Prospective time study derivation of emergency physician workload predictors

The National Emergency Department Overcrowding Scale and Perceived Staff Workload: Evidence for Construct Validity in a Pediatric Setting

OBJECTIVE

The aim of the study is to determine if there is a correlation between perceived staff workload, measured by the NASA Task Load Index (TLX), and the National Emergency Department Overcrowding Scale (NEDOCS) in a pediatric ED.

METHODS

We collected staff questionnaires in a large, urban pediatric ED to assess perceived workload on each of six different TLX subscales, which we weighted evenly to create an overall estimate of workload. We evaluated the correlation between individual TLX responses and NEDOCS overall and by staff subgroup. Additionally, we analyzed: (1) the correlation between mean TLX responses and NEDOCS within a given hour and (2) the performance of a logistic regression model, using TLX as a predictor for "severely overcrowded," as measured by NEDOCS.

RESULTS

Four hundred one questionnaires between 6/2018 and 1/2019 demonstrated significant variation between concurrently collected TLX responses and an overall poor correlation between perceived workload and NEDOCS (R2 0.096 [95% confidence interval, 0.048-0.16]). TLX responses by subgroups of fellows (n = 4, R2 0.96) and patient financial advisors (n = 15, R2 0.58) demonstrated the highest correlation with NEDOCS. Taking mean TLX responses within a given hour, during periods with NEDOCS >60 (extremely busy or overcrowded), a polynomial trend line matched the data best (R2 0.638). On logistic regression, the TLX predicts "severely overcrowded" with an area under the curve of the receiver operating characteristic of 0.731.

CONCLUSIONS

NEDOCS does not have a strong correlation with individual responses on questionnaires of perceived workload for staff in a pediatric ED. NEDOCS, as a measure of overcrowding, may be better correlated with perceived workload during periods with elevated crowding or when interpreted categorically as yes/no "severely overcrowded".

Strategies to Measure and Improve Emergency Department Performance: A Review

Emergency Departments (EDs) globally face escalating challenges such as overcrowding, resource limitations, and increased patient demand. This study aims to identify and analyze strategies to enhance the structural performance of EDs, with a focus on reducing overcrowding, optimizing resource allocation, and improving patient outcomes. Through a comprehensive review of the literature and observational studies, the research highlights the effectiveness of various approaches, including triage optimization, dynamic staffing, technological integration, and strategic resource management. Key findings indicate that tailored strategies, such as implementing advanced triage protocols and leveraging telemedicine, can significantly reduce wait times and enhance patient throughput. Furthermore, evidence suggests that dynamic staffing models and the integration of cutting-edge diagnostic tools contribute to operational efficiency and improved quality of care. These strategies, when combined, offer a multifaceted solution to the complex challenges faced by EDs, promising better patient care and satisfaction. The study underscores the need for a comprehensive approach, incorporating both organizational and technological innovations, to address the evolving needs of emergency healthcare.

Assessing the reliability of pediatric emergency medicine billing code assignment for future consideration as a proxy workload measure

OBJECTIVES

Prediction of pediatric emergency department (PED) workload can allow for optimized allocation of resources to improve patient care and reduce physician burnout. A measure of PED workload is thus required, but to date no variable has been consistently used or could be validated against for this purpose. Billing codes, a variable assigned by physicians to reflect the complexity of medical decision making, have the potential to be a proxy measure of PED workload but must be assessed for reliability. In this study, we investigated how reliably billing codes are assigned by PED physicians, and factors that affect the inter-rater reliability of billing code assignment.

METHODS

A retrospective cross-sectional study was completed to determine the reliability of billing code assigned by physicians (n = 150) at a quaternary-level PED between January 2018 and December 2018. Clinical visit information was extracted from health records and presented to a billing auditor, who independently assigned a billing code-considered as the criterion standard. Inter-rater reliability was calculated to assess agreement between the physician-assigned versus billing auditor-assigned billing codes. Unadjusted and adjusted logistic regression models were used to assess the association between covariables of interest and inter-rater reliability.

RESULTS

Overall, we found substantial inter-rater reliability (AC2 0.72 [95% CI 0.64-0.8]) between the billing codes assigned by physicians compared to those assigned by the billing auditor. Adjusted logistic regression models controlling for Pediatric Canadian Triage and Acuity scores, disposition, and time of day suggest that clinical trainee involvement is significantly associated with increased inter-rater reliability.

