A Descriptive Analysis of the Cumulative Experiences of Emergency Medicine Residents in the Pediatric Emergency Department

Abstract

Objectives

Most children seeking emergency care are evaluated in general emergency departments (EDs). The cumulative pediatric clinical experiences of emergency medicine (EM) residents are largely unknown. This study examined EM resident pediatric clinical experience through the lens of the Accreditation Council for Graduate Medical Education requirements and the Model of the Clinical Practice of Emergency Medicine.

Methods

Retrospective, observational study of the cumulative clinical experience of two classes of EM residents from a 4‐year training program at two pediatric EDs of a quaternary care pediatric center. A database of resident patient encounters was generated from the electronic medical record. Experiences classified included: diagnosis categories per the Model of the Clinical Practice of Emergency Medicine, procedures, and resuscitations. Results were stratified by age, acuity, and disposition.

Results

Twenty‐five EM residents evaluated 17,642 patients (median = 723). Most patients (73.5%) were emergent acuity (Emergency Severity Index triage level 2 or 3 or non–intensive care admission); 2% were critical. Residents participated in 598 (median = 22) medical resuscitations and 483 (median = 19) trauma resuscitations. Minor procedures (e.g., laceration repair) were commonly performed; critical procedures (e.g., intubation) were rare. Exposure to neonates was infrequent and pediatric deaths were rare. Abdominal pain (5.7%), asthma exacerbation (4.6%), and fever (3.8%) were the most common diagnoses.

Conclusions

Emergency medicine residents encountered a wide array of pediatric diagnoses throughout training and performed a substantial number of common pediatric procedures. Exposure to critical acuity and procedures, neonatal pathology, and certain pediatric‐specific diagnoses, such as congenital heart disease, was limited despite training in a large, quaternary care children’s hospital. Curriculum development and collaboration should focus on these areas.

Most (80%–90%) children, including the majority of medically complex children, presenting for emergency care in the United States are evaluated in general and community emergency departments (ED). ¹ , ² , ³ , ⁴ , ⁵ When a pediatric patient and their family present for care, they expect that their emergency medicine (EM) physician has the necessary knowledge and experience. Langhan et al. ⁶ found that EM physicians felt less prepared to handle pediatric patients, compared to adult patients with similar presentations, and reported particular stress managing pediatric resuscitation. Furthermore, Simon and Sullivan, ⁷ in a survey of physicians working in general community EDs, reported that 25% of respondents were uncomfortable performing potentially lifesaving procedures on children.

Training of the EM resident in contrast to that of other subspecialties is focused on signs and symptoms rather than a particular organ system. ⁸ According to the Model of the Clinical Practice of Emergency Medicine followed by the American Board of Emergency Medicine (ABEM), the approach to patient care for an EM resident “begins with the recognition of patterns in the patient’s presentation that point to a specific diagnosis or diagnoses. Pattern recognition is both the hallmark and cornerstone of the clinical practice of EM, guiding the diagnostic tests and therapeutic interventions during the entire patient encounter.” ⁸ It is through repetition that this pattern recognition develops, allowing the resident to organize knowledge into well‐defined illness scripts (i.e., mental representations of specific illnesses) to aid in clinical reasoning. ⁹ To achieve this pattern recognition and construct effective illness scripts for children, the Accreditation Council for Graduate Medical Education (ACGME) has determined that 20%, or 5 full‐time equivalent months, of training must be spent caring for pediatric patients (<18 years of age) in the pediatric ED (PED) or other pediatric settings. ⁹ , ¹⁰ , ¹¹ Whether or not this is sufficient exposure is not known.

Prior studies indicate that EM residents may have fewer opportunities to evaluate pediatric patients and perform critical procedures and resuscitations than anticipated. ¹² , ¹³ , ¹⁴ , ¹⁵ Escalating these concerning findings, a study of categorical pediatric residents rotating five nonconsecutive months in a large, academic PED during the entirety of their training noted that their cumulative experience was insufficient to achieve the minimum exposure to pediatric emergency and acute illness recommended by the ACGME at the time. ¹⁶ This calls to question whether EM residents face similar challenges. Simulation can augment these experiences but cannot supplant them. ¹⁷

Our study therefore aims to examine the depth and breadth of EM resident clinical experiences in one of the largest pediatric health care centers in the United States focused on pediatric encounters in a high‐acuity, academic urban PED and an affiliated suburban ED through the lens of ACGME program requirements and the Model of the Clinical Practice of Emergency Medicine. We believe a better and deeper understanding of the pediatric clinical experiences of EM residents in our medical center will provide a “best‐case” scenario for an EM residency writ large.

METHODS

Study Design

This is a retrospective, observational study of the cumulative clinical experiences of EM residents from a 4‐year program in two large, academic PEDs within a single quaternary‐care pediatric center. The local institutional review board determined this study to be exempt.

Study Setting

A 700‐bed quaternary care pediatric center with two freestanding PEDs, one urban and one suburban. It is the only regional referral center for children with a catchment area of greater than 25 counties. During the study period, the admission rate was 10.5%, and the annual volumes were approximately 78,000 patients at the urban PED and 37,000 patients at the suburban PED. This effective yearly volume of approximately 115,000 visits does not include urgent care volumes that feed into these PEDs and makes this center one of the largest providers of emergency care in North America. EM residents rotate at both sites during their training. There were approximately 2,600 patients evaluated in the combined resuscitation areas from both sites per year (2.3% of all PED patients), with approximately 43% of those presenting following trauma.

Study Population

The study sample included two recent graduating classes of EM residents from a large (14 residents per year) 4‐year academic EM residency training program. Residents complete a dedicated half‐month block in the urban PED during the first half of their first postgraduate year (PGY‐1). Following their first rotation, EM residents participate in all patient care areas including the resuscitation area. Subsequently, 20% of their remaining PGY‐1 as well as all PGY‐2 through PGY‐4 ED shifts are longitudinally scheduled in the urban and suburban PEDs. After their initial half‐month rotation, residents are typically assigned two to three PED shifts at either site per month without dedicated PED rotations.

During the initial 4 years of the study period, residents worked 10‐hour shifts. In the final year of the study period, shifts were 9 hours long. EM residents were directly supervised by either board‐certified or board‐eligible pediatric EM (PEM) faculty physicians at both sites and worked concurrently with PEM fellows, pediatric residents, family practice residents, medical students, and nurse practitioners.

Residents also complete the following required rotations at our pediatric center outside the PED: 1‐month block in the pediatric intensive care unit (ICU; PGY‐1), 1‐month block of pediatric plastic surgery (PGY‐3), and 1‐week block of pediatric anesthesia (PGY‐1). In addition, residents may encounter pediatric patients during prehospital transport experiences, in the urban, academic ED at their home institution (approximately 200 pediatric patients annually, 0.3% of patient encounters) as well as at two suburban, community EDs at which they rotate (approximately 800 pediatric patients annually for 3% of patient encounters and 1,600 patients for 3.5% of patient encounters at each site). During training, EM residents also participate quarterly in high‐fidelity simulation involving critically ill and injured pediatric patients.

