Impact of scribes on patient throughput in adult and pediatric academic EDs

Heaton, Heather A.; Nestler, David M.; Jones, Derick D.; Lohse, Christine M.; Goyal, Deepi G.; Kallis, J.S.; Sadosty, Annie T.

doi:10.1016/j.ajem.2016.07.011

Cited by 24 publications

(22 citation statements)

References 8 publications

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“…However, the study methods were limited, all were non-randomised, and half were retrospective. Since then, Heaton et al have published a single centre prospective block allocation study,11 finding no significant change in physicians’ productivity in adult or paediatric emergency department regions, which differs from our overall analysis but not from one of our individual sites. Our study found that productivity changes varied according to the role of the physician, which is contrary to the findings of a previous small study 16…”

Section: Discussioncontrasting

confidence: 85%

“…Limited economic research on scribes has been conducted in emergency medicine in the US 17 10 11 12 13 14 Some pilot economic data are available from emergency departments showing that allocation of scribes to some, but not all, physicians is likely to prove economically viable in Australia 1516 17 18 Studies from other specialties support the scribe role 19…”

Section: Introductionmentioning

confidence: 99%

“…20 21 22 23 Evaluations have shown increased medical productivity,1 12 15 16 20 24 25 but not necessarily faster emergency department throughput, for which the literature is in equipoise 17 10 11 13 15 16…”

Section: Introductionmentioning

confidence: 99%

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

Walker

Ben‐Meir

Dunlop

et al. 2019

BMJ

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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.

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Section: Discussioncontrasting

confidence: 85%

Section: Introductionmentioning

confidence: 99%

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

Walker

Ben‐Meir

Dunlop

et al. 2019

BMJ

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“…28,32 However, other studies have shown no significant improvement in LOS with most, including a meta-analysis by Heaton et al, also citing an increase in patient volume. 29,[33][34][35][36] Therefore, implementation expectations and details are of great consequence. 36 By the end of 2015, the Vertical Zone and Fast Track accounted for approximately onethird of the total ED census.…”

Section: Discussionmentioning

confidence: 99%

Impact of Scribes with Flow Coordination Duties on Throughput in an Academic Emergency Department

Thomas

Marcum

Wagner

et al. 2020

WestJEM

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Introduction: With the increasing influence of electronic health records in emergency medicine came concerns of decreasing operational efficiencies. Particularly worrisome was increasing patient length of stay (LOS). Medical scribes were identified to be in a good position to quickly address barriers to treatment delivery and patient flow. The objective of this study was to investigate patient LOS in the midand low-acuity zones of an academic emergency department (ED) with and without medical scribes. Methods: A retrospective cohort study compared patient volume and average LOS between a cohort without scribes and a cohort after the implementation of a scribe-flow coordinator program. Patients were triaged to the mid-acuity Vertical Zone (primarily Emergency Severity Index [ESI] 3) or low-acuity Fast Track (primarily ESI 4 and 5) at a tertiary academic ED. Patients were stratified by treatment zone, acuity level, and disposition. Results: The pre-intervention and post-intervention periods included 8900 patients and 9935 patients, respectively. LOS for patients discharged from the Vertical Zone decreased by 12 minutes from 235 to 223 minutes (p<0.0001, 95% confidence interval [CI],-17,-7) despite a 10% increase in patient volume. For patients admitted from the Vertical Zone, volume increased 13% and LOS remained almost the same, increasing from 225 to 228 minutes (p=0.532, 95% CI,-6,12). For patients discharged from the Fast Track, volume increased 14% and LOS increased six minutes, from 89 to 95 minutes (p<0.0001, 95% CI, 4,9). Predictably, only 1% of Fast Track patients were admitted. Conclusion: Despite substantially increased volume, the use of scribes as patient flow facilitators in the mid-acuity zone was associated with decreased LOS. In the low-acuity zone, scribes were not shown to be as effective, perhaps because rapid patient turnover required them to focus on documentation. [West J Emerg Med. 2020;21(3)653-659.] increasing concerns about physician efficiency and rapid patient throughput 17,18 , as well as the issue of worsening emergency department (ED) crowding 19-23 , the use of medical scribes increased nationwide. 24-26 Importance Strategies that reduce LOS and improve patient flow are critical to the efficient and humane delivery of emergency medical care. 27 Implementation of traditional scribe programs

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“…Their use is being evaluated in many settings: Emergency Departments (EDs) [3][4][5][6][7][8][9][10][11], consultant offices [12][13][14][15], primary care [16,17] and hospital wards [1]. Medical scribes have been found to improve physician productivity [3,4,[8][9][10]12] in most Emergency studies, but not all [5,15]. They have also been useful in most office settings [12][13][14] and wards, but again, not all [15].…”

Section: Background and Significancementioning

confidence: 99%

The 9-Item Physician Documentation Quality Instrument (PDQI-9) score is not useful in evaluating EMR (scribe) note quality in Emergency Medicine

Walker¹,

Wang²,

Dunlop³

et al. 2017

Appl Clin Inform

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SummaryBackground: Scribes are assisting Emergency Physicians by writing their electronic clinical notes at the bedside during consultations. They increase physician productivity and improve their working conditions. The quality of Emergency scribe notes is unevaluated and important to determine. Objective: The primary objective of the study was to determine if the quality of Emergency Department scribe notes was equivalent to physician only notes, using the Physician Documentation Quality Instrument, Nine-item tool (PDQI-9). Methods: This was a retrospective, observational study comparing 110 scribed to 110 non-scribed Emergency Physician notes written at Cabrini Emergency Department, Australia. Consultations during a randomised controlled trial of scribe/doctor productivity in 2016 were used. Emergency physicians and nurses rated randomly selected, blinded and de-identified notes, 2 raters per note. Comparisons were made between paired scribed and unscribed notes and between raters of each note. Characteristics of individual raters were examined. The ability of the tool to discriminate between good and poor notes was tested. Results: The PDQI-9 tool has significant issues. Individual items had good internal consistency (Cronbach's alpha=0.93), but there was very poor agreement between raters (Pearson's r=0.07, p=0.270). There were substantial differences in PDQI-9 scores allocated by each rater, with some giving typically lower scores than others, F(25,206)=1.93, p=0.007. The tool was unable to distinguish good from poor notes, F(3,34)=1.15, p=0.342. There was no difference in PDQI-9 score between scribed and non-scribed notes. Conclusions: The PDQI-9 documentation quality tool did not demonstrate reliability or validity in evaluating Emergency Medicine consultation notes. We found no evidence that scribed notes were of poorer quality than non-scribed notes, however Emergency scribe note quality has not yet been determined.

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Impact of scribes on patient throughput in adult and pediatric academic EDs

Cited by 24 publications

References 8 publications

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

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

Impact of Scribes with Flow Coordination Duties on Throughput in an Academic Emergency Department

The 9-Item Physician Documentation Quality Instrument (PDQI-9) score is not useful in evaluating EMR (scribe) note quality in Emergency Medicine

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