CONCLUSIONS

Our work identified that there is substantial agreement between PED physician and a billing auditor assigned billing codes, and thus are reliably assigned by PED physicians. This is a crucial step in validating billing codes as a potential proxy measure of pediatric emergency physician workload.

Acuity-based rotational patient-to-physician assignment in an emergency department using electronic health records in triage

Emergency department (ED) operational metrics generated by a new acuity-based rotational patient-to-physician assignment (ARPA) algorithm are compared with those obtained with a simple rotational patient assignment (SRPA) system aimed only at an equitable patient distribution. The new ARPA method theoretically guarantees that no two physicians' assigned patient loads can differ by more than one, either partially (by acuity levels) or in total; whereas SRPA guarantees only the latter. The performance of the ARPA method was assessed in practice in the ED of the main public hospital (Hospital Compound of Navarra) in the region of Navarre in Spain. This ED attends over 140 000 patients every year. Data analysis was conducted on 9,063 ED patients in the SRPA cohort, and 8,892 ED patients in the ARPA cohort. The metrics of interest are related both to patient access to healthcare and physician workload distribution: patient length of stay; arrival-to-provider time; ratio of patients exceeding the APT target threshold; and range of assigned patients across physicians by priority levels. The transition from SRPA to ARPA is associated with improvements in all ED operational metrics. This research demonstrates that ARPA is a simple and useful strategy for redesigning front-end ED processes.

Emergency Department Mean Physician Time per Patient and Workload Predictors ED-MPTPP

One key element for emergency department (ED) staff calculation is the mean physician time per patient (MPTPP) and its influencing factors. The aims of this study were measuring the MPTPP, identifying factors with significant influence on the MPTPP, and developing a model to predict the MPTPP. This study was a prospective trial conducted at the ED of a university hospital in Germany. The MPTPP was measured with a specifically developed app. The influence of different factors on MPTPP were first tested in univariate analysis. Then, all significant factors were used in a multivariant regression model to minimize collinearities and to develop a prediction model. In total, 202 patients treated by 32 different physicians were observed within one year. The MPTPP was 47 min (standard deviation: 34 min). Relevant factors influencing the MPTPP were treatment area, Emergency Severity Index (ESI) triage level, guiding symptom category, and physician level (all p < 0.001). This model predicted 45% of the variance in the MPTPP (p < 0.001), which corresponds to a large effect size. We developed an effective prediction model for ED MPTPP, resulting in an MPTPP of 47 min. Future studies are needed to validate our model, which could serve as a benchmark for other EDs where the MPTPP is not available.

Consistency of triage scores by presenting complaint pre- and post-implementation of a real-time electronic triage decision support tool

OBJECTIVE

eCTAS is a real-time electronic decision-support tool designed to standardize the application of the Canadian Triage and Acuity Scale (CTAS). This study addresses the variability of CTAS score distributions across institutions pre- and post-eCTAS implementation.

METHODS

We used population-based administrative data from 2016-2018 from all emergency departments (EDs) that had implemented eCTAS for 9 months. Following a 3-month stabilization period, we compared 6 months post-eCTAS data to the same 6 months the previous year (pre-eCTAS). We included triage encounters of adult (≥17 years) patients who presented with 1 of 16 pre-specified, high-volume complaints. For each ED, consistency was calculated as the absolute difference in CTAS distribution compared to the average of all included EDs for each presenting complaint. Pre-eCTAS and post-eCTAS change scores were compared using a paired-samples t-test. We also assessed if eCTAS modifiers were associated with triage consistency.

RESULTS

There were 363,214 (183,231 pre-eCTAS, 179,983 post-eCTAS) triage encounters included from 35 EDs. Triage scores were more consistent (P < 0.05) post-eCTAS for 6 (37.5%) presenting complaints: chest pain (cardiac features), extremity weakness/symptoms of cerebrovascular accident, fever, shortness of breath, syncope, and hyperglycemia. Triage consistency was similar pre- and post-eCTAS for altered level of consciousness, anxiety/situational crisis, confusion, depression/suicidal/deliberate self-harm, general weakness, head injury, palpitations, seizure, substance misuse/intoxication, and vertigo. Use of eCTAS modifiers was associated with increased triage consistency.

CONCLUSIONS

eCTAS increased triage consistency across many, but not all, high-volume presenting complaints. Modifier use was associated with increased triage consistency, particularly for non-specific complaints such as fever and general weakness.