Measurements and Outcomes

The primary outcome of this study was a detailed description of the cumulative clinical experience in the PED over the course of a 4‐year residency as defined by diagnoses seen, procedures performed, and participation in pediatric medical and trauma resuscitations. Experiences were further classified by patient age, acuity, and disposition.

Study Protocol

The roster of all eligible EM residents based on graduation year was obtained. An application specialist queried the electronic medical record (EMR; Epic, Verona, WI) to identify patient encounters linked to these residents. A database was generated containing the following elements: resident name, patient encounter ID, patient sex and age, patient arrival date and time, visit location, triage level (performed by triage nurse), trauma and medical resuscitation team activation, disposition, billing diagnoses and descriptions with corresponding International Classification of Diseases, 9th Revision (ICD‐9) and ICD‐10 codes, and procedure codes for the encounter. Deidentified data from these visits were extracted from the medical record using SAP Crystal Reports. Data were then exported and loaded into IBM SPSS (Version 24.0.0.0, 2016) for analysis. Although all billing diagnoses were collected for each patient encounter, only the primary diagnosis was analyzed to capture the principal reason for the visit and accurately characterize resident clinical experiences. Prior to analysis, all patient identifiers were removed, and each resident’s name was substituted with a unique identifier known only to the application specialist to maintain confidentiality.

Primary EMR billing diagnoses were grouped into 17 specific categories described by the 2016 Model of the Clinical Practice of Emergency Medicine. ¹⁸ Diagnoses were combined when similar diagnostic and ICD codes existed. For example, all encounters with a primary billing diagnosis code of “acute serous otitis media right ear” or “acute serous otitis media bilateral” were grouped under an “acute otitis media” diagnosis. If more than one resident was assigned to a single patient encounter, only the resident who was initially assigned was credited with the diagnosis.

Procedures of interest included central venous catheter placement, tube thoracostomy placement, endotracheal intubation, incision and drainage (I&D), intraosseous line placement, laceration repair, lumbar puncture, and splint application. Procedures were identified through Current Procedural Terminology (CPT) codes and additional billing codes with the exception of endotracheal intubation, which was obtained via an existing internal database of all resuscitation area patients that undergo intubation. Individual chart review was subsequently performed to verify that the resident attempted the procedure, regardless of success, for all procedures.

Medical resuscitations were defined as any patient initially presenting to or upgraded to the resuscitation area at either PED with a nontraumatic complaint. Trauma resuscitations were defined by patients initially presenting to or upgraded to the resuscitation area following activation of any level of the three‐tiered trauma system. A detailed description of medical and trauma activation criteria is shown in Table 1. If more than one resident was assigned to a single patient encounter, only the resident who was initially assigned to the encounter was credited with the resuscitation.

Table 1.

Activation Criteria for the Resuscitation Area

Medical team
Actively seizing Cardiopulmonary arrest without apparent trauma Altered mental status with neurologic deficit ED discretion (including but not limited to hypoxia, respiratory distress, shock)
Trauma stat
Any penetrating injury to the head, neck, or trunk GSW to the extremities proximal to the elbow/knee Respiratory difficulty as evidenced by one or more of the following: significant increase or decrease in respiratory rate, significant retractions or grunting, patient intubated prior to arrival, unable to maintain or difficult airway Tachycardia and/or poor perfusion or unexplained tachycardia Hypotension Blood given prior to the patient’s arrival 40 mL/kg bolus given prior to arrival GCS ≤ 8 GCS deterioration by 2
Trauma alert
Evidence of abdominal injury GCS 9–13 Spinal cord injury with neurologic deficit Two or more proximal long‐bone fractures Ejection from automobile Partial or full‐thickness burn of >15% TBSA Significant vascular injury including amputation of limb proximal to the wrist or ankle ED discretion
Trauma evaluation
Motor vehicle collision Struck or run over by motor vehicle (pedestrian or bike) Fall greater than 10 feet Any mechanism deemed to place the patient at risk for multi‐system injury Any patient immobilized with a backboard and/or cervical collar Partial or full‐thickness burns between 5 and 14% TBSA Any burn less than 5% requiring immediate pain management Any GSW (non‐BB) distal to the knee or elbow

GCS = Glasgow Coma Scale; GSW = gunshot wound; TBSA = total body surface area.

Patients were stratified by age in accordance with the American Academy of Pediatrics “Ages & Stages,” with the modification of creating a distinct category for neonates, in the following manner: neonate (0–28 days), infant (29 days–1 year), toddler (1–3 years), preschooler (3–5 years), gradeschooler (5–12 years), teen (12–18 years), young adult (18–21 years), and adult (≥21 years). ¹⁸ , ¹⁹

Acuity of condition was stratified in accordance with the 2016 Model of the Clinical Practice of Emergency Medicine as low, emergent, or critical for each encounter based primarily on patient disposition and initial Emergency Severity Index (ESI) triage level. ²⁰ A patient encounter was considered critical with an initial ESI level 1 or level 2 plus any one of the following: endotracheal intubation, cardiopulmonary resuscitation, death in the PED, or admission to an ICU. Emergent patients were those with an ESI level 2 or 3 or those admitted to a non‐ICU bed. Low‐acuity patients had an initial ESI level of 4 or 5. A patient encounter was assigned the highest acuity for which criteria were met.

Data Analysis

Data were analyzed using the IBM SPSS (Version 24.0.0.0, 2016). Descriptive statistics were generated for the outcomes of interest and are presented as total counts, percentages, medians, interquartile ranges (IQR), and complete ranges.

RESULTS

Resident‐Level Data

A total of 17,642 patients were evaluated by the 25 EM residency graduates for a median of 723 patients (range = 415–1,103; IQR = 613–794) per resident. The majority of patients (73.5%) were emergent acuity. Only 2% were critical. Most patients (81%) were evaluated at the urban PED, with 19% seen at the suburban PED. The overall admission rate to either facility for patients evaluated by the resident cohort was 21.6% (admission rate for all patients evaluated during the study period was 10.5%); 2% were ICU‐level admissions.

Table 2 depicts data on a per‐resident level, stratified by the Model of the Clinical Practice of Emergency Medicine categories, age groupings, acuity, and disposition. The most common Model of the Clinical Practice of Emergency Medicine categories in order of number of patients were signs, symptoms, and presentations (32.3%); traumatic (18.8%); and thoracic‐respiratory (13.8%). Overall, most patients were less than 12 years old (67.6%), with the greatest proportion in the grade school (5‐12 years) age range (26.3%); 2% were neonates.

Table 2.

