A comparison of emergency medicine resident clinical experience in a rural versus urban emergency department

Introduction: Strategies for increasing the numbers of American Board of Emergency Medicine certified/emergency medicine (EM) residency trained physicians practicing in rural emergency departments (EDs) include providing rural EM experiences during residency training. However, no studies to date describe the clinical work of EM residents rotating in a rural ED. The objective of the study was to compare the clinical experience of EM residents participating in a rural ED rotation with that on an urban university-based ED rotation. Methods: Second-year EM residents completing both urban and rural clinical ED rotations self-reported the number of patients evaluated, number of patients admitted and admitting bed type, and the number and type of procedures performed over a 6 month period. Total admission rates, telemetry admission rates, and intensive care unit (ICU) admission rates were calculated and compared by z-test for two proportions. Total numbers for central venous access, conscious sedation, dislocation or fracture relocation/reduction endotracheal intubation, laceration repair, lumbar puncture, tube thoracostomy adult medical resuscitation,


Introduction:
Strategies for increasing the numbers of American Board of Emergency Medicine certified/emergency medicine (EM) residency trained physicians practicing in rural emergency departments (EDs) include providing rural EM experiences during residency training.However, no studies to date describe the clinical work of EM residents rotating in a rural ED.The objective of the study was to compare the clinical experience of EM residents participating in a rural ED rotation with that on an urban university-based ED rotation.
Methods: Second-year EM residents completing both urban and rural clinical ED rotations self-reported the number of patients evaluated, number of patients admitted and admitting bed type, and the number and type of procedures performed over a 6 month period.Total admission rates, telemetry admission rates, and intensive care unit (ICU) admission rates were calculated and compared by z-test for two proportions.Total numbers for central venous access, conscious sedation, dislocation or fracture relocation/reduction endotracheal intubation, laceration repair, lumbar puncture, tube thoracostomy adult medical resuscitation,

Introduction
Most emergency medicine (EM) residency programs are located in metropolitan areas in the USA with the majority of resident clinical experience occurring at the primary institution's urban emergency department (ED).Some programs also include a 'community ED' rotation, but these experiences typically occur in a suburban or urban environment in close proximity to the sponsoring institution.
Few EM residency programs provide the opportunity to participate in a clinical rotation in a rural ED and only one, to the best of our knowledge, requires a rural EM month.

Studies describing low numbers of EM residency trained/board certified emergency physicians (EPs)
practicing in rural EDs has led to various initiatives intended to encourage residency graduates to consider a rural practice setting 1,2 .The development of clinical experiences in rural EM, limited to a few programs nationally, seeks to impact the EM residency graduate's choice of future practice location.However, beyond the perceived benefit of exposing EM residents to a rural practice environment, the clinical experience in a rural ED must provide a sufficient number of patients and adequate acuity to serve as a legitimate training site for EM resident physicians.
The purpose of this study was to compare the clinical experience of EM residents participating in a rural ED rotation with that of an urban university-based ED rotation.

Methods
The urban ED is located in a mid-western US city with a population of 404 267 and a metropolitan area population of 716 998.The ED serves a tertiary referral center with 31 beds including 4 trauma bays and a four-room fast-track area with an annual census of 42 647.The rural ED is located in a community of 14 814, approximately 480 miles (722.5 km) from the metropolitan area of the primary ED.
The rural ED is a Level II trauma center and serves as a regional referral center for a four-state area.The ED is a 12 bed facility, including 3 trauma bays, with an annual census of 15 283.
Post-graduate year 2 (PGY2) EM residents completing both urban and rural clinical ED rotations self-reported the number of patients evaluated, number of patients admitted and admitting bed type, and the number and type of procedures performed over a 6 month period.Total admission rates, telemetry admission rates, and intensive care unit (ICU) admission rates were calculated and compared by z-test for two proportions.Total numbers for central venous access, procedural sedation, dislocation or fracture relocation/reduction, endotracheal intubation, laceration repair, lumbar puncture, tube thoracostomy, adult medical resuscitation, adult trauma resuscitation, pediatric medical resuscitation, pediatric trauma resuscitation, and the total number of ED hours completed at each clinical site were collected.Procedure and resuscitation numbers were calculated per 100 resident-hours in the ED.

Results
Five of six residents (83%) completed the clinical data forms.Patients evaluated per hour in the rural versus urban EDs were not different by a statistically significant margin at 1.22 and 1.21, respectively.Rural versus urban ED total admission rates were 21.74% (95% CI, 19.01-24.47)versus 33.35% (31.50-35.20),telemetry admission rates were 3.40% (2.28-4.52)versus 14.24% (12.87-15.61),and ICU admission rates were 0.9% (0.31-1.49) versus 4.38% (3.58-5.18),with the differences in all admission rates determined to be statistically significant (Table 1).Rural versus urban procedures/100 resident-hours in the ED were 0 versus 0.6 for central venous access (p = 0.087), 0.8 versus 0.   Using data obtained from the only required rural ED rotation for EM residents in the USA at the time of the present study, the clinical experience of a single resident at a rural site-as determined by patients per hour and frequency of most procedures and resuscitation types was found to closely approximate that of a resident rotating in the primary ED of the residency program located in an urban area.A nearly identical number of patients per hour was found in residents rotating at the urban and rural sites, and similar procedure numbers for four out of seven procedures.Of the three procedures with statistically significant differences between the urban and rural sites, two occurred more frequently in the rural ED (fracture/dislocation management and laceration repair), while only intubations were performed more often in the urban ED.Likewise, resuscitations yielded a mixed result, with no statistically significant differences between two of four types (adult and pediatric medical), but resident experience with adult trauma occurring more frequently at the urban site and pediatric trauma at the rural ED.
Although residents rotating at both urban and rural sites reported a similar number of patients evaluated per hour, statistically significant differences in the acuity measures of telemetry and intensive care admissions -14.24% versus 3.40% and 4.38% versus 0.9% for the urban and rural sites, respectively -indicate a rural site may not provide adequate ED critical care opportunities to serve as a primary training site.Furthermore, the statistically significant differences in the frequency of certain critical procedures and resuscitation types (such as intubations and adult trauma) require an assessment of the amount of time allocated for a rural ED experience in order to ensure adequate clinical experience during the course of residency training.However, while the residents included in this study performed fewer intubations than their urban counterparts during the 6 month study period, other procedures, such as the management of fractures and dislocations and complex laceration repair, were performed more frequently in the rural ED by statistically significant margins.In view of these findings, recommendations for locating EM residencies in rural areas may require specific modifications emphasizing the urbanrural hybrid approach, with balanced clinical experience incorporating the benefits available at both types of training sites.

Conclusion
A rural ED rotation provides an active clinical experience, with patients per hour and most procedure frequencies being similar to those at urban sites, but with lower patient acuity, as determined by both total and intensive care admission rates.

Table 2 : Rural and urban emergency department procedures and resuscitations
11riety of hospitals which may include rural EDs10.Some countries have focused on fellowship programs to improve the clinical skills of primary care physicians responsible for ED staffing in rural communities.Specifically, New Zealand and Canada offer postgraduate training programs designed to enhance the EM skills of non-EM residency trained practitioners11.