Turning lemons into lemonade: Teaching strategies in boarded emergency departments

Boarding of inpatients in emergency department (ED) beds presents unique challenges and opportunities for clinician educators.1 Severe overcrowding of the ED and operational responses to boarding of inpatients leads to fewer ED patients seen per hour by residents in training, changes in acuity of patients seen by residents, and the potential for decreased learning.2-4 Though the research to date on the educational impacts of boarding on ED residents has not shown decreases in In-training Exam (ITE) performance,1 the result of decreasing number of patient encounters and decreased opportunity to practice the rapid task-switching skills that are required of attending ED physicians represents a significant threat to residency education. Given that boarding of inpatients in ED patient care spaces is an international phenomenon5 and that it is unlikely to substantively change without fundamental changes to the medical system,6 educators need to adapt their teaching strategies to this new environment. The existing literature focusing on teaching in times of boarding outlines global attributes of effective teachers but often fails to delineate concrete strategies and solutions to teaching.7, 8 Here we describe a set of educational strategies and opportunities that can be easily implemented to help teach learners in times of boarding. These teaching strategies were initially developed by the chief residents within our residency training program during the 2021–2022 academic year. The initial set of teaching strategies was vetted and refined by our department's teaching faculty and the residency leadership team to ensure that the strategies were rooted in an understanding of the existing literature, that they emphasized previously successful strategies within our institution, and that they were practical and feasible. By decreasing the number of patients seen, boarding threatens emergency medicine (EM) resident education by limiting opportunities to expand resident medical knowledge through exposure to a wide variety of patient presentations. Successful strategies for teaching in times of boarding address this by identifying and highlighting the dynamic nature of ED patient presentations. While still attending to their needs, learners can engage with boarded patients in the ED to obtain brief histories, review the diagnostic evaluation they had in the ED, and review the diagnostic and therapeutic approaches taken by the inpatient team. Rather than waiting for educational opportunities to present during new patient encounters, educators can strategically cover specific topics or literature/guideline discussions while still maintaining a case-based format. Additionally, successful teaching strategies seek to capitalize on the knowledge and experience of all members of the health care team. By introducing near-peer learning in group rounding, case review, and procedural observation instruction, you can multiply the numbers of learners engaged, encourage development of residents-as-teachers, and allow for knowledge transfer and emotional debriefing of similar cases. Decreases in patients per hour seen by residents threatens EM resident education by limiting opportunities to develop the rapid task-switching skills that are needed to run an ED. Successful strategies that address this threat seek to create situations where rapid task switching can be simulated (see “stop, drop, resuscitate” in Table 1). Teachers can also encourage their learners to improve and perfect the base skills that lead to efficient patient care (e.g., electronic medical record optimization, efficient chart biopsy, workflow efficiency). “Walking the Board”—group rounding allowing residents to learn from active cases Reviewing patients in the waiting room Discuss appropriate workups Observe the resuscitation bay Teach through oral boards style cases—sources to consider: Interpretation of specific diagnostics (ECGs, CXRs, US, CT, etc.) “Cash for Cases” Medical Scattergories Use phantoms to review and practice core emergency medicine procedural skills Educational Ultrasounds (USs) Peripheral IV (PIV) line placement and troubleshooting How to draw off labs/blood a line IV pump mechanics Arterial lines Ventilator mechanics Maximize ED patient volume by identifying and responding to patient-level and department-level operational barriers to care Assist with patient safety Optimize your EMR Prewrite chief complaint–based discharge instructions (frameworks that can be further tailored to the patient) Build notes tailored to specific chief complaints (some examples below) Discuss the benefits and risks of using order sets in the ED (e.g., stroke, sepsis, STEMI) Improve workflow efficiency using SMART goal setting Simulate high-level multitasking: “stop, drop, resuscitate” Interrupt your residents workflow with a simulated critical patient (ensure that this does not negatively impact actual patient care) Review notes in detail Critical care documentation and billing Discuss supervisory documentation Providing telephone medical direction Simulate common medical direction call questions EMTALA considerations On-shift clinical questions Have the resident propose a clinical question relevant to a patient they are seeing, ask them to do a brief literature search and present an article on the topic. Skills to focus on: Ask residents to present a brief summary of the literature supporting their treatment plan as part of a patient presentation. Examples: Additionally, successful teaching strategies during boarding seek to take advantage of increases in provider downtime. Teachers can use this time to hone procedural skills using high- or low-fidelity task trainers and to improve ultrasound (US) acquisition and interpretation skills by performing educational USs with patient consent on boarded inpatients. During periods of downtime, learners can practice evidence-based clinical practice skills, searching for and identifying literature based on the patient pathologies present in the ED. Learners can also use downtime to take advantage of opportunities for interdisciplinary learning. Residents can observe and be taught the skills of nonphysician health care providers (e.g., ventilator set-up and adjustment, obtaining ECGs, adjusting IV pumps, medication administration). Not only does this increase interprofessional respect and understanding but also enables learners to better understand the overall operations of the ED. Many of the teaching strategies outlined are relatively easy to implement within a given shift without onerous impacts on either the teacher or learner (e.g., SMART goals for workflow efficiency, “walking the board,” observing in the resuscitation bay). Some of the strategies may require additional preparation (e.g., making task trainers available for procedural training, preparing specific cases for presentation, medical Scattergories). For strategies that require additional time for supervising physician, it is encouraged to have a set threshold to start using them. This may be based on a department-wide boarding score (e.g., National Emergency Department Overcrowding Scale NEDOCS or number of boarded inpatients) or a patients-per-provider number. Having an agreed-upon threshold can help limit shift-to-shift variability in the utilization of these strategies. It may also be helpful if one senior-level provider is assigned to transition to a more educational role in the event of significant boarding. This person can scout valuable patient encounters from the boarding patients and serve as the facilitator of one-on-one learning with other health care staff. It is important to note that while these strategies can be helpful in maximizing learning opportunities on particularly boarded shift, teaching physicians should be very attentive to the changing operational state of the ED and ensure that these strategies do not negatively impact the throughput of active ED patients.