How Do Physicians and Nurses Spend Their Time in the Emergency Department?,☆☆,,★★

Presented at the American College of Emergency Physicians Research Forum, San Diego, CA, March 1994.
https://doi.org/10.1016/S0196-0644(98)70287-2Get rights and content

Abstract

Study objectives: To determine how emergency physicians and nurses spend their time on emergency department activities. Methods: An observational time-and-motion study was performed at a 36-bed ED with annual census of 84,000 in a central city teaching hospital sponsoring an emergency medicine residency program. Participants were emergency medicine faculty physicians, second- and third-year emergency medicine resident physicians, and emergency nurses. A single investigator followed individual health care providers for 180-minute periods and recorded time spent on various activities, type and number of activities, and distance walked. Activities were categorized as direct patient care (eg, history and physical examination), indirect patient care (eg, charting), or non- patient care (eg, break time). Results: On average, subjects spent 32% of their time on direct patient care, 47% on indirect patient care, and 21% on non-patient care. Faculty physicians, residents, and emergency nurses differed in the time spent on these three categories of activities. Although the overall time spent on direct patient care activities was not significantly different, emergency nurses spent more of their time (2.2%) providing comfort measures (a subcategory of direct patient care) than did faculty physicians (.05%) or resident physicians (.03%). Emergency nurses spent 38.9% of their time performing indirect care, whereas faculty physicians spent 51.3% and resident physicians 53.7%. Resident physicians spent more time charting than did faculty physicians or emergency nurses (21.4%, 11.9%, and 6.9%, respectively). Emergency nurses spent more time on personal activities than did physicians, and faculty physicians walked less than either emergency nurses or resident physicians. Conclusion: Emergency physicians and nurses spent almost half of their time on indirect patient care. Physicians spent significantly more time on indirect patient care activities and significantly less time on personal activities than did nurses. [Hollingsworth JC, Chisholm CD, Giles BK, Cordell WH, Nelson DR: How do physicians and nurses spend their time in the emergency department? Ann Emerg Med January 1998;31:87-91.]

Introduction

The goals of health care managers, policy makers, and workers include improving efficiency and productivity, reducing waste, redistributing resources, and decreasing costs. Van de Leuv wrote, “The ultimate goal of the emergency department director, or anyone on the staff of the emergency department for that matter, should be to attain maximum efficiency.”1 Hendrickson and Kovner emphasized that “in an era of nurse shortage, it is important to maximize the time nurses spend on patient care and minimize the time spent on tasks that do not require professional nursing expertise.”2

Achieving these goals depends in part on understanding the type of tasks health care workers perform and the amount of time they spend accomplishing them. For example, in one study it was found that “some 31% of the average healthcare worker's time was wasted through paperwork, rework, duplicate work or inappropriate work.”3 How health care workers spend their working time is of interest not only to managers and policymakers but to health services researchers. Finkler et al4 noted that studies requiring such information range from evaluations of the use of physical therapy personnel time, through work measurements for nursing services, to Hsiao's work on development of a relative-value scale for physician services.

Mamlin and Baker wrote, “In spite of the growing interest in health planning and new health care delivery systems, very little refinement of measurement technique has been published describing methodologies for measuring such fundamental parameters of clinic operation as patient temporal movement and physician activity.”5 Almost a quarter century later, the same could be said of emergency medicine, a field in which few work measurement or task analysis studies have been conducted to better define the work environment.

We conducted a time-and-motion study to determine how emergency physicians and nurses spend their time in the ED. The number and types of activities performed by subjects and the time spent on these activities were evaluated, and the distances walked by subjects while on clinical duty was measured.

Section snippets

Materials and Methods

The study was conducted from June 14 to July 23, 1993, in a 36-bed ED with an annual census of 84,000 in a central city teaching hospital. The hospital sponsors an emergency medicine residency program (postgraduate years 1 through 3). At the time of the study, faculty physicians worked 8-hour shifts, resident physicians 9-hour shifts, and emergency nurses 11- or 12-hour shifts. For 15 hours of the day, the sole job of one faculty physician (the staffing faculty physician) was to oversee patient

Results

Thirty-nine ED care providers were observed: 10 faculty physicians, 12 resident physicians, and 17 emergency nurses. All of the faculty physicians were men; their mean age was 42.7±7.1 years, and their mean full-time ED experience was 15.6±6.3 years. Of the resident physicians observed, 11 were men, and 1 was a woman; their mean age was 28.3±1.5 years. Eight were second-year residents and four were third-year residents. Of the emergency nurses, 16 were women and 1 was a man; their mean age was

Discussion

Our time-and-motion study demonstrated that emergency physicians and nurses spent almost half of their time on indirect patient care activities. Physicians spent more time on indirect patient care activities than nurses. Whether this difference resulted primarily from the difference in charting time or from other factors is unknown. Emergency nurses spent more time on personal activities than did physicians. One possible explanation for this findings is that nurses in our ED work 12-hour shifts

Acknowledgements

We thank the emergency physicians and nurses at the Emergency Medicine and Trauma Center, Methodist Hospital of Indiana, for participating in this study; and Bruce D Janiak, MD, and Debra Mauk of The Toledo Hospital for sharing the methodology and results of their unpublished ED time-and-motion study.

References (9)

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From the Summer Research Program,* the Emergency Medicine and Trauma Center, and the Department of Medical Research,§ Methodist Hospital of Indiana, Indianapolis, and Wabash College, Crawfordsville, IN.

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Supported by a grant from Hill-Rom Company, Batesville, IN.

Reprint no. 47/1/82924

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Address for reprints: Journal Reprint Requests, Emergency Medicine and Trauma Center, Methodist Hospital of Indiana, 1701 North Senate Boulevard, Indianapolis, IN 46202, 317-929-3525, [email protected]

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