Adequate Physician Staffing

[GatorCHOMPions]

Does anyone have a general formula to determine adequate staffing in an ED given a certain volume and acuity?

I’m looking around at jobs, seeing a lot of different MD and MLP ratios and hard to determine what’s under, adequate, or overstaffing.

Example: 20-25k volume, 20% admit rate, 24 hour MD and 12 hour daytime MLP coverage. Is this good?

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[TooMuchResearch]

We cover one site with similar admit/transfer rate and coverage, but the volume is only about 12k. We like heavy staffing though.

 

[GeneralVeers]

Does anyone have a general formula to determine adequate staffing in an ED given a certain volume and acuity?

I’m looking around at jobs, seeing a lot of different MD and MLP ratios and hard to determine what’s under, adequate, or overstaffing.

Example: 20-25k volume, 20% admit rate, 24 hour MD and 12 hour daytime MLP coverage. Is this good?

I usually add up the total coverage of MD and MLP, so in your case 36 hours of coverage. Divide by the yearly volume by 365, then by the hours of coverage. The example you gave is 1.90 pts/hr which is quite reasonable on the low-end. I would run away from any jobs where this number is > 2.5/hr.

 

[Backpack234]

As low as possible. Physicians are our number one cost and can easily see more patients per hour. Fewer physicians, fewer nurses, more profits.


Oh wait, isn’t this the annual cmg meeting? Must have stepped in the wrong room. Whoops.

 

[Janders]

How 'bout them gators?

The best way to guesstimate it is to figure out their pt/hr and reverse engineer as @GeneralVeers suggests.

Of course, this is a rough estimate, as acuity changes what is reasonable (35% admit shop versus 10% admit shop). Of course, the ancillary staffing and throughput of the hospital also modifies this quite a bit too. Hell the EMR design will affect this to a big degree.

Anyway, if the total provider coverage is around 2/hr you're fine.

You'll have a different PoV on this question if you are an hourly CMG employee with minimal productivity incentive versus an eat-what-you-kill shop where you might want to be pushed a bit more on volume...

 

[GeneralVeers]

How 'bout them gators?



You'll have a different PoV on this question if you are an hourly CMG employee with minimal productivity incentive versus an eat-what-you-kill shop where you might want to be pushed a bit more on volume...

Correct. I love quiet days where I see 15 patients on a shift at my salaried job. I hate quiet days at my neighboring RVU place where if I see less than 20 patients I don't get to eat that night.

 

[namethatsmell]

I also do the math as Veers describes.

OP, there’s a big difference between 20k and 25k with that staffing though. I'd find out which number is more accurate. While 25k puts you at 1.9pts/hr, 20k puts you at 1.5/hr.

When it comes to salaried gigs, I'm leery of places that advertise 2/hr. If you have great support, good nursing, EMR w/good dragon or a scribe, and streamlined admitting processes then sure 2/hr is fine. The problem when you're at 2/hr though is that you've already lost your cushion for when things get worse. If you suddenly have a rise in volume, your EMR changes, the hospitalist group decides to become a wall, etc then "2/hr" can easily become much more work and a grind.

 

[Hercules]

Does anyone have a general formula to determine adequate staffing in an ED given a certain volume and acuity?

I’m looking around at jobs, seeing a lot of different MD and MLP ratios and hard to determine what’s under, adequate, or overstaffing.

Example: 20-25k volume, 20% admit rate, 24 hour MD and 12 hour daytime MLP coverage. Is this good?

Quick answer is no. There are too many variables. I’ve worked at hell holes where seeing 2 pph taxed me beyond belief due to a whole slew of system (nursing, EMR, ancillary staffing combo) issues. I’ve also worked where seeing 3 pph was relatively easy due to having a near perfect system in place.

 

[GonnaBeADoc2222]

The CMGs will misquote their pph. It will be higher than what they say and won't include what the midlevels are seeing, which you are also responsible for.

 

[NYEMMED]

The CMGs will misquote their pph. It will be higher than what they say and won't include what the midlevels are seeing, which you are also responsible for.

Exactly, I see about 2 pph at my place, on my own. When I finish signing the midlevel charts its more like 3.5

 

[RustedFox]

The CMGs will misquote their pph. It will be higher than what they say and won't include what the midlevels are seeing, which you are also responsible for.