Median Patients Evaluated Per Resident by Model of the Clinical Practice of Emergency Medicine Category, Patient Age, Acuity, and Disposition

All patients		Total Number	Median (range)	IQR
		17,642	723 (415–1103)	613–794
Model of the Clinical Practice of Emergency Medicine category
	Abdominal and gastrointestinal	883	35 (16–59)	26–45
	Cardiovascular	88	3 (1–7)	2–5
	Cutaneous	614	25 (7–55)	17–31
	Endocrine, metabolic, and nutritional	188	8 (3–12)	5–10
	Environmental	44	2 (0–5)	1–3
	Head, ear, eye, nose, throat	1,087	43 (21–70)	34–55
	Hematologic	146	5 (1–12)	3–9
	Immune system	115	4 (0–8)	3–7
	Musculoskeletal (nontraumatic)	144	6 (0–11)	4–8
	Nervous system	761	31 (14–47)	26–36
	Obstetrics and gynecology	248	10 (4–19)	8–12
	Psychobehavioral	658	25 (17–43)	19–33
	Renal and urogenital	453	19 (7–34)	12–23
	Signs, symptoms, and presentations	5,695	229 (139–342)	206–251
	Systemic infectious	533	22 (9–44)	14–28
	Thoracic–respiratory	2,428	91 (47–151)	75–116
	Toxicologic	236	9 (4–18)	7.5–11
	Traumatic	3,321	120 (70–233)	112–159
Age category
	Neonate (0–28 days)	354	13 (8–30)	12–16
	Infant (29 days–1 year)	2,197	85 (53–139)	74–99
	Toddler (1–3 years)	2,947	119 (69–184)	101–129
	Preschooler (3–5 years)	1,844	74 (30–116)	62–87
	Gradeschooler (5–12 years)	4,589	179 (101–288)	152–216
	Teen (12–18 years)	4,583	181 (105–280)	160–212
	Young Adult (18–21 years)	788	31 (21–48)	25–36
	Adult (≥21 years)	340	14 (3–21)	11–17
Acuity
	Low	4,331	179 (96–287)	138–197
	Emergent	12,964	538 (303–792)	453–586
	Critical	347	14 (4–26)	9–18
Disposition
	Discharged home	13,543	554 (316–896)	455–605
	Admitted to the floor	2,992	119 (71–180)	108–138
	Admitted to an ICU (PICU/CICU)	326	13 (5–25)	9–17
	Admitted to the NICU	26	1 (0–4)	0–2
	Admitted to psych	285	10 (5–24)	7–16
	Expired	11	1 (0–2)	0–1
	Transferred to another facility	199	9 (2–17)	4–11
	Admitted to the OR	167	6 (4–12)	5–8
	Other (left AMA or eloped)	93	3 (1–7)	2–6

AMA = against medical advice; CICU = cardiac intensive care unit; ICU = intensive care unit; IQR = interquartile range; NICU = neonatal intensive care unit; OR = operating room; PICU = pediatric intensive care unit.

Diagnosis‐level Data

Table 3 displays the three most common diagnoses seen within each Model of the Clinical Practice of Emergency Medicine category, listed by age, acuity, and disposition. A comprehensive listing of all diagnoses is available in Table S1 (available as supporting information in the online version of this paper, which is available at http://onlinelibrary.wiley.com/doi/10.1002/aet2.10462/full), accompanying the online article. Notably, the most common nontraumatic diagnosis was abdominal pain (n = 997, 5.7%) followed by asthma exacerbation (n = 820, 4.6%), fever (n = 662, 3.8%), upper respiratory infection (n = 582, 3.3%), nausea/vomiting (n = 524, 3%), bronchiolitis (n = 413, 2.3%), headache (n = 351, 2%), and cough (n = 291, 1.6%). The most common traumatic diagnoses were closed extremity fracture (n = 512, 2.9%), closed head injury (n = 287, 1.6%), and contusion (n = 128, 0.7%). Other frequently encountered diagnoses included otitis media (n = 268, 1.5%), urinary tract infection (n = 196, 1.1%), migraine headache (n = 193, 1.1%), depression (n = 183, 1%), and appendicitis (n = 179, 1%). Not depicted in Table 3, but available in Table S1, are the frequencies of the following diagnoses, which are either exclusively seen in the pediatric population or present with distinct pediatric‐specific management considerations: febrile seizure (n = 118, 0.7%), nursemaid’s elbow (n = 23, 0.1%), intussusception (n = 21, 0.1%), congenital heart disease (n = 18, 0.1%), Henoch‐Schonlein purpura (n = 7, 0.04%), and Kawasaki disease (n = 6, 0.03%).

Table 3.

Top Three Diagnoses Evaluated Within Each Model of the Clinical Practice of Emergency Medicine Category by Age, Acuity, and Disposition