[Physician staffing and shift work schedules : Concepts for emergency and intensive care medicine]

Human resource development is a key factor for a successful management of Intensive Care Units (ICU) and Emergency Departments (ED). It comprises the processes of recruiting and retaining employees. The present article offers strategies how the optimal manning level in ICUs and EDs can be determined and highlights the importance of active management of well being in acute care units. The manning level can be determined by using the work place method which is the common method for ICUs. For the EDs a method based on the specific times which are needed for patient care in relation to the intensity of care is more appropriate. This method needs to integrate the patient number per hour, the time needed per patient, and the defined service level particularly with respect to the time to be seen by a physician. For detailed staff calculation, complex mathematical models are needed (e.g. Erlang formula). The resulting manning level needs then to be distributed on the various shifts. Additional resources are needed for observation units and additional tasks like management tasks etc. Retainment of employees is only possible when the working field remains attractive over many years. While a structured and competence based education is of utmost importance in the beginning of a carrier, attractive rooster plans and the compatibility between work and private life, becomes more important when the specialisation has been achieved.

Interrater Reliability, Accuracy, and Triage Time Pre- and Post-implementation of a Real-Time Electronic Triage Decision-Support Tool

STUDY OBJECTIVE

The electronic Canadian Triage and Acuity Scale (eCTAS) is a real-time electronic triage decision-support tool designed to improve patient safety and quality of care by standardizing the application of the Canadian Triage and Acuity Scale (CTAS). The objective of this study is to determine interrater agreement of triage scores pre- and post-implementation of eCTAS.

METHODS

This was a prospective, observational study conducted in 7 emergency departments (EDs), selected to represent a mix of triage documentation practices, hospital types, and patient volumes. A provincial CTAS auditor observed triage nurses in the ED pre- and post-implementation of eCTAS and assigned an independent CTAS score in real time. Research assistants independently recorded triage time. Interrater agreement was estimated with κ statistics with 95% confidence intervals (CIs).

RESULTS

A total of 1,491 individual triage assessments (752 pre-eCTAS, 739 post-implementation) were audited during 42 7-hour triage shifts (21 pre-eCTAS, 21 post-implementation). Exact modal agreement was achieved for 567 patients (75.4%) pre-eCTAS compared with 685 patients (92.7%) triaged with eCTAS. With the auditor's CTAS score as the reference, eCTAS significantly reduced the number of patients over-triaged (12.0% versus 5.1%; Δ 6.9; 95% CI 4.0 to 9.7) and under-triaged (12.6% versus 2.2%; Δ 10.4; 95% CI 7.9 to 13.2). Interrater agreement was higher with eCTAS (unweighted κ 0.89 versus 0.63; quadratic-weighted κ 0.93 versus 0.79). Median triage time was 312 seconds (n=3,808 patients) pre-eCTAS and 347 seconds (n=3,489 patients) with eCTAS (Δ 35 seconds; 95% CI 29 to 40 seconds).

CONCLUSION

A standardized, electronic approach to performing triage assessments improves both interrater agreement and data accuracy without substantially increasing triage time.

Understanding better how emergency doctors work. Analysis of distribution of time and activities of emergency doctors: a systematic review and critical appraisal of time and motion studies

BACKGROUND

Optimising the efficiency and productivity of senior doctors is critical to ED function and delivery of safe patient care. Time and motion studies (TMS) can allow quantification of how these doctors spend their working time, identify inefficiencies in the current work processes and provide insights into improving working conditions, and enhancing productivity. Three questions were addressed: (1) How do senior emergency doctors spend their time in the ED? (2) How much of their time is spent on multitasking? (3) What is the number of tasks completed per hour?

METHODS

The literature was systematically searched for TMS of senior emergency doctors. We searched for articles published in peer-reviewed journals in English language from 1998 to 2018 in the following databases: MEDLINE, EMBASE, Scopus, Web of Science and Cochrane. Studies were assessed for methodological quality using evidence-based quality criteria relevant for TMS including duration of observation, observer bias, Hawthorne effect and whether the task classification acknowledged any previous existing schemes. A narrative synthesis approach was followed.

RESULTS

Fourteen TMS were included. The studies were liable to several biases including observer and Hawthorne bias. Overall, the time spent on direct face-to-face contact with the patient accounted for at least around 25%-40% of the senior doctors' time. The remaining time was mostly spent on indirect clinical care such as communication (8%-44%), documentation (10%-28%) and administrative tasks (2%-20%). The proportion of time spent on multitasking ranged from 10% to 23%. When reported, the number of tasks performed per hour was generally high.

