ORIGINAL RESEARCH

Medical Trainee Continuity of Care Following Emergency Department Consultations in a Pediatric Hospital Kim Bjorklund, MD Emily A. Eismann, MS Roger Cornwall, MD ABSTRACT Background The importance of continuity of care in training is widely recognized; however, a broad-spectrum assessment across all specialties has not been performed. Objective We assessed the continuity of care provided by trainees, following patient consultations in the emergency department (ED) across all specialties at a large pediatric tertiary care center. Methods Medical records were reviewed to identify patients seen in consultation by a resident or fellow trainee in the ED over a 1-year period, and to determine if the patient followed up with the same trainee for the same condition during the next 6 months. Results Resident and fellow trainees from 33 specialties participated in 3400 ED consultations. Approximately 50% (1718 of 3400) of the patients seen in consultation by a trainee in the ED followed up with the same specialty within 6 months, but only 4.1% (70 of 1718) followed up with the same trainee for the same condition. Trainee continuity of care ranged from 0% to 21% among specialties, where specialties with resident clinics (14.4%) have a greater continuity of care than specialties without resident clinics (2.7%, P , .001). Continuity of care did not differ between fellows (4.2%) and residents (4.0%, P ¼ .87), but did differ between postgraduate years for residents (P , .001). Conclusions Trainee continuity of care for ED consultations was low across all specialties and levels of training. If continuity of care is important for patient well-being and trainee education, efforts to improve continuity for trainees must be undertaken.

Introduction Continuity of care in medicine has important benefits for patients, physicians, and the health care system as a whole.1 Patients who have developed a strong relationship with their physician report greater satisfaction, knowledge, and compliance with selected treatment regimens.2 Traditionally, for physicians, the most powerful motivator for learning has been a deep sense of commitment to patients.3 Ongoing interaction with the same patient over time can help trainees develop clinical skills, judgment, and a sense of responsibility.4 As noted by Hirsh et al,3 ‘‘to anchor clinical learning in caregiving, students must have relevant involvement with patients at the site and time of initial medical decision making, ideally before the diagnosis is made, and be able to follow patients for the duration of an illness episode (and beyond), ideally across care venues.’’ The importance of continuity of care in training is widely recognized in the primary care literature, DOI: http://dx.doi.org/10.4300/JGME-D-15-00018.1

where it is considered a cornerstone of training and an integral part of practice.5–7 A number of studies from the surgical literature have also examined resident continuity of care.8–13 Mittal et al8 highlighted the importance of surgical residents participating in all phases of patient care to fully appreciate the impact of preoperative and intraoperative decisions on postoperative outcomes. Ledwidge et al9 advocated measures to increase care continuity for surgical residents after their study noted that only 23% of patients had the same admitting resident from the emergency department for all phases of care. A broad-spectrum assessment of trainee continuity of care across all specialties has not been performed. The purpose of this study was to assess the continuity of care provided by resident and fellow trainees across all specialties for patients seen in consultation in the emergency department (ED) at a large pediatric tertiary care center during a 1-year period. A patient was considered to have continuity of care if the same trainee who performed the initial consultation in the ED treated him or her for the same condition within the following 6 months. Journal of Graduate Medical Education, February 1, 2016

33

ORIGINAL RESEARCH

Methods Sample Selection Electronic health records were searched to identify all patients treated over a 1-year period (February 1, 2012, to January 31, 2013) in the ED at a large pediatric tertiary care center. Patient records were then reviewed to determine whether a resident or fellow trainee from any medical or surgical specialty other than the ED participated in an ED consultation. Participation in the consultation was defined as electronically writing and/or signing a consultation, progress, history, and/or physical note while the patient was in the ED. The trainee’s name, level of training, and specialty were recorded.

Data Collection The medical records of patients who were seen in consultation by a trainee in the ED were searched for 6 months following their initial ED visit to determine if they were seen by the same resident or fellow for the same condition. Being seen was defined as any consult, progress, procedure, or operative notes written or signed by the resident or fellow for any subsequent inpatient or outpatient hospital visit. If patients were seen by the same resident or fellow, then their diagnosis, and if necessary a note, was reviewed to confirm that they were being treated for the same condition at their follow-up visit as their initial ED visit. Structured interviews were performed with the program directors of specialties with the highest rates of trainee continuity of care in order to obtain information on their residency and fellowship program designs (eg, number of residents per year, duration of rotations, responsibilities, protocols for consultations and follow-up, pros and cons of program structures). This retrospective study was approved by our Institutional Review Board. Informed consent was waived.

