Background

Speed and efficiency are important qualities for an ED doctor. On every shift there is constant pressure to see patients, make decisions, and maintain flow through our departments.

Do you think of yourself as particularly fast, or do you worry that you might be a little slow? Have you ever wondered how you compare to the average?

Physician productivity is often defined as new patients evaluated per hour. Current scheduling recommendations are made using an average calculated over an entire shift. This study suggests this may not be the most accurate way of doing things…

The paper

Joseph JW, Davis S, Wilker EH. Modelling attending physician productivity in the emergency department: a multicentre study. Emerg Med J. 2018 May;35(5):317-322^​[1]​

This was a retrospective, observational study of timestamp data in three separate suburban community hospital EDs in north-eastern USA. Each site had similarly structured 8 or 9-hour shifts. There were dedicated ‘Minors’ areas (limited to patients with Emergency Severity Index level 4 and 5 complaints, such as an ankle sprain or medication refill) that were staffed by mid-level providers (MLPs) operating largely independently, and no resident or trainee physicians were rotating at the sites. Therefore, this is a study of attending physicians’ (consultants in the UK) productivity over time, uninterrupted by supervisory or management concerns.

The final data set for analysis comprised 200,772 patient encounters, across 9,822 shifts, evaluated by 64 attending physicians. Physicians saw an average of 16.4 patients per shift. They saw an average of 2.7 patients in the first hour, but by the midpoint of the shift, they had lost around half of their initial productivity relative to the first hour. By the seventh hour of the shift physicians at all three sites fell below one patient per hour.

Why does productivity decline over a shift?

There are likely two reasons for this. The first is purely mechanistic. At the beginning of a shift, a doctor can see as many patients as she wishes. However, each patient may need further investigation, observation or treatment before a decision about disposition can be made. The doctor can pick up more patients, but at some point she must return to her existing patients and address the new data.

The second reason is psychological. As a shift progresses, doctors experience a build-up of physical and cognitive fatigue, which results in slower practice in general, and decision making in particular. ED shift schedules are also often out of alignment with circadian rhythms, further compounding the problem.

The bottom line

The number of new patients a doctor sees declines significantly over subsequent hours of the shift. Doctors should expect this and be wary of taking on too high a workload towards the end of a shift. Schedulers should acknowledge this and aim to schedule shifts to start near times of high volume.

What about registrars / residents?

In 2017 a similar paper^​[2]​ looked at the productivity of residents (roughly rquivalent to core trainees and registrars in the UK). Overall, residents treated a mean of 10.1 patients per shift. In the initial hour, residents treated a mean of 2.14 patients, and every subsequent hour was associated with a significant decrease. It was 1.2 at 4 hours and 0.5 at 8 hours.

Is there any guidance from RCEM on this?

A 2015 document^​[3]​ sets forth the following expectations for staff of various levels working in the ED, as a guide to staffing and scheduling departments:

• A nurse practitioner (ENP) working in Minors, and seeing mostly minor injury, would generally be expected to see 2-3 patients per hour.

• Tier 2 practitioners (F2, CT1-2, PA) are generally thought to see about 1 Majors patient per hour.

• Tiers 3 and 4 practitioners (CT3 and above) will see between about 0.5 and 3 patients per hour, depending on such variables as experience, professional development, case mix, the effectiveness of efforts to maximise workforce efficiency, the requirement to move between physical areas, procedures undertaken and supervisory demands


• Tier 5 (consultants supervising a department) may see no new patients, in order to maximise their efficacy in the ‘command and control’ role, and to avoid potentially disadvantaging patients they do see through interruptions and multitasking.

References

1. 
   
   
   

   Joseph J, Davis S, Wilker E, Wong M, Litvak O, Traub S, et al. Modelling attending physician productivity in the emergency department: a multicentre study. Emerg Med J [Internet] 2018;35(5):317–22. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29545355

   
   
   
   


2. 
   
   
   

   Joseph J, Henning D, Strouse C, Chiu D, Nathanson L, Sanchez L. Modeling Hourly Resident Productivity in the Emergency Department. Ann Emerg Med [Internet] 2017;70(2):185-190.e6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28110994

   
   
   
   


3. 
   
   
   

   Service Design and Delivery C. Medical and Practitioner Staffing in Emergency Departments [Internet]. RCEM (Royal College of Emergency Medicine)2015 [cited 2019 Nov];Available from: https://www.rcem.ac.uk/docs/Workforce/RCEM%20Medical%20and%20Practitioner%20Staffing%20in%20EDs.pdf