CONCLUSION

The review revealed that senior doctors spent a large percentage of their time on direct face-to-face contact with patients. The review findings provided a grounded understanding of how senior doctors spent their time in the ED and could be useful in implementing improvements to the emergency care system.

Evaluating the Relationship between Productivity and Quality in Emergency Departments

BACKGROUND

In the United States, emergency departments (EDs) are constantly pressured to improve operational efficiency and quality in order to gain financial benefits and maintain a positive reputation.

OBJECTIVES

The first objective is to evaluate how efficiently EDs transform their input resources into quality outputs. The second objective is to investigate the relationship between the efficiency and quality performance of EDs and the factors affecting this relationship.

METHODS

Using two data sources, we develop a data envelopment analysis (DEA) model to evaluate the relative efficiency of EDs. Based on the DEA result, we performed multinomial logistic regression to investigate the relationship between ED efficiency and quality performance.

RESULTS

The DEA results indicated that the main source of inefficiencies was working hours of technicians. The multinomial logistic regression result indicated that the number of electrocardiograms and X-ray procedures conducted in the ED and the length of stay were significantly associated with the trade-offs between relative efficiency and quality. Structural ED characteristics did not influence the relationship between efficiency and quality.

CONCLUSIONS

Depending on the structural and operational characteristics of EDs, different factors can affect the relationship between efficiency and quality.

Prehospital Application of the Canadian Triage and Acuity Scale by Emergency Medical Services

OBJECTIVES

Triage is fundamental to emergency patient assessment. Effective triage systems accurately prioritize patients and help predict resource utilization. CTAS is a validated five-level triage score utilized in Emergency Departments (EDs) across Canada and internationally. Historically CTAS has been applied by triage nurses in EDs. Observational evidence suggests that the CTAS might be implemented reliably by paramedics in the prehospital setting. This is the first system-wide assessment of CTAS interrater reliability between paramedics and triage nurses during clinical practice.

METHODS

Variables were extracted from hospital and EMS databases. EMS providers determined CTAS on-scene, CTAS pre-transport, and CTAS on-arrival at hospital for each patient (N=14,378). The hospital arrival EMS CTAS (CTAS arrival ) score was compared to the initial nursing CTAS score (CTAS initial ) and the final nursing CTAS score (CTAS final ) incuding nursing overrides. Interrater reliability between ED CTAS initial and EMS CTAS arrival scores was assessed. Interrater reliability between ED CTAS final and EMS CTAS arrival scores, as well as proportion of patient encounters with perfect or near-perfect agreement, were evaluated.

RESULTS

Our primary outcome, interrater reliability [kappa=0.437 (p<0.001, 95% CI 0.421-0.452)], indicated moderate agreement. EMS CTAS arrival and ED CTAS initial scores had an exact or within one point match 84.3% of the time. The secondary interrater reliability outcome between hospital arrival EMS CTAS (CTAS arrival ) score and the final ED triage CTAS score (CTAS final ) showed moderate agreement with kappa =0.452 (p<0.001, 95% CI 0.437-0.466).

CONCLUSIONS

Interrater reliability of CTAS scoring between triage nurses and paramedics was moderate in this system-wide implementation study.

Exploring Medical Student Learning Needs in the Pediatric Emergency Department: "What Do You Want to Learn Right Now?"

BACKGROUND

When precepting medical students in the emergency department, faculty physicians often have only minutes per patient encounter to devote to direct teaching. Instructional strategies that promote independent student learning after each case may have merit. It is not known, however, to what degree patient-triggered learning needs are amenable to independent study.

OBJECTIVE

The aims of this study were to determine self- and faculty-reported learner needs at the time of patient encounters and to assess the degree to which these perceived needs may be satisfied by independent study.

METHODS

We interviewed medical students and faculty in our pediatric emergency department. Immediately before or after they saw a patient, we asked "What do you want to learn right now?". For half of the student interviews, we separately asked the same questions of their preceptors. Interviews were taped and transcribed. Responses were coded by 3 investigators who did content analysis to identify dominant themes and the extent to which the learning need could be addressed independently. Investigators agreed that Accreditation Council for Graduate Medical Education competency domains could be used to classify the responses.

