The Effect of Operational Stressors on Emergency Department Clinician Scheduling and Patient Throughput

We assess the effect of emergency department (ED) operational stressors on clinician scheduling and throughput.

We evaluated 2014 to 2018 data from a national ED group. Operational stressors included measures of workload, patient acuity, and complexity. We used multilevel linear regression to estimate the effect of operational stressors, temporal factors, and facility characteristics on ED clinician scheduling; patient throughput, measured as shift-level patient departures per corrected clinician hour; and length of stay.

In greater than 14 million ED visits across 359 facility-years, the mean of patient departures per corrected clinician hour was 2.23 (95% confidence interval [CI] 2.15 to 2.31). Temporal and facility effects had the greatest influence on patient departures per hour (eg, -0.55 [95% CI -0.75 to -0.36] in 7 am to 3 pm shifts versus midnight to 7 am on Mondays, 0.25 [95% CI 0.03 to 0.47]) in teaching versus nonteaching hospitals, and 0.43 (95% CI 0.24 to 0.61) in larger EDs (30,000 to 59,999 ED visits/year) versus smaller EDs. Operational stressors had significant but small effects on patient departures per hour (eg, length of stay [per-minute increase] 0.002 [95% CI 0.0019 to 0.0023] and percentage admitted [per 1% increase] -0.003 [95% CI -0.004 to -0.001]). Weekday nights, particularly Mondays, had the highest proportion of shifts with increasing length of stay compared with previous years in the same ED.

ED operational stressors had minimal influence on patient throughput when included in adjusted ED clinician scheduling models, whereas temporal and facility factors were more influential. Therefore, incorporating operational stressors into ED clinician scheduling is less likely to balance workloads than accounting for temporal and facility-level factors alone. Length of stay on some shifts, particularly Monday nights, became increasingly long, suggesting they require additional resources.