BACKGROUND AND OBJECTIVES:

Graduating residents are expected to be competent in triaging patients to appropriate resources. Before 2017, pediatric residents were not involved in admission triage decisions. In 2017, after implementing an admission triage curriculum (ATC), residents had opportunities to be involved in overnight admission calls with the emergency department (ED), which were initially supervised (joint calls), and as skills progressed, residents conducted calls and admitted patients independently. We implemented and evaluated the impact of a graduated ATC intervention bundle on pediatric resident opportunities to participate in admission triage, while monitoring resident confidence, the ED experience, and patient safety.

METHODS:

We evaluated the impact of our ATC using quality improvement methodology. The primary outcome was the frequency of resident participation in joint and independent triage calls. Other measures included resident confidence, the ED clinician experience, and patient safety. Resident confidence and the ED clinician experience were rated via surveys. Safety was monitored with daytime hospitalist morning assessments and postadmission complications documented in the medical record.

RESULTS:

The percent of joint calls with the hospitalist increased from 7% to 88%, and 125 patients were admitted independently. Residents reported significant increases in adequacy of triage training and confidence in 3 triage skills (P < .001) after ATC. There were no complications or safety concerns on patients admitted by residents. ED clinicians reported increased admitting process efficiency and satisfaction.

CONCLUSIONS:

Our ATC intervention bundle increased the number of admission decision opportunities for pediatric residents, while increasing resident triage confidence, maintaining safety, and improving ED clinician experience.

After completion of training, pediatric residents are expected to “provide transfer of care that ensures seamless transitions” and “coordinat[e] patient care across the health care continuum” per Accreditation Council for Graduate Medical Education requirements,1  which are key skills learned in admission patient triage.

Although previous work has been focused on resident triage of parent calls in the primary care setting,25  little information exists regarding admission triage education in the hospital setting. Discussions with emergency department (ED) clinicians regarding appropriate patient placement are vital for patient care but come with challenges,610  highlighting the importance of learning this skill. Residents may not feel comfortable determining which ED patients can be safely discharged or require admission. Communication errors can occur when exchanging and obtaining pertinent patient information. Training and practice during residency may help promote more effective conversations around admission triage.11 

A trend of decreased resident autonomy with increased attending coverage occurred in pediatric hospitals since duty hour changes in 2011.12  According to a 2014 survey, 65% of night in-house pediatric hospitalists approve admissions and transfers,12,13  potentially limiting resident opportunity to practice admission triage conversations independently. Despite increasing hospitalist involvement, overnight hospitalist coverage did not improve clinical outcomes, suggesting that residents may not need more direct supervision overnight.14  Moreover, Biondi et al15  found that removing the hospitalist from the admission triage conversation did not adversely affect patient outcomes. Therefore, letting residents lead these conversations, independently, when appropriate, provides an avenue to expand resident autonomy and hone important triage and communication skills.

In our pediatric residency program, we did not previously provide formal education or skill-building opportunities regarding the hospital admission triage process. To address this gap in education, we adopted an admission triage curriculum (ATC) intervention bundle consisting of triage process instructions, audio sample calls, joint call practice with the hospitalist attending physician, and allowing residents to independently accept admissions for the pediatric hospital medicine (PHM) service from our ED. In planning our study, we applied the conceptual framework of deliberate practice, allowing residents to develop triage skills through real life practice and immediate feedback.16 

Our primary outcome and aim were to increase joint call conference calls with our residents, attending physicians, and ED clinicians to 70% and initiate resident independent ED calls by 2019 (Supplemental Figure 4).

Our secondary outcomes were to (1) improve resident confidence and perceived skill in admission triage, (2) increase resident satisfaction with the night rotation, and (3) increase ED clinician efficiency and satisfaction. Our balancing measure was patient safety during independent ED calls.

