CONCEPTS administration, emergency department
Physician Staffing in the Emergency Departments of Public Teaching Hospitals: A National Survey I
From the Division of Emergency
Joseph E Holley, MD*
_Medicine, Department of
Arthur L Kellermann, MD, MPH*
Medicine, University of
Dennis P Andrulis, PhW
Tennessee, Memphis;* and the
I
I
Study hypothesis: To evaluate factors influencing emergency physician staffing patterns in an important subset of US hospitals. Design: Survey of emergency department directors and hospital administrators.
National Association of Public Hospitals, Washington, D.C.4 Receivedfor publication April 18, ] 991. Revision received July 22, 1991. Acceptedfor publication August 23, 1991. Supported in part by the Robert Wood Johnson Foundation under grant #15263. Presented at the Winter Symposium of the American College of Emergency Physicians in Tucson, Arizona, March 1990.
JANUARY 1992 21:1 ANNALS OF EMERGENCY MEDICINE
Member institutions of the National Association of Public Hospitals and the Council of Teaching Hospitals.
Participants:
Measurements: Of 498 hospitals enrolled, two mailings and telephone follow-up yielded 277 replies (56% response rate). To adjust for differences in ED size and volume, levels of staffing were converted to fuN-time equivalents (FTEs)per 10,000 annual ED visits. Results: Responding institutions included 160 private and 115 public hospitals, 74 of which were Veterans Administration hospitals. Formal medical school affiliation was noted by 86% of responding institutions, and 82 (30%) supported emergency medicine residency programs. Fulltime attending emergency physician staffing varied widely, from less than one to more than three FTEsper 10,000 visits; however, mean levels of staffing at public hospitals did not differ significantly from private institutions (2.7 _+1.6vs 2.5 +3.1, respectively; P = ,50). Three of four hospitals reported using part-time emergency physician attendings but only 33% used nurse practitioners or physicians' assistants. Two thirds of responding hospitals used rotating house officers-in-training. Of note, hospitals that supported emergency medicine residency programs reported significantly higher levels of staffing by housestaff (2.2 +_1.8vs 1.0 +_1.2 FTEs/10,000 visits; P< .0004), but levels of total staffing by full- and part-time attending physicians were virtually identical (2.69 +_1.6 vs 2.67 +_2.6 FTEs/10,000 visits; respectively; P= .95). Marked variability in levels and patterns of ED staffing at public and teaching hospitals currently exists, but the differences are not explained by hospital ownership. The reasons for such variations and their implications for patient care must be explored. [Holley JE, Kellermann AL, And@is DP: Physician staffing in the emergency departments of public and teaching hospitals: A national survey. Ann Emerg Med January 1992;21:53-57,]
53/ B 5
PHYSICIAN H&y,
STAFFING
Kellermann
& Andrulis
INTRODUCTION In contrast to physicians engaged in office-based ambulatory care practice, emergency physicians have little control over the volume or complexity of the clinical problems of patients presenting to their departments. Levels of physician staffing in emergency departments are, therefore, the principal determinant of physician work load, job satisfaction, and, most important, quality of care. Unfortunately, the supply of qualified emergency physicians is limited, and salaries for residency-trained emergency physicians are relatively high. Therefore, many institutions may seek to staff their EDs with the lowest number of emergency physicians consistent with acceptable levels of care. Although the level of physician staffing in the ED probably plays a critical role in defining the quality of care, this issue has not been studied previously in any systematic way. To gain insight into staffing patterns at an important subset of US hospitals, we analyzed data collected during a recent survey of the EDs of member institutions of the National Association of Public Hospitals (NAPH) and the Council of Teaching Hospitals (COTH). We were particularly interested in answering the following questions. Among US public and private teaching hospitals, how much variation exists in ratios of emergency physician to patient visits? How variable is the use of “par+ time” (eg, moonlighting) emergency physicians? What percentages of public and private teaching hospitals currently use physician extenders (ie, physicians’ assistants [PAS] and nurse practitioners) to supplement physician staffing? Are hospital EDs that support emergency medicine residency programs better staffed than hospitals that lack these programs? What critical methodologic issues must be addressed before implementing a broad-based survey of ED staffing levels nationwide?