	Total (n)	Age								Acuity			Disposition
		Neonate	Infant	Toddler	Preschool	Grade School	Teen	Young Adult	Adult	Low	Emergent	Critical	Home	Admit Floor	Admit ICU	Admit Psych	Expired	Transfer	Admit OR	Other
All patients	17,642	354 (2.0)	2,197 (12.5)	2,947 (16.7)	1,844 (10.5)	4,589 (26.0)	4,583 (26.0)	788 (4.5)	340 (1.9)	4,331 (24.5)	12,964 (73.5)	347 (2.0)	13,543 (76.8)	2,992 (17.0)	352 (2.0)	285 (1.6)	11 (0.1)	199 (1.1)	167 (0.9)	93 (0.5)
Abdominal and gastrointestinal disorders	883	27 (3.1)	121 (13.7)	130 (14.7)	71 (8.0)	246 (27.9)	231 (26.2)	44 (5.0)	13 (1.5)	117 (13.3)	756 (85.6)	10 (1.1)	412 (46.7)	378	11 (1.2)	0	0	8 (0.9)	73 (8.3)	1 (0.1)
Appendicitis	179	0	0	1 (0.6)	5 (2.8)	82 (45.8)	89 (49.7)	2 (1.1)	0	0	178 (99.4)	1 (0.6)	1 (0.6)	123 (68.7)	1 (0.6)	0	0	1 (0.6)	53 (29.5)	0
Other noninfectious gastroenteritis/colitis	172	0	22 (12.8)	52 (30.2)	19 (11.0)	48 (27.9)	23 (13.4)	7 (4.1)	1 (0.6)	52 (30.2)	120 (69.8)	0	156 (90.7)	15 (8.7)	0	0	0	0	0	1 (0.6)
Intestinal infection	87	0	12 (13.8)	27 (31.0)	10 (11.5)	28 (32.2)	7 (8.0)	2 (2.3)	1 (1.2)	17 (19.5)	69 (79.3)	1 (1.2)	48 (55.2)	37 (42.5)	2 (2.3)	0	0	0	0	0
Cardiovascular disorders	88	0	15 (17.0)	8 (9.1)	5 (5.7)	16 (18.2)	29 (33.0)	2 (2.3)	13 (14.8)	3 (3.4)	64 (72.7)	21 (23.9)	33 (37.5)	30 (34.1)	12 (13.6)	0	9 (10.2)	4 (4.5)	0	0
Other dysrhythmias	21	0	2 (9.5)	2 (9.5)	1 (4.8)	5 (23.8)	8 (38.1)	0	3 (14.3)	0	19 (90.5)	2 (9.5)	13 (61.9)	5 (23.8)	2 (9.5)	0	0	1 (4.8)	0	0
Congenital heart disease	18	0	6 (33.3)	3 (16.7)	1 (5.6)	4 (22.2)	2 (11.1)	0	2 (11.1)	1 (5.6)	13 (72.2)	4 (22.2)	5 (27.8)	9 (50.0)	4 (22.2)	0	0	0	0	0
Hypertension	11	0	0	0	0	1 (9.1)	6 (54.5)	1 (9.1)	3 (27.3)	1 (9.1)	10 (90.9)	0	6 (54.5)	3 (27.3)	0	0	0	2 (18.2)	0	0
Cutaneous disorders	614	10 (1.6)	66 (10.7)	140 (22.8)	86 (14.0)	161 (26.2)	118 (19.2)	21 (3.4)	12 (2.0)	218 (35.5)	395 (64.3)	1 (0.2)	506 (82.4)	96 (15.6)	1 (0.2)	0	0	5 (0.8)	3 (0.5)	3 (0.5)
Cellulitis and abscess (cutaneous only)	213	0	14 (6.6)	44 (20.6)	29 (13.6)	57 (26.8)	53 (24.9)	12 (5.6)	4 (1.9)	36 (16.9)	177 (83.1)	0	155 (72.8)	50 (23.5)	0	0	0	3 (1.4)	3 (1.4)	2 (0.9)
Urticaria	51	0	4 (7.8)	11 (21.6)	12 (23.5)	16 (31.4)	6 (11.8)	2 (3.9)	0	28 (54.9)	23 (45.1)	0	49 (96.1)	2 (3.9)	0	0	0	0	0	0
Abscess without cellulitis (cutaneous only)	44	0	0	14 (31.8)	7 (15.9)	10 (22.7)	11 (25.0)	0	2 (4.6)	7 (15.9)	37 (84.1)	0	36 (81.8)	8 (18.2)	0	0	0	0	0	0
Endocrine, metabolic, and nutritional disorders	188	4 (2.1)	11 (5.9)	18 (9.6)	13 (6.9)	38 (20.2)	73 (38.8)	20 (10.6)	11 (5.9)	3 (1.6)	162 (86.2)	23 (12.2)	58 (30.9)	101 (53.7)	26 (13.8)	0	0	3 (1.6)	0	0
Type 1 diabetes mellitus, not in ketoacidosis	56	0	0	4 (7.1)	3 (5.35)	15 (26.8)	30 (53.6)	3 (5.35)	1 (1.8)	1 (1.8)	55 (98.2)	0	26 (46.4)	30 (53.6)	0	0	0	0	0	0
Type 1 diabetes mellitus, in ketoacidosis	49	0	1 (2.05)	2 (4.1)	0	12 (24.5)	22 (44.9)	11 (22.4)	1 (2.05)	0	39 (79.6)	10 (20.4)	1 (2.05)	36 (73.5)	11 (22.4)	0	0	1 (2.05)	0	0
Hypoglycemia	17	0	1 (5.9)	6 (35.3)	4 (23.5)	0	5 (29.4)	1 (5.9)	0	1 (5.9)	14 (82.3)	2 (11.8)	6 (35.3)	8 (47.0)	2 (11.8)	0	0	1 (5.9)	0	0
Environmental disorders	44	0	3 (6.8)	15 (34.1)	6 (13.6)	18 (40.9)	2 (4.5)	0	0	21 (47.7)	21 (47.7)	2 (4.5)	39 (88.6)	2 (4.5)	3 (6.8)	0	0	0	0	0
Insect/arthropod bite	23	0	0	12 (52.2)	3 (13.0)	8 (34.8)	0	0	0	14 (60.9)	9 (39.1)	0	23 (100.0)	0	0	0	0	0	0	0
Drowning/submersion	8	0	2 (25.0)	1 (12.5)	2 (25.0)	3 (37.5)	0	0	0	0	6 (75.0)	2 (25.0)	4 (50.0)	1 (12.5)	3 (37.5)	0	0	0	0	0
Toxic effect of venom	5	0	0	1 (20.0)	1 (20.0)	3 (60.0)	0	0	0	4 (80.0)	1 (20.0)	0	5 (100.0)	0	0	0	0	0	0	0
Head, ear, eye, nose, throat disorders	1,087	11 (1.0)	158 (14.5)	222 (20.4)	161 (14.8)	313 (28.8)	173 (15.9)	43 (4.0)	6 (0.6)	579 (53.3)	506 (46.6)	2 (0.2)	993 (91.4)	75 (6.9)	5 (0.5)	0	0	2 (0.2)	3 (0.3)	9 (0.8)
Otitis media	268	0	68 (25.4)	105 (39.2)	46 (17.2)	43 (16.0)	4 (1.5)	2 (0.7)	0	167 (62.3)	99 (37.0)	2 (0.7)	257 (95.9)	6 (2.2)	3 (1.1)	0	0	0	0	2 (0.7)