Our pediatric residency program consists of 100 residents (categorical and combined). Residents complete PHM rotations at our 294-bed stand-alone academic children’s hospital. Our division consists of 32 hospitalists with a substantial role in resident education. PHM admits an average of 12 patients per day. There are 60 upper-level, postgraduate year (PGY) 2 through PGY4 residents, and each categorical resident completes 4 to 5 night-shift 4-week rotations during residency. Combined PGY3 and PGY4 residents complete 1 night-shift rotation. Each night a designated admitting resident is involved in ED admission calls and assigning patients to 1 of 3 PHM teams. Our ATC was implemented during this night rotation because one PGY2, PGY3, or PGY4 resident is assigned for the entirety of a night shift, and a primary focus is learning to diagnose diseases and manage patients admitted at night.

Using hospitalist materials and local and national admission guidelines, several hospitalists created our ATC, which included triage process instructions and audio sample calls (Table 1), staged practice in joint calls with hospitalists over 2 blocks of the night rotation as a PGY2 and PGY3, and, finally, additional practice with independent phone triage as PGY3 or PGY4.

TABLE 1

Triage Process Instructions and Audio Sample Calls

ItemDescriptionFormat
Admission guidelines Local clinical practice guidelines and PHM admission practices are used to create a disease specific admission guideline. 1-page table 
Step-by-step admission triage instructions Triage instructions included how to best review the patient in the EHR before calling the ED, a template to guide obtaining vital information, potential interventions needed before admission, how to determine the need for admission and floor placement, and how to receive handoff from the ED clinician efficiently. 18-page PowerPoint presentation 
Audio sample calls Audio recordings of case examples are provided, some run effectively and efficiently and some run poorly to illustrate common pitfalls. 5 previously recorded case examples in a PowerPoint presentation 
Independent ED call protocols Clear eligibility requirements are outlined and instructions for the residents to contact the attending physician with concerns. 2 documents 
ItemDescriptionFormat
Admission guidelines Local clinical practice guidelines and PHM admission practices are used to create a disease specific admission guideline. 1-page table 
Step-by-step admission triage instructions Triage instructions included how to best review the patient in the EHR before calling the ED, a template to guide obtaining vital information, potential interventions needed before admission, how to determine the need for admission and floor placement, and how to receive handoff from the ED clinician efficiently. 18-page PowerPoint presentation 
Audio sample calls Audio recordings of case examples are provided, some run effectively and efficiently and some run poorly to illustrate common pitfalls. 5 previously recorded case examples in a PowerPoint presentation 
Independent ED call protocols Clear eligibility requirements are outlined and instructions for the residents to contact the attending physician with concerns. 2 documents 

The ATC intervention bundle included interventions aimed at increasing resident active practice in phone triage and promoting process culture change.

Pretriage ATC Intervention

In Table 2, we outline the workflow before curriculum intervention. The resident could ask the ED questions about the patient but lacked clinical decision-making opportunities because placement decisions were already made by the attending hospitalist. This system contained inefficiencies for ED clinicians because it included 2 separate discussions with the resident and hospitalist to admit 1 patient.

TABLE 2

Resident Triage Workflow

Before Triage CurriculumAfter Joint Calls Were InitiatedAfter Resident Independent ED Calls Were Initiated
ED provider pages hospitalist ED provider pages hospitalist ED provider pages hospitalist pager 
↓ ↓ ↓ 
Hospitalist calls ED provider back Hospitalist and admitting resident call ED back Between midnight and 5:30am, the admitting resident responds to the page 
↓ ↓ ↓ 
ED provider discusses possible admission with hospitalist ED provider discusses possible admission with both resident and hospitalist (joint calls) ED provider discusses possible admission with resident 
↓ ↓ ↓ 
If deemed appropriate, patient is accepted If deemed appropriate, patient is accepted If deemed appropriate, the patient is accepted by admitting resident on behalf of the hospitalist 
↓   
ED provider pages admitting resident   
↓   
Admitting resident calls ED provider back   
↓   
ED provider discusses patients with resident   
Before Triage CurriculumAfter Joint Calls Were InitiatedAfter Resident Independent ED Calls Were Initiated
ED provider pages hospitalist ED provider pages hospitalist ED provider pages hospitalist pager 
↓ ↓ ↓ 
Hospitalist calls ED provider back Hospitalist and admitting resident call ED back Between midnight and 5:30am, the admitting resident responds to the page 
↓ ↓ ↓ 
ED provider discusses possible admission with hospitalist ED provider discusses possible admission with both resident and hospitalist (joint calls) ED provider discusses possible admission with resident 
↓ ↓ ↓ 
If deemed appropriate, patient is accepted If deemed appropriate, patient is accepted If deemed appropriate, the patient is accepted by admitting resident on behalf of the hospitalist 
↓   
ED provider pages admitting resident   
↓   
Admitting resident calls ED provider back   
↓   
ED provider discusses patients with resident   

