Impact of COVID‐19 on emergency medicine resident procedure performance

Abstract

Background

As a result of the COVID‐19 pandemic, patterns of patient presentations and medical education have changed, potentially resulting in fewer and different types of patient encounters. Procedural proficiency is a cornerstone of emergency medicine (EM) training, and residents must meet Accreditation Council for Graduate Medical Education (ACGME) requirements to graduate. It is feared there may have been a pandemic‐induced decrease in opportunities for residents to perform procedures. This study investigates the change in procedures performed by EM residents during the initial year of the pandemic.

Methods

This study utilized a multicenter retrospective design. Across three EM residency programs, logs of 14 ACGME‐required procedures performed by residents were reviewed. For each procedure, counts were compared prepandemic year (March 2019 to February 2020) to during pandemic year (March 2020 to February 2021). Procedures were further grouped into 4‐month periods: March to June, July to October, and November to February.

Results

A total of 113 EM resident physicians were included in this study. Procedures performed by EM residents tended to decrease during the COVID‐19 pandemic. There were statistically significant decreases in number of annual cricothyrotomies (2.4 vs. 0.9, p < 0.001) and pediatric trauma resuscitations (5.7 vs. 3.9, p = 0.024). Comparing the first 4‐month periods of each year, there were significant decreases in cardiac pacing (6.3 vs. 5.4, p = 0.038), chest tubes (2.2 vs. 1.0, p < 0.001), cricothyrotomies (0.6 vs. 0.1, p = 0.001), intubations (8.2 vs. 4.4, p = 0.002), and pericardiocenteses (1.7 vs. 0.2, p < 0.001).

Conclusions

The COVID‐19 pandemic has led to a decrease in the number of procedures performed per EM resident in many of the domains required by the ACGME. Although only some procedures had statically significant decreases, it remains to be seen if this will lead to decreased resident procedural competency. Further research may be required in this area to determine any such effect.

INTRODUCTION

Background

On March 13, 2020, the United States declared the coronavirus disease 2019 (COVID‐19) a national emergency. ¹ The COVID‐19 pandemic has had significant effects on the entire United States health care system. Specifically, emergency departments (ED) served at the forefront during the pandemic, with early triage and management of patients with unknown, suspected, or confirmed infection. ² Despite being at the forefront of care during the initial phases of the pandemic, ED visits decreased by 42% from March 29 to April 25, 2020, though a greater proportion of visits were of higher acuity. ¹ , ³

These special circumstances gave rise to unique challenges for emergency medicine (EM) resident physicians during the pandemic. One study found that at the beginning of the pandemic, there was a reduced number of patients per hour managed by residents in the adult ED and pediatric ED and, overall, decreased trauma patient volume. ⁴

Importance

The challenges brought on by the COVID‐19 pandemic may have significant consequences for residents and patients. Procedural proficiency is a cornerstone of care for patients in the ED. Throughout their careers, EM physicians rely heavily on the procedural training they receive throughout their residency training. EM residents are required to perform a minimum number of designated procedures as a requirement for graduation as set by the Accreditation Council for Graduate Medical Education (ACGME; Table 1). ⁵ It is feared that there has been a decrease in resident procedures performed during the COVID‐19 pandemic.

TABLE 1.

ACGME procedural requirements for emergency medicine residents ⁵

Procedure	Number required
Adult medical resuscitation	45
Adult trauma resuscitation	35
Bedside ultrasound	150
Cardiac pacing	6
Central venous access	20
Chest tube	10
Cricothyrotomy	3
Dislocation reduction	10
Intubation	35
Lumbar puncture	15
Pediatric medical resuscitation	15
Pediatric trauma resuscitation	10
Pericardiocentesis	3
Procedural sedation	15
Vaginal delivery	10

Abbreviation: ACGME, Accreditation Council for Graduate Medical Education.

Goals of this investigation

This study aims to investigate the effects of the pandemic on the procedures performed by EM resident physicians, specifically comparing the number of procedures performed during the first year of COVID‐19 to the year prior.

