The graphs and tables below were created by matching patient arrivals with physician and advanced practice clinician (PA/ARNP) staffing hours. Creating a functional graph requires the following information:
- Hourly patient arrivals, preferably by day of the week
- Proposed physicians and APP schedule
- Average patients per hour seen by a physician
- Average patients per hour seen by an APC
Once these factors are known, a simple table can be generated displaying the total number of physicians and APCs present at any given hour, and the number of patients each is capable of seeing. Here are some examples of methods to display the information.
This graph shows two areas. The patient arrivals are red, the staffing is blue. The following conclusions can be drawn from looking at the graph:
- Anywhere there is red with no overlapping blue = patient arrivals exceed staffing. This means that staff present must see more than the average number of patients per hour.
- Anywhere there is blue with no overlapping red = staffing exceeds patient arrivals. In this scenario, physicians and APCs may see less than the average number of patients per hour, and there is room for redistribution.
This is another method of displaying the same information. The columns represent the hourly arrivals and patients capable of being seen based on staffing. Colors per column are displayed as a “heat map” where higher numbers are more intense in color. Also, the final column represents either a positive or negative difference to show areas of potential improvement.
Regardless of the method chosen to display the data, the key factor involves matching arrivals with appropriate staffing. Doing so requires some data, and knowledge of some key caveats. Importantly, this calculation does not require expensive software, just the correct data.
Caveats
- Physicians and APCs are typically more productive at the beginning of their shift. It is acceptable to expect them to see more than the average number of patients per hour during the start of the shift. More than 2 hours at this rate leads to significant fatigue. For example, an average physician seeing two patients per hour would see 3 patients an hour for the first two hours of their shift.
- Physicians and APCs are typically less productive at the end of their shift. Their hourly productivity is likely to be below average for the last two hours, especially if documentation is typically delayed until the end of the shift.
- Including some time of overlap with the oncoming staff is recommended in order to allow for smoother transitions, less patient wait time at the end of the shift, and time for documentation.
- Patient acuity matters. Emergency departments in urban centers with urgent care and walk-in clinics nearby typically see higher acuity patients. Lower acuity patients are pulled away by these other centers. In this scenario, adding staffing typically requires physicians, not advanced practice clinicians.
- If you are taking advantage of a physician in triage model, it is necessary to alter the model to account for this role. Typically this position is providing screening and initial assessment and not discharging many patients. Although this is a critical function, it is not accounted for in this staffing graph and would need to be added as an additional provider.
Arrivals vs Bed Time
There is some discussion regarding which time stamp to use for staffing models. Patient arrival time indicates when the patient physically arrives at the ED and begins the check-in process. Some have argued that a more appropriate time stamp would be patient placement in a bed or an assessment area.
In general, I discourage the use of bed placement as the time stamp. Many factors, especially boarding, will influence the time a patient arrives in a bed. Focusing on a rapid assessment as soon after arrival as possible improves safety for the patient. If you are struggling with providing a space for assessment of the patient on arrival, it is better to focus on solutions to that problem than to alter staffing to reflect patient arrival in a bed. Most emergency departments that calculate staffing based on patient arrival to a bed will find increasing wait times and walk-outs. In addition, increasing physician dissatisfaction is common as patients arrive and wait while physicians with additional capacity are paralyzed waiting to gain access to the patient.
In this scenario, focus should be shifted to triage models, results pending areas, and other unconventional models of patient intake to alleviate the need for a traditional “bed” for patient examination.
If you would like assistance modeling your current staffing or building an ideal schedule matching patient arrivals, please contact us here.