Post-triage ATC Intervention

We planned our education interventions using a quality improvement framework. The study period was September 2017 to June 2019.

Beginning October 2017, all night rotation PGY2, PGY3, and PGY4 residents received the triage process instructions and audio sample calls (Table 1) via e-mail and were asked to review before starting their night rotation (no formal tracking of the completion of this activity was performed [ie, the “honor system”]). At this time, hospitalists were instructed to conference in the resident when calling the ED (Table 2), defined as “joint calls.” The resident initially listened to these triage calls, and, as their comfort increased, they took leadership and asked triage questions with the hospitalist listening in. The hospitalist provided real-time feedback to the residents after the calls.

Multiple meetings with the hospitalists, residents, and ED clinicians lead to buy-in for this intervention, which was vital to its success. Reminders by e-mail and in-person meetings were conducted to remind the residents and hospitalists of the process change (Fig 1).

FIGURE 1

Run chart: percentage of PHM admission calls reported as joint calls across the intervention period.

FIGURE 1

Run chart: percentage of PHM admission calls reported as joint calls across the intervention period.

Close modal

Seven months after joint calls were initiated, PGY3 and PGY4 residents participated in independent ED calls. To determine eligibility for independent calls, each resident was evaluated with a call assessment tool. Hospitalists completed a 30-minute training on the use of this tool. The tool evaluated triage performance with an 11-item checklist, including the resident’s ability to ask pertinent questions about the patient’s story, ED evaluation, and response to interventions and if the patient was triaged to the correct service, vital components of an emergency clinician-hospitalist handoff.17  Residents who passed 2 evaluations could take independent ED calls. By March 2019, all 20 categorical PGY3 residents and 6 of 12 combined PGY3 and PGY4 residents became eligible. Because combined PGY3 and PGY4 residents only have 1 night-shift rotation, some did not have the opportunity to be evaluated.

If admission was deemed appropriate after discussion with the ED clinicians, the resident then accepted patients independently on behalf of the hospitalist (Table 2). Protocols instructed the residents to contact the hospitalist if the resident had any concerns about the patient or if there was disagreement with the ED clinician on patient placement. The hospitalist reviewed the patient in the electronic health record (EHR) and contacted the resident if there were concerns.

Primary Outcomes

PGY2, PGY3, and PGY4 residents were surveyed to estimate what percent of admission calls to the ED were joint calls (Supplemental Figure 5). Hospitalists tracked resident independent ED calls.

Self-assessment of Confidence in Triage Skills

PGY2, PGY3, and PGY4 residents rated their training in admission triage and confidence with triage questions, inpatient criteria, and patient placement at baseline and after each night block on a 4-point Likert scale (Supplemental Information).

Satisfaction With Program Evaluation Committee Night Rotation Evaluations

All residents are required to complete rotation evaluations at the end of each of night-shift rotations, per the program evaluation committee (PEC). A 5-point Likert scale was used for the items “overall quality of the rotation,” “appropriate level of autonomy,” and “appropriate level of responsibility.”

ED Efficiency and Satisfaction

ED clinicians (attending physicians, fellows, pediatric residents, and advanced practice clinicians) were surveyed regarding the efficiency and the satisfaction of the PHM admission process by using a 5-point Likert scale before and periodically after ATC was implemented. ED clinicians reported the number of calls needed to admit 1 patient to PHM.

The daytime hospitalist who assumed care of a patient accepted independently by a PGY3 or PGY4 resident was asked to complete a morning assessment on the appropriateness of care, triage placement, and safety concerns with yes or no responses to monitor safety.

