicine residency program.InterventionsTwenty-two faculty provided either (1) increased direct supervision in which attending physicians joined work rounds on previously admitted patients or (2) standard supervision in which attending physicians were available but did not join work rounds. Each faculty member participated in both arms in random order.Main outcomes and measuresThe primary safety outcome was rate of medical errors. Resident education was evaluated via a time-motion study to assess resident participation on rounds and via surveys to measure resident and attending physician educational ratings.ResultsOf the 22 attending physicians, 8 (36%) were women, with 15 (68%) having more than 5 years of experience. A total of 1259 patients (5772 patient-days) were included in the analysis. The medical error rate was not significantly different between standard vs increased supervision (107.6; 95% CI, 85.8-133.7 vs 91.1; 95% CI, 76.9-104.0 per 1000 patient-days; P = .21). Time-motion analysis of 161 work rounds found no difference in mean length of time spent discussing established patients in the 2 models (202; 95% CI, 192-212 vs 202; 95% CI, 189-215 minutes; P = .99). Interns spoke less when an attending physician joined rounds (64; 95% CI, 60-68 vs 55; 95% CI, 49-60 minutes; P = .008). In surveys, interns reported feeling less efficient (41 [55%] vs 68 [73%]; P = .02) and less autonomous (53 [72%] vs 86 [91%]; P = .001) with an attending physician present and residents felt less autonomous (11 [58%] vs 30 [97%]; P < .001). Conversely, attending physicians rated the quality of care higher when they participated on work rounds (20 [100%] vs 16 [80%]; P = .04).Conclusions and relevanceIncreased direct attending physician supervision did not significantly reduce the medical error rate. In designing morning work rounds, residency programs should reconsider their balance of patient safety, learning needs, and resident autonomy.Trial registrationClinicalTrials.gov Identifier: NCT03318198.

Project description:Several prior studies have examined the impact of learners (medical students or residents) on overall emergency department (ED) flow as well as the impact of resident training level on the number of patients seen by residents per hour. No study to date has specifically examined the impact of learners on emergency medicine (EM) attending physician productivity, with regards to patients per hour (PPH). We sought to evaluate whether learners increase, decrease, or have no effect on the productivity of EM attending physicians in a teaching program with one student or resident per attending.This was a retrospective database review of an urban, academic tertiary care center with 3 separate teams on the acute care side of the ED. Each team was staffed with one attending physician paired with either one resident, one medical student or with no learners. All shifts from July 1, 2008 to June 30, 2010 were reviewed using an electronic database. We predefined a shift as "Resident" if > 5 patients were seen by a resident, "Medical Student" if any patients were seen by a medical student, and "No Learners" if no patients were seen by a medical student or resident. Shifts were removed from analysis if more than one learner saw patients during the shift. We further stratified resident shifts by EM training level or off-service rotator. For each type of shift, the total number of patients seen by the attending physician was then divided by 8 hours (shift duration) to arrive at number of patients per hour.We analyzed a total of 7,360 shifts with 2,778 removed due to multiple learners on a team. For the 2,199 shifts with attending physicians with no learners, the average number of PPH was 1.87(95% confidence interval [CI] 1.86,1.89). For the 514 medical student shifts, the average PPH was 1.87(95% CI 1.84,1.90), p = 0.99 compared with attending with no learner. For the 1,935 resident shifts, the average PPH was 1.99(95% CI 1.97,2.00). Compared with attending physician with no learner, attending physicians with a resident saw more PPH (1.99 vs 1.87, p<0.005). There was no statistically significant difference found between EM1: 1.98PPH, EM2: 1.99PPH, EM3: 1.99PPH, and off-service rotators: 1.99PPH.EM attending physicians paired with a resident in a one-on-one teaching model saw statistically significantly more patients per hour (0.12 more patients per hour) than EM attending physicians alone. EM attending physicians paired with a medical student saw the same number of patients per hour compared with working alone.

Project description:IntroductionMedical professionalism is a core competency for emergency medicine (EM) trainees; but defining professionalism remains challenging, leading to difficulties creating objectives and performing assessment. Because professionalism is dynamic, culture-specific, and often taught by modeling, an exploration of trainees' perceptions can highlight their educational baseline and elucidate the importance they place on general conventional professionalism domains. To this end, our objective was to assess the relative value EM residents place on traditional components of professionalism.MethodsWe performed a cross-sectional, multi-institutional survey of incoming and graduating EM residents at four programs. The survey was developed using the American Board of Internal Medicine's "Project Professionalism" and the Accreditation Council of Graduate Medical Education definition of professionalism competency. We identified 27 attributes within seven domains: clinical excellence, humanism, accountability, altruism, duty and service, honor and integrity, and respect for others. Residents were asked to rate each attribute on a 10-point scale. We analyzed data to assess variance across attributes as well as differences between residents at different training levels or different institutions.ResultsOf the 114 residents eligible, 100 (88%) completed the survey. The relative value assigned to different professional attributes varied considerably, with those in the altruism domain valued significantly lower and those in the "respect for others" and "honor and integrity" valued significantly higher (p<0.001). Significant differences were found between interns and seniors for five attributes primarily in the "duty and service" domain (p<0.05). Among different residencies, significant differences were found with attributes within the "altruism" and "duty and service" domains (p<0.05).ConclusionResidents perceive differences in the relative importance of traditionally defined professional attributes and this may be useful to educators. Explanations for these differences are hypothesized, as are the potential implications for professionalism education. Because teaching professional behavior is taught most effectively via behavior modeling, faculty awareness of resident values and faculty development to address potential gaps may improve professionalism education.

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Differences in outcomes between ICU attending and senior resident physician led medical emergency team responses.

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Differences in outcomes between ICU attending and senior resident physician led medical emergency team responses.

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