Emergency Physician Productivity
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>Does anyone have a reference on patient loads per hour in the ER? We are
>seaching for that efficiency eutopia. ACEP has a recommendation if anyone
>knows it.. 

 As has been pointed out in a previous post the answer to this
question is a function of the patient acuity level seen in your ED.  In an
attempt to take this factor into consideration a 'LIVES' formula has been
developed that allows one to predict physician staffing needs in different
settings (ref 1). 

 Basically the formula assumes that the 'amount' of physican
services (W) needed is the product of the patient volume (V) and the
physician time spent per patient (T). Thus:  

 (1) W = V*T

The intensity of service (I) is the fraction of the patients
length of stay (L) in the ED that requires direct physician time:  

 (2) I = T/L and so substituting T in (1) above 

 (3) W = L*I*V

This formula, however, does not differentiate EDs that have different
proportions of more acutely ill patients.  Thus patients may be classified
based upon intensity of services required as follow:  Code (c), Critical
(cr), Observation (o) and Routine care (r).  Thus the above formula
becomes:  

(4) W = L(r)*I(r)*V(r) + L(cr)*I(cr)*V(cr) + L(c)*I(c)*V(c) +
L(o)*I(o)*V(o) 

 Where e.g., I(r) is the intensity of service for routine
patients, V(cr) is the volume of critical patients etc... 

 The authors made the following assumptions (which you are free to
modify):  T(r) = 0.37 (which translates to 2.7 patient/hour for 'routine'
care). Thus I(r) = 0.37/L(r) where L(r) is the average length of stay for
routine patients.  In this study L(r) was 1.44 hours (your may substitute
your data which may be different) and thus I(r) = 0.37/1.44 = 0.25. The
authors further assumed that I(c) = 1.00 and I(cr) = 1.00 (code and
critical patients require 100% of LOS for physician time).  They used an
I(o) = 0.0625 based upon JCAHO recommendations. 

Let's assume the following breakdown:  

Category	Yearly Visits   LOS(hours) 
Routine		35000		1.44 
Critical	1500 		3.00 
Code 		200 		0.50 
Observation	3500 		8.00 
TOTAL 		40,200


 Using the above values of I one obtains:  W = 1.5*0.25*35000 +
3.00*1.00*1500 + 0.5*1.00*200 + 8.00*0.0625*3500 =

 19475 physician hours. 

 Thus this ED would require the equivalent of 10 FTE (assuming 40 
hours/week per FTE). 

 Note that (e.g.) critical patients may not require an I(o) = 1.00. 
Part of the time may reqire intense physician monitoring followed by a
longer interval simply waiting for a bed to become available after the
patient is stabilized. Similar modifications may be made to to other
estimates of 'I' based upon your own particular circumstances. Furthermore
the 'I' values may change with time and may need to be modified. 

 Read the article.  


H. Louzon MD 


(1) Graff et. al. Formula for Emergency Physician Staffing. Am J Emer Med
1990;8:194-199.