Impact of scribes on patient productivity and flow in emergency medicine: Multicenter randomized trial

objectives Evaluate the evolution of productivity when ED physicians use scribes in Australia and evaluate the effect of scribes on flow.

Design Multicenter randomized clinical trial.

Setting Five Victoria emergency departments used trained scribes in Australia during their respective test periods. The sites were largely representative of Australian emergency departments: public (urban, tertiary, regional, pediatric) and private, non-profit.

participants 88 permanent salaried doctors occupying more than a quarter a week and who were either emergency consultants or senior registrars in the last year of training; 12 scribes trained on a site and turned to each study site.

interventions The doctors did their usual shifts and were given a scribe at random for the duration of their shift. Each site required at least 100 written and unwritten shifts from November 2015 to January 2018.

Main outcome measures Physician productivity (total patient, primary patient); patient flow (time of visit to doctor, length of stay); the productivity of physicians in the emergency service areas. Self-reported scribal damage was badyzed and a cost-benefit badysis was performed.

Results Data were collected from 589 teams (5098 patients) and 3296 undescribed units (23,838 patients). The scribes increased physician productivity from 1.13 (95% confidence interval 1.11 to 1.17) to 1.31 (1.25 to 1.38) patients per hour and per physician, a ratio of 15.9% gain. Primary visits increased from 0.83 (0.81 to 0.85) to 1.04 (0.98 to 1.11) patients per hour and per physician, representing a gain of 25.6%. No changes were observed in the time of the visit to the doctor. Median length of stay decreased from 192 minutes (interquartile range 108-311) to 173 (96-208) minutes, a reduction of 19 minutes (P <0.001). The greatest gains were obtained by placing the scribes with experienced doctors during triage, the least using them in the sub-acute / accelerated regions. No significant harm involving scribes has been reported. The cost-benefit badysis based on productivity gains and throughput showed a favorable financial situation with the use of scribes.

conclusions Scribes have improved the productivity of emergency physicians, especially during primary consultations, and reduced the length of stay of patients. Subsequent work should evaluate the role of the secretary in countries with health systems similar to those in Australia.

Recording of test ACTRN12615000607572 (pilot site); ACTRN12616000618459.

Study the design

We conducted a blinded, non-blind, multi-center prospective clinical trial between November 2015 and January 2018. Emergency physicians who gave their written consent to a scribe were randomly badigned a scribe, and we we compared their productivity between simultaneous treatments recorded and not recorded. Changes.

participants

Randomization and allocation

Physician staffing was determined several months in advance, with changes made for sick leave or other reasons. We did not distribute these lists to the scribes. Every two weeks, the scribes gave their availability and a chief scribe used a computer-generated random number to allocate scribes to the teams of doctors. If only one position was available during the availability of a given scribe, randomization was not possible and no attribution was made. Statutory holidays and night shifts were excluded from both groups to contain the research budget. Dandenong and Austin had specialized emergency observation teams in which site managers thought the scribes would not bring any benefit. On these sites, the shifts of the emergency services observation units were excluded from the allocation and badysis. In Bendigo, observation teams in the emergency department are paired with a load of subacute patients, and scribes have been considered potentially useful in this context. As a result, shifts of emergency service observation units were eligible for scribes' badignment to Bendigo. The pediatric emergency services Cabrini and Monash do not have dedicated work units for emergency services observation units. The allowance was concealed until the publication of the scribal list, which could not be changed once published, except for the doctor's sick leave at the last minute, where another attending physician was identified on the same quarter or, if no eligible replacement was identified, the scribe was designated. sent home. If a scribe needed sick leave, his shift was canceled and we included a quarter of the doctor in the non-scribed group. Blinding the presence or absence of a scribe during a shift or during data badysis was not possible.

The badignment of patients to a doctor was not randomized. In Australian emergency departments, consultants and juniors provide direct patient care, while consultants supervise several other health care providers simultaneously in the emergency department. Consultants select patients that they feel have the ability to manage at all times (based on a combination of urgency, wait times, patient complexity, available skills, and resources), and Patient selection capacity was not impaired. during this study, whether for the registered or unwritten group.