MATERIALS
AND METHODS
Staffing data were derived from a previously reported national survey of hospital and ED overcrowding of member institutions of both NAPH and COTH.l Collectively, these two organizations represent virtually all of the United States’ premier public and teaching hospitals. Four hundred ninety-eight surveys were disseminated during Fall 1988. A second mailing was sent in January 1989, and telephone follow-up was completed a few months later. Information was based on the year September 1, 1987, through August 31, 1988. Included in this survey were questions regarding general hospital and ED characteristics, patient volumes, and measures of the extent and impact of ED overcrowding. ED directors also
66154 I
were asked to indicate the number of full-time equivalent (FTE) emergency physicians, part-time emergency physicians, senior housestaff, and interns staffing their department. To adjust for differences in ED size and volume, these levels of staffing were converted to FTEs per 10,000 annual ED visits. Because levels of staffing did not fit a normal distribution, nonparametric tests of statistical significance such as MannWhitney-Hugh were used to analyze these data. Dichotomous variables were assessed using the ~2 test.
RESULTS Two hundred seventy-seven hospitals from 40 states responded to the survey, for a 56% response rate. Data from both sponsoring organizations and the American Hospital Association were used to demonstrate that responding institutions were comparable to nonresponding institutions with respect to hospital size, community size, and hospital ownership.1 Responding institutions included 160 private hospitals (virtually all of which were nonprofit) and 115 public hospitals (including 74 Veterans Administration hospitals). Formal medical school affiliation was noted by 86% of responding institutions, and 65 (24%) supported emergency medicine residency programs. Hospitals averaged slightly more than 500 floor and 60 ICU beds, with a total range of 95 to more than 1,300 beds. Annual ED visits at responding institutions averaged 46,900, with a range of from 1,428 to 236,979 visits. All responding EDs were staffed by at least one full-time emergency physician (range, one to 25); however, levels of fulltime attending staffing per 10,000 visits varied widely. Only 7% of hospitals staffed their EDs with more than three full-time staff per 10,000 visits, and 17% reported that their department was staffed by one or fewer FTEs per 10,000 visits. Forty-five percent covered their department with one to 1.9 full-time emergency physicians per 10,000 visits, with 30% staffing at a level of two to 2.9 FTEs per 10,000 visits. Public hospitals did not differ significantly from private institutions in their levels of full-time emergency physician staffing (1.9 f 3.0 vs 2.1 f 2.9, respectively; P = .63). Three of four responding hospitals supplement their staffing with part-time attending physicians (mean, 0.95 FTE part-time staff per 10,000 visits; range, 0 to 25 per 10,000 visits). Public hospitals tended to use more part-time staffing, with 1.2 * 3.0 versus 0.82 f 1.2 FTEs per 10,000 visits (P = .19). When total FTE full-time and part-time staffing were combined, hospital EDs averaged 2.7 FTEs per 10,000 visits, but large differences b were still noted between institutions. Despite such vari-
ANNALS
OF EMERGENCY
MEDICINE
21:l
JANUARY1992
PHYSICIAN STAFFING Holley, Kellermann & Andrulis
ability, mean overall levels of attending staff at public hospital EDs were not significantly different than those at private institutions (3.1 + 4.8 vs 2.9 +_3.0 FTEs per 10,000 visits; P = .72). The use of PAs and nurse practitioners does not appear to be common among surveyed hospitals. Use of nonphysician primary care providers to supplement attending physician staffing was reported by only 33% of responding EDs. Thirty-one (12.7%) use nurse practitioners, 36 (14.8%) use PAs, and 5.3% use both. Twenty-seven percent of responding public hospitals use PAs compared with only 16% of responding private hospitals (P = .03). Fifteen percent of public hospitals use nurse practitioners in their EDs compared with 27% of private institutions (P = .03). In addition to staffing with attending physicians, 6.5% of the hospital EDs that responded to our survey use the services of rotating physicians-in-training. Thirty-five percent are staffed by postgraduate year (PGY)-I residents (mean, 0.60 FTEs per 10,000 visits), and 35% are staffed by PGY-2 or higher residents (mean, 0.96 FTEs per 10,000 visits). Twenty-one percent are staffed by both intern s and residents at higher levels of training. When we compared the 82 hospitals that reported supporting emergency medicine residency programs with the remaining 175 institutions that did not, we found that emergency medicine residency hospitals averaged significantly higher levels of staffing by housestaff (2.1 + 1.6 vs 1.1 + 2.0 FTEs per 10,000; P < .3) than hospitals without emergency medicine residency programs. However, staffing levels for attending physicians were comparable among residency-affiliated and nonresidencyaffiliated hospitals. Hospitals with emergency medicine residency programs staffed 2.76 + 1.7 attending per 10,000 visits, whereas hospitals not affiliated with an emergency medicine residency staffed 2.79 + 1.9 attending per 10,000 visits (P = .96).
