Heather A. Heaton

Effect of scribes on patient throughput, revenue, and patient and provider satisfaction: a systematic review and meta-analysis ☆ ☆☆ ★ ★★

BACKGROUND Scribes offer a potential solution to the clerical burden and time constraints felt by health care providers. OBJECTIVES This is a systematic review and meta-analysis to evaluate scribe effect on patient throughput, revenue, and patient and provider satisfaction. METHODS Six electronic databases were systematically searched from inception until May 2015. We included studies where clinicians used a scribe. We collected throughput metrics, billing data, and patient/provider satisfaction data. Meta-analyses were conducted using a random effects model and mean differences (MDs) with 95% confidence intervals (CIs) with adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. RESULTS From a total of 210 titles, 17 studies were eligible and included. Qualitative analysis suggests improvement in provider/patient satisfaction. Meta-analysis on throughput data was derived from 3 to 5 studies depending on the metric; meta-analysis revealed no impact of scribes on length of stay (346 minutes for scribes, 344 minutes for nonscribed; MD -1.6 minutes, 95% CI -22.3 to 19.2 minutes) or provider-to-disposition time (235 minutes for scribes, 216 for nonscribed; MD -18.8 minutes, 95% CI -22.3 to 19.2) with an increase in patients seen per hour (0.17 more patient per hour; 95% CI 0.02-32). Two studies reported relative value units, which increased 0.21 (95% CI 0-0.42) per patient with scribe use. CONCLUSION We found no difference in length of stay or time to disposition with a small increase in the number of patients per hour seen when using scribes. Potential benefits include revenue and patient/provider satisfaction.

Impact of scribes on patient throughput in adult and pediatric academic EDs

OBJECTIVES Assess the impact of scribes on an academic emergency departments (ED) patient-specific throughput. METHODS Study design, setting, participants: A prospective cohort design compared throughput metrics of patients managed when scribes were and were not a part of the treatment team during pre-defined study hours in a tertiary academic ED with both an adult and pediatric ED. INTERVENTION Eight scribes were hired and trained on-site by a physician with experience in scribe implementation. Scribes provided 1-to-1 support for a providers work shift. An alternating-day pattern in months 2 to 5 post implementation ensured balance between the scribe and non-scribe groups in time of day, day of week, and patient complexity. RESULTS Adult: Overall length of stay (LOS) was significantly longer for scribed patients (265 vs. 255 minutes, P=.028). The remaining throughput measures analyzed (door to provider, provider to disposition, and patient duration in treatment room) had higher summary values, but were not significant. Subgroup analysis revealed that patients seen by postgraduate year (PGY) 3 residents had significantly shorter LOS when seen with a scribe (244 vs. 262 minutes, P=.021). Pediatric: Overall LOS (163 vs. 151 minutes, P=.011), door to provider (21 vs. 16 minutes, P<.001), and treatment room duration (130 vs. 123 minutes, P=.020) were significantly longer when the treatment team had a scribe. CONCLUSIONS Scribes failed to improve patient-specific throughput metrics in the first few months post implementation. Future work is needed to understand whether throughput efficiencies may eventually be gained after scribe implementation.

Impact of scribes on emergency department patient throughput one year after implementation

Objectives: Assess the impact of scribes on an academic emergency departments (ED) throughput one year after implementation. Methods: A prospective cohort design compared throughput metrics of patients managed when scribes were and were not a part of the treatment team during pre‐defined study hours in a tertiary academic ED with both an adult and pediatric ED. An alternating‐day pattern one year following scribe implementation ensured balance between the scribe and non‐scribe groups in time of day, day of week, and patient complexity. Results: Adult: Overall length of stay (LOS) was essentially the same in both groups (214 vs. 215 min, p = 0.34). In area A where staffing includes an attending and residents, scribes made a significant impact in treatment room time in the afternoon (190 vs 179 min, p = 0.021) with an increase in patients seen per hour on scribed days (2.00 vs. 2.13). There was no statistically significant changes in throughput metrics in area B staffed by an attending and a nurse practitioner/physician assistant, however scribed days did average more patients per hour (2.01 vs. 2.14). Pediatric: All throughput measurements were significantly longer when the treatment team had a scribe; however, patients per hour increased from 2.33 to 2.49 on scribed days. Conclusions: Overall patient throughput was not enhanced by scribes. Certain areas and staffing combinations yielded improvements in treatment room and door to provider time, however, scribes appear to have enabled attending physicians to see more patients per hour. This effect varied across treatment areas and times of day.

