Attending Physician Coverage Research Articles

A Prospective Trial of an In-house Overnight Fellow Rotation in the Intensive Care Unit.

Although previous studies in academic intensive care units (ICUs) have found no improvement in patient care outcomes with in-house overnight attending physician coverage compared with home call coverage, the effect of in-house supervision on trainee education and well-being is less clear. In addition, no studies have examined the effect of in-house coverage by fellow physicians overnight. What is the impact of an in-house overnight critical care fellow on resident, fellow, and attending perception of patient safety, house staff education, and house staff well-being? A prospective trial alternating 2-week periods of in-house overnight critical care fellow coverage with 2-week periods of home call coverage was performed in our tertiary medical ICU. Residents, fellows, and attendings were surveyed to evaluate perceptions of the night fellows' impact on patient care, communication, supervision, educational experience, autonomy, well-being, and job satisfaction. Over the 6-month study period, surveys were sent to 83 residents, 22 fellows, and 23 attendings, with completion by 56 (67%), 22 (100%), and 16 (70%), respectively. Overall, 89% of residents, 68% of fellows, and 81% of attendings reported perceived improvements in patient care with an in-house fellow. The in-house fellow was also associated with improved well-being in 79% of residents and 73% of fellows, and 82% of residents felt that it positively impacted education. As compared with the traditional home call system, an in-house night critical care fellow can improve the perception of patient care, trainee well-being, and education in a tertiary ICU at an academic hospital.

Virtual Remote Attending Supervision in an Academic Emergency Department During the COVID-19 Pandemic.

Background: As the surge of patients with COVID-19 increased, our academic university faculty needed to explore ways to protect the more vulnerable physicians in the group from infection while maintaining the service to our patients and the educational objectives of our residency training program. Methods: We utilized telehealth carts used for other purposes in the institution and the ED to allow the replacement of one physically present supervising attending physician with a virtual remote attending physician. This physician, working from home, can be virtually present for resident history and physicals with all patients in the supervised pod. Discussions about patient care, review of studies, and decision on final disposition can also be performed. Resident teaching can also be accomplished. Results: Our innovation represents a novel use of telemedicine capabilities which allows us to protect vulnerable faculty from infection during the COVID-19 pandemic while maintaining appropriate EM resident supervision and patient care. We found some advantages of this process which allow us to more directly observe the initial resident assessment of the patient. The residents responded favorably to the degree of supervision and patient care that we can provide remotely. Conclusions: Our novel use telemedicine during the COVID-19 pandemic has allowed us to decrease the exposure of more vulnerable faculty while maintaining the ability of these faculty to continue to contribute to patient care and resident education. It is well accepted by our residents and seems to be a viable alternative to physical presence in the ED for at least one faculty member. This modality might also be utilized by an attending who fell ill and was not yet able to return to physical work. We hope our description of this process might be useful to other academic departments or community hospital groups who may have at-risk members.

The Influence of Inpatient Physician Continuity on Hospital Discharge.

Inpatient attending physicians may change during a patient's hospital stay. This study measured the association of attending physician continuity and discharge probability. All patients admitted to general medicine service at a tertiary care teaching hospital in 2015 were included. Attending inpatient physician continuity was measured as the consecutive number of days each patient was treated by the same staff-person. Generalized estimating equation methods were used to model the adjusted association of attending inpatient physician continuity with daily discharge probability. 6301 admissions involving 41 internists, 5134 patients, and 38,242 patient-days were studied. The final model had moderate discrimination (c-statistic = 0.70) but excellent calibration (Hosmer-Lemeshow statistic 11.5, 18 df, p value 0.89). Daily discharge probability decreased significantly with greater severity of illness, higher patient death risk, and longer length of stay, on admission day, for elective admissions, and on the weekend. Discharge likelihood increased significantly with attending inpatient physician continuity; daily discharge probability increased for the average patient from 15.3 to 20.9% when the consecutive number of days the patient was treated by the same attending inpatient physician increased from 1 to 7days. Inpatient attending physician continuity is significantly associated with the likelihood of patient discharge. This finding could be considered if resource utilization is a factor when scheduling attending inpatient physician coverage.