Quoted for truth.

 

[gamerEMdoc]

Every place has the pt/hr and rvu/hr data for its ED docs. Ask to see their metrics. They could say that the average is one thing, but that may be thrown off if there are some really slow docs, making the rest of the crew see well above that. I think looking at the dept productivity metrics gives you a good idea of what the workload is truly like, if they will show it to you.

 

[EctopicFetus]

Personally, I think you have to look at 2pph for a doc and 1 pph for a midlevel assuming the docs are responsible for the cases and the acuity isnt super low. As mentioned working at a place with a 10% admit/tranfer rate is very different than 30-40% admit/transfer.

Also, if a low volume ED find out about the transfer process, to me that can make or break how decent a job is.

 

[GatorCHOMPions]

Thanks for the comments thus far. In the situation where you see 2 pph on your own and MLP 1 pph, are you able to at least hear about all the patients in real time if not see them all? What is the threshold at which you just give up and realize you just need to sign the chart after shift and move on? I've currently been at a job with no MLP chart signing so I guess I've been blessed in that way, but I'm looking elsewhere at the moment. For those who must sign off on MLP charts, how much does this impact your stress level and job satisfaction?

From lurking on here frequently I get the sense that no one has successfully negotiated a job whereby they got out of having to sign MLP charts. It's a shame most of our jobs have come to this. Perhaps the quest for independence on their part could help us in a small way in this regard.

 

[GonnaBeADoc2222]

Thanks for the comments thus far. In the situation where you see 2 pph on your own and MLP 1 pph, are you able to at least hear about all the patients in real time if not see them all? What is the threshold at which you just give up and realize you just need to sign the chart after shift and move on? I've currently been at a job with no MLP chart signing so I guess I've been blessed in that way, but I'm looking elsewhere at the moment. For those who must sign off on MLP charts, how much does this impact your stress level and job satisfaction?

From lurking on here frequently I get the sense that no one has successfully negotiated a job whereby they got out of having to sign MLP charts. It's a shame most of our jobs have come to this. Perhaps the quest for independence on their part could help us in a small way in this regard.

One site I used to work at we just all said no

 

[emergentmd]

Seems well staffed depending on how good the MLP is. If they generally are good, and this place runs with avg efficiency then this is a pretty cush place.

 

[trackrunner321]

A rule of thumb I was taught in residency was 1 hour of physician coverage per 1000 patients per year. So, 40 hrs of physician coverage for a 40,000 per year volume. I do not believe that this took midlevels into account though...

 

[cyanide12345678]

Does anyone have a general formula to determine adequate staffing in an ED given a certain volume and acuity?

I’m looking around at jobs, seeing a lot of different MD and MLP ratios and hard to determine what’s under, adequate, or overstaffing.

Example: 20-25k volume, 20% admit rate, 24 hour MD and 12 hour daytime MLP coverage. Is this good?

Big difference between 20 and 25k.

24 hour doc coverage with 12 hrs MLP daily is pretty good for 20k. When I signed at my place it was that level of staffing, but by the time I started the CMG reduced the MLP hours on 3 days of the week (Thursday, Friday, Saturday) to 10 hours. I definitely feel the difference on those days, but it's definitely not that bad.

A place with 25k volume should ideally have more coverage, maybe 20 hrs MLP in my opinion. Even my 20k volume place on a busy day can mean 30-40 patients in 12 hours by yourself

 

[namethatsmell]

A rule of thumb I was taught in residency was 1 hour of physician coverage per 1000 patients per year. So, 40 hrs of physician coverage for a 40,000 per year volume. I do not believe that this took midlevels into account though...

This sounds arbitrary. And bad. Was this at a CMG shop? I ask because that's where I've heard this before.

By this logic you'd be at 2/hr at an 18k site and more than that you're headed towards a steady state of 2.7/hr.

 

[EctopicFetus]

Big difference between 20 and 25k.

24 hour doc coverage with 12 hrs MLP daily is pretty good for 20k. When I signed at my place it was that level of staffing, but by the time I started the CMG reduced the MLP hours on 3 days of the week (Thursday, Friday, Saturday) to 10 hours. I definitely feel the difference on those days, but it's definitely not that bad.