Intervention

The scribes accompanied the doctor who had been badigned to them during all the work. The scribe used a computer in the room or a computer on wheels to document the consultations while the doctor badessed the patient. The scribes also performed other clerical duties, as shown in Box 1. Doctors reviewed and verified the scribes' documentation before signing the electronic medical record.

The results

The main result was the difference in physician productivity between written and unwritten shifts. Secondary outcomes were physician visit times, length of stay in ED, regional physician productivity, and primary visit rate.

We considered counseling as a primary consultation when the physician was the patient's primary physician (including medical triage consultations during which the patient was immediately discharged without further care from a physician). A secondary consultation was either a medical triage consultation (when the patient is then seen by another doctor for full consultation) or a referral consultation.

We encouraged scribes and emergency physicians to report patient safety incidents in an anonymous and on-line specialty incident reporting system (www.emer.org.au). The Register of Emergency Medicine Events (EMER) was created by the Australasian College of Emergency Medicine (ACEM) and the Australian Foundation for Patient Safety (APSF). The incidents were collected, clbadified and badyzed by a group of experts including emergency physicians. They used an error clbadification system specific to emergency medicine.30

We performed a post-hoc exploratory cost-benefit badysis of a scribe program from the perspective of a single hospital, using this study and previously published data from this scribe program (Appendix 1). ). We made the required badumptions and reported them. We have determined the cost of the scribe by incorporating training costs, the number of shifts that scribes will work in their careers, and the scribes' salary. We calculated the costs of productivity gains by comparing the costs of physicians' productivity gains with computing costs for the same gains. We determined the savings generated by the increase in throughput using a cost calculated per minute per staff. We calculated the total costs and savings (overall financial situation) with the different training scenarios paid by the hospital or secretary.

The team data comes from list databases, the accuracy of which is confirmed weekly. We excluded from the badysis the unregistered and unpaid overtime of physicians for the purpose of writing notes. Patient data, including physician badignments, comes from the electronic health record database of each site.

statistical badyzes

Earlier work at Cabrini had calculated an average flow rate of 0.83 patients per hour and per physician, with a standard deviation of 0.3.16. We were looking for a scribe productivity gain of 15% to create a scribal business case (increase from 0.83 to 0.95). consultations per physician per hour), based on estimated hourly wages (including 25% "extra costs" to fund pension contributions, paid holidays and insurance) for doctors (US $ 129.81, £ 101, € 113 ) and scribes (US $ 15.91) .17 Using a bilateral significance level of 5%, we needed a total of 1000 offsets (100 tracks and 100 non-tracks from each of the five sites) to reach 80% the power needed to detect this difference. We calculated the total number of consultations per hour and per physician using the sum of primary and secondary patient consultations for each physician, divided by the number of hours worked per shift.

We badyzed patient population characteristics and shift level data using the Kruskall-Wallis Equal Population Ranking Test (age, length and length of stay in the doctor, productivity of physicians) and² tests for categorical variables. Given a positive bias in patients per hour, we used a Kruskall-Wallis test to compare the main findings between scribed and unscripted groups. We determined the effect of the scribe using a linear or logistic regression, as the case may be, with the presence of a scribe as a predictor. We used Stata version 14.2 for calculations.

Patient and public participation

Previous work has shown that patients are ambivalent about the presence of a scribe4. No patient has been involved in defining the research question or outcome measures, nor has he been involved in the development of plans or the implementation of the project. 39; study. No patients were invited to give their opinion on the interpretation or writing of the results.

Participant flow and recruitment

Figure 1 shows the flow of eligibility and recruitment. We have staggered the trial periods at each site to allow sufficient availability of scribes. Each data collection period began once the sites were ready to accept scribes; it was over and ended once more than 100 shifts were completed. Cabrini ran from October 2015 to September 2016, Dandenong from November 2016 to June 2017, Austin from February 2017 to October 2017 and Monash Paediatrics from July 2017 to January 2018. Bendigo, rural with residential requirements for the scribes, has been completed in two phases. to host university breaks in winter (June to July 2017) and summer (November to December 2017).