Association of 24/7 In-House Intensive Care Unit Attending Physician Coverage With Outcomes in Children Undergoing Heart Operations

Multicenter data regarding the around-the-clock (24/7) presence of an in-house critical care attending physician with outcomes in children undergoing cardiac operations are limited. Patients younger than 18 years of age who underwent operations (with or without cardiopulmonary bypass [CPB]) for congenital heart disease at 1 ofthe participating intensive care units (ICUs) in the Virtual PICU Systems (VPS, LLC) database were included (2009-2014). The study population was divided into 2 groups: the 24/7 group (14,737 patients; 32 hospitals), and the No 24/7 group (10,422 patients; 22 hospitals). Propensity-score matching was performed to match patients 1:1 in the 24/7 group and in the No 24/7 group. Overall, 25,159 patients from 54 hospitals qualified for inclusion. By propensity matching, 9,072 patients (4,536 patient pairs) from 51 hospitals were matched 1:1 in the 2 groups. After matching, mortality at ICU discharge was lower among the patients treated in hospitals with 24/7 coverage (24/7 versus No 24/7, 2.8% versus 4.0%; p= 0.002). The use of extracorporeal membrane oxygenation (ECMO), the incidence of cardiac arrest, extubation within 48 hours after operation, the rate of reintubation, and the duration of arterial line and central venous line use after operation were significantly improved in the 24/7 group. When stratified by surgical complexity, survival benefits of 24/7 coverage persisted among patients undergoing both high-complexity and low-complexity operations. The presence of 24-hour in-ICU attending physician coverage in children undergoing cardiac operations is associated with improved outcomes, including ICU mortality. It is possible that 24-hour in-ICU attending physician coverage may be a surrogate for other factors that may bias the results. Further study is warranted.

The Effect of Emergency Medicine Residents on Clinical Efficiency and Staffing Requirements.

The effect of emergency medicine (EM) residents on the clinical efficiency of attending physicians is controversial. The authors hypothesized that implementing a new EM residency program would result in an increase in relative value units (RVUs) generated per hour by attending physicians and decrease staffing requirements. This was a retrospective observational analysis of an emergency department before, during, and after the establishment of a new EM residency program. We analyzed the change in RVUs billed, patients seen, and hours worked by attending physicians, midlevel providers (MLPs), and residents, and addressed potential confounding factors. The clinical efficiency of attending physicians increased by 70%, or 4.98 RVUs/hour (from 7.12 [SD±1.4] RVUs/hour to 12.1 [SD±2.2] RVUs/hour, p<0.001) with the implementation of an EM residency program. Overall, net department RVU generation rose by 32%, even as attending physician coverage decreased by 6.3% (p<0.05), and MLP coverage dropped by 60% (p<0.05). We estimated that the implementation of the residency saved 4,860 hours of attending physician coverage and 5,828 hours of MLP coverage per year. This represents an estimated $1,741,265 in annual staffing savings, comparable to the residency program's annual operating cost of $1,821,108. The implementation of an EM residency program had a positive effect on the clinical efficiency of attending physicians and decreased staffing requirements.

Increased Occurrence of Tracheal Intubation–Associated Events During Nights and Weekends in the PICU*

Adverse tracheal intubation-associated events are common in PICUs. Prior studies suggest provider and practice factors are important contributors to tracheal intubation-associated events. Little is known about how the incidence of tracheal intubation-associated events is affected by the time of day, day of the week, or presence of in-hospital attending-level intensivists. We hypothesize that tracheal intubations occurring during nights and weekends are associated with a higher frequency of tracheal intubation-associated events. Retrospective observational cohort study. Twenty international PICUs. Critically ill children requiring tracheal intubation. None. We analyzed 5,096 tracheal intubation courses from July 2010 to March 2014 from the prospective multicenter National Emergency Airway Registry for Children. Frequency of a priori-defined tracheal intubation-associated events was the primary outcome. Occurrence of any tracheal intubation-associated events and severe tracheal intubation-associated events were more common during nights (19:00 to 06:59) and weekends compared with weekdays (19% vs 16%, p = 0.01; 7% vs 6%, p = 0.05, respectively). This difference was significant in emergent intubations after adjusting for site-level clustering and patient factors: for any tracheal intubation-associated events: adjusted odds ratio, 1.20; 95% CI, 1.02-1.41; p = 0.03; but not significant in nonemergent intubations: adjusted odds ratio, 0.94; 95% CI, 0.63-1.40; p = 0.75. For emergent intubations, PICUs with home-call attending coverage had a significantly higher frequency of tracheal intubation-associated events during nights and weekends (adjusted odds ratio, 1.29; 95% CI, 1.01-1.66; p = 0.04), and this difference was attenuated in PICUs with in-hospital attending coverage (adjusted odds ratio, 1.12; 95% CI, 0.91-1.39; p = 0.28). Higher occurrence of tracheal intubation-associated events was observed during nights and weekends. This difference was primarily attributed to emergent intubations. In- hospital attending physician coverage attenuated this discrepancy between weekdays versus nights and weekends but was not fully protective for tracheal intubation-associated events.