Viral pharyngitis	136	0	1 (0.7)	19 (14.0)	18 (13.2)	42 (30.9)	45 (33.1)	11 (8.1)	0	72 (42.9)	64 (47.1)	0	122 (89.7)	13 (9.6)	0	0	0	0	0	1 (0.7)
Sinusitis	79	3 (3.8)	44 (55.7)	8 (10.1)	5 (6.3)	7 (8.9)	7 (8.9)	5 (6.3)	0	31 (39.2)	48 (60.8)	0	73 (92.4)	4 (5.1)	0	0	0	0	0	2 (2.5)
Hematologic disorders	146	1 (0.7)	4 (2.7)	20 (13.7)	11 (7.5)	33 (22.6)	38 (26.0)	30 (20.5)	9 (6.2)	1 (0.7)	135 (92.5)	10 (6.8)	37 (25.3)	98 (67.1)	11 (7.5)	0	0	0	0	0
Sickle cell anemia with crisis	60	0	0	6 (10.0)	1 (1.7)	12 (20.0)	15 (25.0)	22 (36.7)	4 (6.6)	0	59 (98.3)	1 (1.7)	15 (25.0)	44 (73.3)	1 (1.7)	0	0	0	0	0
Acute lymphoid leukemia	16	0	0	2 (12.5)	5 (31.25)	5 (31.25)	2 (12.5)	1 (6.25)	1 (6.25)	0	15 (93.75)	1 (6.25)	2 (12.5)	12 (75.0)	2 (12.5)	0	0	0	0	0
Neutropenia	16	0	1 (6.25)	2 (12.5)	3 (18.75)	5 (31.25)	3 (18.75)	0	2 (12.5)	0	13 (81.25)	3 (18.75)	0	13 (81.25)	3 (18.75)	0	0	0	0	0
Immune system disorders	115	0	6 (5.2)	14 (12.2)	14 (12.2)	44 (38.3)	26 (22.6)	8 (7.0)	3 (2.6)	15 (13.0)	98 (85.2)	2 (1.7)	71 (61.7)	41 (35.7)	2 (1.7)	0	0	1 (0.9)	0	0
Anaphylaxis	40	0	3 (7.5)	5 (12.5)	5 (12.5)	15 (37.5)	10 (25.0)	1 (2.5)	1 (2.5)	1 (2.5)	38 (95.0)	1 (2.5)	24 (60.0)	14 (35.0)	1 (2.5)	0	0	1 (2.5)	0	0
Allergic reaction	33	0	1 (3.0)	4 (12.1)	4 (12.1)	15 (45.5)	9 (27.3)	0	0	9 (27.3)	24 (72.7)	0	32 (97.0)	1 (3.0)	0	0	0	0	0	0
Allergic rhinitis	7	0	0	1 (14.3)	1 (14.3)	4 (57.1)	1 (14.3)	0	0	5 (71.4)	2 (28.6)	0	7 (100.0)	0	0	0	0	0	0	0
Musculoskeletal disorders(nontraumatic)	144	0	8 (5.6)	17 (11.8)	20 (13.9)	42 (29.2)	48 (33.3)	7 (4.9)	2 (1.4)	35 (24.3)	108 (75.0)	1 (0.7)	95 (66.0)	44 (30.6)	0	0	0	5 (3.5)	0	0
Localized limb swelling	24	0	1 (4.2)	5 (20.8)	3 (12.5)	6 (25.0)	6 (25.0)	2 (8.3)	1 (4.2)	6 (25.0)	18 (75.0)	0	22 (91.7)	1 (4.15)	0	0	0	1 (4.15)	0	0
Joint effusion	17	0	0	1 (5.9)	7 (41.2)	4 (23.5)	4 (23.5)	1 (5.9)	0	9 (52.9)	8 (47.1)	0	15 (88.2)	0	0	0	0	2 (11.8)	0	0
Osteomyelitis	13	0	0	2 (15.4)	2 (15.4)	5 (38.4)	4 (30.8)	0	0	0	13 (100.0)	0	0	13 (100.0)	0	0	0	0	0	0
Nervous system disorders	761	8 (1.0)	40 (5.3)	128 (16.8)	62 (8.1)	180 (23.7)	261 (34.3)	61 (8.0)	21 (2.8)	54 (7.1)	682 (89.6)	25 (3.3)	527 (69.3)	194 (25.5)	25 (3.3)	0	0	10 (1.3)	3 (0.4)	2 (0.3)
Migraine headache	193	0	0	0	0	36 (18.7)	122 (63.2)	29 (15.0)	6 (3.1)	3 (1.6)	189 (97.9)	1 (0.5)	163 (84.5)	27 (14.0)	1 (0.5)	0	0	1 (0.5)	0	1 (0.5)
Other convulsions	152	1 (0.7)	7 (4.6)	20 (13.2)	15 (9.9)	59 (38.8)	35 (23.0)	9 (5.9)	6 (3.9)	7 (4.6)	143 (94.1)	2 (1.3)	121 (79.6)	24 (15.8)	2 (1.3)	0	0	5 (3.3)	0	0
Seizure, not febrile or status	141	0	8 (5.7)	15 (10.6)	17 (12.1)	52 (36.9)	32 (22.7)	12 (8.5)	5 (3.5)	1 (0.7)	129 (91.5)	11 (7.8)	70 (49.65)	59 (41.85)	10 (7.1)	0	0	1 (0.7)	1 (0.7)	0
Obstetrics and gynecology	248	94 (37.9)	4 (1.6)	4 (1.6)	2 (0.8)	5 (2.0)	88 (35.5)	43 (17.3)	8 (3.2)	45 (18.1)	196 (79.0)	7 (2.8)	176 (71.0)	49 (19.8)	6 (2.4)	0	0	7 (2.8)	8 (3.2)	2 (0.8)
Ovarian cyst	25	0	0	0	0	0	25 (100.0)	0	0	0	25 (100.0)	0	13 (52.0)	8 (32.0)	0	0	0	0	4 (16.0)	0
Cervicitis	23	0	0	0	0	0	10 (43.5)	12 (52.2)	1 (4.3)	0	23 (100.0)	0	23 (100.0)	0	0	0	0	0	0	0
Dysfunctional uterine bleeding	17	0	0	0	0	1 (5.9)	12 (70.6)	4 (23.5)	0	1 (5.9)	16 (94.1)	0	15 (88.2)	2 (11.8)	0	0	0	0	0	0
Psychobehavioral disorders	658	2 (0.3)	10 (1.5)	11 (1.7)	15 (2.3)	119 (18.1)	472 (71.7)	22 (3.3)	7 (1.1)	60 (9.1)	592 (90.0)	6 (0.9)	295 (44.8)	56 (8.5)	6 (0.9)	284 (43.2)	0	15 (2.3)	0	2 (0.3)
Depression	183	0	0	0	0	6 (3.3)	172 (94.0)	5 (2.7)	0	11 (6.0)	171 (93.4)	1 (0.6)	51 (27.9)	7 (3.8)	1 (0.6)	121 (66.1)	0	3 (1.6)	0	0
Mood disorder	68	0	0	0	0	13 (19.1)	52 (76.5)	3 (4.4)	0	2 (2.9)	66 (97.1)	0	25 (36.8)	4 (5.9)	0	36 (52.9)	0	3 (4.4)	0	0
Intermittent explosive disorder	56	0	0	0	2 (3.6)	27 (48.2)	26 (46.4)	1 (1.8)	0	2 (3.6)	54 (96.4)	0	15 (26.8)	6 (10.7)	0	35 (62.5)	0	0	0	0
Renal and urogenital disorders	453	3 (0.7)	37 (8.2)	36 (7.9)	38 (8.4)	133 (29.4)	136 (30.0)	50 (11.0)	20 (4.4)	55 (12.1)	387 (85.4)	11 (2.4)	323 (71.3)	101 (22.3)	12 (2.6)	0	0	2 (0.4)	13 (2.9)	2 (0.4)
