How many patients should residents see?

[NinerNiner999]

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Our institution has recently changed the ED triage system into a two-team system. Each team is composed of two residents, and one team has an additional PA. Each team has a leader who initially screens each patient assigned to their team in triage and starts their workup. We have double attending coverage during the day, and single coverage at night. Our current ED volume is 70k. Since this change, my fellow residents and I have found we are seeing between 30-40 patients during an 8-hour shift, and sometimes more during our 12-hour shifts (which are over the weekend and usually lower volume). PGY-2 and PGY-3 residents serve as team leaders (usually see every patient and send them to other team members to complete workup).

I am incredibly tired and disoriented when I come home, and I have noticed that my teaching has dropped incredibly (our attendings are four times as busy as we are with the new surge of patients being seen). How many patients do you see during a shift, and what type of patient volume do you think PGY-2 and PGY-3 residents should be comfortable with? Do you know of any data out there giving specific recommendations (my search was unfruitful). Above 3pph on a regular basis is making me delirious...

PLEASE, IF YOU ARE NOT A PGY-2 OR HIGHER, KEEP YOUR INPUT TO A MINIMUM (I still love you all, but I would really like to keep this thread on target).

 

[peksi]

This IS the next issue for academic EM to address, volume's eefect on education (+/-)as well as a "team traige", concept set fourth by many of the gurus of benchmarking such as Todd Taylor et all right down there at Inova in VA.

there is NO data on the effect of such a treatment pathway and burnout ( aka you feeling disoriented and spent)

First of all 9er9er, you are not alone. Many ED's are seeing this huge surge along the eastern seaborad as the result of this late flu and rota virus season. We are having days of 300-330 patients per day at Christiana alone, that's like 120K visits per year! 😱 Just at Christiana!

The issue is that much of the PPH data for EM reisdents is old and not up to date with the new world ED volume and surge phenomenon. Nor is it corrected for new attempted remedies, team traige, hallway medicine. The real world EM is no longer steady flow, but oceanic waves at the beach with high tide, low tide and the occasional tsunami!

One response to this educational/volume need is usually more docs. I remember when I was a medstudent that i was told that by 2000 there would be no more academic positions......RIIIIGHT! It is well mapped for day and time nationally and regionally for surge, but i think that as the babyboomers, self consumed folks get older this WILL get worse. eg. last night work 7p-3a, at 2 Am we had 8 folks sign in with "chest pain all day", why, it was nice all day 68 degreess, and the local St. patricks weekend, so everyone waited and then the bum rush!

We see a similar volume of 30-40 pph in an 8 hour shift when we hit the traige team, we as attendings see patients as well, and I would think that our residents on SDN, Pelivar and Turtle, MD could answer this better. I'll email the PD and get some info from him.

By the way I found this abstract tiltle:
Validation of the ED Work Index at Six Academic EDs. Melissa Lee McCarthy, Johns Hopkins University---you may know more than i do on this issue.

Paul

 

[BKN]

Our institution has recently changed the ED triage system into a two-team system. Each team is composed of two residents, and one team has an additional PA. Each team has a leader who initially screens each patient assigned to their team in triage and starts their workup. We have double attending coverage during the day, and single coverage at night. Our current ED volume is 70k. Since this change, my fellow residents and I have found we are seeing between 30-40 patients during an 8-hour shift, and sometimes more during our 12-hour shifts (which are over the weekend and usually lower volume). PGY-2 and PGY-3 residents serve as team leaders (usually see every patient and send them to other team members to complete workup).

I am incredibly tired and disoriented when I come home, and I have noticed that my teaching has dropped incredibly (our attendings are four times as busy as we are with the new surge of patients being seen). How many patients do you see during a shift, and what type of patient volume do you think PGY-2 and PGY-3 residents should be comfortable with? Do you know of any data out there giving specific recommendations (my search was unfruitful). Above 3pph on a regular basis is making me delirious...

PLEASE, IF YOU ARE NOT A PGY-2 OR HIGHER, KEEP YOUR INPUT TO A MINIMUM (I still love you all, but I would really like to keep this thread on target).