Physician Staffing Models Impact the Timing of Decisions to Limit Life Support in the ICU

A growing trend is the implementation of 24-h attending physician coverage in the ICU. Our aim was to measure the impact of 24-h, in-house, attending intensivist coverage on the quality of end-of-life care and the timing of end-of-life decision-making. A retrospective cohort study was conducted of all ICU deaths 6 months before and 6 months after the implementation of mandatory 24-h attending intensivist coverage in a medical ICU. Data relevant to end-of-life care per established consensus recommendations were abstracted from the medical record. The following changes were observed after implementation of 24-h intensivist coverage: Time from ICU admission to decision to withdraw mechanical ventilation and time to decision to change to do-not-resuscitate code status both were shortened by 2 days (both P = .03). Quality measures, such as increased family presence around time of death ( P = .01) also improved. Other findings, which did not reach statistical significance, included the following: Time to family conference was shortened by 2 days ( P = .09), time to decision to limit any life support was shortened by 1 day ( P = .08), time to death was shortened by 2 days ( P = .08), and intubations against patient wishes decreased (from three to none; P = .12). The implementation of mandatory 24-h, in-house, attending intensivist coverage was associated with earlier decision-making across a number of domains related to end-of-life care. Positive trends were noted in quality of end-of-life care as reflected in the presence of family at the time of death.

Results of the 2012 Survey of the American Association of Academic Chief Residents in Radiology

Every year, the American Association of Academic Chief Residents in Radiology conducts a survey of the chief residents in accredited radiology training programs in North America. The survey serves as a tool for gathering information, sharing ideas, and voicing opinions. An online survey was made available to the chief residents from 187 training programs in North America. Questions were presented in multiple-choice and free response formats, designed to address many issues ranging from program structure to on-call policies, changes for the new board examination format and fellowships, and the effects of health care reform on radiology practices. The results of the survey were tabulated and responses to the repeated questions were compared with those from earlier surveys dating to 2003. Among those surveyed, 185 individual responses representing 135 unique programs were completed, yielding a 73% response rate. Thirty-eight percent of programs responded from the northeast and 17% of programs responded from the southeast. Nineteen percent of responses were from central United States, 14% of responses were from western United States, and 12% of responses were from Canada. There is an increasing number of programs, which cover more hospitals, during the past decade. There are more programs providing ultrasound and magnetic resonance services after hours, with an associated increase in after-hours attending physician coverage. Many changes are being made for the future board examination format. Health care reform is affecting how residents are preparing themselves for their future practices.

The impact of 24-hr, in-hospital pediatric critical care attending physician presence on process of care and patient outcomes*

