Abstract
Objectives
Emergency medicine (EM) physicians and pediatricians who provide acute pediatric care depend on clinical exposure during residency to learn pediatric EM. Increasing volumes of pediatric patients, especially with behavioral health complaints, have stressed pediatric emergency departments (ED) and prompted clinical operations innovations including alternative care sites outside the main ED. We investigated the impact of these recent trends and resulting alternative care sites on the exposure of residents to core pediatric conditions.
Methods
This retrospective study reviewed patient encounters between July 1, 2018, and December 31, 2022, at a pediatric ED that hosts one pediatric and three EM residencies. During the study, the hospital employed alternative care sites in response to increased and shifting patient populations. Median patients per resident per academic year were compared before and after the opening of alternative care sites, overall and stratified by patient factors (age, sex, Emergency Severity Index [ESI], and diagnostic category). The study also compared the percentage of residents who saw no patients with a given diagnosis between the two periods.
Results
Of 231,101 patient encounters, 199,947 were seen in the main ED and 31,154 in alternative care sites. The median number of patients seen by a single resident in a single academic year ranged from 82 to 136 for pediatric residents and from 128 to 183 for EM residents. The median number of patients per resident per year did not decrease for any age group, sex, ESI level, or diagnosis across the two periods. Residents saw a median of 19 more patients with psychiatric diagnoses (95% CI 15.4–22.7) in the more recent period. Seven diagnoses were not seen by at least 20% of residents during both periods.
Conclusions
Current pediatric ED capacity challenges can be addressed with alternative care sites without decreasing volume or variety of patients seen by residents.
Keywords: alternative care sites, clinical operations, resident exposure
INTRODUCTION
Pediatric patients with acute medical and surgical emergencies are not exclusively seen in pediatric emergency departments (EDs). The majority of ED visits occur in general EDs. 1 , 2 , 3 , 4 In these settings, they may be cared for by emergency medicine (EM) physicians or pediatricians without specific training in pediatric emergency medicine (PEM). Although clinical competency cannot be assumed from clinical exposure, patient care is a core competency in graduate medical education and precepted patient care is an essential component of medical training. 5 , 6 , 7 , 8 Pediatric and emergency physicians gain the clinical exposure that helps build their PEM knowledge and skills during residency. 9 , 10 Residency programs leverage rotations in the pediatric ED to deliver this exposure. 5 , 6
Prior studies have shown variability and gaps in exposure to core pediatric diagnoses during pediatric ED rotations. 11 More recent trends, including significantly increasing volumes of pediatric patients with behavioral health complaints, large fluctuations in patient volumes, the SARS‐CoV‐19 pandemic, and new transmission patterns of infectious diseases, have stressed pediatric EDs. 12 , 13 , 14 , 15 , 16 , 17 While patient volumes and mix do not change abruptly, they eventually reach a threshold that prompts pediatric EDs to innovate clinical operations models in response. These include increasing primary care utilization, transferring care for boarding patients to inpatient teams, increasing the care provided in triage, and creating alternative care sites for seeing patients. 18 , 19 , 20 , 21 Alternative care sites are spaces temporarily converted for health care delivery to provide additional capacity and capability. 22 In the case of the ED, alterative care site refers to a space converted for clinical use outside of the main ED where care is provided by the ED staff.
As these patient trends and resulting care models persist, it is important to consider how they are impacting residents. Alterations to the volume or case mix seen by residents has potential implications for the comfort and knowledge obtained when they care for pediatric emergencies in EDs after completing training. Anticipated effects of the increased volumes, shifting case mix, and resulting alternative care sites on PEM exposure in residency are different and sometime conflicting. While growing patient volumes would be expected to increase resident exposure, directing patients to alternative care sites not staffed by trainees might limit it. Furthermore, changing patterns in the types of patients presenting to pediatric EDs, as well as decisions about which can be seen in alternative care sites, can affect the variety of patients seen by residents. The net result of these recent trends has not been investigated. In this study, we explored how opening alternative care sites in response to increased volumes and changing patient mix impacted the exposure to core pediatric patient populations for rotating residents.
