Decreased trainee autonomy suggested with in-hospital intensivist coverage

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1. Pediatric trainees and intensivists report less autonomy and readiness for independent practice when training in an in-hospital attending coverage model versus a home-call model within the Pediatric Intensive Care Unit (PICU). 

2. Almost all survey respondents, regardless of coverage model, felt the PICU was a good educational experience for pediatric trainees. 

Evidence Rating Level: 3 (Average) 

Study Rundown: Due to concerns for patient safety, more hospitals in the United States have turned to 24/7 in-hospital coverage by intensivists in the PICU in the recent years. While this closer PICU attending coverage on nights and weekends has addressed patient safety concerns, it has subsequently raised questions regarding whether such an in-hospital attending model compromises pediatric resident and fellow education opportunities. To assess perspectives on these training models, researchers conducted a survey of pediatric residents, critical care fellows, and intensivists across both in-hospital and home-call models. Findings showed that though the majority of trainees and attendings were satisfied with the PICU educational experience, there was still uneasiness over housestaff autonomy and preparedness for independent practice when training in an in-hospital coverage compared to a home-call model. Such concerns were reported at higher levels by intensivists than trainees themselves. This study was limited by its data collection from self-selected respondents, but suggests continued attention to the balance of educational opportunities with greater attending coverage.

Click to read the study published today in Pediatrics

Click to read a commentary, published today in Pediatrics

Relevant Reading: ACGME: Duty Hours Standards

Study Author, Dr. Kyle J. Rehder, MD, talks to 2 Minute Medicine: Division of Pediatric Critical Care Medicine, Department of Pediatrics, Duke Children’s Hospital, Duke University Medical Center, Durham, North Carolina

“As an increasing number of hospitals are moving towards 24/7 in-hospital intensivist coverage of their ICUs, we must also be thoughtful of the unintended consequences of this shift in coverage model, both on faculty and trainees. Autonomy is an important facet of housestaff education, and we were concerned that autonomy would be diminished with increased attending bedside presence. Our survey of North American pediatric intensivists, critical care fellows, and residents demonstrates that this concern is prevalent, with over one-third of respondents reporting their perception that housestaff will not be prepared for independent practice after training in a program with 24/7 attending coverage. Moving forward, we need to utilize increased attending presence to enhance the overall educational experience while also continuing to pursue methods to ensure opportunities for housestaff to make autonomous decisions.”

In-Depth [cross-sectional study]: This cross-sectional study examined results from an 80-question online survey centered on pediatric resident, medicine-pediatric resident, and critical care fellow educational experiences in relation to in-hospital attending coverage. In-hospital attending coverage, which includes the presence of a pediatric intensivist in the hospital 24 hours daily, was compared to a home-call model where intensivists are nearby but not in the hospital during night and weekend hours and to a mixed model. The survey generated 1323 responses from pediatric or medicine-pediatric residents (620), pediatric critical care fellows (174), and pediatric intensivists (457). An overwhelming majority (96%) noted the PICU to be a good educational experience overall. However, significantly less intensivists than trainees (50% v. 67%, P < 0.0001) felt in-hospital coverage adequately prepared residents and fellows for independent practice when compared to a home-call model; self-reported readiness, though, for pediatric emergency response was similar between the two models. Residents with in-hospital models were additionally noted to have less adequate procedural experience (36% in-hospital v. 51% home-call, P < 0.01).

By Neha Joshi and Leah H. Carr

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