Attending physicians are only required to provide in-hospital coverage during daytime hours in many pediatric intensive care units. An in-hospital 24-hr pediatric intensive care unit attending coverage model has been increasingly popular, but the impact of 24-hr, in-hospital attending coverage on care processes and outcomes has not been reported. We compared processes of care and outcomes before and after the implementation of a 24-hr in-hospital pediatric intensive care unit attending physician model. Retrospective comparison of before and after cohorts. A single large, academic tertiary medical/surgical pediatric intensive care unit. : Pediatric intensive care unit admissions in 2000-2006. Transition to 24-hr from 12-hr in-hospital pediatric critical care attending physician coverage model in January 2004. A total of 18,702 patients were admitted to intensive care unit: 8,520 in 24 hrs; 10,182 in 12 hrs. Duration of mechanical ventilation was lower (median 33 hrs [interquartile range 12-88] vs. 48 hrs [interquartile range 16-133], adjusted reduction of 35% [95% confidence interval 25%-44%], p < .001) and intensive care unit length of stay was shorter (median 2 days [interquartile range 1-4] vs. 2 days [interquartile range 1-5], adjusted p < .001) for 24 hr vs. 12 hr coverage. The reduction in mechanical ventilation hours was similar when noninvasive, mechanical ventilation was included in ventilation hours (median 42 hrs vs. 56 hrs, adjusted reduction in ventilation hours: 33% [95% confidence interval 20-45], p < .001). Intensive care unit mortality was not significantly different (2.2% vs. 2.5%, adjusted p =.23). These associations were consistent across daytime and nighttime admissions, weekend and weekday admissions, and among subgroups with higher Pediatric Risk of Mortality III scores, postsurgical patients, and histories of previous intensive care unit admission. Implementation of 24-hr in-hospital pediatric critical care attending coverage was associated with shorter duration of mechanical ventilation and shorter length of intensive care unit stay. After accounting for potential confounders, this finding was consistent across a broad spectrum of critically ill children.

Impact of Nonphysician Staffing on Outcomes in a Medical ICU

As the number of ICU beds and demand for intensivists increase, alternative solutions are needed to provide coverage for critically ill patients. The impact of different staffing models on the outcomes of patients in the medical ICU (MICU) remains unknown. In our study, we compare outcomes of nonphysician provider-based teams to those of medical house staff-based teams in the MICU. We conducted a retrospective review of 590 daytime (7:00 am-7:00 pm) admissions to two MICUs at one hospital. In one MICU staffed by nurse practitioners and physician assistants (MICU-NP/PA) there were nonphysicians (nurse practitioners and physicians assistants) during the day (7:00 am-7:00 pm) with attending physician coverage overnight. In the other MICU, there were medicine residents (MICU-RES) (24 h/d). The outcomes investigated were hospital mortality, length of stay (LOS) (ICU, hospital), and posthospital discharge destination. Three hundred two patients were admitted to the MICU-NP/PA and 288 to the MICU-RES. Mortality probability model III (MPM(0)-III) predicted mortality was similar (P = .14). There was no significant difference in hospital mortality (32.1% for MICU-NP/PA vs 32.3% for MICU-RES, P = .96), MICU LOS (4.22 ± 2.51 days for MICU-NP/PA vs 4.44 ± 3.10 days for MICU-RES, P = .59), or hospital LOS (14.01 ± 2.92 days for MICU-NP/PA vs 13.74 ± 2.94 days for MICU-RES, P = .86). Discharge to a skilled care facility (vs home) was similar (37.1% for MICU-NP/PA vs 32.5% for MICU-RES, P = .34). After multivariate adjustment, MICU staffing type was not associated with hospital mortality (P = .26), MICU LOS (P = .29), hospital LOS (P = .19), or posthospital discharge destination (P = .90). Staffing models including daytime use of nonphysician providers appear to be a safe and effective alternative to the traditional house staff-based team in a high-acuity, adult ICU.

24/7 Neonatal Intensive Care Unit Attending Physician Coverage

24/7 Neonatal Intensive Care Unit Attending Physician Coverage

215: A Profile of Emergency Medicine Board-Certified Physicians: 2001-2007

215: A Profile of Emergency Medicine Board-Certified Physicians: 2001-2007

On-Call Resident Preliminary Reads: Should the Process Continue?

