Curious how you guys are calculating this. For example, say you pick up patients for 8hrs, see 20 people but stay 2 hours after to tidy everything up. Would you say you see 2.5 pph or 2.0pph? Also, curious on how heavily this is pushed on you in residency. Our residency is extremely heavy in seeing a lot of patients, to the point where I feel it is see more patients > teaching, which as I had been out on the job interview trail is quite atypical. We recently had an email sent to us saying 3rd years should be seeing at least 20 pt per shift (8hrs of picking up) which is tough because we have a designated fast track (not a problem there, we work in as well) but when you aren't in it you are consistently seeing patients age 50-90 generally requiring major work ups and then obviously you have to run things past attendings. Just curious on input from other programs/people.
Patients Per Hour
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IMHO that'd be 2pph. If it makes you feel any better, we have the same dilemma with pph at my shop--low acuity stuff is skimmed off in fast track and our admission rate is typically 25-30%. Getting to >2pph in such an environment is tough...and as somebody who is still learning I wouldn't want to go faster.
My interpretation of pph as a busy community ER doc:
Seeing 2 pph of legit ED patients (ED patients = workups, complex medical decision, critical care, MD level procedures, etc... - UC types siphoned off in fast track or by PAs along side) is at the upper end of safe.
2.5pph is doable if seeing a significant percentage of UC/Easy complaints.
And pph = patients/hours of your actual scheduled shift. Hopefully you are able to stop picking up around 1.5 hours before shift end to avoid consistently heavy sign outs.
Seeing 2 pph of legit ED patients (ED patients = workups, complex medical decision, critical care, MD level procedures, etc... - UC types siphoned off in fast track or by PAs along side) is at the upper end of safe.
2.5pph is doable if seeing a significant percentage of UC/Easy complaints.
And pph = patients/hours of your actual scheduled shift. Hopefully you are able to stop picking up around 1.5 hours before shift end to avoid consistently heavy sign outs.
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My thoughts - You are seeing 2.5 PP/hr. in 8 hrs, you saw 20 pts. Staying to chart, eat, go to bathroom, surf the internet doesn't change the fact that you saw/dispoed 2.5 pts/hr
In my place, some days we are scheduled to see pts for 7 hrs before the next guy comes in. We see no Fast track pts as we have a FT with midlevels. We are a busy ED, high acuity, lots of complicated pts, referral center. If I see 14 pts, I feel bored. If I see 19-21 pts, I feel busy but not overwhelmed. I would say that this is my "sweet zone" where I make the most and feel comfortable. These days, I would stay for about 1-1.5 hrs to chart. When I see 24+ pts, I feel close to my limit. My max was 32 and it felt like just putting out fires. We do not even have scribes.
I think our system is just more efficient. Admitting is easy, I text admission, things are done quickly.
Where I moonlight, if I see 2 pts/hr it feels like 3/hr b/c I constantly have to check when labs are back, call nurses about things that should have been done, etc.
Depends heavily on the system. As a 3rd yr resident seeing 2pph is difficult, i spend 15-20 minutes everytime i need to do any procedure getting crap together including pelvics. Call 1-3 ppl per admission waiting 5-15 mins ea for call back, and talk to most rns about the plan. I look forward to not wasting all this time at my new gig.
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2.5 is about the sweet spot; but I (think?) that I can realistically see 3 an hour.
You guys hit the nail on the head about system efficiency being a big help. Having RNs being able to take and enter verbal orders, and having them empowered to "start the chest pain workup" is a big deal. Having techs on-hand to grab items and do various tasks is a big help too.
Charting and order entry systems are important, too - a bad one can totally drain you. We're going to Cerner at my one shop this summer. Has me worried.
You guys hit the nail on the head about system efficiency being a big help. Having RNs being able to take and enter verbal orders, and having them empowered to "start the chest pain workup" is a big deal. Having techs on-hand to grab items and do various tasks is a big help too.
Charting and order entry systems are important, too - a bad one can totally drain you. We're going to Cerner at my one shop this summer. Has me worried.
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Facility has everything to do with it.
My main job advantages
1. I know all of the doctors here and can get a sprained ankle admitted without much discussion. I text all admissions so it takes me 30 secs to admit someone
2. When I put orders in, it is done. Xrays are done. I can get CT without any discussion. I can get an MRI without issues. We do not use PO contrast anymore so CTs with read comes back within an Hr. If a pt is in the ED more than 2 hrs without a dispo, it is rare.
3. Everything is set up for me. I put an order in and all trays/procedures are set up. I come in, do it, walk out.
I can see 6 pts in my first hour and feel relaxed. I have seen 15 pt the first hour and it didn't seem too bad.
My locums gig
1. Admitting requires multiple calls, multiple discussions, I put in holding orders. So admitting a pt could take me 30 minutes or more talking to a bunch of docs and putting orders in
2. I check labs constantly and hound the nurses to do it assuming I can find them as no one carries phones.
3. I do not know the system well, have no relationships with docs, and it appears different docs like it "their" way so I have to tailor admissions for them
4. Getting CT/US reads take over 2 hrs after it gets done. So I constantly check the computer to see if there is a read.
If I see more than 6 my first hour, I feel like walking in quicksand.
its night and day. If I saw 3 pts/hr in the locums I would be pulling my hair out carrying 15 pts all the time.