Maximizing Patient Coverage Through Optimal Allocation of Residents and Scribes to Shifts in an Emergency Department

Residents and scribes in an Emergency Department (ED) work closely with an attending physician. Residents care for patients under the supervision of the attending physician, whereas scribes assist physicians with documentation contemporaneously with the patient encounter. Optimal allocation of these roles to shifts is crucial to improve patient care, physician productivity, and to increase learning opportunities for residents. Since resident and scribe availability varies on a monthly basis, the allocation of these roles into different shifts within a pre-designed ED physician shift template must be dynamically adjusted. Using historical patient flow timestamp data as well as information about the patient-coverage capacity of an ED care team, a data-driven model was developed for optimally determining which shifts must be staffed by residents and scribes to maximize patient coverage and to calculate the relative importance of a shift. This relative importance metric aids decision-making in adjusting the allocation of residents and scribes to various shifts as their availability fluctuates. Since the model uses historical timestamp data, which all EDs are mandated to collect, the approach is generalizable to all EDs.

In Support of the Medical Apology: The Nonlegal Arguments

BACKGROUND More than 30 million people are affected annually by medical errors. Apologies can heal patients, families, and providers and, if deployed and structured appropriately, can enrich clinical encounters-yet they rarely occur. OBJECTIVES This article will address the nonlegal arguments in favor of the medical apology and discuss a structure for delivering a meaningful apology. In addition, we will review reasons why some providers feel compelled to apologize while others faced with similar circumstances do not. DISCUSSION Medical apologies bring value to both patients and providers. Apologies can preserve therapeutic relationships and save careers for professionals by restoring their self-respect and dignity. The four Rs of the ideal apology-recognition, responsibility, regret, and remedy-provide a framework to help providers apologize for unintended outcomes. When deployed and structured appropriately, apologies can heal patients, families, and providers and can enrich clinical encounters. CONCLUSION For providers, forgiving ones self is key to professional wellbeing and continued effective practice. For patients, apologies are desirable and also serve as a conduit for often wanted emotional support from their physician.

Presentation and Medical Management of Fibrocartilaginous Embolism in the Emergency Department

BACKGROUND Fibrocartilaginous embolism is an exceedingly rare condition that was formerly a clinical diagnosis based on mechanism of injury, physical examination findings, and older magnetic resonance imaging (MRI) technologies without a specific histologic diagnosis. Spinal cord MRI diffusion-weighted imaging allows for a more specific diagnosis. CASE REPORT A 14-year-old male felt a sudden pop in his back while running sprints in his gym class. He slowly developed bilateral lower extremity weakness and urinary incontinence, prompting an emergency department evaluation. A MRI scan of his lumbar spine revealed degeneration, desiccation, and bulging of the T12-L1 disc with an accompanying subacute Schmorls nodule. There was adjacent cord swelling and central cord T2 hyperintensity, with accompanying restricted diffusion consistent with spinal cord infarction. These findings, in conjunction with paraplegia and mechanism of injury, were highly suggestive of fibrocartilaginous embolism. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: An emergent MRI scan with the proper sequencing and immediate consultation with a spine surgery specialist are important to exclude a compressive myelopathy that would necessitate acute surgical decompression. There is significant uncertainty in the initial management and stabilization of this rare condition that has not been addressed in the emergency medicine literature.