I read with great interest the most recent “Residents’ Column,” in which Dr Bansal [ 1 Bansal A. Twenty-four-hour attending physician coverage and its impact on resident training. J Am Coll Radiol. 2005; 2: 642-644 Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar ] described the impact of 24-hour attending physician coverage on the resident training at his institution. The majority of the residents at his institution seemed to be in favor of this new system, because it led to a decrease in on-call hours as well as a decrease in “fear and uncertainty” while on call. Twenty-Four-Hour Attending Physician Coverage and Its Impact on Resident TrainingJournal of the American College of RadiologyVol. 2Issue 7Preview…is committed to serving the community. We are dedicated to enhancing patient care, teaching and research, and to taking a leadership role as an integrated health care system. Full-Text PDF Author’s ReplyJournal of the American College of RadiologyVol. 2Issue 12PreviewAs the diagnostic capabilities of radiology continue to expand, clinicians’ reliance on imaging studies will only increase. The evaluation of patients with suspected appendicitis is an excellent example of an area in which imaging has become indispensable [1]. Given that radiology has now become a 24-hour specialty, we are faced with making an important decision about who should be rendering interpretations. Does it make logical sense to have a resident make what in essence amounts to a final decision at night but not during the day? After all, you can’t very well have a surgeon place a normal appendix back into someone’s abdomen after an attending physician comes in and renders an official reading at 8 am. Full-Text PDF

Author’s Reply

As the diagnostic capabilities of radiology continue to expand, clinicians’ reliance on imaging studies will only increase. The evaluation of patients with suspected appendicitis is an excellent example of an area in which imaging has become indispensable [ 1 Rhea J.T. Halpern E.F. Ptak T. Lawrason J.N. Sacknoff R. Novelline R.A. The status of appendiceal CT in an urban medical center 5 years after its introduction experience with 753 patients. Am J Roentgenol. 2005; 184: 1802-1808 Crossref PubMed Scopus (87) Google Scholar ]. Given that radiology has now become a 24-hour specialty, we are faced with making an important decision about who should be rendering interpretations. Does it make logical sense to have a resident make what in essence amounts to a final decision at night but not during the day? After all, you can’t very well have a surgeon place a normal appendix back into someone’s abdomen after an attending physician comes in and renders an official reading at 8 am. On-Call Resident Preliminary Reads: Should the Process Continue?Journal of the American College of RadiologyVol. 2Issue 12PreviewI read with great interest the most recent “Residents’ Column,” in which Dr Bansal [1] described the impact of 24-hour attending physician coverage on the resident training at his institution. The majority of the residents at his institution seemed to be in favor of this new system, because it led to a decrease in on-call hours as well as a decrease in “fear and uncertainty” while on call. Full-Text PDF

Author’s Reply

Dr Branstetter makes an accurate point in his letter; the studies referenced in my column do indeed compare overnight resident reads to those of a subspecialist [ 1 Bansal A. Twenty-four hour attending physician coverage and its impact on resident training. J Am Coll Radiol. 2005; 2: 642-644 Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar ]. However, I did make it quite clear that in our hospital, the new overnight attending radiologist coverage is provided by nighthawk attending radiologists, who in reality are dedicated emergency radiologists who cover not only our emergency department but also many smaller surrounding community emergency rooms. Are Residents’ On-call Errors Worse Than the Alternatives?Journal of the American College of RadiologyVol. 2Issue 10PreviewI would like to thank Dr. Bansal for raising awareness of the effect that 24-hour attending call coverage has on resident education in academic radiology residency programs (The Residents’ Column, July 2005) [1]. This important consideration is often overlooked in the rush of hospital politics. Although I agree with the majority of Dr. Bansal’s analysis, there is one statement in the column that concerns me: “Having an attending radiologist on staff with an on-call resident would have theoretically eradicated most or all of [the resident’s] errors.” Full-Text PDF

Twenty-Four-Hour Attending Physician Coverage and Its Impact on Resident Training

� is committed to serving the community. We are dedicated to enhancing patient care, teaching and research, and to taking a leadership role as an integrated health care system. The above is excerpted from the mission statement of the hospital that sponsors my residency program. Such a statement is likely to be found similarly worded, if not verbatim, in many others around the country. Although different instruments have occasionally generated contradictoryresults(i.e.,PressGaneyAssociates), at least one major survey (NRCPicker Group) has reported that smaller community hospitals generally achieve greater patient satisfaction than larger teaching institutions [1]. The most common explanation offered for this finding is that community hospitals focus exclusively on the mission of patient care, without having to expend additional resources on teaching and research, and are therefore able to accomplish this singular goal more effectively. These data seem to put the mission of patient care somewhat at odds with those of teaching and re

Resident education does not correlate with the degree of emergency department crowding