Data Analysis We used a Spearman correlation to assess the association between the percentage of specialty follow-up and trainee continuity of care. Chi-square tests assessed if there was a difference in the percentage of trainee continuity of care between all specialties and between all postgraduate years. Fisher exact tests compared the percentage of trainee continuity of care between residents and fellows, between a specific postgraduate year of residents and

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Journal of Graduate Medical Education, February 1, 2016

What was known and gap Continuity of care is an important concept in quality of care and in graduate medical education, but is relatively underexamined. What is new A study at a large tertiary children’s hospital finds low continuity of care across 33 specialties and subspecialties. Limitations Study methodology may have resulted in underreporting actual continuity of care. Bottom line Specific interventions may be needed to enhance trainees’ continuity of care.

all other residents, between a specific specialty and all other specialties, and between specialties with and without a resident clinic. For the purpose of the study, resident clinics were defined as outpatient clinics led by residents with attending physician supervision. Patients were primarily seen by resident physicians with investigations, diagnoses, and treatment plans determined by the resident. In cases where attending physicians were not physically present, nurse practitioners saw patients with the residents, and the attending physician was available in the hospital if needed. In situations where the attending physician was present, his or her involvement was as a resource for residents and patients (such as providing advice for difficult cases or for patients asking to be seen by an attending physician). This differed from standard outpatient clinics held in most specialties where the attending physician primarily runs the clinic and the residents participate in various aspects of patient care.

Results Resident and fellow trainees participated in a total of 3400 ED consultations for 3224 patients during the 1year period. Emergency department consultations were performed by 244 different trainees (177 residents, 67 fellows) from 33 specialties. More than 70% of ED consultations by trainees were performed by 5 specialties (TABLE 1). Overall, 2.1% (70 of 3400) of patients seen in consultation by a trainee in the ED were treated by the same trainee for the same condition in the following 6 months. However, to account for patients who did not follow up at our institution and could not have continuity of care, the denominator in subsequent analyses was limited to the 1718 (51%) patients who followed up again with the consulting specialty during the next 6 months (TABLE 1). Of these

ORIGINAL RESEARCH

1 Medical Trainee Continuity of Carea Following Pediatrics Emergency Department (ED) Consultations by Specialty

TABLE

Specialty

All Specialties

ED Trainee Consultations, n (%) 3400 (100)

Followed Up With Same Specialty in Next 6 Months, n (%) 1718 (5)

Treated by Same Trainee for Same Condition, n (%)

Difference in Continuity of Care Between Specialties,b P Value

70 (4)

...

1005 (30)

851 (85)

26 (3)

.04c

Ear, nose, throat

491 (14)

168 (34)

1 (1)

.001c

Surgery

446 (13)

125 (28)

0 (0)

.008c

Ophthalmology

257 (8)

114 (44)

2 (2)

.32

Plastic surgery

226 (7)

140 (62)

17 (12)

, .001d

Urology

224 (7)

118 (53)

5 (4)

.81

Dental

212 (6)

0 (0)

0 (0)

. .99

Cardiology

172 (5)

54 (31)

1 (2)

.72

Neurology

89 (3)

58 (65)

12 (21)

, .001d

Orthopaedics

Trauma service

86 (3)

0 (0)

0 (0)

. .99

Neurological surgery

46 (1)

25 (54)

0 (0)

.62

Gynecology

24 (0.7)

16 (67)

0 (0)

. .99 . .99

Psychiatry

20 (0.6)

1 (5)

0 (0)

Endocrinology

14 (0.4)

5 (36)

1 (20)

Nephrology

14 (0.4)

5 (36)

0 (0)

Pulmonary

10 (0.3)

8 (80)

1 (13)

Gastroenterology

10 (0.3)

8 (80)

0 (0)

Colorectal

7 (0.2)

5 (71)

1 (20)

Hematology

7 (0.2)

4 (57)

1 (25)

Infectious disease

6 (0.2)

2 (33)

0 (0)

. .99

Oral-maxillofacial surgery

6 (0.2)

0 (0)

0 (0)

. .99

Rheumatology

5 (0.1)

2 (40)

1 (50)

Critical care

4 (0.1)

0 (0)

0 (0)

