EM patients per hour

[traumajd]

Hi all.  I'm a newly minted Lead PA in an ER utilizing an "intake" system.  We have only recently started the system, in which the patient has a brief triage (VS and chief complaint), are placed in an intake room where they are quickly evaluated by a PA/NP, then moved to a waiting area based on their particular workup (just x-rays go to one room, IV and CT scan workup to another and GYN or procedural to a third).  This keeps the waiting room relatively empty, makes the patients relatively happy that they are seen quickly by a provider and is supposed to increase the flow through the ER.  All stable level 3-5 patients come through intake.

 

What I am trying to find out is how many patients per hour should we reasonably be able to treat effectively.  THe physicians in the main ED are expected to see 2 patients per hour with a scribe doing a majority of their electronic charting.  Administration wants us to see 3 patients per hour without a scribe, although the physicians mostly agree we should have them (that's another topic altogether).  Does anyone know of any resources where this information may be available?  I appreciate any input.  Thank you.

[EMEDPA]

I have done this system several times, both with and without an EMR. In our model we had no triage nurse and the PA either dispo'd or started the workup on every pt who did not arrive by ambulance.

 charting on paper or dictating you can easily do 6/hr if they are all super-minor. Our system excluded pelvics, anyone needing imaging beyond plain film, IVs etc from being seen start to finish by the pa in this model.

sicker folks we( the PAs) would write orders from triage for and send them to the back to be seen by another provider.

once we went to an emr it cut productivity way down to 2-3/hr. At that point we abandoned the model and went to a traditional fast track model for low acuity pts.

[traumajd]

We see everything that can walk with realtively stable vitals.  That includes acute abdominal pain with stable vitals (ie: normal or elevated BP).  THey can be febrile and tachycardia.  So we get our fair share of workups, although the true sepsis patients are usually weeded out.  So anecdotally, I would say we work up (IV, labs, imaging, pelvics) about 30-40% of the patients, another 10-15% are lacs and abscesses and the rest are simple x-rays or require no workup.  I have been averaging over 3 patients per hour, but I have 17 years experience as a PA although not all in ER.  My other midlevels have between 1-5 years experience as midlevels.  on my busiest day, I saw 48 patients in a 12 hour shift, clocked out on time with every chart completed and no patients turned over to the next shift, without a scribe and using EMR.

[EMEDPA]

We see everything that can walk with realtively stable vitals.  That includes acute abdominal pain with stable vitals (ie: normal or elevated BP).  THey can be febrile and tachycardia.  So we get our fair share of workups, although the true sepsis patients are usually weeded out.  So anecdotally, I would say we work up (IV, labs, imaging, pelvics) about 30-40% of the patients, another 10-15% are lacs and abscesses and the rest are simple x-rays or require no workup.  I have been averaging over 3 patients per hour, but I have 17 years experience as a PA although not all in ER.  My other midlevels have between 1-5 years experience as midlevels.  on my busiest day, I saw 48 patients in a 12 hour shift, clocked out on time with every chart completed and no patients turned over to the next shift, without a scribe and using EMR.

48 in 12 is moving. I saw 56 once in 12.5 hrs in fast track during flu season using a very basic emr flu template. the doc working with me that shift saw 8, none sicker than any of mine.

prior to EMR I saw 60 once in 10 hrs in 1997 using a 1 page paper template with tear off rx at the bottom.

charting really is the rate limiting factor. In Haiti I can see 100 pts in 6 hrs charting on 3x5 cards like this:

c/c h/a x 1 week

exam benign

tx tylenol

[traumajd]

Oh, the good 'ol days!

[gbrothers98]

What's a mid level?

 

 

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[gbrothers98]

You can see a lot of low acuity patients with an EMR, just have to set up a lot of precompleted notes that you minimally adjust and then finish. You also need to understand your workflow and how to work that to your advantage, something a PA with 17 years experience can do but not a PA with just one or two. Still 48 in 12 is moving. I hope you are recognized financially for your abilities.

GB PA-C

 

 

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[traumajd]

What I am really trying to find is some data that gives a realistic impression to administration of the number of patients per hour we should be expected to see.  We need a benchmark in order to a) be able to accurately evaluate the providers and b) have a realistic goal so that administration does not expect more than is realistic.

[gbrothers98]

http://www.acep.org/clinical---practice-management/emergency-medicine-provider-productivity

 

I only skimmed it.

Seems to come down to RVUs and your practice site.

In reality, I dont think you will find data that will help you. 

You can read in several places that EM docs should see 2-3 pts per hour. Sounds like your docs have worked this to their advantage. On the other hand, if you are working in a fee for service group or have compensation based upon RVUs, then you will see as many patients as you possibly can in order to make your money.

So I think if you are a hospital employee, paid salary or hourly, you can likely drive this process.

Does this hospital have a clinic associated with it? How many patients are scheduled per hour? You could use the same metric. If a same day appt for a simple problem gets 15 minutes, why dont you get that in the ED? Is it because you are in the ED and you are magically faster and better?

If so, then your compensation should reflect it. If they want things done faster then provide the resources, such as techs setting up your suture sets and I&D equipment, nurses obtain POC tests based upon CC, things tee'd up for you.

Good luck with this, I think you have a challenge.

GB PA-C

[traumajd]

Thanks all for your help  I appreciate it.

[EMEDPA]

 

"if you are working in a fee for service group or have compensation based upon RVUs, then you will see as many patients as you possibly can in order to make your money."

 

this leads to sloppy work in my opinion. folks try to cram as many pts into a shift as they can and do crap workup and documentation. I prefer straight hourly regardless of how busy I am. production bonuses lead to poor quality work.

[gbrothers98]

 

"if you are working in a fee for service group or have compensation based upon RVUs, then you will see as many patients as you possibly can in order to make your money."

 

this leads to sloppy work in my opinion. folks try to cram as many pts into a shift as they can and do crap workup and documentation. I prefer straight hourly regardless of how busy I am. production bonuses lead to poor quality work.

 

There is definitely a conflict of interest there.

Same as everyone with a kidney stone the new urologist sees that needs a stent.

The list can go on and on.

GB PA-C

[EMEDPA]

There is definitely a conflict of interest there.

Same as everyone with a kidney stone the new urologist sees that needs a stent.

The list can go on and on.

GB PA-C

agree. I work at a place that does base salary + production. I also work 2 per diem jobs with high straight hourly pay and no production.  I decided several years ago I will pretend that the production bonus doesn't exist and base my spending patterns on my base salary alone. If I get 200 bucks/quarter, great-the wife and I go to a nice dinner and a movie. If I get $19,000 dollars/quarter, great- I buy a new car for cash. both have happened. I just can't justify trying to cram in more pts/hr to make a few more bucks/hr. it leads to poor decision making and very sloppy documentation. some of my partners write things like "consulted cardiology, pt discharged" in a chart with no mention of who, what the discussion was about, etc. My note would say " spoke with dr smith of cascade cardiologists @ 0245 hrs. case, ekg, and labs discussed. He states pt had a normal stress test 2 weeks ago in his office and a normal cath last year. he does not feel additional testing is needed at this time and will see the pt in his office tomorrow at 0945. pt should return to ER sooner if pain changes or new sx occur." which note would you rather defend if you learned 1 year later that the pt had died while driving home and the family was now suing you?