Study objectives: We study the effect of emergency department (ED) crowding on medical student and emergency medicine resident perception of educational interaction with attending physicians. Our hypothesis is that the perceived quality of clinical teaching is decreased when crowding conditions exist in the ED. Methods: An emergency medicine residency program (postgraduate years [PGYs] 1 to 3) with an annual census of 92,000 patient visits and 64 hours of attending physician coverage at the primary hospital served as the study site. A 1-page survey was completed by study participants at the close of their shift and was used to quantify perception of the quality of teaching received, as well as crowding in the ED. The surveys used a 10-cm visual analog scale evaluating whether the attending physician was effective at didactic/bedside teaching, available/accessible, efficient in patient management, approachable, and professional and provided adequate supervision. Participants were asked to rate the value of the learning experience, whether the ED seemed busy, and whether there was adequate time to spend with patients. The data were analyzed using regression analysis. Results: A total of 184 surveys were completed during a 3-month period, representing a 42% return rate. The degree of actual and perceived ED crowding did not correlate with effectiveness of didactic and bedside teaching, attending availability, efficiency in patient management, approachability, professionalism, and adequacy of supervision. Correlation coefficients ranged from <i>r</i>=−0.06 to 0.19. Furthermore, study participants' perceptions of ED crowding and actual daily ED census did not correlate (<i>r</i>=0.06). Conclusion: Medical students' and emergency medicine residents' perception of teaching does not correlate with the degree of actual or perceived ED crowding. Study participants could not consistently identify when ED crowding existed. Educational interactions with attending physicians appear to be minimally affected by fluctuations in patient care demands.

Shift overtime among emergency medicine residents: Results of a national survey

Study objectives: Recently regulated resident physician work hours have largely unaffected emergency medicine residents because of a scheduled shift work routine. However, anecdotal reports indicate emergency medicine residents may continue work after their allotted shift has ended. This study seeks to identify factors associated with emergency medicine resident shift overtime. Methods: A survey was mailed to the chief residents and program director of each of the 124 emergency medicine residency programs approved by the residency review committee of emergency medicine in the fall of 2002. Multiple choice, Likert scale (1 to 5; 1 most positive, 5 most negative), and open-ended questions were used. Two mailings were sent, and a reminder e-mail was sent using a list-serve e-mail list. χ 2 Tests, Student's t tests and Mann-Whitney U tests were used to compare nominal, ordinal, and interval variables, and Spearman's ρ was used for correlations. Results: Seventy-six percent of program chief residents and 65% of program directors returned surveys. There was a similar return rate for both chief residents and program directors in regard to sex and the length and size of program, but program directors were older (41.8 years versus 30.8 years; P P =.84). Chief residents and program directors reported multiple reasons for shift overtime, most commonly arranging a patient admission (71% versus 63%; P =1.0) or discharge (70% versus 56%; P =.27). Chief residents and program directors believed that an increased number of resident (3.15 versus 3.29; P =.83) or attending physicians (3.92 versus 3.83; P =.58) would not affect resident shift overtime. Length of shift overtime was not correlated to attending physician coverage during the busiest times in the ED (chief resident P =.47; program director P =.86). Conclusion: Chief residents and program directors report that emergency medicine residents routinely work after their shift because of a variety of delays. Chief residents and program directors thought that increasing the number of residents or attending physicians would not affect resident overtime.

The training of pediatric residents in the care of acutely ill and injured children.