MATERIALS AND METHODS
Study setting and participant selection
This was a retrospective, single center study that examined patients presenting to an academic pediatric ED within a freestanding pediatric hospital between July 1, 2018, and December 31, 2022. The pediatric ED sees more than 60,000 patients per year and hosts one pediatric residency and three EM residencies. Residents complete between one to three rotations over the course of residency, with a maximum of two rotations per year. Rotations range from 2 weeks for pediatric residents to 4 weeks for EM residents. The main pediatric ED consists of 45 patient rooms and has space for 14 hallway beds. It is staffed by PEM fellowship–trained attendings, who see patients independently and supervise PEM fellows, medical students, physician assistants, and nurse practitioners in addition to resident physicians.
During the study period, the center created three alternative care sites staffed by pediatric emergency physicians in response to changes in patient volumes and increased hours of care for boarding patients. Many EDs, including ours, have fast track or urgent care programs. Prior to creation of the alternative care sites, there had been a pediatrician‐staffed urgent care site that ceased to exist once alternative care sites were opened. As the urgent care was staffed by pediatricians, it saw only low‐acuity (ESI Level 4–5) patients and the attendings were not qualified to precept residents in PEM. In contrast, alternative care sites saw higher acuity level patients (ESI Levels 2–5) and were staffed by PEM physicians qualified to precept residents. Transitioning to the alternative care site model thus meant that more lower acuity patients were being seen by PEM physicians and that there was the potential for more precepted patient care if residents rotated in these alternative care sites.
The opening of the alternative care sites was used to divide the study period in two. The first alternative care site was opened November 1, 2019, meaning our baseline period was between July 1, 2018, and October 31, 2019. The newly opened alternative care site was temporarily closed from March 11 to August 9, 2020, in response to the World Health Organization declaration of the SARS‐CoV‐19 pandemic. It reopened August 10, 2020, and two additional alternative care sites were subsequently added in March 2022. Alternative care site consisted of:
Site 1: Nine patient rooms, never staffed by residents; available evening hours.
Site 2: Six to 12 patient rooms, never staffed by residents; available 24 h.
Site 3: Five patient rooms, occasionally staffed by residents; pediatric emergency physicians staffing this site also independently saw patients in the main ED waiting room; available 24 h.
These sites could see patients with Emergency Severity Index (ESI) Levels 2–5. Patients requiring significant respiratory interventions (e.g., continuous albuterol, noninvasive ventilation, or intubation), patients with active seizure disorders, and patients requiring lengthy procedures or procedural sedation were cohorted to the main ED as much as possible. Patients presenting with behavioral health complaints were triaged as ESI Level 2 and cohorted to the main ED if they required 1:1 observation.
All encounters for patients presenting to the pediatric ED between July 1, 2018–March 10, 2020, and August 10, 2020–December 31, 2022, were included, regardless of patient age. The period between March 11 to August 9, 2020, was excluded from the analysis because patient volumes were well below normal pediatric ED volumes in the setting of the SARS‐CoV‐19 public health emergency. 23 , 24 In addition, resident exposure was impacted by residents being pulled from PEM rotations to staff other care settings and by cohorting of patients within the ED to minimize resident exposure to patients potentially infected with SARS‐CoV‐19. Therefore, it did not constitute a true baseline nor could it be considered a period in which alternative care sites were utilized.
Data collection
The electronic health record was queried to extract patient volumes as well as data on each encounter including patient age, sex, ESI, ICD‐10 diagnostic code, in‐room time, checkout time, and whether a resident participated in the initial evaluation of the patient. The study focused on the initial evaluation because it requires interpretation of age‐specific vital signs and physical examination findings as well as development of pediatric‐specific differential diagnoses and management plans.