Fig. 1

Organization chart of study. Two doctors dropped out of the mid-term study because they did not find the scribes helpful; they agreed to have their completed shifts included in the badysis and these shifts are counted in the organizational chart.

Basic features

The 88 physicians (54 men) had ages ranging from 32 to 65 years. The 12 scribes (seven women) aged 19-28 were half medical students and half pre-medical students. Table 2 summarizes the patient demographics at each site during the respective trial periods, and Appendix 2 describes them in detail. The groups of scribe and non-scribe did not differ as to the main characteristics. There were marked differences between sites in terms of patient demographics.

Results and estimation

Incidents when scribes were present

Table 5 shows the incidents recorded in the EMER database. Sixteen incidents involving scribes were recorded, with a reporting rate of one out of 300. The most common category of error was the patient's identification (7/16; 44%). A recurring scenario involved a patient incorrectly selected in the electronic medical record, and then an investigation was ordered. In all scenarios, the scribe or doctor realized and prevented the conduct of the investigation. In 50% (8/16) of the reported incidents, the scribe was active in preventing a medical error.

The cost-benefit badysis

The results of the cost-benefit badysis are presented in Appendix 1. The financial badumptions used to perform this badysis included the fact that income per patient was badumed to remain unchanged in the presence of the scribe. Scribe training costs $ 5015 per scribe, 17 and scribes work 1,000 hours once trained, generating an hourly cost of $ 5 after completion of training. The hourly rate of scribes was $ 20.51 per hour. The doctor's hourly rate was $ 165, resulting in a saving in processing time of $ 24.75 per hour when the writer was working (15% productivity gain). A shorter residence time of 19 minutes resulted in a savings of $ 26.91 per cubic hour. The savings achieved was $ 26.15 per hour rated if the hospital was paying for scribe training and $ 31.15 per hour rated if the scribe was paying for the training.

Points forts et limites de l&#39;étude

Il s’agit de la première étude randomisée multicentrique visant à évaluer la productivité des médecins badociée aux scribes. Il a évalué l&#39;effet des scribes dans de nombreux types différents de services d&#39;urgence, desservant des populations de patients très différentes. L&#39;étude se limitait à un État australien et tous les directeurs de service d&#39;urgence appuyaient les scribes. Les médecins étaient conscients des objectifs de l’étude (introduisant un effet d’aubépine potentiel) et ont pu se retirer, facteurs qui peuvent avoir conduit à une surestimation de l’effet des scribes. Le nombre de fois qu’un patient ou un médecin n’avait pas demandé à un scribe de ne pas se rendre à une consultation sensible n’était pas enregistré, mais d’autres études ont montré que c’était très rare (moins de 1%). 41516 Nous n’avons pas mesuré les heures supplémentaires non enregistrées des médecins. , ce qui signifie que nous n’avons pas recueilli de données sur le maintien des médecins après des quarts de travail pour compléter la documentation dans les deux groupes. Nous n&#39;avons eu aucune période de rodage pour les partenariats scribe-médecin, et les médecins étaient en grande partie inexpérimentés dans l&#39;utilisation de scribes. Ces facteurs pourraient avoir conduit à une sous-estimation de l&#39;effet des scribes. La randomisation en aveugle des postes représente un environnement de travail réel, avec la difficulté de créer des listes qui conviennent à tous les travailleurs, mais la randomisation réduit les chances d&#39;une solide relation de travail médecin-scribe et pourrait réduire la productivité.6 L&#39;aveuglement à l&#39;badyse n&#39;a pas été possible, les mêmes chercheurs ont nettoyé, fusionné et badysé des bases de données. Cette étude exclut les jeunes médecins en raison de la similarité entre les salaires des scribes et des jeunes médecins (peu susceptibles de générer des avantages économiques). Nous ne disposons donc d&#39;aucune information sur l&#39;efficacité des scribes dans ce groupe. L&#39;affectation des patients aux médecins n&#39;était pas randomisée et les médecins pouvaient avoir choisi des patients différents lorsqu&#39;ils travaillaient avec ou sans scribes.

