Resident productivity as a function of emergency department volume, shift time of day, and cumulative time in the emergency department

doi:10.1016/j.ajem.2008.03.002

The American Journal of Emergency Medicine

Volume 27, Issue 3, March 2009, Pages 313-319

https://doi.org/10.1016/j.ajem.2008.03.002 Get rights and content

Abstract

Objectives

We sought to determine if resident productivity changed based on emergency department (ED) volume, shift time of day, or over time during a shift.

Methods

This is a retrospective review of patients evaluated in the ED by emergency medicine residents. Data were collected using the computerized tracker that provides time of physician assignment and daily volume. Regression analysis was used to determine relationship between productivity and volume as well as relationship between productivity and accumulated time in the ED. Analysis of variance was used to assess for productivity differences by shift time of day.

Results

One hundred sixty-one postgraduate year-1 (PGY-1), 264 PGY-2, and 193 PGY-3 shifts were included. PGY-1, PGY-2, and PGY-3 residents saw 0.85, 1.13, and 1.25 patients per hour, respectively. PGY-3 and PGY-2 productivity had a weak relationship to ED volume (R = 0.28, P = .03; and R = 0.36, P = .03), whereas PGY-1 productivity had a moderate relationship to ED volume (R = 0.44, P = .0001). There were no differences in productivity based on shift time of day. Accumulated time in the ED had a strongly negative relationship to productivity, with R values from −0.79 to −0.93 (P < .002 for all comparisons).

Conclusions

Resident productivity is not strongly linked to volume or time of day. If specific times have statistically higher volume, they should be staffed with larger numbers of residents. In addition, emergency medicine resident productivity declines reliably over shift time. Therefore, scheduling should be adjusted to create larger shift overlaps to aid in smoother patient flow.

Section snippets

Background

For emergency medicine (EM) residents, productivity (number of patients evaluated per hour) improves throughout training [1], [2], [3], [4], [5]. Whether resident productivity varies as a function of patient volume in the emergency department (ED) or whether productivity varies as a function of time of day the shift occurs has not been studied. Whether resident productivity varies as a function of accumulated time in the ED during the course of a given shift or based on level of training has

Methods

This is a retrospective chart review of patients evaluated in the ED by first- (PGY-1), second- (PGY-2), and third-year EM residents (PGY-3) in a 65,000-volume tertiary care center. None of the residents at the time of the study had previous postgraduate training beyond their EM residency. The institutional review board reviewed and approved the study protocol. All ED resident shifts during the study period were included. The period for the study was a 3-month period starting November 1, 2006.

Results

One hundred sixty-one PGY-1, 264 PGY-2 (101 twelve-hour shifts and 163 eight-hour shifts), and 193 PGY-3 shifts (156 twelve-hour shifts and 37 eight-hour shifts) met our inclusion criteria. PGY-1 residents saw a mean of 0.85 patients per hour on 12-hour shifts (95% CI, ±0.04). PGY-2 residents saw a mean of 1.13 patients per hour during the study (95% CI, ±0.03). PGY-3 residents saw a mean of 1.25 patients per hour during the study (95% CI, ±0.04). Emergency department volume ranged from 127 to

Discussion

Although there is a growing body of literature regarding resident productivity, it is unclear what factors beyond level of training contribute to productivity. Prior studies have established productivity figures similar to ours for resident productivity as a function of level of training [1], [2], [3], [4], [6]. These data make sense intuitively, for as residents increase their experience, they are able to handle multiple patients with more speed and confidence. However, there are many other

Limitations

There are several limitations to our study. We did not control for patient acuity because our tracking system lists a patient's chief complaint but does not assign an acuity value. Clearly, acuity level could influence productivity comparisons. It would be possible to control for this variable using a standardized acuity scale at the time of patient registration. We did not incorporate RVUs into productivity, which is also a limitation. However, RVU scores are highly dependent on patient length

Conclusions

Resident productivity is not strongly linked to patient volume or shift time of day at our institution. Based on our analysis, only PGY-1 residents can increase productivity in terms of patients per hour in response to departmental need, and even then, the relationship is weak. Rather than rely on residents to see more patients, if specific days of the week or times of the day are known statistically to have higher volume, those times should be staffed with a larger number of residents. Aside

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In Emergency Departments (ED) in which physicians sign up for new patients at their own pace (ad libitum), physicians tend to see fewer new patients over each hour of their shift [1-3].
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Previous studies on emergency medicine resident productivity have been relatively small, and often have primarily examined productivity as a static number—the average number of patients per hour—in relation to residents' year of postgraduate training (1,5,6). Although a pair of previous studies has examined gradual decreases in overall productivity with increasing shift length, to date, no study has examined if there is an association between the variability of residents' hourly productivity and their overall productivity (7,8). Understanding the relationship between residents' peak and overall productivity is important because variable productivity is inherent to emergency medicine.
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A total of 14,361 shifts were evaluated. Multivariate analysis showed that the total number of patients seen was significantly associated with the number of patients seen during the peak hour, level of training, the timing of the shift, but most prominently, lower variance in patients seen per hour (coefficient of variation < 0.10).
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A PubMed search for “efficiency and emergency medicine” (productivity is under the Medical Subject Headings term “efficiency”) returned only 30 studies examining shift-level productivity. Only one article addressed productivity during the length of a shift and was powered to examine shift quartiles.2 No article addressed this issue for attending physicians.
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Original ContributionResident productivity as a function of emergency department volume, shift time of day, and cumulative time in the emergency department

Abstract

Objectives

Methods

Results

Conclusions

Section snippets

Background

Methods

Results

Discussion

Limitations

Conclusions

Int J Med Inform

Emergency medicine resident work productivity in an academic emergency department

Acad Emer Med

Progression of emergency medicine resident productivity

Acad Emer Med

Original Contribution
Resident productivity as a function of emergency department volume, shift time of day, and cumulative time in the emergency department