My main job advantages
1. I know all of the doctors here and can get a sprained ankle admitted without much discussion. I text all admissions so it takes me 30 secs to admit someone
2. When I put orders in, it is done. Xrays are done. I can get CT without any discussion. I can get an MRI without issues. We do not use PO contrast anymore so CTs with read comes back within an Hr. If a pt is in the ED more than 2 hrs without a dispo, it is rare.
3. Everything is set up for me. I put an order in and all trays/procedures are set up. I come in, do it, walk out.
I can see 6 pts in my first hour and feel relaxed. I have seen 15 pt the first hour and it didn't seem too bad.
My locums gig
1. Admitting requires multiple calls, multiple discussions, I put in holding orders. So admitting a pt could take me 30 minutes or more talking to a bunch of docs and putting orders in
2. I check labs constantly and hound the nurses to do it assuming I can find them as no one carries phones.
3. I do not know the system well, have no relationships with docs, and it appears different docs like it "their" way so I have to tailor admissions for them
4. Getting CT/US reads take over 2 hrs after it gets done. So I constantly check the computer to see if there is a read.
If I see more than 6 my first hour, I feel like walking in quicksand.
its night and day. If I saw 3 pts/hr in the locums I would be pulling my hair out carrying 15 pts all the time.
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No one. NO ONE in medicine, in any specialty pushes themselves this hard, this consistently on a per hour basis. I'm not saying other specialties don't work hard. They do. But none have anywhere near to work density of EM. There is nearly zero downtime in EM. Almost everything else has some form of downtime interspersed, in some form. EM doesn't. This is due to the "anti-dumping law" EMTALA. It was put in place in 1986 by Congress as there was a critical need to prevent you from ever taking a dump on your shift.
An EP does 1.5 hr of heavy lifting per every 1 hr worked. One hr of EM work = 1.5 hr of anything else.
One time, I saw 99 patients in a two day stretch (2 12-hr shifts back to back, so 4.1 PPH) with decent acuity including a 22 yo with bacterial meningitis, at an ED that accepts ambulances (not an urgent care). There was a hundredth patent I could have seen in the last five minutes of the second shift but I didn't pick it up. I refused. I decided my brain would have exploded if I had to see 100 in 36 hr time frame (between 7am day one, and 7 pm day two, of two 7-7 shifts).
2 PPH is sustainable over the long hall, but with high acuity, 2 pph is by no means a cake walk. 4 PPH over any sustained time frame is brutal, with any significant acuity. A lot depends on the system, EMR, ease of admitting, acuity as mentioned and other factors, so there's no blanket number to cover all sites. 3 PPH at some places is easier than 1.8 PPH at some others.
Sometimes residencies give you and overblown goal with the purpose of motivating your to push yourself, maximize efficiency and find your limit. They may not expect you to hit the numbers goal, if they seem outrageous. Don't freak out about some unattainable numbers goal. Just stay middle of the pack, at your site.
The goal should be to hit your PPH goal and get out on time, not stay 2 hr to chart. It may inflate your PPH numbers to stay 2 hr late, but if you calculate your pay in a $/hr format, by staying 2 hr late on an 8 hr shift, you're cutting your hourly pay by 20% to boost your PPH 20%. It also boosts a 144 hr month (18 8hr shifts) to 180 hours (now 18 10hr shifts) and all of a sudden you're wondering why you feel burned out on 144 hr per month. Well, it's because you're staying 2 hr late every day trying (unsuccessfully) to cram 10 hr worth of patient in 8 hr so you look better on paper.
Take home point:
Look at the bell curve of your fellow docs/residents in your ED and find out what the average PPH in your system is. Don't try to be the fastest and try not to be the slowest one or two, and you'll be fine.
Bonus point: Cherry picking 2 zero-acuity patients at the end of every shift can but your numbers up dramatically on the PPH bell curve. Blasphemy, I know, but everyone does it. Only the liars don't.
An EP does 1.5 hr of heavy lifting per every 1 hr worked. One hr of EM work = 1.5 hr of anything else.
One time, I saw 99 patients in a two day stretch (2 12-hr shifts back to back, so 4.1 PPH) with decent acuity including a 22 yo with bacterial meningitis, at an ED that accepts ambulances (not an urgent care). There was a hundredth patent I could have seen in the last five minutes of the second shift but I didn't pick it up. I refused. I decided my brain would have exploded if I had to see 100 in 36 hr time frame (between 7am day one, and 7 pm day two, of two 7-7 shifts).
2 PPH is sustainable over the long hall, but with high acuity, 2 pph is by no means a cake walk. 4 PPH over any sustained time frame is brutal, with any significant acuity. A lot depends on the system, EMR, ease of admitting, acuity as mentioned and other factors, so there's no blanket number to cover all sites. 3 PPH at some places is easier than 1.8 PPH at some others.