RESULTS

We interviewed 82 students and 44 preceptors yielding 126 patient-triggered learning needs. Competency area(s) were medical knowledge (70), patient care (1), interpersonal skills (27), systems-based practice (2), practice-based learning (3), and professionalism (4). Two raters independently assigned the same competency in 89%. Medical knowledge competency learning needs were almost all at least moderately amenable to independent learning (68/70, 98%), but the other competencies were not (22/57, 39%) according to the raters (interrater reliability, 0.7). Preceptor responses were congruent in competency type with students' responses in 29 (67%) of 43. Students listed interpersonal skills deficits far more often than did faculty (24% vs 5%, P < 0.05).

CONCLUSIONS

Most student learning needs in the pediatric emergency department focus on medical knowledge. These deficits could be amenable to structured independent study at the point of care.

Using Computer Simulation to Study Nurse-to-Patient Ratios in an Emergency Department

OBJECTIVE

To study the impact of nurse-to-patient ratios on patient length of stay (LOS) in computer simulations of emergency department (ED) care.

METHODS

Multiple 24-hour computer simulations of emergency care were used to evaluate the impact of different minimum nurse-to-patient ratios related to ED LOS, which is composed of wait (arrival to bed placement) and bedtime (bed placement to leave bed).

RESULTS

Increasing the number of patients per nurse resulted in increased ED LOS. Mean bedtimes in minutes were impacted by nurse-to-patient ratios.

CONCLUSIONS

In computer simulation of ED care, increasing the number of patients per nurse resulted in increasing delays in care (ie, increasing bedtime).

Implementation of an automated, real-time public health surveillance system linking emergency departments and health units: rationale and methodology

In September 2004, Kingston, Frontenac, Lennox and Addington (KFL&amp;A) Public Health, in collaboration with the Public Health Division of the Ontario Ministry of Health and Long-Term Care, Queen's University, the Public Health Agency of Canada, Kingston General Hospital and Hotel Dieu Hospital, began a 2-year pilot project to implement and evaluate an emergency department (ED) chief complaint syndromic surveillance system. Our objective was to evaluate a comprehensive and readily deployable real-time regional syndromic surveillance program and to determine its ability to detect gastrointestinal or respiratory outbreaks well in advance of traditional reporting systems. In order to implement the system, modifications were made to the University of Pittsburgh's Real-time Outbreak and Disease Surveillance (RODS) system, which has been successfully integrated into public health systems, and has enhanced communication and collaboration between them and EDs. This paper provides an overview of a RODS-based syndromic surveillance system as adapted for use at a public health unit in Kingston, Ontario. We summarize the technical specifications, privacy and security considerations, data capture, classification and management of the data streams, alerting and public health response. We hope that the modifications described here, including the addition of unique data streams, will provide a benchmark for future Canadian syndromic surveillance systems.

Physician workload and the Canadian Emergency Department Triage and Acuity Scale: the Predictors of Workload in the Emergency Room (POWER) Study

Introduction:

The Canadian Emergency Department Triage and Acuity Scale (CTAS) is a 5-level triage tool used to determine the priority by which patients should be treated in Canadian emergency departments (EDs). To determine emergency physician (EP) workload and staffing needs, many hospitals in Ontario use a case-mix formula based solely on patient volume at each triage level. The purpose of our study was to describe the distribution of EP time by activity during a shift in order to estimate the amount of time required by an EP to assess and treat patients in each triage category and to determine the variability in the distribution of CTAS scoring between hospital sites.

Methods:

Research assistants directly observed EPs for 592 shifts and electronically recorded their activities on a moment-by-moment basis. The duration of all activities associated with a given patient were summed to derive a directly observed estimate of the amount of EP time required to treat the patient.

Results:

We observed treatment times for 11 716 patients in 11 hospital-based EDs. The mean time for physicians to treat patients was 73.6 minutes (95% confidence interval [CI] 63.6–83.7) for CTAS level 1, 38.9 minutes (95% CI 36.0–41.8) for CTAS-2, 26.3 minutes (95% CI 25.4–27.2) for CTAS-3, 15.0 minutes (95% CI 14.6–15.4) for CTAS-4 and 10.9 minutes (95% CI 10.1–11.6) for CTAS-5. Physician time related to patient care activities accounted for 84.2% of physicians' ED shifts.

Conclusion:

In our study, EPs had very limited downtime. There was significant variability in the distribution of CTAS scores between sites and also marked variation in EP time related to each triage category. This brings into question the appropriateness of using CTAS alone to determine physician staffing levels in EDs.