. .99

Vascular malformation

3 (0.1)

2 (67)

0 (0)

. .99 . .99

.19 . .99 .28 . .99 .19 .15

.08

Hospital medicine

3 (0.1)

0 (0)

0 (0)

Oncology

2 (0.1)

2 (100)

1 (50)

Genetics

2 (0.1)

2 (100)

0 (0)

. .99

.08

Dermatology

2 (0.1)

1 (50)

0 (0)

. .99

Anesthesiology

2 (0.1)

0 (0)

0 (0)

. .99

Physical medicine/rehabilitation

2 (0.1)

0 (0)

0 (0)

. .99

Allergy

1 (, 0.1)

1 (100)

0 (0)

. .99

Community pediatrics

1 (, 0.1)

1 (100)

0 (0)

. .99

Bone marrow transplant

1 (, 0.1)

0 (0)

0 (0)

. .99

a

Continuity of care was defined as having the trainee who performed the ED consultation follow up with the same patient for the same condition in the same specialty during the next 6 months. b Fisher exact tests compared the continuity of care for each specialty to all other specialties combined. c P , .05 indicates statistical significance (lower continuity of care). d P , .05 indicates statistical significance (higher continuity of care).

Journal of Graduate Medical Education, February 1, 2016

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ORIGINAL RESEARCH TABLE 2 Medical Trainee Continuity of Carea Following Pediatrics Emergency Department (ED) Consultations by Postgraduate Year (PGY)

All Trainees Fellows

Trainees, n

ED Trainee Consultations That Followed Up With Same Specialty in Next 6 Months, n

Treated by Same Trainee for Same Condition, n (%)

Difference in Continuity of Care Between PGY Levels,b P Value

244

1718

70 (4.1)

...

67

306

13 (4.2)

...

Residents

177

1412

57 (4.0)

...

PGY-1

35

102

5 (4.9)

.60

PGY-2

31

401

6 (1.5)

.001c

PGY-3

64

676

29 (4.2)

.69

PGY-4

24

173

9 (5.2)

.41

PGY-5

13

47

8 (17.0)

, .001d

PGY-6

2

2

0 (0)

. .99

a

Continuity of care was defined as having the trainee who performed the ED consultation follow up with the same patient for the same condition in the same specialty during the next 6 months. Fisher exact tests compared continuity of care for each PGY level to all other PGY levels combined. c P , .05 indicates statistical significance (lower continuity of care). d P , .05 indicates statistical significance (higher continuity of care). b

patients, 4.1% (70 of 1718) were treated for the same condition by the same trainee from their ED consultation (TABLE 1). The specialties differed in the percentage of patients with ED consultations who followed up during the next 6 months (v2 ¼ 1020, P , .001; TABLE 1), and greater follow-up predicted greater continuity of care by trainees (r ¼ 0.37, P ¼ .03). The percentage of continuity of care did not differ between residents (4.0%, 57 of 1412) and fellows (4.2%, 13 of 306, P ¼ .87), but did differ between postgraduate year (PGY) for residents (v2 ¼ 28, P , .001; TABLE 2). PGY-5 residents had greater continuity of care (17%, 8 of 47) than all other residents combined (P , .001), while PGY-2 residents had less continuity of care (1.5%, 6 of 401, P ¼ .001). All PGY-5 residents with continuity of care were trainees in neurology. Continuity of care was significantly greater for surgical specialties (12%, 5 of 42) than nonsurgical specialties (3.9%, 65 of 1676, P ¼ .03). Trainees in neurology and plastic surgery had greater continuity of care than all other specialties combined (P , .001; TABLE 1). Neurology had trainees participate in 89 ED consultations over the 1-year period, with 65% (58 of 89) following up in clinic and 21% (12 of 58) following up with the same trainee. Four to 5 residents (PGY-3 to PGY-5) rotate through neurology at a time for 2 years and conduct a resident clinic once a week for patients seen in the ED. Plastic surgery had trainees participate in

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Journal of Graduate Medical Education, February 1, 2016

226 ED consultations during the 1-year period, with 61.9% (140 of 226) following up in clinic and 12.1% (17 of 140) following up with the same trainee. Two to 4 residents rotate through plastic surgery at a time for 2 months and conduct a resident clinic once a week for patients seen in the ED. Six specialties had resident clinics: neurology, plastic surgery, dental, psychiatry, genetics, and oncology. Specialties with a resident clinic had greater continuity of care by trainees (14.4%, 29 of 201) than specialties without a resident clinic (2.7%, 41 of 1517, P , .001).

