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To meet the challenges of workforce efficiency, we must conduct intelligent research on staffing levels.

I recently returned from the 2010 ACEP Scientific Assembly in Las Vegas, where men wage great debates and former car salesmen hock their electronic medical gadgets on the exhibit floor. From what I observed, it is clear that there are shifts in the tides of emergency medicine, one being particularly obvious. That is workforce: How we staff our EDs and what roles do those staff play.

This year, on the exhibit floor, there were at least four booths advertising scribe systems. I don’t understand why there weren’t 14. As there is going to be more pressure on medicine to produce more patient care for less money, the scribe is the obvious way to go. (“Scribe” is probably an inadequate term – it should probably be “physician’s personal assistant”.) There is absolutely no reason why the most expensive talent in the department should be doing menial tasks like sitting at the computer filling out order sheets, trying to get people on the phone, etc... We have 2010 knowledge and we’re running a 1950’s system.

No matter how you cut it, workforce is the new issue in emergency medicine. Over the last 42 years of formal emergency medicine training, we have blindly gone along thinking we have a model that works. It is clear that we don’t. And yet, interestingly, if you looked at the Research Forum at ACEP – where young researchers come to display their latest conquests of science – no one is really studying workforce or examining the appropriate levels for ED staffing. Work force is the thousand pound dead moose in the middle of the room; no one wants to talk about it. The appropriate ratio between doctors and mid levels is rarely discussed. The use of mid levels only, with electronic communication to major medical centers, is never discussed. The exact role of nursing versus techs is infrequently discussed. We hear continuously that there is a nursing shortage. If that is the case, it may not be that we need more nurses, but that we merely need more, or different, bodies to perform certain tasks. I strongly believe nurses should be doing nursing functions, dealing with critically ill patients and their medications. Almost everything else in the department can be done by techs who cost half as much per hour to do the same work.

When was the last time you walked into a room to see a patient with low back pain and they still had their shoes, socks and pants on? This is inexcusable; it ruins the efficiency of an emergency physician. Patients need to be properly prepared so that you can move from room to room and increase both the quality and productivity of each doctor involved. Before you see a patient who was put in a room with an eye complaint, they should have visual acuity taken, they should be sitting at the slit lamp, the medication tray should be out and the instruments should be readily available. If this is not done, it is a failure of the system. We need to assess exactly what is needed to make a physician productive. After listening to the various discussions at the Scientific Assembly, if anyone still believes that there is going to be more money per patient in emergency medicine, they clearly didn’t listen to what was happening. We are going to have to learn to do more with less. And that will only happen if we are being able to concentrate the physician’s time and efforts on those areas that actually require a physician.

What was the last real piece of research you saw on total staffing efforts in emergency departments? I for one believe that the Emergency Medicine Foundation should be running trials or cooperating with various hospitals on staffing experiments. What should staffing levels really be? What should the work response be, and where does physician input actually make a difference in outcomes? If we believe that every sprained ankle has to be worked up by the physician we are sowing the seeds of our own destruction. If we are not proactive, people outside of emergency medicine will present cost-effective alternatives to our inefficiency (e.g. the autonomous practice of advanced practice nurses), and we will have no research data available to counter these ideas. We can give out better care. We can do a better job. The physician can see more patients, but only if the mechanisms are in place for the physician to concentrate on those areas where his or her knowledge base is actually required. To see a physician holding on the phone for 15 minutes while waiting to speak to an outside consultant is the ultimate insult for both the physician and the system.

When are we going to demand the proper respect that is given to other specialists in health care? I’m not talking about expanding cost; everything I have suggested can be done for less money. We need to be the people who go in and present programs that show better outcomes for more people for less dollars. This will never come about until the professional organizations are willing to stand up and face the music. Efficient work distribution can be our salvation if we are only willing to confront workforce problems and ask the right set of questions.
 

Greg Henry, MD, Founder and CEO of Medical Practice Risk Assessment, Inc.; past president of ACEP.

Comments   

# David Ross 2010-11-05 08:55
Dr. Henry:
I couldn't agree more with your opinions in "Time is of the Essence." These are repeated scenarios day in and out in most EDs, I believe.
We have come to accept the constant interruptions and recurring non-physician aspects of the job as a part of the routine - just part of the overall stress and hectic atmosphere of the ED. That is, this is "normal."
Indeed, these facets add plenty of stress yet are really unnecessary if we stopped and thought more carefully about what an EP should be actually doing in an ED.
No specialist that I am aware of tolerates constant phone interruptions requiring hasty retreats from a patient's bed side to answer a call from a consultant who is just getting around to return an ED page one hour after it was made. We do this because of the system we have to work in and because of the chronic feeling of apology we have for just bothering consultant in the first place.
As you point out, we live with examining patients who are often not prepared by nursing staff with the tools and procedures that should have been anticipated - let alone not properly undressed. This wastes our time as we have to set up our own procedures or go out and find a staffer who can round up the gear we needed in the first place.
I believe this is due to the fact that we do not directly employ ED staff and therefore have no direct control over their behavior and job performance.
I am frequently impressed by the level of staff efficiency I see when I am a patient myself either at my primary care doctor or a specialist's office. I wish we had something approaching that staff efficiency in the ED.
As you say,we can do better. I think that more focused research on this crucial aspect of our practice would help us immensely.
Thanks again.
David Ross, DO FACEP
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# My sentiments exactly...Jon Allen 2010-11-14 04:06
Dr. Henry,
Long-time listener, first-time caller. I couldn't agree more with your words. The parent organization of our hospital recently adopted a CPOE system that is inefficient to say the least. The worst part is, the decision to implement the system was made essentially by the corporate IT folks without any involvement from the affected end-users. So now, my partners and I go see each patient (with all of the previously unresolved inefficiencies still in place) and then have to sit down at a computer and enter in our own orders. Even though, as the IT folks say, it only takes a few minutes, when you multiply that across the 30 or so patients we see in a shift, it turns out to be a very expensive "few minutes."
I've forwarded the link to your article to the rest of the department in hopes that someone will realize that an increased workload on the most expensive resources in the department just doesn't make any sense. Thanks again for your excellent analysis of a very touchy subject.
Many thanks...
Jon Allen, MD
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# Mike Lozano, MD 2010-11-19 02:49
Greg, great article. Any chance at improving the inefficiencies in the ED has to start by looking within. Only when everyone, I mean everyone, who is in the ED realizes that it's not all about themselves and making their particular lives easier will there be improvement. It's all about the patient, and let's stop hiding behind "it's patient care" to cover for our personal work arounds. Only by the entire group (docs, nurses, techs, registration etc.) becoming selfless toward the patient can we truly seve them.
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