Data analysis
Relevant ICD‐10 diagnoses were identified by using the Pediatric Emergency Care Applied Research Network (PECARN) Diagnosis Grouping System and the Model of Clinical Practice of Emergency Medicine. 8 , 25 The Model of Clinical Practice of Emergency Medicine was developed by the American Board of Emergency Medicine, the American College of Emergency Physicians, the Council of Emergency Medicine Residency Directors, the Emergency Medicine Residents' Association, the Residency Review Committee for Emergency Medicine, and the Society for Academic Emergency Medicine. 8 The 2016 version of the Model of Clinical Practice of Emergency Medicine was refined into core diagnoses commonly seen or associated with major morbidity and mortality in the pediatric population. 11 Our study group compared the updated Model of Clinical Practice of Emergency Medicine published in 2019 with the previously identified core pediatric diagnoses to reconcile additions, subtractions, and modifications. These diagnoses were then aligned with the PECARN diagnostic groupings, resulting in 21 diagnostic groups or subgroups for analysis. The study used monthly hours of care to capture both the volume of patients presenting and the length of time they were in the department, as both are important contributors to decisions about when to open alternative care sites.
With descriptive statistics, we characterized demographic and clinical factors (age, sex, ESI level, and ICD‐10 diagnoses) of patients stratified by care location (in the main ED vs. alternative care sites) using frequencies with proportions and medians with interquartile ranges (IQRs) for categorical and continuous variables, respectively. We calculated volume using monthly hours of care to capture both number of patients presenting to the ED and increased length of stay. Monthly hours of care were calculated by summing the time from room to ED checkout (admission or discharge) for each patient presenting to the ED in a single month.
For each resident, we determined the number of patients seen across each academic year of the study period (2018 through 2023) as well as by subgroups of patients defined by demographic (age, sex) and clinical (ESI, diagnoses) factors. Some residents may have had ED rotations in multiple academic years: for these residents, each year was analyzed separately. The resident‐level median and interquartile ranges (IQRs) of number of patients seen were reported. We then compared the resident‐level median number of patients seen between the baseline and alternative care site periods using median differences with 95% confidence intervals (CIs). We also compared the percentage of residents who saw no patients with a given diagnosis between the baseline and alternative care site periods using risk differences with 95% CIs. 11 The study was reviewed by the institutional review board at Boston Children's Hospital and determined to be exempt.
RESULTS
The study population comprised a total of 231,101 patient encounters. Across the entire study period, 87% (199,947) were seen in the main ED and 13% (31,154) were seen in alternative care sites. Comparing the baseline period to the period when alternative care sites opened, there were no differences in median patient age or sex (Table 1). The percentage of patients with psychiatric diagnoses increased from 5.4% to 6.9% in the period when alternative care sites were open (median difference 1.6%, 95% CI 1.4%–1.8%). Monthly hours of patient care ranged from 9391 (April 2020) to 36,614 (October 2022; Figure 1). The mean (±SD) monthly hours of care increased from 21,715 (±3304) in the baseline period to 30,107 (±4243) during the alternative care site period.
TABLE 1.
Patient characteristics before and after opening of alternative care sites.