Discussion Our study demonstrates that trainee continuity of care following ED consultations is low across all programs at a large pediatric tertiary care center. Across 33 specialties, only 2.1% of patients seen by a trainee during consultation in the ED were treated by the same trainee for the same condition during the next 6 months. The highest rate of continuity of care for any specialty was 21%. Previous studies of individual specialties suggest poor continuity of care in outpatient follow-up is not unique to our study population.10,11,14 A study of general surgery residents identified outpatient continuity of care in only 1% of cases when a resident had been involved in the operative procedure.14 Holmboe et al15 noted that trainees’ frequent rotational

ORIGINAL RESEARCH

transitions promote a ‘‘trainee as a tourist’’ mentality in current medical education. Although consistent with poor trainee continuity of care in other studies, our population is unique as it includes all pediatrics specialties within a tertiary care institution. In addition, we sought to identify the factors associated with higher trainee continuity of care. Better continuity of care among trainees in our study was noted with greater specialty ED follow-up, having a resident clinic, and being in PGY-5 of residency training. Neurology and plastic surgery had greater continuity of care than all other specialties combined (21% and 12%, respectively). Both of these specialties had greater overall followup for ED consultations as well as resident clinics for treating patients seen in the ED. The neurology resident clinic was a continuity clinic for general follow-up not specific to ED cases, whereas the plastic surgery resident clinic was a weekly ED follow-up clinic. Timing and duration of pediatrics subspecialty rotations varied, with neurology residents in PGY-3 to PGY-5 rotating for a 2-year period and plastic surgery residents across all PGYs on 2month rotations approximately twice yearly. We also found that continuity of care differed by resident training level, with PGY-5 residents having the greatest continuity of care (17%). However, all PGY-5 residents with continuity of care were trainees in neurology, suggesting that this finding had less to do with resident training level and more to do with the structure of our neurology resident training program. Reasons for poor trainee continuity of care likely are multifactorial. Trainees’ low attendance in outpatient clinics may be explained by daily responsibilities managing inpatient wards, performing emergency room consultations, or assisting with procedures in the operating room.14 Physical lack of access to outpatient clinics due to multiple satellite locations and a traditional lack of emphasis by faculty and residents on outpatient clinic may also be factors.14 A number of strategies have been suggested to improve continuity of care, including resident clinics, preceptor-based rotations, and minimizing transitions that jeopardize trainees’ relationships with patients and members of the multidisciplinary team.8,10,11,14–16 Pu et al16 suggested that resident surgery clinics provide trainees with an invaluable patient-physician interaction. Resident clinics, however, are not without shortcomings. For patient safety, medicolegal purposes, and trainee education, resident clinics are overseen by an attending physician, which requires considerable effort and scheduling coordination that is not always feasible. Furthermore, some families may be opposed to

being treated by a trainee, and some patients may require more specialized care. Holmboe et al15 stressed the need to reduce transitions that may result in unfortunate consequences in professional development, quality improvement, and patient safety. Continuity may be improved with preceptor-based rotations or outpatient rotations where ED follow-ups are routinely treated.17 Chung et al10 reported that 98% continuity of care was achieved with preceptor-based mentorship rotations compared with 42% achieved in typical in-hospital rotations. If all trainees are required to have documentation of continuity of care for a predetermined number of ED consultations, then this could be made a mandatory component of the practice-based learning and improvement competency. Our study has limitations, which may have resulted in underestimation of overall trainee continuity of care. For ED consultations admitted as inpatients, we identified only 1 patient seen by the same resident following inpatient admission. Electronic notes signed by a resident or fellow were used as an indication that a trainee had been involved in a patient’s care. In cases where patients were seen by a team and notes were written by nurse practitioners or medical students, trainee continuity of care would not have been captured. Furthermore, by focusing on ED consultations, we likely underestimated overall trainee continuity of care that may have occurred through other pathways. Going forward, an in-depth examination of individual specialty rotations will be important to identify where opportunities exist to minimize transitions and improve trainee continuity of care. Future directions may also include multi-institutional collaboration to build on the generalizability of our outcomes.