To describe the current educational experience of pediatric residents in pediatric emergency care, to identify areas of variability between residency programs, and to distinguish areas in need of further improvement. A 63-item survey mailed to all accredited pediatric residency training program directors in the United States and Puerto Rico. Pediatric residency programs and their directors. Primary training settings, required and elective rotations related to the care of the acutely ill and injured child, supervision of care, procedural and technical training, and didactic curriculum in pediatric emergency medicine (PEM). One hundred fifty-three (72%) of 213 residency programs responded. One hundred nine (71%) were based at general or university hospitals, the remaining 44 (29%) were based at freestanding children's hospitals. Residents most commonly saw patients in pediatric emergency departments (54%), followed by acute care clinics (21%), general emergency departments (21%), and urgent care clinics (5%). The mean number of weeks of PEM training required was 11, but varied widely from 0 to 36 weeks. Forty programs (27%) required their residents to spend 4 or fewer weeks rotating in an emergency department setting. The best predictor of the number of weeks spent in emergency medicine was residency program size, with small programs requiring fewer weeks (7 weeks for small [1-8 postgraduate year 1 residents] vs 13 for medium [9-17 postgraduate year 1 residents] vs 15 for large [> or =18 postgraduate year 1 residents]). Pediatric surgery (18%), orthopedic (8%), anesthesia (6%), and toxicology (4%) rotations were rarely required. Ninety-two percent of the programs had 24-hour on-site attending physician coverage of the emergency department. Supervising physicians varied widely in their training and included PEM attendings and fellows, general emergency medicine attendings, and general pediatric attendings. Small programs were less likely to have PEM coverage (57% at small vs 95% at large) and more likely to have general emergency medicine coverage (79% at small vs 29% at large). Reported opportunities to perform procedures were uniformly high and did not differ by program size or affiliated fellowship. Residency program directors were uniformly confident in their residents' training in medical resuscitation, critical care, emergency care, airway management, and minor trauma. Thirty-seven percent of all respondents were not confident in their residents' training in major trauma. Most programs reported that they had a didactic PEM curriculum (77%), although the number of hours devoted to the lectures varied substantially. Wide variability exists in the amount of time devoted to emergency medicine within pediatric residency training curricula and in the training background of attendings used to supervise patient care and resident education. Nevertheless, pediatric residency training programs directors feel confident in their residents training in most topics related to PEM. Residents' training in major trauma resuscitation was the most frequently cited deficiency.

THE TRAINING OF PEDIATRIC RESIDENTS IN THE CARE OF ACUTELY ILL AND INJURED CHILDREN

Objectives To describe the current educational experience of pediatric residents in pediatric emergency care, to identify areas of variability between residency programs, and to distinguish areas in need of further improvement. Design A 63-item survey mailed to all accredited pediatric residency training program directors in the United States and Puerto Rico. Setting and Participants Pediatric residency programs and their directors. Main Outcome Measures Primary training settings, required and elective rotations related to the care of the acutely ill and injured child, supervision of care, procedural and technical training, and didactic curriculum in pediatric emergency medicine (PEM). Results One hundred fifty-three (72%) of 213 residency programs responded. One hundred nine (71%) were based at general or university hospitals, the remaining 44 (29%) were based at freestanding children's hospitals. Residents most commonly saw patients in pediatric emergency departments (54%), followed by acute care clinics (21%), general emergency departments (21%), and urgent care clinics (5%). The mean number of weeks of PEM training required was 11, but varied widely from 0 to 36 weeks. Forty programs (27%) required their residents to spend 4 or fewer weeks rotating in an emergency department setting. The best predictor of the number of weeks spent in emergency medicine was residency program size, with small programs requiring fewer weeks (7 weeks for small [1-8 postgraduate year 1 residents] vs 13 for medium [9-17 postgraduate year 1 residents] vs 15 for large [≥18 postgraduate year 1 residents]). Pediatric surgery (18%), orthopedic (8%), anesthesia (6%), and toxicology (4%) rotations were rarely required. Ninety-two percent of the programs had 24-hour on-site attending physician coverage of the emergency department. Supervising physicians varied widely in their training and included PEM attendings and fellows, general emergency medicine attendings, and general pediatric attendings. Small programs were less likely to have PEM coverage (57% at small vs 95% at large) and more likely to have general emergency medicine coverage (79% at small vs 29% at large). Reported opportunities to perform procedures were uniformly high and did not differ by program size or affiliated fellowship. Residency program directors were uniformly confident in their residents' training in medical resuscitation, critical care, emergency care, airway management, and minor trauma. Thirty-seven percent of all respondents were not confident in their residents' training in major trauma. Most programs reported that they had a didactic PEM curriculum (77%), although the number of hours devoted to the lectures varied substantially. Conclusions Wide variability exists in the amount of time devoted to emergency medicine within pediatric residency training curricula and in the training background of attendings used to supervise patient care and resident education. Nevertheless, pediatric residency training programs directors feel confident in their residents training in most topics related to PEM. Residents' training in major trauma resuscitation was the most frequently cited deficiency.