BISCUSSION The patterns and characteristics of physician staffing of hospital EDs have evolved considerably over the past 20 years. Initially, many EDs were staffed by variations of the Pontiac Plan, through which physicians in the community united to staff the ED by each serving several shifts per month.2 At teaching hospitals, housestaff-in-training were often the exclusive providers of care, with little or no direct faculty supervision. With the emergence of the specialty of emergency medicine, these haphazard approaches to ED staffing were steadily (albeit slowly) replaced by the recognition that patients are better served by physicians specifi-
JANUARY 1992
2 1 : 1 ANNALS OF EMER6ENCY MEDICINE
cally trained to meet the unique demands of this clinical environment. Despite recognition that levels of physician staffing have profound impacts on both the quality and costs of emergency care, few guidelines have been published. No group has previously published information about the patterns or levels of staffing in a substantial number of US hospitals. In 1984, the American College of Emergency Physicians endorsed the concept that hospital EDs should be staffed 24 hours a day by specialists trained to practice emergency medicine on a full-time basis, but ACEP provided no specific guidance regarding the number of physicians necessary to meet various levels of demand. 3 van de Leuv suggested that hospital EDs treating 20,000 to 30,000 patients per year be staffed by five emergency physicians; one additional physician is recommended for every 5,000 annual visits above that number. 4 Mills concluded that one physician is needed for every 5,000 to 7,000 patient visits. 5 In 1973, Hannas noted that three physicians are needed for fewer than 20,000 patient visits, four physicians for 20,000 to 35,000 patient visits, and additional physicians if the volume is more than 35,000 patient visits per year. 6 Although all these authors have based their recommendations on actual patient visit statistics, patient volume is not the sole determinant of physician work load. Different levels of patient acuity require different levels of physician care. Many patient groups and problems require more lengthy or complex evaluation and care. Teaching may also necessitate increased staffing levels because staffing medical students, interns, and residents takes time away from direct patient care. As a result, teaching EDs may require additional staffing at peak times to meet the twin demands for education and patient care. Furthermore, academic emergency physicians generally spend more of their time in pursuit of research or educationally related activities than their colleagues in private practice; actual clinical time per FTE may therefore vary widely. In addition, ED size may require different levels of staffing due to such varied factors as subspecialization and the physical plant. To date, there has been no published information regarding current levels of staffing in EDs. No comparison has been made between the private and academic practices of emergency medicine. In 1981, the Graduate Medical Education National Advisory Committee of the Department of Health, Education, and Welfare predicted that ED visits for 1990 would total 68,335,836 and concluded that 14,686 emergency physicians would be needed to provide care for these patients .7 This level of staffing is equal to 2.14 FTEs per 10,000 annual visits. However, b"
55/57
I
PHYSICIAN H&y,
this
STAFFING
Kellermann
study
grossly
actually
occurred
exceeded
89.7
million
& Andruh
underestimated in 1990. million,
in 1991.8
were
9,099
25,000
board-certified staffing
for all emergency than
Our hospitals
coverage
marked
variability
ization
and teaching
credentials
the pattern
differed
mean
of attending
levels
of full-
somewhat of FTE
between
staff
primary
patients,
adopted
but they
this
may
caregivers
strategy.
The
lack
were
providers
of care,
extended
of our subset
of institutions EDs
variation
in both
the number
their
EDs
is important apparently assigned
without
such
to note,
however,
the result
department
this
hospital
EDs
Second, responders
programs
also
in terms
this
does
standing
officer
the first
than
ownership,1
they
hospitals
in other
important
size,
may
differ
respects.
year
efforts
that
as many
as half
be filled residents
departments
and
of
by from
under-
physician
training
size,
and region
would
more
emergency
medicine
change
was
on a part-time
a clearer
in emergency
programs
and
could
in mind,
to develop
under-
by 1990
‘moonlighting’
type,
they
oversupply
by a serious
expected
emergency
Education
physicians,
to prevent
flawed
observations
EDs.
in emergency
nationwide
and
variations
training
further
staffing It
is
and
a larger
systematic
physician” The
former
current
be useful
health
physicians
work
schedules
than
those
care
from
reported. size,
nonresponding
and
non-
EDs may
require
a comparable
physician.”
to 37 to 40 hours
private
demanding.
teaching
more level
emergency
more
with major
future
than
of direct
and research one full-time patient
care.