METHODS

Study design and setting

This study is a multicenter retrospective review of procedures performed by residents in three ACGME‐accredited EM residency programs, located in the northeast, southeast, and midwest. All programs are 3 years in length and include academic and community hospital settings. Characteristics of the participating residency programs are detailed in Table 2. Procedures performed by current residents of these programs between March 1, 2019, and February 28, 2021, were included. The study was approved by the institutional review board.

TABLE 2.

Characteristics of study residency programs

Characteristic	Program A	Program B	Program C
Location	Northeast	Midwest	Southeast
Residency duration, years	3	3	3
Resident class size, n	13–14	6–9	6
Residents enrolled in study, n	53	36	24
Primary training site	University	Community	Community
Setting	Urban	Urban	Suburban

Measurements

To track the ACGME‐required procedures (Table 1), residents are required to log their procedures in a web‐based residency management software product (MedHub and New Innovations) throughout their time in training. Bedside ultrasound was not included because it was reported in different tracking programs not utilized in this study.

Residency administrators at each of the three programs exported the logs of all procedures performed during the study time frame. Fields included resident name, date of procedure, and name of procedure. Resident names were then coded to include the residents' graduation year, but personal identifiers were removed.

Data analysis

Procedures were divided into those performed pre‐COVID‐19 (March 1, 2019, to February 29, 2020) and during COVID‐19 (March 1, 2020, to February 28, 2021). As the two groups cross academic years (July to June) and some residents were not in a program for an entire period, analyses were performed on 4‐month bases: March to June, July to October, and November to February.

The procedural count for each resident was calculated by averaging the number of procedures per resident for each 4‐month grouping. If a resident was not enrolled in the program for a specific 4‐month period based on graduation year, the number of procedures performed was coded as empty, as to not include the resident in calculations for that period. If a resident was enrolled in the program but had no procedures of a specific type logged during the 4 months, the number of procedures logged was entered as zero. Each 4‐month block pre–COVID‐19 was compared to the corresponding period during COVID‐19. Counts of each procedure by 4‐month block were also averaged together for all periods pre–COVID‐19 compared to during COVID‐19. This provided an overall 4‐month average of procedures performed for each year, which was then multiplied by 3 to get the annual average.

Data were initially obtained and formatted with Excel 365 (Microsoft Corp) and then analyzed using SPSS 27.0 (IBM Corp). T‐tests were used to compare the average procedures performed.

RESULTS

There were 113 EM resident physicians over 5 years (2019–2023) included in this study. Not every residency had data for each time period. During the first 4‐month period of Year 1, one program did not have any third‐year residents, and another program was using a different residency management system for which data could not be obtained. Additionally, residency class sizes varied by year, as one program expanded its residents each year.

Procedures performed by EM residents during the first year of COVID‐19 compared to the year prior is shown in Table 3. The procedures that showed increased numbers were central venous access, procedural sedation, and vaginal delivery. All other procedures decreased in numbers, with the greatest being adult medical resuscitation, adult trauma resuscitation, intubation, pediatric medical resuscitation, and pediatric trauma resuscitation. When analyzing by 4‐month period averages for the entire year, there were statistically significant decreases in cricothyrotomy and pediatric trauma resuscitation.

TABLE 3.

Procedures per resident by 4‐month period and annual averages comparing pre–COVID‐19 to during COVID‐19