| Baseline era (n = 78,865) | Alternative care sites era (n = 152,236) | Median difference (95% CI) a | ||||
|---|---|---|---|---|---|---|
| Age (years), median (IQR) | 6.5 (2.2–13.6) | 6.6 (2.2–13.9) | 0.0 (−0.1 to 0.1) | |||
| Male sex | 41,211 | (52.3) | 79,038 | (51.9) | −0.3 (−0.8 to 0.1) | |
| ESI | ||||||
| 1 | 456 | (0.6) | 857 | (0.6) | −0.0 (−0.1 to 0.0) | |
| 2 | 17,626 | (22.3) | 37,440 | (24.6) | 2.2 (1.9 to 2.6) | ↑ |
| 3 | 37,260 | (47.2) | 69,593 | (45.7) | −1.6 (−2.0 to −1.2) | ↓ |
| 4 | 20,229 | (25.7) | 39,935 | (26.2) | 0.6 (0.2 to 0.9) | ↑ |
| 5 | 3107 | (3.9) | 4202 | (2.8) | −1.2 (−1.3 to −1.0) | ↓ |
| Diagnoses | ||||||
| Fever | 10,762 | (13.6) | 21,206 | (13.9) | 0.3 (0.0 to 0.6) | |
| Vomiting | 5769 | (7.3) | 11,685 | (7.7) | 0.4 (0.1 to 0.6) | ↑ |
| Psychiatric, behavior, substance abuse | 4229 | (5.4) | 10,577 | (6.9) | 1.6 (1.4 to 1.8) | ↑ |
| Fractures and dislocations | 3859 | (4.9) | 7768 | (5.1) | 0.2 (0.0 to 0.4) | |
| Gastroenteritis | 3579 | (4.5) | 7244 | (4.8) | 0.2 (0.0 to 0.4) | |
| Infectious respiratory diseases | 4063 | (5.2) | 9174 | (6.0) | 0.9 (0.7 to 1.1) | ↑ |
| Lacerations, amputations, foreign bodies | 2950 | (3.7) | 5447 | (3.6) | −0.2 (−0.3 to 0.0) | |
| Asthma, bronchospasm, and wheezing | 3347 | (4.2) | 6565 | (4.3) | 0.1 (−0.1 to 0.2) | |
| Brain and skull trauma | 2428 | (3.1) | 4721 | (3.1) | 0.0 (−0.1 to 0.2) | |
| Headache | 2373 | (3.0) | 4520 | (3.0) | −0.0 (−0.2 to 0.1) | |
| Dehydration | 1924 | (2.4) | 3785 | (2.5) | 0.0 (−0.1 to 0.2) | |
| Chest pain | 1295 | (1.6) | 3015 | (2.0) | 0.3 (0.2 to 0.5) | ↑ |
| Infectious urinary tract diseases | 1330 | (1.7) | 2672 | (1.8) | 0.1 (−0.0 to 0.2) | |
| Congenital circulatory + cardiovascular diseases | 984 | (1.2) | 1870 | (1.2) | −0.0 (−0.1 to 0.1) | |
| Diabetes mellitus | 705 | (0.9) | 1590 | (1.0) | 0.2 (0.1 to 0.2) | ↑ |
| Appendicitis | 556 | (0.7) | 1265 | (0.8) | 0.1 (0.1 to 0.2) | ↑ |
| Sickle cell anemia | 619 | (0.8) | 1186 | (0.8) | −0.0 (−0.1 to 0.1) | |
| Chest trauma | 249 | (0.3) | 520 | (0.3) | 0.0 (0.0 to 0.1) | |
| Burns | 215 | (0.3) | 348 | (0.2) | −0.0 (−0.1 to 0.0) | |
| Child abuse | 191 | (0.2) | 344 | (0.2) | −0.0 (−0.1 to 0.0) | |
| Abdominal trauma | 83 | (0.1) | 174 | (0.1) | 0.0 (0.0 to 0.0) | |
| Resident involved in initial evaluation | ||||||
| Pediatric resident | 18,060 | (22.9) | 45,829 | (30.1) | 7.2 (6.8 to 7.6) | ↑ |
| EM resident | 13,889 | (17.6) | 29,588 | (19.4) | 1.8 (1.5 to 2.2) | ↑ |
| Other | 192 | (0.2) | 586 | (0.4) | 0.1 (0.1 to 0.2) | ↑ |
| None | 46,724 | (59.3) | 76,233 | (50.1) | −9.2 (−9.6 to −8.7) | ↓ |
Note: Values in table represent frequency (%) unless otherwise noted. ↑, statistically significant increase; ↓, statistically significant decrease.
Abbreviations: ESI, Emergency Severity Index; IQR, interquartile range.
Median difference for continuous variables; risk difference for binary variables.
FIGURE 1.
ED monthly hours of patient care across all sites. Study timeline—baseline period, July 1, 2018, to October 31, 2019; alternative care sites open, November 1, 2019–March 10, 2020 + August 10, 2020–December 31, 2022; excluded from study, March 11, 2020–August 9, 2020.
During the period when alternative care sites were open, 20% (31,154/152,236) of patients presenting to the ED were seen in an alternative care site. Patients seen in alternative care sites were younger than those seen in the main ED, with a median (IQR) age of 5.0 (1.9–11.5) compared to 7.1 (2.3–14.4) years (median difference −2.2, 95% CI –2.3 to −2.0). Patients seen in alternative care sites had higher ESI scores (Table S1). The most common diagnoses seen in alternative care sites were fever (20%) and vomiting (9%). Less than 10% of patients seen in alternative care sites were seen by a resident (8.9%), while 60.5% of patients in the main ED were seen by a resident.