PICU transfers, rapid response teams (RRTs), and codes within 6 hours of patients accepted independently by PGY3 and PGY4 residents were monitored by using our hospital’s electronic data warehouse.

Outcome measures, including resident and ED clinician surveys, were analyzed by using independent-samples Mann–Whitney U tests to assess for differences between ratings and responses at baseline (before curriculum implementation) and final evaluations. Statistical analysis was conducted by using IBM SPSS version 24 (IBMM SPSS Statistics, IBM Corporation). The institutional review board approved this study as exempt.

The resident-reported number of joint calls increased from 7% to 88%, after initiation (Fig 1). Groups of residents change after each rotation, and it is not known if the same residents, different residents, or a combination completed the survey after each rotation. Before the ATC, residents were not allowed to take independent ED calls. After initiation, over a 15-month period, 125 patients were accepted independently by PGY3 and PGY4 residents.

Self-Assessment of Confidence in Triage Skills

Baseline surveys were sent to 60 PGY2, PGY3, and PGY4 residents, and 30 responses were received (50% response rate). Over the 21-month study period, 150 surveys were sent to PGY2, PGY3, and PGY4 residents after each of their night rotations, and 89 responses were received (59.3% response rate). Perceived resident training and confidence increased in a dose dependent manner (Fig 2). “I received adequate training in admission triage” increased from a score of 2.31 to 3.95, after the third rotation experience (P < .001). Confidence in asking necessary admissions questions, knowing inpatient criteria for common pediatric diseases, and triaging patient placement increased from baseline to the third rotation (P < .001, P < .001, and P < .001, respectively).

FIGURE 2

Self-assessment of confidence in triage skills PICU.

FIGURE 2

Self-assessment of confidence in triage skills PICU.

Close modal

Satisfaction With PEC Night Rotation Evaluations

On the basis of PEC night rotation evaluation responses from a total of 125 PGY2, PGY3, and PGY4 residents pre-ATC intervention and 152 PGY2, PGY3, and PGY4 residents post-ATC intervention, ratings on the “overall quality of this rotation” significantly increased from 4.3 to 4.47 (P = .042). There was no significant change in scores for ratings regarding appropriate “level of autonomy” (4.35 vs 4.31; P = .61) and “level of responsibility” (4.5 vs 4.56; P = .41). All residents are required to fill out these evaluations; thus, the response rate is 100%.

ED Efficiency and Satisfaction

Possible survey participates ranged from 109 to 149, with response rates of 20% to 30%. ED clinician-reported efficiency significantly increased from a baseline score of 2.65 to 3.8 (P < .001), and satisfaction increased from 3.0 to 4.4 (P < .001; Fig 3). ED clinicians reported fewer phone calls needed (2.65, compared to 1.72; P < .001; Fig 3).

FIGURE 3

ED clinician efficiency and satisfaction ratings.

FIGURE 3

ED clinician efficiency and satisfaction ratings.

Close modal

A total of 125 patients were accepted independently by PGY3 and PGY4 residents. A total of 94 daytime hospitalist assessments of these patients were collected (75.2% response rate). Of those patients, 88 (94%) were rated as receiving appropriate care, and 90 (96%) were triaged appropriately.

Of the 6 patients rated as not receiving appropriate care, there was a difference in opinion regarding indication for admission (2 patients), workup of febrile neonates (1 patient), and need for additional testing/monitoring (3 patients). A total of 4 patients were rated by the daytime hospitalist as “not triaged appropriately,” 3 of which were also noted in the group that did not received appropriate care. One was rated as not needing admission, 1 was transferred to the neurology service the following day, 1 may have benefited from telemetry monitoring on a different floor, and another’s respiratory status worsened and required a transfer to the PICU the following day. There were no safety concerns reported.

EHR data revealed no codes, RRTs, or PICU transfers within 6 hours of admission to the floor for these patients. The rate of codes, RRTs, and PICU transfers were <1% in all categories in patients admitted from the ED to PHM in 2018.