CONCLUSION Carefully
designed,
are needed and
many
that are considerably
for faculty to provide
“a full-time
to be equal
however,
academic
before equivalent
study
community
resembled
community
attending
of NAPH
nonteaching
requirements
be needed
with
considered
number
hand,
will
as “a full-time
confused
is generally per week;
our
such
are commonly
work
of
of terms
Expressions
of clinical
hospital
First,
clarification
surveys.
interns
survey
teaching
institutions
institutions
of hospital
slots
the
the credentials,
Medical
of graduates per
but
our nation’s
emergency
of ED visits
by hospital
future
Last,
their
in staffing
respects.
in US private, different
on Graduate
at 400
staff
about
staffing
was badly
who
beds.
data
by the assumption
of current
residency
additional
the number
these
credentials
to target
as no surprise.
not reflect
and private
responding
hospital
With
acuity,
to define
constant
specialties
patient
of inpatient
physicians.
practitioners
basis”7
medicine
staffed
of residents
important
be quite
other
and
of house
increase
to the member
of staffing
although
walk-in
hospital-
emergency
physician
“semiretired
On the other
in several
may
all emergency
considerable
comes
number
represents
was ‘limited Levels
as as
for
scarcity
of trained
compromised
for
emergency
institutions
Council
analysis
impact
admitted
policy.
to be better
and
that
further
emergency
tend
that
the
unclear,
the high
of training
sponsoring
at US public
it is limited
COTH.
an undersupply
of the number
FTEs.
study
staffing
population
in 1980
a profound
surrogates
of physicians
projected
have
responding
seek
Although
the presence
or part-time
experience
estimate
as well.
of a larger
or attending
Although physician
should
and
hospitals
physician
However,
level
hospitals
programs
to the
of faculty
EDs,
that
training
counterparts
surveys
full-
as diverse
to provide
and
requiring
as rough
be held
the commitment
education,
is not surprising.
was noted
observation
residency
of their
Issues
the need
can
important
of ED patients
by a general
Their
use of off-site
resident
cited
be affected
medicine
housestaff
Given
reported and
are
staffing.
beds
percentage
the percentage
by 1990.
care
of nonphysicians
of junior
to medical that
in their
Our
for this
of operation.
coverage staffing
reasons
recom-
ambulatory
responding
or widespread
hours
of US hospitals
proportion
few
use
has been acute
of acceptance
setting,10
with
providers
relatively
in the ED
alternative clinics
but
include
care
way to provide
one of many
for physician
we did not ask
Future
public
coverage
and
recommended
as a cost-effective
to “walk-in”
can
training,
versus
The
are often
by board-certified
in the levels
Although
coverage
hospitals,
Use of nonphysician
68156
that
care
both
covered
is just
inpatient
needs.
intensive
the same.
mended
of available
on staffing
10,000
likely
of the need
(or lack)
on these
it appears
of US public
EDs.
physician
virtually
I
there
per
volume
as the acuity of the patient population, . specialized services (eg, trauma,.burns),
of an estimated FTEs
patient
determinants 90
that
Based
to be 2.77
were
sample
in their
private
have
physicians
annual
Fourth,
of a large
revealed
part-time and
visits
Third,
physicians.
study
staff
of these
reported
nationwide.’
However,
that
to surpass
ACEP
appear
physicians.
half
emergency
levels
visits
ED visits
is expected
1991,
EDs
of ED
nationwide
total
emergency
staffing
current
fewer
In 1989,
and this
As of January
physicians
totals,
the number
prioritize gency residency which
to guide efforts
surveys
allocation
of emergency
to expand
medicine,
recognition
and support
programs. to assess
quantitative
their
ED
adequacy
ANNALS
more
directors
of ED
of staffing
OF EMERGENCY
patterns resources,
of the specialty
of emer-
widespread need
staffing
physician
development
reference
data
relative
MEDICINE
to other
21:l
of
with )
JANUARY1992
PHYSICIAN
STAFFING
Holley, Kellermann & Andrulis
hospital EDs with similar characteristics. Our survey suggests that there is widespread variability. The reasons for such variations and their implications for patient care must be explored carefully. • The authors thank Ms Carol Conway for her assistance in the preparation of this manuscript.