The median number of patients seen by a single resident in a single academic year ranged from 82 to 136 for pediatric residents and 128 to 183 for EM residents (Table 2). The median number of patients per resident in a single academic year for specific age groups, male and female sex, ESI levels, and diagnoses are shown in Table 3. The median number of patients per resident in a single academic year did not decrease for any category. Large increases in median patients seen occurred for patients aged 10–14 (median difference 11, 95% CI 7.3–14.7), patients age 15 years or older (median difference 11, 95% CI 6.8–15.3), patients with ESI 2 (median difference 24, 95% CI 16.4–31.7), and patients with psychiatric diagnoses (median difference 19, 95% CI 15.4–22.7). There were seven diagnoses not seen by 20% or more of residents across the entire study period: congenital circulatory and cardiovascular diseases, appendicitis, sickle cell anemia, chest trauma, burns, child abuse, and abdominal trauma (Table 4).
TABLE 2.
Residents’ annual exposure to patients.
| Patients per resident | ||||
|---|---|---|---|---|
| Pediatric residents | EM residents | |||
| AY 2018–2019 | 98 | (59–177) | 136 | (115–163) |
| AY 2019–2020 | 82 | (60–142) | 128 | (85–159) |
| AY 2020–2021 | 88 | (62–146) | 129 | (101–157) |
| AY 2021–2022 | 136 | (68–231) | 153 | (98–185) |
| AY 2022–2023 | 96 | (60–166) | 183 | (154–214) |
Note: Data are reported as median (IQR).
Abbreviations: AY, annual year; IQR, interquartile range.
TABLE 3.
Resident exposure per academic year to patient categories.
| Patients per resident | ||||
|---|---|---|---|---|
| Diagnoses | Baseline era a | Alternative care sites era a | Median difference (95% CI) | |
| Age | ||||
| <6 months | 10 (6–14) | 12 (7–19) | 2 (0.4 to 3.6) | ↑ |
| 6–23 months | 18 (11–26) | 20 (12–32) | 2 (−0.7 to 4.7) | |
| 2–9 years | 48 (32–62) | 52 (33–81) | 4 (−1.8 to 9.8) | |
| 10–14 years | 26 (16–36) | 36.5 (24–57) | 11 (7.3 to 14.7) | ↑ |
| 15+ years | 33 (21–44) | 44 (28–70) | 11 (6.8 to 15.3) | ↑ |
| Sex | ||||
| Male | 65 (41–86) | 82.5 (53–125) | 18 (10.6 to 25.4) | ↑ |
| Female | 69 (46–92) | 85 (53–126) | 16 (8.4 to 23.6) | ↑ |
| ESI | ||||
| 1 | 0 (0–1) | 1 (0–2) | 1 (0.7 to 1.4) | ↑ |
| 2 | 42 (28–61) | 66 (41–110) | 24 (16.4 to 31.7) | ↑ |
| 3 | 78 (49–98) | 76 (50–112) | −2 (−9.2 to 5.2) | |
| 4 | 11 (6–19) | 19 (11–31) | 8 (5.9 to 10.1) | ↑ |
| 5 | 1 (0–3) | 1 (0–3) | 0 (−0.4 to 0.4) | |
| Diagnoses | ||||
| Fever | 13 (8–20) | 14 (7–24) | 1 (−1.2 to 3.2) | |
| Vomiting | 9 (5–13) | 10 (5–16) | 1 (−0.3 to 2.3) | |
| Psychiatric, behavior, substance abuse | 13 (8–21) | 32 (20–56) | 19 (15.4 to 22.7) | ↑ |
| Fractures and dislocations | 5 (3–8) | 7 (4–13) | 2 (1.1 to 2.9) | ↑ |
| Gastroenteritis | 5 (3–8) | 6 (2–10.5) | 1 (0.1 to 1.9) | ↑ |
| Infectious respiratory diseases | 7 (3–12) | 8 (3–16) | 1 (−0.8 to 2.8) | |
| Lacerations, amputations, foreign bodies | 4 (2–6) | 5 (2–8) | 1 (0.1 to 1.9) | ↑ |
| Asthma, bronchospasm, and wheezing | 5 (2–9) | 6 (2–10) | 1 (−0.1 to 2.0) | |