When I was at the Hop (77-79), the attendings didn't come into the ED at all without an invite-and we would never have invited them (too weak). JHH was where residency was invented and that seems to have imprinted it forever in the mode of superivising the level below and reporting to the level above. The approach on the surgical side was student to intern to pg2 to pg3 (called down from floor). It stopped there for discharges and for admissions or operations then went to the ACS there. The medical side made more sense-no students nor interns allowed. PG2 and 3s were both the examining and admiting physicians.

It took me several years to realize that the way I was trained is not the way it should be done. It is time inefficient and denies the patient the benefit of the best available judgement.

I set up the system differently here. We have a volume perhaps 10% less than JHH, but more acute (at least by the standards of 30 years ago). Everybody reports directly to faculty. PG3s serve a few teaching only shifts, but usually are only seeing patients directly. We moved as many nonurgent people as we could out of the hands of the residents (urgent care clinic, evening pediatric urgent care, faculty non-teaching service). We use a initial triage system similar to your descripition, but staff it with faculty, a nurse practioner or occasionally a senior resident. Our system looks somewhat like your description of the present operation at JHH, but is more faculty intensive. When I'm in a teaching area, I'm probably signing about 4 an hour.

In answer to the original question, I think that you're seeing too many patients. My seniors are averaging about 2.2, but there are few low acuity patients in the mix.

 

[Seaglass]

We have nurse only triage. Residents report directly to Attendings with double coverage during the day, single overnight. We too have seen a real surge in visits in the last 2 months with the flu and rota. Yesterday I saw 2.75 patients per hour which is a little over the amount we are expected to see as a PGY-2. i think that is a pretty average shift for me. 30-40 in an 8 hour shift seems pretty inhuman to me, especially if you are seeing them in triage since most of the work in a patient workup is on the front end. I think it would be hard to see a patient in triage as a physician and limit questions to just the basics to find out just how sick they are.

 

[GeneralVeers]

Our PGY-2s see approximately 10-15 patients in a 12-hour shift. Bear in mind all of these people are sick-as-hell DKAers with dig toxicity.

We have a separate urgent care center staffed by internal medicine, or a PGY-2 in EM that takes care of most of the non-urgent complaints.

 

[DrQuinn]

Depending on where I am working (main ED side versus Fast Track), I'll see 1.8 - 3.0 patients per hour (3.0-4.0 in FT). Our FT is a pretty hustling place (staffed by MLP three days of the week, by PGY3s four days of hte week), and its not unheard of for us to see forty patients in an 10 hour shift. (Those are infrequent, however). On the main side, its sick as stink patients, and on average, I see about 18-20 in a 10 hour shift. Not including sign outs from the previous resident.

I think 30 as a PGY2 is slave labor and shouldn't be tolerated, although, if it is in the "triage and front-end" role, that's a little different that the full workup that we do down here.

Q

 

[southerndoc]

Our interns see about 2 patients per hour in the "central" areas (less acute patients, like abdominal pain, vaginal bleeding, non-cardiac chest pain, etc.).

The critical care residents (2 of them) average about 1.5 patients per hour and are seen exclusively by PGY-2 through 4 residents. The acuity is pretty high with at least one or two intubations and a few central lines each 12-hour shift.

The residents in the pediatric ED usually average about 2 patients per hour. There are some days that you will see 3 or 4 patients per hour for a few hours, almost all of which are fast track type patients.

We have a dedicated pediatric fellow and pediatric attending 24/7 in our pediatric ED. The adult ED has 5 hours of single physician coverage (2a-7a), 8 hours of triple coverage, but mostly double coverage throughout the day. For a few hours there is quadruple attending coverage. All patients are supervised by a senior resident (PGY 3 or 4), available 24/7.

When I first started residency I thought I was seeing too many patients. I'm now glad I see a good volume of patients... it teaches you time management skills that are necessary when you get in the real world and are seeing 2.5 patients per hour on your own. No longer do I spend idle time gazing into the air or surfing the web, but instead I get discharge paperwork ready, write scripts that are anticipated for discharge, etc.