REFERENCES 1. And@is DP, Kellermann AL, Hint EA: Emergencydepartments and crowding in United States Leaching hospitals. Ann EmergMed1991; 20: 980-986. 2. van de LeuvJH: Physicianstaffing, in van de LeuvJH (ed): Managementof Emergency Services. Rockville, Maryland, Aspen Publishing. 1987, p 33. 3. American College of EmergencyPhysicians: Guidelines for emergencydepartment physician staffing. Ann EmergMad 1984;13:1165-I186 4. van de Leuv JH: Physicianstaffing, in van de LeuvJH (ed): Managementof Emergency Services. Rockville, Maryland, Aspen Publishing, 1987, p 34. 5. Mills JP: The emergencydepartment: Organizationand staffing, in Schwartz GR (ed): Principles and Practiceof EmergencyMedicine, ed 2. Philadelphia,WB Saunders,1986, p 623, 8. Hannas RR: Staffing the emergencydepartment. Hospitals1973:43; 83-86. 7. Graduate Medical Education National Advisory Committee to the Secretary, US Department of Health, Education,and Welfare: The EmergencyMedicine Specialty. 1981,Washington. OC, Health ResourcesAdministration, vol 2, 1981. 8. American Hospital Association: HospitalStatistics. Chicago,American Hospital Association, 1990. 9. American College of EmergencyPhysicians: Faotsheet. January 1991, p 3. 10. Sturmann KM, Ehrenberg K, Salzberg MR: Physician assistants in emergencymedicine. Ann EmergMad 1990;19:304-308.
Address for reprints: Joseph E Holley, MD, Emergency Department, 877 Jefferson, Room G071, Memphis, Tennessee 38103
JANUARY 1992
21:1
ANNALS OF EMERGENCY MEDICINE
57/ 69 I
Physician Staffing in the Emergency Departments of Public Teaching Hospitals: A National Survey I
From the Division of Emergency
Joseph E Holley, MD*
_Medicine, Department of
Arthur L Kellermann, MD, MPH*
Medicine, University of
Dennis P Andrulis, PhW
Tennessee, Memphis;* and the
I
I
Study hypothesis: To evaluate factors influencing emergency physician staffing patterns in an important subset of US hospitals. Design: Survey of emergency department directors and hospital administrators.
National Association of Public Hospitals, Washington, D.C.4 Receivedfor publication April 18, ] 991. Revision received July 22, 1991. Acceptedfor publication August 23, 1991. Supported in part by the Robert Wood Johnson Foundation under grant #15263. Presented at the Winter Symposium of the American College of Emergency Physicians in Tucson, Arizona, March 1990.
JANUARY 1992 21:1 ANNALS OF EMERGENCY MEDICINE
Member institutions of the National Association of Public Hospitals and the Council of Teaching Hospitals.