| Brain and skull trauma | 3 (2–5) | 4 (2–6) | 1 (0.4 to 1.6) | ↑ |
| Headache | 4 (2–6) | 4.5 (2–7) | 1 (0.3 to 1.7) | ↑ |
| Dehydration | 4 (2–6) | 4 (2–7) | 0 (−0.7 to 0.7) | |
| Chest pain | 2 (1–4) | 3 (1–4) | 1 (0.7 to 1.4) | ↑ |
| Infectious urinary tract diseases | 2 (1–4) | 3 (1–5) | 1 (0.7 to 1.4) | ↑ |
| Congenital circulatory + cardiovascular diseases | 2 (1–3) | 2 (1–4) | 0 (−0.4 to 0.4) | |
| Diabetes mellitus | 1 (0–3) | 2 (1–4) | 1 (0.7 to 1.4) | ↑ |
| Appendicitis | 1 (0–2) | 1 (0–3) | 0 (−0.2 to 0.2) | |
| Sickle cell anemia | 1 (0–2) | 1 (0–2) | 0 (−0.2 to 0.2) | |
| Chest trauma | 0 (0–1) | 0 (0–1) | Not estimable | |
| Burns | 0 (0–0) | 0 (0–1) | Not estimable | |
| Child abuse | 0 (0–1) | 0 (0–1) | 0 (−0.2 to 0.2) | |
| Abdominal trauma | 0 (0–0) | 0 (0–0) | Not estimable | |
Note: ↑ = statistically significant increase in the median resident exposure per academic year to the specified category.
Abbreviations: ESI, Emergency Severity Index; IQR, interquartile range.
Data are reported as median (IQR). A total of 271 residents in baseline era; 476 residents in alternative care sites era.
TABLE 4.
Inadequate resident clinical exposure to diagnoses (no cases seen).
| Residents who saw no patients with diagnosis in single academic year | ||||
|---|---|---|---|---|
| Diagnoses | Baseline a | Alternative care sites open a | Risk difference (95% CI) | |
| Fever | 5 (1.8) | 14 (2.9) | 1.1 (−1.1 to 3.3) | |
| Vomiting | 8 (3.0) | 13 (2.7) | −0.2 (−2.7 to 2.3) | |
| Psychiatric, behavior, substance abuse | 10 (3.7) | 8 (1.7) | −2.0 (−4.5 to 0.5) | |
| Fractures and dislocations | 13 (4.8) | 35 (7.4) | 2.6 (−0.9 to 6.0) | |
| Gastroenteritis | 12 (4.4) | 33 (6.9) | 2.5 (−0.8 to 5.9) | |
| Infectious respiratory diseases | 17 (6.3) | 39 (8.2) | 1.9 (−1.9 to 5.7) | |
| Lacerations, amputations, foreign bodies | 25 (9.2) | 44 (9.2) | 0.0 (−4.3 to 4.3) | |
| Asthma, bronchospasm, and wheezing | 19 (7.0) | 34 (7.1) | 0.1 (−3.7 to 4.0) | |
| Brain and skull trauma | 22 (8.1) | 42 (8.8) | 0.7 (−3.4 to 4.8) | |
| Headache | 20 (7.4) | 32 (6.7) | −0.7 (−4.5 to 3.2) | |
| Dehydration | 28 (10.3) | 43 (9.0) | −1.0 (−5.7 to 3.2) | |
| Chest pain | 57 (21.0) | 69 (14.5) | −6.5 (−12.3 to −0.8) | ↓ |
| Infectious urinary tract diseases | 47 (17.3) | 64 (13.4) | −3.9 (−9.4 to 1.6) | |
| Congenital circulatory + cardiovascular diseases | 61 (22.5) | 102 (21.4) | −1.1 (−7.3 to 5.1) | |
| Diabetes mellitus | 70 (25.8) | 77 (16.2) | −9.7 (−15.8 to −3.5) | ↓ |
| Appendicitis | 86 (31.7) | 125 (26.3) | −5.5 (−12.3 to 1.3) | |
| Sickle cell anemia | 92 (33.9) | 146 (30.7) | −3.3 (−10.3 to 3.7) | |
| Chest trauma | 194 (71.6) | 305 (64.1) | −7.5 (−14.4 to −0.6) | ↓ |
| Burns | 210 (77.5) | 346 (72.7) | −4.8 (−11.2 to 1.6) | |
| Child abuse | 173 (63.8) | 267 (56.1) | −7.8 (−15.0 to −0.5) | ↓ |
| Abdominal trauma | 235 (86.7) | 391 (82.1) | −4.6 (−9.9 to 0.7) | |
Note: Data are reported as number (%). ↓, statistically significant decrease in the risk of inadequate resident clinical exposure to the specified diagnosis.