Emergency physician workload modeling

Background:

A variety of models are used by hospitals, provincial governments, and departments of emergency medicine to “predict” the number of physician hours of coverage necessary to staff emergency departments. These models have arisen to meet specific requirements—some for the purpose of determining hourly rates of compensation, others to determine the amount of funding that will be provided to “purchase” physician coverage, and others to determine the number of hours of coverage necessary to maintain patient waits within “acceptable” limits. All such models have their strengths and weaknesses and have been criticized as not reflecting the “real” needs of any given department.

Objective:

In the article that follows, a review of existing models is presented, annotating their strengths and weaknesses to derive the characteristics of an “ideal” workload model.

Conclusion:

None of the models currently used to measure emergency department workload can be relied on to accurately predict the number of staffed hours necessary. Models that may achieve this objective are suggested.

Safety in numbers: lack of evidence to indicate the number of physicians needed to provide safe acute medical care

Patient safety in hospital is dependent on a multitude of factors. Recent reports into the failings of healthcare organisations in the UK have highlighted low staffing levels as a significant factor. There is research into the impact of nurse-to-patient ratios on patient safety, but our literature search found little published data that would allow healthcare providers to define a minimum number of physician staff and skills mix that would assure safety in the largest hospital specialty: unscheduled (acute) medicine. Future work should focus on the evaluation of existing data on hospital mortality rates and physician staffing levels as well as on empirical time and motion studies to ascertain the resources required to undertake safe medical care at times of peak demand.

Insights into physician scheduling: a case study of public hospital departments in Sweden

PURPOSE

The purpose of this paper is to describe current physician scheduling and concomitant opportunities for improvement in public hospital departments in Sweden.

DESIGN/METHODOLOGY/APPROACH

A total of 13 departments spread geographically across Sweden covering seven different specialties participated in the study. Data were collected through interviews with individuals involved in creating physician schedules. All departments investigated provided copies of the documents necessary for physician scheduling.

FINDINGS

Physician scheduling required the temporal coordination of patients, physicians, non-physician staff, rooms and equipment. A six-step process for creating physician schedules could be distinguished: capacity and demand overview, demand goal and schedule setting, vacation and leave requests, schedule creation, schedule revision, and schedule execution. Several opportunities for improvement could be outlined; e.g. overreliance on memory, lacking coordination of resources, and redundant data entering.

RESEARCH LIMITATIONS/IMPLICATIONS

The paucity of previous studies on physician scheduling lends an exploratory character to this study and calls for a more thorough evaluation of the feasibility and effects of the approaches proposed. The study excluded the scheduling of non-physician staff.

PRACTICAL IMPLICATIONS

To improve physician scheduling and enable timeliness, three approaches are proposed: reinforcing centralisation, creating learning opportunities, and improving integration.

ORIGINALITY/VALUE

This paper is among the few to investigate physician scheduling, which is essential for delivering high quality care, particularly concerning timeliness. Several opportunities for improvement identified in this study are not exclusive to physician scheduling but are pervasive in healthcare processes in general.

Development and validation of a multilevel model for predicting workload under routine and nonroutine conditions in an air traffic management center

OBJECTIVE

The aim of this study was to develop a model capable of predicting variability in the mental workload experienced by frontline operators under routine and nonroutine conditions.

BACKGROUND

Excess workload is a risk that needs to be managed in safety-critical industries. Predictive models are needed to manage this risk effectively yet are difficult to develop. Much of the difficulty stems from the fact that workload prediction is a multilevel problem.

METHOD

A multilevel workload model was developed in Study I with data collected from an en route air traffic management center. Dynamic density metrics were used to predict variability in workload within and between work units while controlling for variability among raters.The model was cross-validated in Studies 2 and 3 with the use of a high-fidelity simulator.

RESULTS

Reported workload generally remained within the bounds of the 90% prediction interval in Studies 2 and 3. Workload crossed the upper bound of the prediction interval only under nonroutine conditions. Qualitative analyses suggest that nonroutine events caused workload to cross the upper bound of the prediction interval because the controllers could not manage their workload strategically.

CONCLUSION

The model performed well under both routine and nonroutine conditions and over different patterns of workload variation.

APPLICATION

Workload prediction models can be used to support both strategic and tactical workload management. Strategic uses include the analysis of historical and projected workflows and the assessment of staffing needs.Tactical uses include the dynamic reallocation of resources to meet changes in demand.