With our ATC intervention bundle, we increased the number of admission decision opportunities, both supervised and independent, for pediatric residents. In addition, our interventions were associated with increased upper-level resident admission triage confidence, improved quality of the night rotation, and increased ED admission satisfaction and efficiency, without safety concerns. Previously, residents received little formal training on patient triage, reflected in their baseline scores. As they completed more night rotations, gradual and steady improvement in their confidence in patient placement, asking necessary admission questions, and knowledge of inpatient criteria were noted, which matches gains in outpatient programs.2,3 

We achieved necessary buy-in from key stakeholders, hospitalists, residents, and ED clinicians, which lead to the successful admission triage process change. Most importantly, our primary outcome, increasing joint calls, increased rapidly and was maintained throughout the study period. This intervention gave residents the ability to contribute to and build skills for admission triage.

We used Kirkpatrick and Kirkpatrick’s18  pyramid for curriculum evaluation and demonstrated benefits in the levels of reaction (1), behavior change (3), and high stakes patient and educational outcomes (4). Residents had a positive reaction to the curriculum, with increased confidence in 3 important areas of triage: patient placement, asking necessary admission questions, and inpatient criteria. Survey responses increased from “not very confident” to “somewhat or very confident.” Residents reported increased confidence in the new skill of admission triage, although it should be noted that changes in confidence can be difficult to determine over time; there is a natural increase in confidence that occurs with performing a rotation multiple times. Substantial behavior change was revealed with an increased number of joint calls and resident independent ED calls. The high stakes outcome of preserved patient safety was achieved as rated by hospitalists and surveillance of rates of codes, RRTs, and PICU transfers. Another high stakes outcome of ED efficiency also revealed improvement on the basis of multiple levels of clinician ratings. Furthermore, a high stakes educational outcome was evidenced by the significant increase in resident ratings of the night-shift rotation with the addition of the triage curriculum.

The quality of the night rotation increased after our intervention bundle, which we believe is because of participating in inpatient triage regularly and safely engaging in a higher level of responsibility. Appropriate levels autonomy and responsibility scores remained unchanged, likely because these scores were previously high and many other factors contributed outside of admission triage.

By removing the hospitalist from the ED admission conversation during independent ED calls, we empowered our residents to use clinical reasoning and judgement and develop their own process. A total of 94 patients accepted independently by residents were evaluated by the daytime hospitalist. The majority (94%) of patients received appropriate care, as defined by the daytime hospitalist. The differences in perspective between the resident night team and daytime hospitalist occurred mainly in diagnostic areas in which finding consensus on management is difficult even among expert groups, such as the workup and management of febrile neonates. These residents were provided feedback and no safety concerns were reported.

Teaching hospitals with trainees practicing in the ED are less effective at determining patient placement and, often, lead to more admissions than expected,19  making this conversation vital. Educating our residents and providing them the opportunity to triage calls for admission to the hospital lead to an excellent rate of appropriate triage; 96% of patients accepted by this process were triaged appropriately. There were no complications after admission (PICU transfers, RRTs, or codes within 6 hours) in patients who were accepted during resident independent ED calls, suggesting this process is safe and consistent with a previous study.15  It is important to stress that these patients were still evaluated by the hospitalist in the EHR and the hospitalist was supervising the residents from afar.

Increasing ED efficiency is an important factor in any hospital setting. ED overcrowding has been associated with a higher risk of mortality, decreased patient satisfaction, and increased cost and could decrease teaching effectiveness.2023  By decreasing the steps needed for admission, we have increased the efficiency and satisfaction of our ED clinicians.

Further research, including well-studied call assessment tools to determine competency, admission triage calls in other specialty settings (including surgical and adult medicine), clinical outcomes of attending physicians who received similar training as residents, and larger patient populations, is needed to better define and determine the clinical impact of letting residents lead.

Implementing a significant process change in the resident admission triage workflow was a difficult endeavor. Our most important lesson was obtaining feedback and buy-in, especially from the pediatric residents. Initially, residents were hesitant to take on another role at night. The hospitalists tempered their anxieties by being supportive and available. The hospitalist group was willing to include residents in joint calls and their comfort allowing eligible residents to take independent ED calls also grew over time. The intervention bundle is now a permanent part of our night rotation and daytime admission calls, highlighting its success.