271 residents in baseline era; 476 residents in period when alternative care sites era.
DISCUSSION
Our study found that the number and diversity of patients seen by rotating residents did not decrease despite opening alternative care sites to address capacity issues resulting from increases in patient volumes and the proportion with behavioral health complaints. This was true despite differences in the patient populations seen in the main ED and alternative care sites and despite over 20% of patients being seen in alternative care sites.
Given previously documented gaps in exposure to core pediatric diagnoses during residency training, it is critical to consider how the more recent trends impacting pediatric emergency care are concurrently impacting resident exposure. 11 One of the most notable trends has been the increase in the volume of patients with behavioral health complaints, which has overwhelmed pediatric psychiatric resources and resulted in prolonged boarding for these patients in the ED. 14 , 15 , 20 , 26 , 27 Our study documents that residents are seeing a 2.5‐fold increase in the number of patients with psychiatric problems compared to only 3 years ago. This highlights the need for adequate training in caring for children with psychiatric emergencies, which has been previously identified as an area where EM and pediatric residents need additional education. 27 , 28 , 29 This is especially important if the behavioral health challenges do not dissipate with the end of the pandemic. Recent data pointing to the ongoing negative impact of social media suggest that the increase in pediatric patients with psychiatric complaints may persist. 30
In addition to the increasing number of behavioral health boarders, pediatric EDs have faced fluctuations in patient volumes due to the SARS‐CoV‐19 pandemic and novel bacterial and viral transmission patterns. 16 , 31 , 32 , 33 To address these recent trends, new clinical care models have been developed including alternative care sites. 13 , 18 , 19 , 34 To date, no studies have examined the impact that these trends and resulting changes in clinical operations have on patient exposure during residency training. While there is no ability to ensure clinical exposure translates to competency, clinical care is a core part of training. 5 , 6 , 7 , 8 Seeing fewer patients with a given diagnosis for whatever reason represents a potential area of inadequate clinical exposure. 11 Our institutional approach to alternative care sites is that patients are predominately seen by faculty without trainees, and the implications of opening such sites is likely to be greatest in systems where more patients are seen without trainees in these sites. Thus, caring for patients in alternative care sites without residents rather than in the main ED has the potential to effect resident exposure by counteracting overall increases in patient volume and shifting the types of patients seen. Our findings that nearly one‐third of patients can be seen in alternative care sites without decreasing resident exposure to core pediatric patient populations means that increasing ED throughput using this care model does not need to come at the cost of training. However, educators must still consider possible drawbacks of failing to pass on the full increase in patient volumes to trainees, who will be tasked with overseeing care to increased patient loads if current trends continue after they complete their training.
It is reassuring that neither the increased proportion of behavioral health patients nor the use of alternative care sites decreased resident exposure to core pediatric diagnoses because exposure to several of these diagnoses is limited. There were seven diagnoses to which residents had minimal exposure, with at least 20 percent of residents seeing no cases in a single year. Many of these aligned with previous findings of diagnoses rarely encountered in the pediatric ED, including congenital circulatory and cardiovascular disease, child abuse and chest trauma. 11 We also found that approximately 30% of residents saw no cases of appendicitis in a single year. This underlines the need for close attention to resident exposure since residents are not guaranteed the opportunity to see even relatively “bread‐and‐butter” diagnoses. Fortunately, resident exposure to these rarer diagnoses increased during the period when alternative care sites were open. This period was associated with lower risk of inadequate resident exposure to pediatric patients with abdominal trauma, chest pain, chest trauma, child abuse, and diabetes mellitus compared to the baseline. This may simply represent the increased patient volume, or it may result from these patients being kept in the main ED where they could be seen by residents while other more common diagnoses such as fever were sent to alternative care sites. Efforts to ensure adequate exposure to core pediatric diagnoses likely need to consider both clinical exposure and alternative models, such as simulation. 35 Decisions about which patients to see in alternative care sites has direct bearing on the former, while ongoing monitoring of resident exposure can inform the latter.