Procedure	Pre–COVID‐19	During COVID‐19	Difference (95% CI)	p‐value
Adult medical resuscitation
4‐month average	13.1	11.4	−1.7 (−4.9 to 1.5)	0.301
Annual average	39.3	34.2
Adult trauma resuscitation
4‐month average	6.4	5	−1.4 (−3.5 to 0.7)	0.18
Annual average	19.2	15
Cardiac pacing
4‐month average	0.9	0.7	−0.2 (−0.4 to 0.1)	0.191
Annual average	2.7	2.1
Central venous access
4‐month average	5.3	6.4	1.1 (−0.1 to 2.3)	0.079
Annual average	15.9	19.2
Chest tube
4‐month average	1.8	1.6	−0.3 (−0.7 to 0.1)	0.187
Annual average	5.4	4.8
Cricothyrotomy
4‐month average	0.8	0.3	−0.5 (−0.7 to −0.3)	<0.001
Annual average	2.4	0.9
Dislocation reduction
4‐month average	2.2	2	−0.2 (−0.6 to 0.3)	0.476
Annual average	6.6	6
Intubation
4‐month average	8	7.2	−0.9 (−2.4 to 0.6)	0.25
Annual average	24	21.6
Lumbar puncture
4‐month average	2.1	1.9	−0.2 (−0.6 to 0.2)	0.286
Annual average	6.3	5.7
Pediatric medical resuscitation
4‐month average	2.9	2.2	−0.7 (−1.7 to 0.2)	0.141
Annual average	8.7	6.6
Pediatric trauma resuscitation
4‐month average	1.9	1.3	−0.6 (−1.1 to −0.1)	0.024
Annual average	5.7	3.9
Pericardiocentesis
4‐month average	0.6	0.4	−0.1 (−0.3 to 0.1)	0.218
Annual average	1.8	1.2
Procedural sedation
4‐month average	2.5	2.6	0.1 (−0.4 to 0.7)	0.605
Annual average	7.5	7.8
Vaginal delivery
4‐month average	1.7	2.3	0.6 (−0.4 to 1.6)	0.227
Annual average	5.1	6.9

Comparing first 4‐month period of the year pre‐ and during COVID‐19, there were statistically significant decreases in cardiac pacing, chest tube placement, cricothyrotomy, intubation, and pericardiocentesis (Table 4). Comparing second 4‐month period pre‐ and during COVID‐19, there were statistically significant increases in cardiac pacing, pericardiocentesis, and procedural sedation with no procedures that decreased significantly (Table 4). Comparing the third 4‐month period pre‐ and during COVID‐19, there were statistically significant decreases in cardiac pacing and central venous access and a statistically significant increase in vaginal delivery (Table 4).

TABLE 4.

Procedures per resident by 4‐month period comparing pre‐COVID‐19 to during COVID‐19