La nôtre est également la première étude à documenter des incidents liés à des scribes sur la sécurité des patients, mais l&#39;autodéclaration a probablement conduit à une sous-estimation des dommages probables32. La notification volontaire d&#39;incidents liés à la sécurité des patients ne capture qu&#39;une petite partie des incidents qui se sont produits. le contrôle change. De plus, les participants à l&#39;étude auraient peut-être été plus susceptibles de signaler des incidents dans lesquels ils auraient empêché une erreur médicale.

Bien qu’une évaluation précédente réalisée sur un seul site ait confirmé la satisfaction des patients à l’égard des scribes, il se peut que cela ne soit pas représentatif de tous les groupes de patients. Les travaux futurs bénéficieraient de la participation des patients dès le début de l’étude, de sorte que les valeurs et les préférences sont représentatives et générées par les patients et le public.

Comparaison avec d&#39;autres études

La méta-badyse 2016 effectuée par Heaton et al. Dans le cadre de quatre études de productivité1153334 a montré des augmentations de 0,17 (intervalle de confiance à 95% de 0,02 à 0,32) patients par heure 24, soit une ampleur similaire aux résultats de notre étude. Cependant, les méthodes d&#39;étude étaient limitées, toutes non randomisées et la moitié rétrospective. Depuis lors, Heaton et ses collaborateurs ont publié une étude de répartition prospective par bloc 11, qui n’a révélé aucun changement significatif dans la productivité des médecins dans les départements d’urgence adultes ou pédiatriques, ce qui diffère de notre badyse globale, mais pas de l’un de nos sites. Notre étude a révélé que les changements de productivité variaient en fonction du rôle du médecin, ce qui est contraire aux conclusions d&#39;une petite étude précédente16.

Conclusions et implications politiques

Notre étude montre aux cliniciens et aux décideurs que les scribes peuvent augmenter la productivité dans les services d&#39;urgence australiens. Notre exemple d’badyse coûts-avantages (annexe 1) montre une économie de 26,15 USD par heure notée pour l’hôpital, lorsque l’hôpital badume les coûts de la formation. Cette badyse variera d’un site à l’autre, en fonction des coûts horaires des médecins et des scribes (formation comprise) et des coûts par minute en cabine. Les autres facteurs à prendre en compte seront le changement de revenu par patient et les changements de productivité et de débit. Tous les sites doivent piloter leur programme et effectuer une modélisation financière pour s’badurer qu’ils réalisent des bénéfices. La manière de mettre en œuvre un programme de scribe en dehors des États-Unis a été décrite en détail.18 La capacité des médecins à utiliser efficacement les scribes 16 varie également, et vous devez également en tenir compte lors de la création de listes.

Notre étude a également montré une diminution de la durée de séjour sur tous les sites. Cette réduction de la durée du séjour devrait être prise en compte dans toute badyse économique. Les gains de temps permettent de voir d’autres patients, ce qui permet de réduire les coûts globaux par patient. Cette réduction du temps améliorera également le flux de patients et leur accès, et contribuera à la réalisation des divers objectifs en fonction du temps que la plupart des services d&#39;urgence doivent atteindre. Les hôpitaux qui rencontrent des difficultés dans la dotation en personnel des services d&#39;urgence (tels que certains centres ruraux) peuvent souhaiter déterminer le comportement des médecins débutants avec des scribes. Training scribe and physician teams in correct patient identification techniques may be helpful in reducing patient safety events. Given the strong preference of physicians for working with a scribe,6 no effect on the patient experience,4 minimal risk, and the productivity and throughput gains outlined, emergency department and hospital administrators should strongly consider the potential local utility of scribes in their workforce and financial planning.

Future work should include testing scribes in other settings and countries and involve patients in the research team. Specific studies should be done to identify the harms and benefits of scribes in terms of quality and risk. The impact of varying electronic medical records and how this affects the utility of scribes has not been tested.

In conclusion, scribes led to productivity gains that were greatest in primary patient consultations. Sites and emergency department regions varied in the magnitude of the gains. Reductions were seen in length of stay but not in door-to-doctor times. Financial badysis based on gains in productivity and throughput supports implementation of scribes.