Urinary tract infection	196	2 (1.0)	27 (13.8)	12 (6.1)	14 (7.1)	53 (27.0)	46 (23.5)	27 (13.8)	15 (7.7)	32 (16.3)	156 (79.6)	8 (4.1)	145 (74.0)	41 (20.9)	8 (4.1)	0	0	0	1 (0.5)	1 (0.5)
Pyelonephritis	52	0	3 (5.8)	2 (3.85)	6 (11.5)	14 (26.9)	19 (36.55)	7 (13.5)	1 (1.9)	4 (7.7)	48 (92.3)	0	23 (44.2)	28 (53.9)	0	0	0	0	0	1 (1.9)
Kidney stones	29	0	0	0	0	5 (17.2)	16 (55.2)	8 (27.6)	0	2 (6.9)	27 (93.1)	0	16 (55.2)	12 (41.4)	0	0	0	0	1 (3.4)	0
Signs, symptoms, and presentations	5,695	137 (2.4)	802 (14.1)	865 (15.2)	487 (8.6)	1,427 (25.1)	1,526 (26.8)	284 (5.0)	167 (2.9)	1,404 (24.6)	4,269 (75.0)	22 (0.4)	5,071 (89.0)	456 (8.0)	24 (0.4)	0	0	74 (1.3)	14 (0.2)	56 (1.0)
Abdominal pain	997	1 (0.1)	7 (0.7)	34 (3.4)	59 (5.9)	380 (38.1)	420 (42.1)	77 (7.7)	19 (1.9)	142 (14.2)	855 (85.8)	0	901 (90.4)	71 (7.1)	0	0	0	14 (1.4)	2 (0.2)	9 (0.9)
Fever	662	1 (0.2)	215 (32.5)	228 (34.4)	82 (12.4)	96 (14.5)	28 (4.2)	8 (1.2)	4 (0.6)	266 (40.2)	396 (59.8)	0	622 (94.0)	30 (4.5)	0	0	0	0	0	10 (1.5)
Nausea/vomiting	524	23 (4.4)	135 (25.8)	125 (23.9)	61 (11.6)	104 (19.8)	54 (10.3)	17 (3.2)	5 (1.0)	171 (32.6)	352 (67.2)	1 (0.2)	488 (93.1)	27 (5.2)	1 (0.2)	0	0	2 (0.4)	0	6 (1.1)
Systemic infectious disorders	533	37 (6.9)	86 (16.1)	126 (23.6)	57 (10.7)	118 (22.1)	71 (13.3)	31 (5.8)	7 (1.3)	135 (25.3)	362 (67.9)	36 (6.8)	337 (63.2)	154 (28.9)	38 (7.1)	0	0	2 (0.4)	1 (0.2)	1 (0.2)
Viral infection	315	1 (0.3)	63 (20.0)	88 (28.0)	42 (13.3)	71 (22.6)	35 (11.1)	14 (4.4)	1 (0.3)	111 (35.2)	198 (62.9)	6 (1.9)	257 (81.6)	52 (16.5)	6 (1.9)	0	0	0	0	0
Bacteremia/sepsis	60	3 (5.0)	9 (15.0)	13 (21.7)	6 (10.0)	17 (28.3)	7 (11.7)	3 (5.0)	2 (3.3)	0	39 (65.0)	21 (35.0)	5 (8.3)	32 (53.3)	22 (36.7)	0	0	1 (1.7)	0	0
Influenza	44	0	11 (25.0)	8 (18.2)	4 (9.1)	12 (27.3)	4 (9.1)	3 (6.8)	2 (4.5)	2 (4.5)	37 (84.1)	5 (11.4)	22 (50.0)	17 (38.6)	5 (11.4)	0	0	0	0	0
Thoracic–respiratory disorders	2,428	16 (0.7)	623 (25.7)	635 (26.1)	352 (14.5)	539 (22.2)	199 (8.2)	45 (1.9)	19 (0.8)	532 (21.9)	1,795 (73.9)	101 (4.2)	1,570 (64.7)	730 (30.1)	110 (4.5)	0	0	5 (0.2)	4 (0.2)	9 (0.4)
Asthma exacerbation	820	0	18 (2.2)	165 (20.1)	167 (20.4)	340 (41.5)	109 (13.3)	20 (2.4)	1 (0.1)	97 (11.8)	680 (82.9)	43 (5.3)	545 (66.5)	222 (27.1)	50 (6.1)	0	0	1 (0.1)	0	2 (0.2)
Upper respiratory infection	582	5 (0.9)	208 (35.7)	177 (30.4)	77 (13.2)	82 (14.1)	25 (4.3)	5 (0.9)	3 (0.5)	284 (48.8)	296 (50.9)	2 (0.3)	514 (88.3)	63 (10.8)	2 (0.3)	0	0	0	0	3 (1.0)
Bronchiolitis	413	10 (2.4)	304 (73.6)	89 (21.6)	9 (2.2)	0	1 (0.2)	0	0	44 (10.7)	342 (82.8)	27 (6.5)	169 (40.9)	214 (51.8)	28 (6.8)	0	0	0	1 (0.25)	1 (0.25)
Toxicologic disorders	236	1 (0.4)	7 (3.0)	64 (27.1)	33 (14.0)	29 (12.3)	97 (41.1)	4 (1.7)	1 (0.4)	17 (7.2)	191 (80.9)	28 (11.9)	117 (49.6)	89 (37.7)	27 (11.4)	1 (0.4)	0	1 (0.4)	0	1 (0.4)
Ingestion of other analgesic	23	0	0	6 (26.1)	2 (8.7)	1 (4.3)	14 (60.9)	0	0	0	23 (100.0)	0	8 (34.8)	15 (65.2)	0	0	0	0	0	0
Ingestion of antidepressant	15	0	0	1 (6.67)	1 (6.67)	0	13 (86.67)	0	0	0	10 (66.7)	5 (33.3)	1 (6.7)	9 (60.0)	5 (33.3)	0	0	0	0	0
Ingestion of mushroom/poisonous plants	13	0	0	1 (7.7)	1 (7.7)	5 (38.4)	4 (30.8)	2 (15.4)	0	6 (46.2)	7 (53.8)	0	12 (92.3)	1 (7.7)	0	0	0	0	0	0
Traumatic disorders	3,321	3 (0.1)	196 (5.9)	494 (14.9)	411 (12.4)	1,128 (34.0)	995 (30.0)	73 (2.2)	21 (0.6)	1,037 (31.2)	2,245 (67.6)	39 (1.2)	2,883 (86.8)	298 (9.0)	33 (1.0)	0	2 (0.1)	55 (1.7)	45 (1.4)	5 (0.15)
Closed extremity fracture	512	0	10 (1.9)	50 (9.8)	51 (10.0)	241 (47.1)	148 (28.9)	10 (1.9)	2 (0.4)	60 (11.7)	451 (88.1)	1 (0.2)	371 (72.5)	108 (21.1)	1 (0.2)	0	0	18 (3.5)	14 (2.7)	0
Closed head injury	287	2 (0.7)	49 (17.1)	56 (19.5)	40 (13.9)	64 (22.3)	73 (25.4)	3 (1.1)	0	109 (38.0)	178 (62.0)	0	285 (99.3)	1 (0.35)	0	0	0	1 (0.35)	0	0
Contusion	128	0	1 (0.8)	11 (8.6)	13 (10.1)	57 (44.5)	44 (34.4)	1 (0.8)	1 (0.8)	42 (32.8)	86 (67.2)	0	121 (94.5)	3 (2.3)	0	0	0	2 (1.6)	0	2 (1.6)