Matching clinicians to operative cases: a novel application of a patient acuity score

BACKGROUND

Patient and surgical case complexity are important considerations in creating appropriate clinical assignments for trainees in the operating room (OR). The American Society of Anesthesiologists (ASA) Physical Status Classification System is the most commonly used tool to classify patient illness severity, but it requires manual evaluation by a clinician and is highly variable. A Risk Stratification System for surgical patients was recently published which uses administrative billing codes to calculate four Risk Stratification Indices (RSIs) and provides an objective surrogate for patient complexity that does not require clinical evaluation. This risk score could be helpful when assigning operating room cases.

OBJECTIVES

This is a technical feasibility study to evaluate the process and potential utility of incorporating an automatic risk score calculation into a web-based tool for assigning OR cases.

METHODS

We created a web service implementation of the RSI model for one-year mortality and automatically calculated the RSI values for patients scheduled to undergo an operation the following day. An analysis was conducted on data availability for the RSI model and the correlation between RSI values and ASA physical status.

RESULTS

In a retrospective analysis of 46,740 patients who received surgery in the year preceding the web tool implementation, RSI values were generated for 20,638 patients (44%). The Spearman's rank correlation coefficient between ASA physical status classification and one-year mortality RSI values was 0.404.

CONCLUSION

We have shown that it is possible to create a web-based tool that uses existing billing data to automatically calculate risk scores for patients scheduled to undergo surgery. Such a risk scoring system could be used to match patient acuity to physician experience, and to provide improved patient and clinician experiences. The web tool could be improved by expanding the input database or utilizing procedure booking codes rather than billing data.

The time burden of alcohol-based hand cleanser when using nonsterile gloves

We quantified the time burden of alcohol-based handrub accompanying nonsterile-glove use among emergency physicians, through observation in controlled and clinical settings. We report gloving episodes per hour, gloving times with and without handrub, and handrub recommendations compliance. Handrub adds 46 seconds to each glove-use episode, and we provide national extrapolations.

Reinforcing outpatient medical student learning using brief computer tutorials: the Patient-Teacher-Tutorial sequence

BACKGROUND

At present, what students read after an outpatient encounter is largely left up to them. Our objective was to evaluate the education efficacy of a clinical education model in which the student moves through a sequence that includes immediately reinforcing their learning using a specifically designed computer tutorial.

METHODS

Prior to a 14-day Pediatric Emergency rotation, medical students completed pre-tests for two common pediatric topics: Oral Rehydration Solutions (ORS) and Fever Without Source (FWS). After encountering a patient with either FWS or a patient needing ORS, the student logged into a computer that randomly assigned them to either a) completing a relevant computer tutorial (e.g. FWS patient + FWS tutorial = "in sequence") or b) completing the non-relevant tutorial (e.g. FWS patient + ORS tutorial = "out of sequence"). At the end of their rotation, they were tested again on both topics. Our main outcome was post-test scores on a given tutorial topic, contrasted by whether done in- or out-of-sequence.

RESULTS

Ninety-two students completed the study protocol with 41 in the 'in sequence' group. Pre-test scores did not differ significantly. Overall, doing a computer tutorial in sequence resulted in significantly greater post-test scores (z-score 1.1 (SD 0.70) in sequence vs. 0.52 (1.1) out-of-sequence; 95% CI for difference +0.16, +0.93). Students spent longer on the tutorials when they were done in sequence (12.1 min (SD 7.3) vs. 10.5 (6.5)) though the difference was not statistically significant (95% CI diff: -1.2 min, +4.5).

CONCLUSIONS

Outpatient learning frameworks could be structured to take best advantage of the heightened learning potential created by patient encounters. We propose the Patient-Teacher-Tutorial sequence as a framework for organizing learning in outpatient clinical settings.

Application of emergency severity index in pediatric emergency department

BACKGROUND

The purpose of triage is to identify patients needing immediate resuscitation, to assign patients to a pre-designed patient care area, and to initiate diagnostic/therapeutic measures as appropriate. This study aimed to use emergency severity index (ESI) in a pediatric emergency room.

METHODS

From July 2006 to August 2010, a total of 21 904 patients visited the International Department of Beijing Children's Hospital. The ESI was measured by nurses and physicians, and compared using SPSS.