Our study had several limitations. First, as stated above, changes in confidence over time may be secondary to repeated night rotations. However, because phone triage was not previously part of the inpatient resident role, we suspect these improvements reflect real gains not previously occurring. The use of a control group would have better defined this. Second, it is important to also recognize the difference between confidence and competency. We did not evaluate competency in admission triage, and it is possible that changes in confidence do not necessarily equate to changes in competence. Additionally, data suggest that physicians are inaccurate at self-assessment.24 

Another limitation includes the difficulty in determining “appropriateness of triage decisions” because there is a subjective aspect to hospitalist next day assessments of this. Many of the ratings of “inaccurate triage” reflected areas of controversy in management in which not all attending physicians would have rated the decisions the same way. However, we were reassured about the safety of the program by the absence of clear examples of inaccurate triage that would have been widely agreed on. Additionally, we did not analyze further medical management beyond the day after admission, and other issues could have arisen. ED clinician survey response rates were low; however, given a significant improvement in scores, we believe we made positive impact on their PHM admission experience. Lastly, we do not have a baseline cohort of patients to compare standard of care and safety outcomes, yet we know that our rate of RRT’s, PICU transfers, and codes within 6 hours in general is more than none.

Our results suggest that the implementation of a stepwise ATC intervention bundle for upper-level residents is an effective way to increase resident confidence, and opportunities in performing these skills and safety appears to be preserved. With this curriculum, we may have improved the ratings of the quality of our night-shift rotation and the ED workflow.

We acknowledge Dr Robert Kliegman, Dr Amanda Rogers, Mark Nimmer, and Dan Eastwood for their expertise and guidance throughout this study.

Dr Bauer is the corresponding author and principal investigator and drafted the initial version of the manuscript, developed the curriculum and project design, interpreted the data, and revised the manuscript; Drs McFadden, Madhani, and Kaeppler assisted with the development of the project, interpreted the data, and assisted in manuscript revisions; Ms Porada assisted with survey design and distribution, interpretation of the data, statistical analysis, and manuscript revisions; Dr Weisgerber was a mentor throughout the entirety of the project, interpreted the data, and assisted in manuscript revisions; and all authors approved the final manuscript as submitted.

FUNDING: No external funding.

