Abstract 3 Impact of Trainee Experience on the Decision to Perform Endoscopy on Weekends

Abstract

Guidelines recommend endoscopy with 24 hours of admission for patients who present with suspected upper gastrointestinal bleeding (GIB). Endoscopy units often operate only during weekdays, however, resulting in logistical barriers to performing endoscopy on weekends. Weekend endoscopy is therefore typically reserved for a subset of higher acuity patients. We sought to determine if trainee experience influences the decision to proceed with upper endoscopy on weekends. In this single-center retrospective cohort study, we reviewed all inpatients who underwent upper endoscopy for suspected GIB within 72 hours of emergency department (ED) triage. Adults who presented between November 2011 and August 2015 were eligible for inclusion. Patient demographics, triage vitals, labs, and transfusion requirements were obtained from the electronic health record. Indications for endoscopy, findings, and need for endoscopic hemostatic therapy were noted. Weekend procedures were defined as endoscopies performed between Friday 6pm and Monday 7am. Initial evaluation of all gastroenterology consults was performed by first-year (PGY 4) fellows, who start their training on July 1. As such, we used progress in the academic year as a surrogate for trainee experience, dividing it in 4 quarters (Jul—Sep, Oct—Dec, Jan—Apr and May—Jun). 690 patients underwent upper endoscopy for an indication of hematemesis, melena, or hematochezia (Table 1). Patients who underwent endoscopy on weekends were more likely to be tachycardic and hypotensive than those who underwent weekday endoscopy. The mean initial hemoglobin concentration was lower and transfusion requirements were higher on weekends. Endoscopic hemostatic therapy was performed more frequently on weekends than weekdays (29.5% vs 18.3%, P = .002). The proportion of all endoscopies performed on the weekend decreased monotonically through the course of the academic year, from 17% in the first 3 months (Jul—Sep) to 10% in final 3 months (Apr—Jun). In the final logistic model, after adjusting for day of patient triage, and patient severity factors including tachycardia, transfusion requirements, and need for endoscopic hemostasis, period in the academic year was independently associated with increased odds of weekend endoscopy (aOR 2.42 for Jul—Sep vs Apr—Jun, 95% CI 1.10—5.35, P = .028, Table 2). Progress through the academic year is associated with decreased likelihood of performing endoscopy on the weekend. The effect of academic progress in determining whether weekend endoscopy is performed is comparable to the effect of patient tachycardia. Greater trainee experience may result in greater comfort with resuscitating and waiting for a weekday procedure. Further study on the impact of trainee behavior on patient outcomes in endoscopy is warranted.Table 1Characteristics of 690 Patients Who Presented to the ED With GIB and Underwent Upper Endoscopy Within 72 Hours of AdmissionMon—Fri EndoscopyWeekend EndoscopyP valuencol %ncol %N59298Males36862.26664.3.688Age, mean (SD)62.8(17.3)65.515.0.137Tachycardia, HR > 10021836.85556.1<.001Hypotension, MAP < 65447.41414.3.024Initial hemoglobin, mean (SD) g/dL9.52.88.42.6.002Units PRBC in first 24h 023639.91313.3 1—218631.43535.7 2—49115.42121.4 ≥57913.32929.6<.001ICU admission16327.58283.7<.001Endoscopic hemostatic therapy None48381.66970.4 Injection/Clip/Thermal/Combo8113.62323.4 Banding284.766.1.002Trainee academic quarternrow %nrow %Q1: Jul–Sep13283.02717.0Q2: Oct–Dec14184.42615.5Q3: Jan–Mar15785.32714.7Q4: Apr–Jun16290.01810.0.066 Open table in a new tab Table 2Logistic Regression for Independent Predictors of Weekend EndoscopyaOR95% CIP valueWeekend ED triage40.518.0—91.4<.001Tachycardia (HR > 100)1.731.03—2.90.037PRBC in first 24h/per unit1.111.05—1.18<.001Endoscopic hemostatic therapy1.271.10—1.50.003Trainee academic quarter Q1: Jul–Sep2.421.10—5.35.028 Q2: Oct–Dec1.490.69—3.21.305 Q3: Jan–Mar1.430.67—3.06.353 Q4: Apr–Jun1 (ref) Open table in a new tab