ER docs less efficient at shifts' end, study says

Pamela Fayerman
http://www.canada.com

VANCOUVER – Emergency room doctors see far fewer patients in the last few hours of their eight-hour shifts because of stress, fatigue and declining efficiency, a study by a Vancouver hospital shows.

The average number of new patients seen by the ER doctors was two per hour on a day shift and 2.4 on night shifts, which is in line with the industry standard in Canada.

Doctors working graveyard shifts, which are five hours long, saw the highest average number of new patients – 2.6 per hour. But in the last hours of all shifts, the health providers saw a much lower number of new patients – anywhere from 0.1 to 1.7 patients per hour.

The study, done by St. Paul’s Hospital over six months last year, covered 2,000 shifts by 31 full- and part-time doctors at St. Paul’s who saw 31,000 patients during that period.

Study leader Dr. Grant Innes, who was head of the ER department at St. Paul’s at the time, acknowledged that another reason doctors see fewer new patients late in their shifts is that they tend to take on only patients with minor problems at that time, because handing over more difficult cases to another doctor means “balls might get dropped and things might get missed.”

“I know from experience that by the end of a shift, it is hard to even fill out a chart because of exhaustion and you just aren’t that functional by the end of a shift,” said Innes, who now heads emergency medicine for the Calgary Health Authority.

“It’s why ER shifts have changed over time, from 24-hour shifts many years ago to 14-hour shifts, then 12 and now eight,” he said.

The study, done with co-researchers Dr. Eric Grafstein and Dr. Rob Stenstrom, was intended to help hospitals determine whether intake capacity declines progressively to the point where doctors “no longer contribute meaningfully to seeing new patients and should be replaced” by the last hours of their shift.

The study looked only at new patients seen by doctors, not their entire workloads. As a shift progresses, the number of patients per doctor accumulates and so does the workload as lab test and other investigation results arrive.

“Understanding emergency physician intake dynamics is critical in establishing optimal shift length, shift scheduling and end-of-shift etiquette in terms of patient handovers,” Innes said.

Innes said the study results imply that shifts should be even shorter, perhaps six hours. Calgary hospitals will try six-hour shifts starting Oct. 1 in a pilot project. But he added it might be hard for hospitals to hire the additional doctors who would be needed if six-hour shifts are implemented. There is already a Canada-wide shortage of ER doctors.

Some studies have shown ER doctors are so dehydrated by the end of their shifts that their cognition begins to suffer. Innes said 90 per cent of ER doctors “don’t stop for anything, whether it’s a coffee break, a lunch break or even a pee.”

While nurses, who usually work 12-hour shifts, are entitled to take a 30-minute meal break every four hours and a 15-minute break every two hours, ER doctors forego the breaks because “if they stopped for that, they would end up working longer and there’s always a department and waiting room full of patients.”

There is no such thing as billing for overtime, even though eight-hour shifts often turn into 10 hours, since doctors don’t want to leave incomplete cases. The average salary for an ER doctor at St. Paul’s is $268,000, and they typically work 14 shifts per month.

“The study is interesting because it looks under the hood, so to speak, in terms of showing how physician energy and efficiency degrade over the course of time,” said Grafstein, head of the ER department at St. Paul’s.

“It doesn’t point to the ideal shift length, but does suggest that it’s important to have overlapping shifts, so that as one doctor winds down, there is another starting who can pick up the pace,” he said.

The study found there is a wide variation in the productivity of doctors. Some saw 40 per cent more patients per hour than others in the same shifts. Innes said less experienced doctors may be a little slower.

“You don’t want to hustle those ones along. And then we have doctors who take their clinical teaching roles very seriously and that can slow things down too, because they are stopping to teach their students as they go along.”

© Vancouver Sun 2008