Sometimes residencies give you and overblown goal with the purpose of motivating your to push yourself, maximize efficiency and find your limit. They may not expect you to hit the numbers goal, if they seem outrageous. Don't freak out about some unattainable numbers goal. Just stay middle of the pack, at your site.
The goal should be to hit your PPH goal and get out on time, not stay 2 hr to chart. It may inflate your PPH numbers to stay 2 hr late, but if you calculate your pay in a $/hr format, by staying 2 hr late on an 8 hr shift, you're cutting your hourly pay by 20% to boost your PPH 20%. It also boosts a 144 hr month (18 8hr shifts) to 180 hours (now 18 10hr shifts) and all of a sudden you're wondering why you feel burned out on 144 hr per month. Well, it's because you're staying 2 hr late every day trying (unsuccessfully) to cram 10 hr worth of patient in 8 hr so you look better on paper.
Take home point:
Look at the bell curve of your fellow docs/residents in your ED and find out what the average PPH in your system is. Don't try to be the fastest and try not to be the slowest one or two, and you'll be fine.
Bonus point: Cherry picking 2 zero-acuity patients at the end of every shift can but your numbers up dramatically on the PPH bell curve. Blasphemy, I know, but everyone does it. Only the liars don't.
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Pretty high admission rate, wow. Is this community or academics?
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If you don't see any fast track patients, admission rate of 20-25% not uncommon. In a shift where I see 20 pts, that is only 5 to hit 25%, a typical day IMO
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Well, the national admission rate average is 13.3%, so 25% is indeed pretty high. Im guessing your ED gets pretty sick patients.
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How do EPs at shops like that survive? Where a lot of the ESI 1/low acuity stuff is seen in the fast track by PAs or what have you. If you're expected to see 2.2 PPH with much sicker patients, that's gotta be killer. I don't know, I'm just a PGY1 and the thought of even hitting 1.5 PPH is unfathomable to me.
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That's minus fast track. 25% of all 3, 2, and 1 level patients is reasonable.
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We are closing in on 1 year. It has been a disaster that has killed not only throughput but collections as well as people have switched from template based charting (because first net templates suck) to dictating stuff with dragon that often miss a lot of the "key points" that the coders need in the hpi/ros/pe. Honestly, Cerner has been so bad that I would almost think twice before taking a job where that was the EMR. How they have conned so many people.into buying a bad product is a bit surprising.
The way I calculate pph is annual volume / (daily hours of coverage x 365) since both those numbers are usually easy to.get when job hunting.
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Part of this depends on how efficient and willing to take patients your admitting services are. What really kills you when you get out of residency and into community practice is procedures. All those LPs and reductions that were interesting in residency just becomes something that keeps you from moving the meat.
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More towards the county/tertiary end of things.
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This really cuts to the chase.
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Do you guys ever find recruiters for locums are lying to you with numbers? I got sent a place with 65k average annual census with doc shifts as this "Physician Shift Times depends on number of docs scheduled for that particular day.
4 DOCS: 6a-6p, 10a-10p, 2p-2a, 8p-7a
5 DOCS: 6a-5p, 8a-7p, Noon-11p, 5p-4a, 9p-7a
Average daily volume of about 150-180 and during the winter months we tend to see about 200 patients per day"
They list the pph as 2.2. But I know this can't be right unless fast track is involved. I get 3.53 pph with the above formula.
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4 DOCS: 6a-6p, 10a-10p, 2p-2a, 8p-7a
5 DOCS: 6a-5p, 8a-7p, Noon-11p, 5p-4a, 9p-7a
Average daily volume of about 150-180 and during the winter months we tend to see about 200 patients per day"
They list the pph as 2.2. But I know this can't be right unless fast track is involved. I get 3.53 pph with the above formula.
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deleted547339
Recruiters lying?????? No......
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Yep...which is why you ask multiple people (nurses, techs, ems, other docs) what the visit volume is on interview day for a realistic assessment. While they aren't going to tell you a 65k shop is 40k they will be happy to fudge numbers 20% or so to get a warm body in the door for the rate and staffing model they have decided upon.
Looking back on things one of the docs in the group was trying to warn me about my first gig out of residency but I was too dense to pick up on it.
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Cerner is SO bad lol
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deleted547339
There is much, much worse.
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I cannot even imagine...
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I'm not even kidding. One place we rotate makes me miss Cerner.
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I believe you, but man Cerner is so terribad that it is hard to believe it can get worse than that garbage.
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Yep Cerner is far from the worst. Meditech makes me want to die.
I can do 3-4/hour comfortably with residents, by myself in a super streamlined community shop 2-3/hour with decent acuity feels almost out of control.
I tell all my residents to avoid any job that routinely asks them to see over 2/hour, in my experience it just doesn't seem worth it in the long run.
I can do 3-4/hour comfortably with residents, by myself in a super streamlined community shop 2-3/hour with decent acuity feels almost out of control.
I tell all my residents to avoid any job that routinely asks them to see over 2/hour, in my experience it just doesn't seem worth it in the long run.