1
Accreditation Council for Graduate Medical Education
.
ACGME program requirements for graduate medical education in pediatrics
.
2
Benjamin
JT
.
Pediatric residents’ telephone triage experience. Relevant to general pediatric practice?
Arch Pediatr Adolesc Med
.
1997
;
151
(
12
):
1254
1257
3
Caralis
P
.
Teaching residents to communicate: the use of a telephone triage system in an academic ambulatory clinic
.
Patient Educ Couns
.
2010
;
80
(
3
):
351
353
4
Blumberg
JS
,
Barajaz
M
,
Roberts
D
,
Clary
C
,
Kumar
S
.
Call me maybe… A simulation based curriculum for telephone triage education in a pediatric residency
.
Front Pediatr
.
2020
;
8
:
283
5
Roth
LT
,
Lane
M
,
Friedman
S
.
A curriculum to improve pediatric residents’ telephone triage skills
.
MedEdPORTAL
.
2020
;
16
:
10993
6
Miles
PV
.
Emergency department admission decision-making: an opportunity for quality improvement in medical education and practice
.
J Pediatr
.
2006
;
149
(
5
):
598
599
7
Chamberlain
JM
,
Patel
KM
,
Pollack
MM
.
Association of emergency department care factors with admission and discharge decisions for pediatric patients
.
J Pediatr
.
2006
;
149
(
5
):
644
649
8
Apker
J
,
Mallak
LA
,
Gibson
SC
.
Communicating in the “gray zone”: perceptions about emergency physician hospitalist handoffs and patient safety
.
Acad Emerg Med
.
2007
;
14
(
10
):
884
894
9
Hilligoss
B
,
Cohen
MD
.
The unappreciated challenges of between-unit handoffs: negotiating and coordinating across boundaries
.
Ann Emerg Med
.
2013
;
61
(
2
):
155
160
10
Amick
A
,
Bann
M
.
Characterizing the role of the “triagist”: reasons for triage discordance and impact on disposition [published online ahead of print June 9, 2020]
.
J Gen Intern Med
.
doi:10.1007/s11606-020-05887-y
11
Wang
ES
,
Velásquez
ST
,
Smith
CJ
, et al
.
Triaging inpatient admissions: an opportunity for resident education
.
J Gen Intern Med
.
2019
;
34
(
5
):
754
757
12
Gosdin
C
,
Simmons
J
,
Yau
C
,
Sucharew
H
,
Carlson
D
,
Paciorkowski
N
.
Survey of academic pediatric hospitalist programs in the US: organizational, administrative, and financial factors
.
J Hosp Med
.
2013
;
8
(
6
):
285
291
13
Oshimura
JM
,
Sperring
J
,
Bauer
BD
,
Carroll
AE
,
Rauch
DA
.
Changes in inpatient staffing following implementation of new residency work hours
.
J Hosp Med
.
2014
;
9
(
10
):
640
645
14
Gonzalo
JD
,
Kuperman
EF
,
Chuang
CH
,
Lehman
E
,
Glasser
F
,
Abendroth
T
.
Impact of an overnight internal medicine academic hospitalist program on patient outcomes
.
J Gen Intern Med
.
2015
;
30
(
12
):
1795
1802
15
Biondi
EA
,
Leonard
MS
,
Nocera
E
,
Chen
R
,
Arora
J
,
Alverson
B
.
Tempering pediatric hospitalist supervision of residents improves admission process efficiency without decreasing quality of care
.
J Hosp Med
.
2014
;
9
(
2
):
106
110
16
Ericsson
KA
.
Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains
.
Acad Med
.
2004
;
79
(
10 suppl
):
S70
S81
17
Apker
J
,
Mallak
LA
,
Applegate
EB
 III
, et al
.
Exploring emergency physician-hospitalist handoff interactions: development of the Handoff Communication Assessment
.
Ann Emerg Med
.
2010
;
55
(
2
):
161
170
18
Kirkpatrick
JD
,
Kirkpatrick
WK
.
Kirkpatrick, Then and Now: A Strong Foundation for the Future
.
Scotts Valley, CA
:
CreateSpace Independent Publishing Platform
;
2009
19
Chamberlain
JM
,
Patel
KM
,
Pollack
MM
.
The Pediatric Risk of Hospital Admission score: a second-generation severity-of-illness score for pediatric emergency patients
.
Pediatrics
.
2005
;
115
(
2
):
388
395
20
Bernstein
SL
,
Aronsky
D
,
Duseja
R
, et al
;
Society for Academic Emergency Medicine, Emergency Department Crowding Task Force
.
The effect of emergency department crowding on clinically oriented outcomes
.
Acad Emerg Med
.
2009
;
16
(
1
):
1
10
21
Jo
S
,
Jeong
T
,
Jin
YH
,
Lee
JB
,
Yoon
J
,
Park
B
.
ED crowding is associated with inpatient mortality among critically ill patients admitted via the ED: post hoc analysis from a retrospective study
.
Am J Emerg Med
.
2015
;
33
(
12
):
1725
1731
22
Lee
I-H
,
Chen
C-T
,
Lee
Y-T
, et al
.
A new strategy for emergency department crowding: high-turnover utility bed intervention
.
J Chin Med Assoc
.
2017
;
80
(
5
):
297
302
23
Wei
G
,
Arya
R
,
Ritz
ZT
,
He
AS
,
Ohman-Strickland
PA
,
McCoy
JV
.
How does emergency department crowding affect medical student test scores and clerkship evaluations?
West J Emerg Med
.
2015
;
16
(
6
):
913
918
24
Colthart
I
,
Bagnall
G
,
Evans
A
, et al
.
The effectiveness of self-assessment on the identification of learner needs, learner activity, and impact on clinical practice: BEME Guide no. 10
.
Med Teach
.
2008
;
30
(
2
):
124
145

Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.