Data are reported as n (%).

ICU = intensive care unit; OR = operating room.

Procedures and Resuscitations

Procedures performed by the residents stratified by patient age, acuity, and disposition are shown in Table 4. The most commonly performed procedures included laceration repair (n = 338), I&D (n = 190), lumbar puncture (n = 135), and splint application (n = 98). Endotracheal intubation (n = 9) and chest tube placement (n = 1) were infrequent; central venous catheter placement was not performed by any residents in our cohort.

Table 4.

Procedures Performed by Age, Acuity, and Disposition

	Total (n)	Age								Acuity			Disposition
		Neonate	Infant	Toddler	Preschool	Grade School	Teen	Young Adult	Adult	Low	Emergent	Critical	Home	Admit Floor	Admit ICU	Admit Psych	Expired	Transfer	Admit OR	Other
Central venous catheter placement	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Chest tube placement	1	0	0	0	0	0	0	1 (100.0)	0	0	1 (100.0)	0	0	1 (100.0)	0	0	0	0	0	0
Endotracheal intubation	9	0	7 (77.8)	1 (11.1)	0	0	0	0	1 (11.1)	0	0	9 (100.0)	0	0	5 (55.6)	0	4 (44.4)	0	0	0
Incision and drainage	190	0	12 (6.3)	45 (23.7)	18 (9.5)	47 (24.7)	53 (27.9)	12 (6.3)	3 (1.6)	37 (19.5)	153 (80.5)	0	172 (90.5)	17 (9.0)	0	0	0	1 (0.5)	0	0
Intraosseous line placement	10	0	4 (40.0)	2 (20.0)	1 (10.0)	2 (20.0)	0	0	1 (10.0)	0	4 (40.0)	6 (60.0)	0	2 (20.0)	3 (30.0)	0	4 (40.0)	1 (10.0)	0	0
Laceration repair	338	0	3 (0.9)	51 (15.1)	69 (20.4)	133 (39.3)	75 (22.2)	7 (2.1)	0	178 (52.7)	159 (47.0)	1 (0.3)	327 (96.7)	8 (2.4)	1 (0.3)	0	0	1 (0.3)	0	1 (0.3)
Lumbar puncture	135	51 (37.8)	45 (33.3)	8 (5.9)	4 (3.0)	11 (8.1)	13 (9.6)	3 (2.2)	0	0	114 (84.4)	21 (15.6)	12 (8.9)	100 (74.1)	23 (17.0)	0	0	0	0	0
Splint application	98	0	3 (3.1)	10 (10.2)	12 (12.2)	37 (37.7)	33 (33.7)	3 (3.1)	0	27 (27.6)	71 (72.4)	0	92 (93.9)	4 (4.1)	0	0	0	2 (2.0)	0	0

Data are reported as n (%).

ICU = intensive care unit; OR = operating room.

Table 5 displays data related to medical and trauma resuscitations. More medical resuscitations were encountered compared with trauma (55.3% vs. 44.7%), and the overall acuity was greater for medical patients compared to that of trauma (22.4% critical acuity vs. 7.7%). When comparing age and disposition, a larger proportion of the medical resuscitation patients were younger (64.4% vs. 52.1% less than 12 years old) and were admitted (61.4% vs. 30.8%).

Table 5.

Resuscitations Performed by Age, Acuity, and Disposition

	Total (n)	Median	Range	IQR	Age								Acuity			Disposition
					Neonate	Infant	Toddler	Preschool	Grade School	Teen	Young Adult	Adult	Low	Emergent	Critical	Home	Admit Floor	Admit ICU	Admit Psych	Expired	Transfer	Admit OR	Other
All	1,081	42	19‐73	34‐53	29 (2.7)	118 (10.9)	147 (13.6)	83 (7.7)	260 (24.0)	325 (30.1)	31 (2.9)	88 (8.1)	14 (1.3)	896 (82.9)	171 (15.8)	487 (45.1)	318 (29.4)	154 (14.3)	8 (0.7)	10 (0.9)	75 (6.9)	26 (2.4)	3 (0.3)
Medical	598	22	9‐49	15‐33	23 (3.8)	85 (14.2)	105 (17.6)	56 (9.4)	116 (19.4)	104 (17.4)	24 (4.0)	85 (14.2)	8 (1.3)	456 (76.3)	134 (22.4)	162 (27.1)	221 (37.0)	124 (20.7)	6 (1.0)	7 (1.2)	66 (11.0)	9 (1.5)	3 (0.5)
Trauma	483	19	8‐33	15‐24	6 (1.2)	33 (6.8)	42 (8.7)	27 (5.6)	144 (29.8)	221 (45.8)	7 (1.5)	3 (0.6)	6 (1.2)	440 (91.1)	37 (7.7)	325 (67.3)	97 (20.1)	30 (6.2)	2 (0.4)	3 (0.6)	9 (1.9)	17 (3.5)	0

ICU = intensive care unit; IQR = interquartile range; OR = operating room.

DISCUSSION

Emergency medicine residency graduates will provide emergency care for the majority of U.S. children and need to be prepared to do so. To our knowledge, we present the most comprehensive report of PEM training experience for EM residents to date. As the origin of this data is an established, 4‐year EM program that is affiliated with one of the busiest children’s hospital EDs in the United States, it is likely that our results represent a best‐case training scenario regarding PEM experience for EM residents. Despite this best‐case scenario, opportunity for improvement clearly exists. For smaller EM programs with less access to a pediatric emergency population, even greater vigilance and expansion of training experiences may be required.

Diagnoses

The ABEM Model of the Clinical Practice of Emergency Medicine categories for which a median of fewer than 10 patients were evaluated by EM residents included cardiovascular, endocrine/metabolic/nutritional, environmental, hematologic, immune system, musculoskeletal (nontrauma), and toxicologic. When contemplating EM resident education in PEM and progression toward unsupervised practice, one must consider the possibility of transfer of skill and knowledge from experience with the adult population. ²¹ , ²² , ²³ , ²⁴ For the categories of environmental, musculoskeletal (nontrauma), and toxicologic, there is likely transfer of knowledge obviating the need for additional exposure to large numbers of pediatric patients in these categories to learn how to effectively provide care for them. However, cardiovascular (e.g., congenital heart disease), endocrine/metabolic/nutritional (e.g., inborn errors of metabolism), hematologic (e.g., childhood leukemia and sickle cell complications), and immune system (e.g., immune deficiency syndromes) categories are less likely to lend themselves to the same knowledge and skill transfer and should be explicitly addressed during curriculum planning.

