Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health

Introduction: Increasing patient utilization and overcapacity threaten efficiency of care provided and the teaching mission. This study investigates the influence of medical students (MS) involvement on ED throughput, resource utilization, clinical outcomes, and addresses gaps in existing literature that primarily focus on resident physicians and singular throughput metrics.

Methods: A retrospective observational analysis was conducted on 123,503 patient encounters with age >21 years at an urban tertiary care hospital, comparing cases with and without medical student participation. Continuous variables were compared using t-tests with bootstrap, and categorical variables by chi-square tests. Continuous variables were reported with mean and standard deviation (SD), and the 95% confidence interval (CI) of mean difference was reported.

Results: Across all encounters, door-to-provider time showed no significant difference between encounters with MS (28.07 minutes ± 38.61) and without MS (28.39 minutes ± 37.99; P = 0.435). However, door-to-triage time was significantly shorter with MS involvement (14.32 minutes ± 15.02 vs. 15.69 minutes ± 27.67; P < 0.01). Arrival-to-disposition time (292.55 minutes ± 193.66 vs. 270.39 minutes ± 532.80; P < 0.01) and doctor-to-disposition time (266.83 minutes ± 186.12 vs. 242.93 minutes ± 376.38; P < 0.01) were both significantly longer with MS involvement. Utilization measures per 100 visits showed significant differences in CT scans (45.17/100 visits with MS vs 40.96/100 without, P<0.01) and plain radiographs (47.12/100 visits with MS vs 44.70/100 visits with, P<0.01) but not in MRIs, ultrasounds, or portable chest radiographs.  Patient outcomes included higher admission rates (23.06% vs. 18.13%; P < 0.01) and higher AMA rates (1.65% vs. 1.12%; P < 0.01) for encounters with MS. However, the discharge rate was lower (56.63% vs. 66.66%; P < 0.01), with no significant difference in the rate of patients returning to the ED within 72 hours (6.27% vs. 6.42%; P = 0.55).

In subgroup analysis of high complexity encounters, MS patients experienced shorter door-to-provider times (26.59 vs. 28.22 minutes, P < 0.01), door-to-triage times (13.55 vs. 14.46 minutes, P = 0.03), arrival-to-disposition (301.13 vs. 307.74 minutes, P =0.02) and doctor-to-disposition times (275.19 vs. 281.34 minutes, P=0.02). Utilization of CT scans and MRIs showed no significant differences. Medical student covered patient admission rates were equivalent (34.35% vs 33.59%, P=0.22), while discharge rates were lower (45.42% vs. 48.44%, P < 0.01), with no significant differences in rates of leaving AMA or returning to the ED within 72 hour. 

Conclusion: Though medical student involvement is generally associated with longer patient stays in the ED, student involvement was shown to improve efficiency in the management of high-complexity cases. Increased rates of some diagnostic imaging and higher admission rates occurred with medical students. Limitations, including the retrospective nature and single-center design, highlight the need for multi-center validation of these findings to inform future resource allocation and educational strategies in the ED.