Procedure	Pre‐COVID‐19	During COVID‐19	Difference (95% CI)	p‐value
Adult medical resuscitation
March to June	10.3	11.7	1.3 (−4.0 to 6.6)	0.617
July to October	11.9	12.5	0.6 (−4.7 to 5.4)	0.833
November to February	15.4	10.1	−5.3 (−10.8 to 0.2)	0.057
Adult trauma resuscitation
March to June	5.7	4.5	−1.2 (−5.0 to 2.6)	0.538
July to October	4.8	5.9	1.1 (−1.6 to 3.7)	0.42
November to February	8.3	4.7	−3.7 (−7.7 to 0.3)	0.073
Cardiac pacing
March to June	1.1	0.5	−0.5 (−1.1 to −0.03)	0.038
July to October	0.5	0.9	0.5 (0.1 to 0.8)	0.011
November to February	1.2	0.7	−0.5 (−0.9 to −0.1)	0.011
Central venous access
March to June	6.3	5.4	−0.9 (−3.5 to 1.8)	0.523
July to October	5.1	6.6	1.5 (−0.5 to 3.4)	0.135
November to February	5.1	7.1	2.1 (0.03 to 4.1)	0.047
Chest tube
March to June	2.2	1	−1.2 (−2.0 to −0.6)	<0.001
July to October	2.1	2.1	−0.03 (−0.7 to 0.7)	0.939
November to February	1.5	1.7	0.2 (−0.4 to 0.9)	0.482
Cricothyrotomy
March to June	0.6	0.1	−0.5 (−0.8 to −0.2)	0.001
July to October	0.9	0.6	−0.3 (−0.7 to 0.03)	0.07
November to February	0.7	0.1	−0.6 (−0.7 to −0.3)	<0.001
Dislocation reduction
March to June	2.2	1.7	−0.6 (−1.5 to 0.4)	0.223
July to October	2	2.2	0.2 (−0.4 to 0.9)	0.467
November to February	2.5	2.2	−0.2 (−1.0 to 0.6)	0.641
Intubation
March to June	8.2	4.4	−3.8 (−6.2 to −1.4)	0.002
July to October	8.8	9	0.2 (−2.4 to 2.8)	0.899
November to February	7.2	8	0.8 (−1.9 to 3.4)	0.567
Lumbar puncture
March to June	1.7	1.7	0 (−0.8 to 0.7)	0.933
July to October	2.6	2.1	−0.5 (−1.2 to 0.2)	0.189
November to February	1.7	1.8	0.1 (−0.5 to 0.7)	0.812
Pediatric medical resuscitation
March to June	3.7	2.1	−1.6 (−3.7 to 0.5)	0.122
July to October	2.4	2	−0.4 (−1.9 to 1.1)	0.601
November to February	3.1	2.5	−0.6 (−2.4 to 1.1)	0.474
Pediatric trauma resuscitation
March to June	2.5	1.4	−1.1 (−2.2 to 0.1)	0.064
July to October	1.8	1.2	−0.6 (−1.2 to 0.1)	0.119
November to February	1.8	1.3	−0.5 (−1.4 to 0.5)	0.319
Pericardiocentesis
March to June	1.7	0.2	−1.5 (−1.9 to −1.1)	<0.001
July to October	0.3	1	0.7 (0.3 to 1.0)	<0.001
November to February	0.4	0.1	−0.2 (−0.4 to 0.01)	0.056
Procedural sedation
March to June	2.7	2.2	−0.5 (−1.7 to 0.7)	0.399
July to October	2.1	3.1	1.0 (0.02 to 1.9)	0.045
November to February	2.7	2.5	−0.2 (−1.1 to 0.7)	0.676
Vaginal delivery
March to June	1.3	1.4	0.1 (−1.6 to 1.9)	0.868
July to October	2.7	2.8	0.1 (−1.7 to 1.9)	0.937
November to February	0.8	2.7	1.8 (0.3 to 3.4)	0.02

DISCUSSION

As a result of COVID‐19, residency programs have been forced to restructure curriculums to meet the needs and adhere to rules of hospitals and communities. This involved changing hours, adapting to new infection control/personal protective equipment standards, and moving many activities to an online virtual platform. ⁶ This led to fewer in‐person learning activities such as didactic conferences and simulation trainings. ⁷ In the ED, the overall acuity of patients during COVID‐19 was higher and the volume of patients presenting to the ED was lower. ¹ , ³ These curricular and patient demographic changes may have caused EM resident procedural training to suffer.

This study evaluated the number of procedures performed by EM residents at three different EM residency programs during the first year of the COVID‐19 pandemic (defined as March 2020 to February 2021) compared to the prior year (defined as March 2019 to February 2020). Our results indicate that most procedures performed by EM residents tended to decrease during the first year of COVID‐19. These effects may have a negative impact on procedural competency.

Procedural skills are among the most important skills for EM residents as they matriculate through training and into their careers as board certified emergency physicians. Studies have shown that prospective residents prefer programs with more procedural training. ⁸ Furthermore, the importance of adequate procedural experience is highlighted by the significant effect of procedures on inpatient morbidity and mortality. ⁹

Given that severe COVID‐19 illness often necessitates intubation, one might have thought that the intubation procedure numbers would have remained steady or increased. However, our data did not find that this was the case. Paradoxically, the intubation numbers decreased. At the beginning of the pandemic, early intubation had been associated with poorer outcomes, and many noninvasive oxygenation techniques were used instead of intubation. ¹⁰ Furthermore, EM programs, including those in this study, had placed restrictions on residents performing intubations. This led to intubations being performed by the “most experienced physician,” typically an attending physician. ¹¹ Another possible reason for the decrease in intubations was that following Centers for Medicare & Medicaid Services recommendations, elective surgeries were stopped or decreased. ¹² Consequently, this may have decreased operating room time for EM residents, who traditionally intubate many patients on their anesthesia rotations.

