Impact of scribes on emergency medicine doctors’ productivity and patient throughput: multicentre randomised trial

Abstract

ObjectivesTo evaluate the changes in productivity when scribes were used by emergency physicians in emergency departments in Australia and assess the effect of scribes on throughput.DesignRandomised, multicentre clinical trial.SettingFive emergency departments in Victoria used Australian trained scribes during their respective trial periods. Sites were broadly representative of Australian emergency departments: public (urban, tertiary, regional referral, paediatric) and private, not for profit.Participants88 physicians who were permanent, salaried employees working more than one shift a week and were either emergency consultants or senior registrars in their final year of training; 12 scribes trained at one site and rotated to each study site.InterventionsPhysicians worked their routine shifts and were randomly allocated a scribe for the duration of their shift. Each site required a minimum of 100 scribed and non-scribed shifts, from November 2015 to January 2018.Main outcome measuresPhysicians’ productivity (total patients, primary patients); patient throughput (door-to-doctor time, length of stay); physicians’ productivity in emergency department regions. Self reported harms of scribes were analysed, and a cost-benefit analysis was done.ResultsData were collected from 589 scribed shifts (5098 patients) and 3296 non-scribed shifts (23 838 patients). Scribes increased physicians’ productivity from 1.13 (95% confidence interval 1.11 to 1.17) to 1.31 (1.25 to 1.38) patients per hour per doctor, representing a 15.9% gain. Primary consultations increased from 0.83 (0.81 to 0.85) to 1.04 (0.98 to 1.11) patients per hour per doctor, representing a 25.6% gain. No change was seen in door-to-doctor time. Median length of stay reduced from 192 (interquartile range 108-311) minutes to 173 (96-208) minutes, representing a 19 minute reduction (P<0.001). The greatest gains were achieved by placing scribes with senior doctors at triage, the least by using them in sub-acute/fast track regions. No significant harm involving scribes was reported. The cost-benefit analysis based on productivity and throughput gains showed a favourable financial position with use of scribes.ConclusionsScribes improved emergency physicians’ productivity, particularly during primary consultations, and decreased patients’ length of stay. Further work should evaluate the role of the scribe in countries with health systems similar to Australia’s.Trial registrationACTRN12615000607572 (pilot site); ACTRN12616000618459.

Description of the effect of patient flow, junior doctor supervision and pandemic preparation on the ability of emergency physicians to provide direct patient care

“…Descriptive data were reported as percentages or means with interquartile ranges. Change in productivity was compared against the baseline of 0.83 patients per h, 5 using a two-tailed, Table 1. Consultant emergency physician time spent on specific task categories in the emergency department (ED)…”

“…The productivity rate of 0.43 primary consults per h for this study was below previously reported results. [5][6][7][8] Australian EP productivity data exists in the literature; 5-7 these papers defined ED physician productivity as a count of primary and secondary consults per hour. The hospital studied underwent digital transformation of the entire network's electronic medical record the year prior, was undergoing renovations at the time and was experiencing the early stage of the COVID-19 pandemic.…”

“…Baseline data exist regarding EP productivity in Australia [5][6][7] and internationally; 1,[8][9][10][11] for example, baseline productivity in an Australian private hospital setting has been measured at 1.04 primary consults per h in 2014 (1.32 patients per h total) 6 and in a mixed public and private setting at 0.81 primary consults per h in 2015-18 (1.13 patients per h in total). 5 A primary consult was when the physician was assigned as the main physician for the patient. 5 A secondary consult was a medical triage consultation in advance of another physician who then provides a full consult, or a patient handover.…”

“…5 A primary consult was when the physician was assigned as the main physician for the patient. 5 A secondary consult was a medical triage consultation in advance of another physician who then provides a full consult, or a patient handover. 5 The baseline productivity rate for patients has been measured as anywhere from 1.89 9 to 2.5 8 patients per h in systems outside of Australia.…”

“…5 A secondary consult was a medical triage consultation in advance of another physician who then provides a full consult, or a patient handover. 5 The baseline productivity rate for patients has been measured as anywhere from 1.89 9 to 2.5 8 patients per h in systems outside of Australia. [8][9][10][11] It is interesting to note, however, that this figure includes supervised 'secondary consult' patients in the patient count.…”