RESULTS

Nurses of the hospital took approximately 2 minutes for triage. The results of triage made by nurses were similar to those made by doctors for ESI in levels 1-3 patients. This finding indicated that the nurses are able to identify severe pediatric cases.

CONCLUSION

In pediatric emergency rooms, ESI is a suitable tool for identifying severe cases and then immediate interventions can be performed accordingly.

How long does it take to perform emergency ultrasound for the primary indications?

Purpose

Although emergency ultrasound (EU) is gaining popularity, EU is performed in a minority of emergency departments (EDs). The perception may exist that EU is too time-consuming. This study sought to determine the duration of EUs performed for the primary indications by staff emergency physicians (EPs).

Methods

A prospective, time–motion study was conducted on a convenience sample of EUs at the Sudbury Regional Hospital ED from June to August 2006. All EPs had Canadian EU certification. A research assistant timed EUs. Primary EU indications in Canada are: cardiac arrest evaluation, rule-out pericardial effusion, rule-out intraperitoneal free fluid in trauma, rule-out abdominal aortic aneurysm, and rule-in intrauterine pregnancy. Descriptive statistics are reported.

Results

Eleven EPs performed 66 EUs for the primary indications on 51 patients. The mean EU duration was 137.8 s (range 11–465; CI 123.0–162.6). There was no difference in the duration of EUs performed by the two most experienced EPs (n = 37; duration = 129.4; CI = 96.4–162.4) compared to the other EPs (n = 29; duration = 148.4; CI = 110.6–186.2). Although subgroups were small, positive (n = 8; duration = 199.4; CI = 97.4–301.4), negative (n = 49; duration = 123.3; CI = 97.9–148.7), and indeterminate (n = 9; duration = 161.6; CI = 91.5–231.7) EUs did not differ in duration. There is some suggestion of differences in duration between types of EU, although again the subgroups were small: cardiac (n = 21; duration = 90.3; CI = 62.6–118.0), abdominal (n = 22; duration = 157.1; CI = 111.9–202.3), aneurysm (n = 15; duration = 170.1; CI = 117.5–222.7), transabdominal pelvic (n = 5; duration = 89.8; CI = 40.3–139.1), transvaginal (n = 3; duration = 246.0; CI = 30.6–461.4).

Conclusion

When performed by staff EPs with EU certification, mean EU duration for the primary indications was brief regardless of EP’s experience, EU type, or results.

An evaluation of resident work profiles, attending-resident teaching interactions, and the effect of variations in emergency department volume on each

OBJECTIVES

This study examines the effect of variations in emergency department (ED) volume on physician work efficiency (new patients per hour) and work profile (patient-related activities, including both direct and indirect patient care) and whether these differ between first- (Postgraduate Year [PGY]1) and third- (PGY3) year residents. The authors also determine if changes in volume are associated with changes in teaching interactions between attending and resident physicians.

METHODS

This was a prospective observational study of resident and attending physicians in the ED. Research assistants (RAs) followed ED residents during clinical shifts and recorded a multitude of data including the amount of time spent in specific activities, the number of new patients seen, and the frequency of attending physician teaching interactions.

RESULTS

Third-year residents see more new patients per hour (1.79 vs. 1.16, p < 0.001) than do their first-year counterparts. In addition, third-year residents spend almost 50% less time with each patient (10.7 minutes vs. 19.4 minutes, p < 0.001), and first-year residents spend three times as much time per shift discussing patients with attending physicians (59.4 minutes vs. 27.3 minutes, p = 0.002). More of the PGY1/attending interactions resulted in educational exchanges (54.9% vs. 34.6%, p = 0.003). PGY1 residents also spend more time on dictations per patient (9.6 minutes vs. 5.4 minutes, p = 0.01) and more time on paperwork per patient (18.5 minutes vs. 6.5 minutes, p = 0.007). As ED volume tripled, PGY1 residents were able to increase their patient load to a greater extent than were PGY3 residents by decreasing the length of each patient encounter as volume increased. Overall, ED volume had no effect on the number of teaching interactions, although the length of exchange decreased as volume increased.

CONCLUSIONS

Third-year residents see and carry more patients than do their first-year counterparts. They do so primarily by decreasing the amount of time spent with patients and attendings and working more efficiently overall. However, they are not as capable of altering their work profiles in the face of increased volume as their first-year counterparts. While the length of teaching interactions is decreased as volume increases, the number of those interactions resulting in teaching remains constant regardless of volume.