174 Resident Clinical Experience in the Emergency Department: Patient Encounters by Post Graduate Year

The aim of our study was to evaluate the clinical experiences of residents in the emergency department based on their level of training. We sought to determine whether patients that residents of different training levels saw varied in their acuity levels, chief complaints, and dispositions. This was a retrospective chart review of patients seen at a safety-net, academic hospital in Los Angeles from July 1, 2015 to June 30, 2016. Medical records for all patients seen by a resident in the emergency department (ED) were reviewed. A pre-determined data collection form was completed including: resident PGY level and specialty, patient acuity, chief complaint, and disposition. Acuity was classified based on the Emergency Severity Index. The chief complaint recorded by the triage nurse was categorized into one of 30 previously published categories of the most common chief complaints. As many patients seen by PGY1s are supervised by an upper-level EM resident, both the intern and upper-level resident were given credit for patients they saw together. Residents were only credited with patients for whom they initiated the workup. Descriptive statistics were reported. 48,073 visits were included. 32,816 (68.3%) of these visits were in the adult ED (AED) and 15,257 (31.7%) were in the pediatric ED (PED). Approximately half of the patients were male. Median acuity levels in both the AED and PED were 3. 27.3% of AED patients and 8.3% of PED patients were admitted. 130 residents were included in the study, consisting of 98 PGY1 residents (16 EM and 82 off-service), 16 PGY2 EM residents, and 16 PGY3 EM residents. We found that residents of different training levels saw different types of patients. EM residents further in their training were more likely to see higher acuity patients and patients who were admitted or died. PGY3s saw much higher percentages of acuity level 1 and 2 patients (2.3% and 35.6% respectively of their total patients) than EM PGY1s (0.3% and 18.9% respectively). PGY2s were in between the 2 groups but were more similar to PGY3s (2.1% and 34.3% respectively). Conversely, EM PGY1s saw higher percentages of acuity level 4 and 5 patients (27.8% and 1.6% respectively) compared to EM PGY3s (10.8% and 0.7% respectively). The five most over-represented chief complaints seen by EM PGY1s (ie, complaints seen disproportionately more by EM PGY1s than the overall prevalence of the complaint) were: ear symptoms, fever, skin symptoms, upper respiratory infections/throat symptoms, and toxic ingestions. The most over-represented chief complaints seen by PGY2s were: fainting/syncope, substance/alcohol-related symptoms, convulsions, palpitations, and altered mental status and by PGY3s were: focal neurological symptoms, general weakness, pregnancy complaints, dizziness/vertigo, and swelling. PGY3s were more likely to see patients who were admitted or expired (23.5% and 0.3% respectively) as compared to EM PGY1s (11.7% and 0% respectively). Interestingly, off-service PGY1s saw more acute patients than EM PGY1s, including patients with higher acuity levels and higher admission rates. Our study shows that the clinical experience of EM residents varies based on their level of training. EM residents were more likely to see higher acuity patients as they progressed in their training. Off-service interns tended to see higher acuity patients than EM interns. Future studies over longer time periods with more residents at additional sites would help verify this trend.