Conclusion Our findings suggest that trainee continuity of care following consultation in the ED is low across all medical and surgical specialties at this large pediatric institution. Changes must be implemented to address these deficiencies across all specialties, with the knowledge that the highest patient continuity of care with residents for ED follow-up was observed in specialties that have designated resident clinics.

References 1. Fletcher KE, Saint S, Mangrulkar RS. Balancing continuity of care with residents’ limited work hours:

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defining the implications. Acad Med. 2005;80(1):39–43. Sudarshan M, Hanna WC, Jamal MH, Nguyen LH, Fraser SA. Are Canadian general surgery residents ready for the 80-hour work week: a national survey. Can J Surg. 2012;55(1):53–57. Hirsh DA, Ogur B, Thibault GE, Cox M. ‘‘Continuity’’ as an organizing principle for clinical education reform. New Engl J Med. 2007;356(8):858–866. Hutter MM, Kellogg KC, Ferguson CM, Abbott WM, Warshaw AL. The impact of the 80-hour resident workweek on surgical residents and attending surgeons [discussion in Ann Surg. 2006;243(6):871–875]. Ann Surg. 2006;243(6):864–871. Schultz K. Strategies to enhance teaching about continuity of care. Can Fam Physician. 2009;55(6):666–668. Saultz JW. Defining and measuring interpersonal continuity of care. Ann Fam Med. 2003;1(3):134–143. Merenstein D, Damico F, Devine B, Mahaniah KJ, Solomon M, Reust CE, et al. Longitudinal versus traditional residencies: a study of continuity of care. Fam Med. 2001;33(10):746–750. Mittal V, David W, Young S, McKendrick A, Gentile T Jr, Casalou R. Improved continuity of care in a community teaching hospital model. Arch Surg. 1999;134(5):555–558. Ledwidge SF, Bryden E, Halestrap P, Galland RB. Continuity of care of emergency surgical admissions: impact on SpR training. Surgeon. 2008;6(3):136–138. Chung RS, Verghese J, Diaz J, Eisenstat M. One-on-one mentor-resident rotation for improving continuity of care in a surgical training program. J Surg Res. 1997;69(2):359–361. Anderson CI, Albrecht RR, Anderson KD, Dean RE. Can continuity-of-care requirements for surgery residents be demonstrated in the current teaching environment? Arch Surg. 1996;131(9):915–921.

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12. Gagnon J, Melck A, Kamal D, Al-Assiri M, Chen J, Sidhu RS. Continuity of care experience of residents in an academic vascular department: are trainees learning complete surgical care? J Vasc Surg. 2006;43(5):999–1003. 13. Sidhu RS, Walker GR. Resident continuity of care experience in a Canadian general surgery training program. Can J Surg. 1999;42(5):353–357. 14. Melck A, Weber EM, Sidhu RS. Resident continuity of care experience: a casualty of ambulatory surgery and current patient admission practices. Am J Surg. 2007;193(2):243–247. 15. Holmboe E, Ginsburg S, Bernabeo E. The rotational approach to medical education: time to confront our assumptions? Med Educ. 2011;45(1):69–80. 16. Pu LL, Thornton BP, Vasconez HC. The educational value of a resident aesthetic surgery clinic: a 10-year review. Aesthet Surg J. 2006;26(1):41–44. 17. Harris KA. Complete surgical training. Can J Surg. 1999;42(5):327–328.

Kim Bjorklund, MD, is Assistant Professor, Division of Plastic and Reconstructive Surgery, Nationwide Children’s Hospital; Emily A. Eismann, MS, is Clinical Research Coordinator, Mayerson Center for Safe and Healthy Children, Cincinnati Children’s Hospital Medical Center; and Roger Cornwall, MD, is Associate Professor and Clinical Director, Division of Pediatric Orthopaedic Surgery, Cincinnati Children’s Hospital Medical Center. Funding: The authors report no external funding source for this study. Conflict of interest: The authors declare they have no competing interests. Corresponding author: Roger Cornwall, MD, Cincinnati Children’s Hospital Medical Center, MLC 2017, 3333 Burnet Avenue, Cincinnati, OH 45229, 513.803.2560, fax 513.636.3928, [email protected] Received January 15, 2015; revision received June 29, 2015; accepted August 12, 2015.

Medical Trainee Continuity of Care Following Emergency Department Consultations in a Pediatric Hospital.

The importance of continuity of care in training is widely recognized; however, a broad-spectrum assessment across all specialties has not been perfor...
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