LIMITATIONS
There are several limitations to our study. Because changes in volume, patient mix, and shifting of patients happened concurrently, we cannot determine how much impact each had on resident exposure. This study was a single‐center study, limiting its generalizability. While the national trends that prompted alternative care sites are more universal, the physical resources available and the staffing models at individual institutions will determine how many and what types of patients can be seen in these sites as well as what type of providers staff them. Our ED has a relatively high percentage of patients seen by faculty without trainees, even at baseline. Other EDs may have a lower percentage of patients seen without trainees. Furthermore, the study relied on ICD‐10 diagnostic codes to measure clinical exposure. This does not fully capture the care provided or the potential learning from evaluating and generating a differential based on a chief complaint. In addition, the selected ICD‐10 codes represent a subset of all ED visits. However, we used previously identified and validated codes to ensure we captured core pediatric diagnoses. We focused on residents involved in the initial evaluation of patients. This is an important learning moment because it entails taking the history, performing a physical examination, and generating a differential diagnosis and management plan. But transitions of care and reassessments of patients are also important learning moments, which this study does not capture. Our study also does not capture resident exposure to pediatric diagnoses for individual residents over multiple years of training in the PED study site nor to exposure in rotations outside the PED study site. Our results do not capture patients seen at their home institutions or any other rotation designed to increase exposure to PEM. Excluding these other rotations does not impact the findings related to changes in exposure during a single year at the study site but including them would help create a more complete picture of which diagnoses residents are seeing over the arc of their training. This is particularly true since rotation length varied across the programs included in our study based on the frequency with which residents rotate in the PED study site and whether they have PEM exposure at other sites. Finally, we performed a retrospective observational study and so cannot comment about causal links between opening alternative care sites and resident exposure. In fact, the decision to open alternative care sites is directly related to changes in patient volume and department capacity. In this study, we attempted to investigate whether the alternative care sites deprived residents of seeing this increase in patient volume or variety.
CONCLUSIONS
Recent pediatric ED capacity challenges such as increasing volumes and behavioral health needs may be addressed by opening alternative care sites without decreasing the volume or case mix of patients seen by residents. Further work is needed to understand how to adapt training to equip residents to care for pediatric patients with psychiatric crises as well as to find ways to increase exposure to rare but important core pediatric diagnoses.
AUTHOR CONTRIBUTIONS
Kelsey A. Miller conceived of the study concept and design, acquired the data, assisted with analysis and interpretation of the data, drafted the initial manuscript, and engaged in critical revision of the manuscript; Andrew F. Miller conceived of the study concept and design, acquired the data, assisted with analysis and interpretation of the data, and engaged in critical revision of the manuscript; Rebekah C. Mannix and Michael C. Monuteaux provided statistical expertise, performed analysis and interpretation of the data, and engaged in critical revision of the manuscript; Sarah Cavallaro, Alexander Hirsch, Joel Hudgins, Jason Levy, Joyce Li, Galina Lipton, Ashley Marchese, and Sara Schutzman conceived of the study concept and design and engaged in critical revision of the manuscript.
CONFLICT OF INTEREST STATEMENT
The authors declare no conflicts of interest.
Supporting information
Table S1.
ACKNOWLEDGMENTS
The authors acknowledge John Porter for his assistance.
Miller KA, Cavallaro S, Hirsch A, et al. Alternative care sites and resident exposure in pediatric emergency medicine: Who, what, and where. AEM Educ Train. 2023;7:e10903. doi: 10.1002/aet2.10903
Presented at the Pediatric Academic Societies Annual Meeting, Washington, DC, May 2023.
Supervising Editor: Daniel P Runde
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Associated Data
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Supplementary Materials
Table S1.