A place with 25k volume should ideally have more coverage, maybe 20 hrs MLP in my opinion. Even my 20k volume place on a busy day can mean 30-40 patients in 12 hours by yourself

20k is a little under 55 patients a day. That’s 2.28 pph.

Many EDs see 2/3 of their volume during the day. The check in curves are really similar across all EDs exceptpeds EDs.

As such for those 55 patients a day that’s 36 during the daytime hours or 3 pph. Very doable with an MLP and a doc.

 

[namethatsmell]

Thanks for the comments thus far. In the situation where you see 2 pph on your own and MLP 1 pph, are you able to at least hear about all the patients in real time if not see them all? What is the threshold at which you just give up and realize you just need to sign the chart after shift and move on? I've currently been at a job with no MLP chart signing so I guess I've been blessed in that way, but I'm looking elsewhere at the moment. For those who must sign off on MLP charts, how much does this impact your stress level and job satisfaction?

From lurking on here frequently I get the sense that no one has successfully negotiated a job whereby they got out of having to sign MLP charts. It's a shame most of our jobs have come to this. Perhaps the quest for independence on their part could help us in a small way in this regard.

For me, leaving a place where I had to blindly sign off on midlevel charts has been great. A recent med-mal study came out showing the only factor associated with lawsuits in EM is the total amount of patients seen... by signing all these midlevel charts you're just giving the trial lawyers more lottery tickets to scratch off with your name attached to it.

I don't know how long it will last, but being free of forced midlevel "collaboration" has significantly lowered my stress level.

 

[Backpack234]

Follow up question: how many patients do you see in your busiest hour? I frequently get to work and see anywhere from 6-9 off the bat.

 

[Interpolfanclub]

Follow up question: how many patients do you see in your busiest hour? I frequently get to work and see anywhere from 6-9 off the bat.

I had a job like that once. Never again.

 

[AlmostAnMD]

Another reason to go SDG over CMG. I have two jobs, one is SDG and one is CMG. The SDG is my main gig and I work PRN at the CMG.

Both are level II trauma centers, though one has twice the volume of the other.

One is staffed barebones. Has midlevels too, but they don't really do much and what they do scares me sometimes (routine CT's on 5 year olds with abdominal pain, conscious sedation for lac repairs for 2 year olds, etc). I don't really measure my dick anymore by number of patients seen per shift, but I know I see a lot. Barely have time to sit, stay late charting quite a bit

The other is staffed amazingly. Midlevels are better, resources inside the ED are newer/better, connection/relationship with hospitalist group is very good, and most importantly I have to make at least a passing effort to see patients since otherwise I'll barely see any myself. Also the doc lounge is a fantastic buffet.

You can guess which is which. I work PRN at the CMG site because I'm junior partner at my main gig and the PRN site pays more than $100/hr more than my main site. However, I probably couldn't work full time at the CMG site. Too much stress. And once I'm full partner at my main gig I'll probably drop off the other place since I'll finally make more there instead.

 

[TooMuchResearch]

That's my favorite type of shift at our big center. See 8ish in the first 2 hours before the next doc arrives, then swap out 1 for 1 the rest of the shift.

Follow up question: how many patients do you see in your busiest hour? I frequently get to work and see anywhere from 6-9 off the bat.

I had a job like that once. Never again.

 

[Groove]

For me, leaving a place where I had to blindly sign off on midlevel charts has been great. A recent med-mal study came out showing the only factor associated with lawsuits in EM is the total amount of patients seen... by signing all these midlevel charts you're just giving the trial lawyers more lottery tickets to scratch off with your name attached to it.

I don't know how long it will last, but being free of forced midlevel "collaboration" has significantly lowered my stress level.

Link?

 

[EctopicFetus]

Link?

Provider and Practice Factors Associated with Emergency Physicians Being Named in a Malpractice Claim

We examine the association between emergency physician characteristics and practice factors with the risk of being named in a malpractice claim.We used malpractice claims along with provider, operational, and jurisdictional data from a national emergency ...

www.ncbi.nlm.nih.gov

 

[namethatsmell]

Provider and Practice Factors Associated with Emergency Physicians Being Named in a Malpractice Claim

We examine the association between emergency physician characteristics and practice factors with the risk of being named in a malpractice claim.We used malpractice claims along with provider, operational, and jurisdictional data from a national emergency ...

www.ncbi.nlm.nih.gov

Yup, that’s the one.