For those diagnoses with high frequency of exposure, such as abdominal pain, asthma exacerbation, fever, and upper respiratory infection, EM residents should strive to develop practice patterns in line with the best available evidence. Examples might include the Pediatric Emergency Care Applied Research Network febrile infant prediction rule ²⁵ or the “step‐by‐step” approach to managing young febrile infants, ²⁶ the Pediatric Appendicitis Risk Calculator for abdominal pain, ²⁷ promotion of dexamethasone use for acute asthma exacerbations, ²⁸ , ²⁹ and withholding antibiotics for viral upper respiratory infections. ³⁰ In‐depth knowledge of these evidence‐based recommendations will translate to high‐quality patient care as well as the necessary knowledge base to most effectively teach the next generation of EM trainees.

Neonatal Patients

The critically ill neonate should be an area of focus based on our exposure data. The number of neonates evaluated was relatively small with a median of 13 per resident and range of eight to 30. Exposure to neonates requiring admission to the neonatal ICU was even more rare with a median of one per resident and an IQR of zero to two. As many cases of congenital heart disease, neonatal sepsis, and inborn errors of metabolism present critically ill during this time period, efforts should be made to broaden this exposure. Optimal methods for achieving this, in our opinion, include high‐fidelity simulation, video‐based review of actual cases, ³¹ and facilitated case discussions allowing trainees to “see through the eyes of experts” as is promoted in the ShadowBox approach to cognitive skills training. ³² Independent study and reading as well as traditional classroom/didactic‐based education may advance knowledge to some degree but are not likely to adequately prepare trainees to competently manage patients of these types when called upon to do so. Close collaboration between EM and PEM training programs, as occurs in our institution, is essential for optimizing the likelihood of educational success in this area.

Critical Patients

Two percent of patients qualified as critical acuity in our study coinciding with the 2% ICU admission rate. In addition to the rarity of neonatal ICU admission discussed above, the 25‐resident cohort was exposed to a total of 10 pediatric deaths, seven of which were medical and three trauma‐related. These numbers are representative of critical illness, injury, and death in the PEM population, and the lack of exposure in the clinical setting cannot be attributed to any curricular deficiency or action of the training program. This is the reality and the challenge of achieving effective learning and comfort in PEM. ³³ , ³⁴ It is a universal obstacle faced by PEM fellowships where the majority of training time is spent in the PED. ³⁵ Despite this challenge, training programs are tasked by regulatory bodies and expected by society to produce trainees capable of managing, both medically and interpersonally, these high‐risk, low‐frequency scenarios. Curricula should explicitly address the means by which these low‐frequency PEM exposures will be taught and competence of trainees assessed. Collaboration with PEM colleagues, as occurs in our institution, may conserve resources and time, rather than attempting to “reinvent the wheel” from an exposure and assessment perspective.

Procedures and Resuscitations

We found that common procedures were performed often by EM residents and that the distribution of patient age groups aligned as might be expected, with lumbar puncture being frequently performed in neonates and infants (71.1%) who are more likely to have a serious bacterial infection evaluation, a majority of laceration repairs and I&Ds performed on toddlers and school‐aged children (74.8 and 57.9%, respectively, in children ages 1–12) and most splint applications in older children (71.4% in children ages 12–18). The overall number of medical and trauma resuscitations performed by our cohort over the course of training was more robust than reported in previous literature reviewing single rotation experiences in the PED. ¹⁴ , ¹⁵

Future Directions

Our findings underscore training gaps that exist for pediatric care in EM training. Ensuring that the outcomes of training prepare graduates to provide the care that patients need is the foundation of competency‐based medical education (CBME). ³⁶ , ³⁷ , ³⁸ Realizing the promise of CBME requires determining individual learner outcomes and collective program outcomes with reasonable certainty to ensure that each graduate is prepared to provide the care that patients need as well as to guarantee that programs have the ability to prepare trainees to possess these skills by the time of graduation. Achieving these goals almost certainly necessitates gleaning information about residents’ training experiences, as we have done in this study. It also requires valid and reliable assessment of resident performance in completing core activities of the profession. Early efforts to export the former data, such as included in this study, from the EMR and capitalize on the power of learning analytics in medical education exist; however, these initiatives will need to be scaled considerably in the coming years. ³⁹ , ⁴⁰ , ⁴¹ , ⁴² Such work to harness “big data” for these purposes are met by fundamental challenges, such as how you attribute data to one resident compared to another and when you attribute data to both of them and even other nonresident members of the team. ⁴³ , ⁴⁴ , ⁴⁵ , ⁴⁶ However, overcoming these challenges are key to fostering the development of an individualized, adaptive curriculum and rotational experiences that address identified gaps and assure that residents are exposed to the spectrum of conditions specified in the Model of the Clinical Practice of Emergency Medicine. Specific interventions to fill identified holes in individuals’ training might include asynchronous online education, simulation experiences, and additional elective opportunities.

LIMITATIONS

Our study is limited to data from a single 4‐year residency program and a cohort of two classes of EM residents. As the residents in our study rotated at a busy quaternary care center with two PEDs, results may not be generalizable to all EM residency programs and potentially represent an idealized pediatric experience regarding volume, acuity, and overall variety of pediatric patients seen. Local program characteristics should be considered carefully when applying these results and additional studies at other EM programs should be conducted. Comparing the training experiences of these residents to what is seen in the system as a whole was beyond the scope of this study. However, it is important to note that the residents in this study worked in the higher‐acuity areas of the PEDs, carried the pager to respond to trauma and medical team activations disproportionately more than other resident types in the PEDs, and had an admission rate approximately double the system‐level admission rate for the patients they cared for. Again, the experiences of these residents likely represent a best‐case training scenario at a high‐volume, high‐acuity system. To characterize the cumulative pediatric clinical experiences, we relied on data extracted from the EMR, which has inherent limitations. For example, we were only able to capture encounters for which the EM resident was assigned as the primary resident physician. In addition, our use of billing diagnoses to reflect patient diagnoses seen is subject to misclassification error. We also elected to limit our study to primary billing diagnoses, and because some patients may have had multiple important diagnoses and findings, additional relevant clinical experiences may not be reflected in our results. Finally, these patient encounters represent the majority, but not the sum total, of all pediatric patients seen by our resident cohort. A smaller proportion of children are evaluated during additional pediatric‐specific rotations including plastic surgery, the pediatric intensive care unit, and anesthesiology as well as at two suburban community EDs and during prehospital transport experiences.

CONCLUSIONS

Emergency medicine residents in our high‐volume pediatric ED were exposed to a wide array of pediatric diagnoses, common procedures, and resuscitations. However, gaps in core areas of pediatrics were also illuminated. These findings warrant consideration across emergency medicine training programs of all sizes to ensure adequate pediatric training and readiness of graduates to provide the care that our patients need and deserve.

Supporting information

Data Supplement S1. All Diagnoses Evaluated within each Model of the Clinical Practice of EM Category by Age, Acuity, and Disposition.

AEM Education and Training 2021;5:1–13