| Summary: | 博士 === 高雄醫學大學 === 公共衛生學系環境暨職業安全衛生博士班 === 104 === Background: It is generally believed that physicians who have more experience have also accumulated knowledge and skills during their years in practice, and are therefore able to deliver higher quality care. The ability of emergency physicians (EPs) to continue within the specialty has been called into question due to high stress in emergency departments (EDs). EPs see a large volume of cases of varying complexity. The major concerns for EP clinical performance can be divided into four areas: the efficiency of patient assessment, the resource usage for patient diagnosis, the outcomes of treated patients, and the accuracy of disposition decisions. However, the relationship between clinical performance and the seniority of EPs is not well established. The first purpose of this study was to evaluate the associations between the duration of EP experience and these aspects of clinical performance.
On the other hand, High quality patient care can only be provided if physicians are well prepared for this task through residency training. In the ED, residents are trained and educated via patient primary care under the supervision of attending physicians, who review histories and physical examinations, adjust treatment options, discuss disposition plans, and assist with procedures. Thus, the aim of the present study is also to clarify the influence of resident seniority on supervised practice in ED. It is believed that the results of this study will help in adjustment of supervision or rearrangement of clinical loading in the ED.
Research Design and Methods: To evaluate the associations between the duration of EP experience and these aspects of clinical performance, a retrospective, one-year, cohort study was conducted across three EDs in the largest healthcare system in Northern Taiwan. Participants included all day-shift non-traumatic adult patients. who presented to the EDs between 1 July 2011 and 30 June 2012. Physicians were categorized as junior, intermediate and senior EPs according to ≤5, 6–10 and >10 years of ED work experience. The door-to-order and door-to-disposition time were used to evaluate EP efficiency. ED resource use indicators included diagnostic investigations of electrocardiography, plain film radiography, laboratory tests and computed tomography scans. Discharge and mortality rates were used as patient outcomes. The outcome involves disposition accuracy included patient dispositions at the end of the shift, patient final dispositions and patient 72-hour ED return.
To investigate the influence of resident seniority on supervised clinical practice in the ED. Another retrospective, one-year cohort study was conducted in five EDs within the same healthcare system. All adult non-trauma visits presenting to the EDs during the day shift during the same period were included in the analysis. Visits were divided into supervised (i.e., treated by resident under attending physician’s supervision) and attending-alone. Supervised visits were further categorized by resident seniority (junior [PGY1, R1], intermediate [R2, R3], and senior [R4, R5]). The decision-making time (door-to-order and door-to-disposition time), patient dispositions (e.g., ED observation and hospital admission), and diagnostic tool use (laboratory examination or computed tomography [CT]) were selected as clinical performance indicators. The differences in clinical performance were determined between supervised visits (i.e., resident-seniority groups) and attending-alone visits.
Results: Senior EPs were found to have longer door-to-order (11.3, 12.4 min) and door-to-disposition (2, 1.7 hours) time than non-senior EPs in urgent and non-urgent patients (junior: 9.4, 10.2 min and 1.7, 1.5 hours; intermediate: 9.5, 10.7 min and 1.7, 1.5 hours). Senior EPs tended to order fewer electrocardiograms, radiographs and computed tomography scans in non-urgent patients. Adjusting for age, sex, disease acuity, and medical setting, patients treated by junior and intermediate EPs had higher mortality in the ED (adjusted-odd-ratios, 1.5 and 1.6, respectively). Senior EPs also kept more patients in the ED (2.7% more than junior EP, 2.3% more than intermediate EP); they took more time for patient discharge (0.2 more hour than junior EP, 0.1 more hour than intermediate EP); they had fewer patients return to the ED within 72 hours after discharge (0.5% fewer than junior EP, 0.3% fewer than intermediate EP).
On the other hand, increasing resident seniority led to decreasing door-to-order and door-to-disposition time among supervised visits. Furthermore, compared with attending-alone visits, supervised visits with junior residents had a greater odds of ED observation (adjusted odds ratio [aOR], 1.1; 95% CI, 1.07–1.20), while supervised visits with all three resident-seniority groups had significantly greater odds of laboratory examinations (junior: aOR, 1.1; 95% CI, 1.03–1.16; intermediate: aOR, 1.1; 95% CI, 1.04–1.15; senior: aOR, 1.1; 95% CI, 1.05–1.15).
Conclusions: Compared to EPs with ≤10 years of work experience, senior EPs take more time for order prescription and patient disposition, use fewer diagnostic investigations, particularly for non-urgent patients, and are associated with a lower ED mortality rate. Senior EPs had the best quality of care (lowest mortality, fewest 72 hour returns). This best quality of care is accompanied with a slightly longer length of stay. In addition, compared to attending-alone visits, supervised visits still resulted in greater use of laboratory examinations and delayed patient disposition.
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