 

[NinerNiner999]

Thanks for the replies - I thought we were being a little too ambitious. In "old" system (pre-February) I would see up to 20 patients (at times) but stay pretty consistent around 1.5-2pph per 8 hour shift. Now, with the new system it is like somebody has opened the flood gates and my volume has almost tripled! We are told this is to reduce walkouts, allow sicker patients to be seen quicker (which in some cases it has worked), but it is also to simulate the community pace of practice. It sounds like we are seeing more than community docs. Anyone care to comment?

 

[southerndoc]

Thanks for the replies - I thought we were being a little too ambitious. In "old" system (pre-February) I would see up to 20 patients (at times) but stay pretty consistent around 1.5-2pph per 8 hour shift. Now, with the new system it is like somebody has opened the flood gates and my volume has almost tripled! We are told this is to reduce walkouts, allow sicker patients to be seen quicker (which in some cases it has worked), but it is also to simulate the community pace of practice. It sounds like we are seeing more than community docs. Anyone care to comment?

I think with that many patients, your program could benefit from hiring PA's to see lower acuity patients (split resident/PA teams seeing lower acuity patients, and resident teams seeing higher acuity patients).

 

[NinerNiner999]

Yeah, we have currently have 2 PA's plus an urgent care center, but we don't have the budget to hire anybody else. I fear that increasing the resident's schedule will be the next move 🙁.

 

[southerndoc]

Yeah, we have currently have 2 PA's plus an urgent care center, but we don't have the budget to hire anybody else. I fear that increasing the resident's schedule will be the next move 🙁.

How many shifts are you guys working right now?

 

[NinerNiner999]

Interns work 22-23 shifts/28 days (58hrs/week), PGY-2 21-22 (55 hrs/week), PGY-3 19-20 (46 hrs/week).

 

[southerndoc]

Interns work 22-23 shifts/28 days (58hrs/week), PGY-2 21-22 (55 hrs/week), PGY-3 19-20 (46 hrs/week).

Those are 8's, correct?

Our interns and R-2's work 18 12's in a 4-week block. R-3's and 4's work 20 shifts (usually 4-6 12's in "major med" with the others being 8-hour shifts supervising junior residents).

 

[NinerNiner999]

8's Tuesday - Friday, 12's Saturday through Monday.

 

[digitaltrader]

Im am a PGY-3 and at our facility our block is 28 days. We work 12 hour shifts except when we are on peds which are 12 hours for R1-R2 and 8 hours for R3's. We typically work 3 peds shift per block. The number of shifts per year is as follows: R1=20 R2=18 R3=16.

Since I have been a resident we also went to a team based system. Our ER is diveided into to separate sides (East = surgical complaints and West = medicine complaints) with the East ER having 2 teams with one attending and the West with 3 teams and one attending. The way the teams are tructured are as follows: The East ER has a Yellow team with an R3 and R1 (ER or off service rotator) and a Blue team with an R2 and R1 (ER or off service rotator). The West ER has a Red team with a R3 and R1 (ER or off service rotator), a Pink team with the R2 and and R1 (ER or off service rotator) and a Green team with only a upper level medicine resident. Patients are placed on their respective teams from triage with medicine complants going to the West ER and surgical complaints to the East ER. Each team is assigned a patient when it is their turn. The Green team (only a single medicine resident) gets skipped every other time to make it fair.

On a given shift I get handed off 12-20 patients from the off going team (only the R3 and R2 can take hand off). Of these 12-20 pateints typically 30-50% are admitted with the remaining 8-15 needing further workup and evaluation. I then typically see another 15-20 patients on my own during the shift. I see the critically ill patients as well as the moderately ill, with all not sick patients being sent to fast track staffed by a PA. Typically I will intubate at least one person per shift and put in a central line. Since the team method was put in the upper level residents see quite a few more patients than previously. It puts pressure on the team leaders R2 & R3 to move patients along quickly or face the embarassment of your list growing out of control on the large electronic tracking board.

Our ER see an average of 130-140k patients per year. I think the team system has helped the residents feel more responsibility of moving along the waiting room patients to beds. We typically have 150 patients in our ED at one time and without assignng patients to a team it is easy to feel like things are so far out of your control that working any harder/faster makes no difference.