There was a notable increase in the per resident number of central venous access procedures performed during COVID‐19. One possible explanation for this is once intubated, many COVID‐19 patients required prolonged central access in the intensive care unit setting.

We posit that the significant decrease in pediatric trauma resuscitations and relative decrease in adult trauma resuscitations may be from the lack of interaction with others during the pandemic. This coincides with a decrease in pediatric ED visits; compared to 2019, there was a 51% visit decline in 2020 and 22% decline in 2021. ¹³ During this time, children were not attending school in person and shelter‐in‐place rules limited travel. Opportunities for people to sustain traumatic injuries likely declined with many confined to their homes.

Interestingly, our data showed an increase in the number of vaginal deliveries. Many EM programs put their OBGYN rotations on hold during the initial phase of the pandemic, which impacted the residencies in this study. The largest increases in deliveries were seen between November 2020 and February 2021, coinciding with the 9 months after many of the initial lockdowns.

Although we found statistically significant differences in frequency of procedures performed, these may not be of clinical significance. The number of procedures required for skill competence is variable between individuals, and a few procedure difference is unlikely to confer mastery. Perhaps during periods of lesser procedures, there may have been more time of faculty teaching and resident studying to compensate for the decrease in performance.

LIMITATIONS

There are several limitations to this study. The first is that there is subjectivity regarding certain procedures. Namely, adult medical resuscitation, adult trauma resuscitation, pediatric medical resuscitation, and pediatric trauma resuscitation. There are no rigid criteria regarding what qualifies for these procedures. Second, procedure logging by residents is not always precise. Residents may have a variety of reasons for not logging a procedure in a timely and accurate manner. Some may forget to log a procedure, while others may have fulfilled a threshold number and not log additional procedures due to lack of perceived need to. Some may procrastinate their logging, which can lead to inaccuracy. These resident logging characteristics are likely similar between the pre‐ and during pandemic periods. Third, we were unable to differentiate procedures performed on actual patients versus simulated procedures because residents did not always specify the setting. For rare procedures, such as pericardiocentesis, cardiac pacing, and cricothyrotomy, the ACGME permits 100% to be performed in a simulated setting. However, during the first few months of the pandemic, simulation labs had closed, essentially eliminating most of these procedures' performance. For the other procedures, perhaps the influence of simulation related procedures may have had a larger effect during the pandemic once the labs reopened. Lastly, our study only involved three programs. This may have not been an accurate reflection of all residencies nationwide.

CONCLUSIONS

The COVID‐19 pandemic has led to a decrease in the number of procedures performed by emergency medicine residents. Whether or not this leads to decreased resident competency remains to be seen and further research may help to elucidate this issue.

AUTHOR CONTRIBUTIONS

Study concept and design: Tony W. Bruno, Rohan Janwadkar, Scott M. Alter. Acquisition of the data: Tony W. Bruno, Leslie A. Bilello, Mary J. Hughes, Scott M. Alter. Analysis and interpretation of the data: Scott M. Alter. Drafting the manuscript: Tony W. Bruno, Rohan Janwadkar, Lisa M. Clayton, Patrick G. Hughes, Joshua J. Solano, Richard D. Shih, Scott M. Alter. Critical revision of the manuscript for important intellectual content: Tony W. Bruno, Lisa M. Clayton, Patrick G. Hughes, Joshua J. Solano, Richard D. Shih, Leslie A. Bilello, Mary J. Hughes, Scott M. Alter. Administrative, technical, or material support: Scott M. Alter. Study supervision: Scott M. Alter.

CONFLICT OF INTEREST

The authors declare no potential conflict of interest.

Bruno TW, Janwadkar R, Clayton LM, et al. Impact of COVID‐19 on emergency medicine resident procedure performance. AEM Educ Train. 2022;6:e10832. doi: 10.1002/aet2.10832