Effect of resident complement on timeliness of stroke team activation in an academic emergency department

Objectives Investigations of the impact of residents on emergency department (ED) timeliness of care typically focus only on global ED flow metrics. We sought to describe the association between resident complement/supervisory ratios and timeliness of ED care of a specific time‐sensitive condition, acute stroke. Methods We matched ED stroke patient arrivals at 1 academic stroke center against resident and attending staffing and constructed a Cox proportional hazards model of door‐to‐activation (DTA) time (ie, ED arrival [“door”] to stroke team activation). We considered multiple predictors, including calculated ratios of residents supervised by each attending physician. Results Among 462 stroke activation patients in 2014–2015, DTA ranged from 1 to 217 minutes, 72% within 15 minutes. The median number of emergency and off‐service residents supervised per attending were 1.7 (interquartile range [IQR], 1.3–2.3) and 0.7 (IQR, 0–1), respectively. A 1‐resident increase in off‐service residents was associated with a 24% decrease (hazard ratio [HR], 0.76; 95% confidence interval [CI], 0.64–0.90) in the probability of stroke team activation at any given time. An independent 1‐resident increase in the number of emergency residents was associated with a 13% increase (HR, 1.13; 95% CI, 1.01–1.25) in timely activation. Conclusion Timeliness of care for acute stroke may be impacted by how academic EDs configure the complement and supervisory structures of residents. Higher supervisory demands imposed by increasing the proportion of rotating off‐service residents may be associated with slower stroke recognition and DTA times, but this effect may be offset when more emergency residents are present.