Participants:
Measurements: Of 498 hospitals enrolled, two mailings and telephone follow-up yielded 277 replies (56% response rate). To adjust for differences in ED size and volume, levels of staffing were converted to fuN-time equivalents (FTEs)per 10,000 annual ED visits. Results: Responding institutions included 160 private and 115 public hospitals, 74 of which were Veterans Administration hospitals. Formal medical school affiliation was noted by 86% of responding institutions, and 82 (30%) supported emergency medicine residency programs. Fulltime attending emergency physician staffing varied widely, from less than one to more than three FTEsper 10,000 visits; however, mean levels of staffing at public hospitals did not differ significantly from private institutions (2.7 _+1.6vs 2.5 +3.1, respectively; P = ,50). Three of four hospitals reported using part-time emergency physician attendings but only 33% used nurse practitioners or physicians' assistants. Two thirds of responding hospitals used rotating house officers-in-training. Of note, hospitals that supported emergency medicine residency programs reported significantly higher levels of staffing by housestaff (2.2 +_1.8vs 1.0 +_1.2 FTEs/10,000 visits; P< .0004), but levels of total staffing by full- and part-time attending physicians were virtually identical (2.69 +_1.6 vs 2.67 +_2.6 FTEs/10,000 visits; respectively; P= .95). Marked variability in levels and patterns of ED staffing at public and teaching hospitals currently exists, but the differences are not explained by hospital ownership. The reasons for such variations and their implications for patient care must be explored. [Holley JE, Kellermann AL, And@is DP: Physician staffing in the emergency departments of public and teaching hospitals: A national survey. Ann Emerg Med January 1992;21:53-57,]
53/ B 5
PHYSICIAN H&y,
STAFFING
Kellermann
& Andrulis
INTRODUCTION In contrast to physicians engaged in office-based ambulatory care practice, emergency physicians have little control over the volume or complexity of the clinical problems of patients presenting to their departments. Levels of physician staffing in emergency departments are, therefore, the principal determinant of physician work load, job satisfaction, and, most important, quality of care. Unfortunately, the supply of qualified emergency physicians is limited, and salaries for residency-trained emergency physicians are relatively high. Therefore, many institutions may seek to staff their EDs with the lowest number of emergency physicians consistent with acceptable levels of care. Although the level of physician staffing in the ED probably plays a critical role in defining the quality of care, this issue has not been studied previously in any systematic way. To gain insight into staffing patterns at an important subset of US hospitals, we analyzed data collected during a recent survey of the EDs of member institutions of the National Association of Public Hospitals (NAPH) and the Council of Teaching Hospitals (COTH). We were particularly interested in answering the following questions. Among US public and private teaching hospitals, how much variation exists in ratios of emergency physician to patient visits? How variable is the use of “par+ time” (eg, moonlighting) emergency physicians? What percentages of public and private teaching hospitals currently use physician extenders (ie, physicians’ assistants [PAS] and nurse practitioners) to supplement physician staffing? Are hospital EDs that support emergency medicine residency programs better staffed than hospitals that lack these programs? What critical methodologic issues must be addressed before implementing a broad-based survey of ED staffing levels nationwide?
MATERIALS
AND METHODS
Staffing data were derived from a previously reported national survey of hospital and ED overcrowding of member institutions of both NAPH and COTH.l Collectively, these two organizations represent virtually all of the United States’ premier public and teaching hospitals. Four hundred ninety-eight surveys were disseminated during Fall 1988. A second mailing was sent in January 1989, and telephone follow-up was completed a few months later. Information was based on the year September 1, 1987, through August 31, 1988. Included in this survey were questions regarding general hospital and ED characteristics, patient volumes, and measures of the extent and impact of ED overcrowding. ED directors also
66154 I
were asked to indicate the number of full-time equivalent (FTE) emergency physicians, part-time emergency physicians, senior housestaff, and interns staffing their department. To adjust for differences in ED size and volume, these levels of staffing were converted to FTEs per 10,000 annual ED visits. Because levels of staffing did not fit a normal distribution, nonparametric tests of statistical significance such as MannWhitney-Hugh were used to analyze these data. Dichotomous variables were assessed using the ~2 test.
RESULTS Two hundred seventy-seven hospitals from 40 states responded to the survey, for a 56% response rate. Data from both sponsoring organizations and the American Hospital Association were used to demonstrate that responding institutions were comparable to nonresponding institutions with respect to hospital size, community size, and hospital ownership.1 Responding institutions included 160 private hospitals (virtually all of which were nonprofit) and 115 public hospitals (including 74 Veterans Administration hospitals). Formal medical school affiliation was noted by 86% of responding institutions, and 65 (24%) supported emergency medicine residency programs. Hospitals averaged slightly more than 500 floor and 60 ICU beds, with a total range of 95 to more than 1,300 beds. Annual ED visits at responding institutions averaged 46,900, with a range of from 1,428 to 236,979 visits. All responding EDs were staffed by at least one full-time emergency physician (range, one to 25); however, levels of fulltime attending staffing per 10,000 visits varied widely. Only 7% of hospitals staffed their EDs with more than three full-time staff per 10,000 visits, and 17% reported that their department was staffed by one or fewer FTEs per 10,000 visits. Forty-five percent covered their department with one to 1.9 full-time emergency physicians per 10,000 visits, with 30% staffing at a level of two to 2.9 FTEs per 10,000 visits. Public hospitals did not differ significantly from private institutions in their levels of full-time emergency physician staffing (1.9 f 3.0 vs 2.1 f 2.9, respectively; P = .63). Three of four responding hospitals supplement their staffing with part-time attending physicians (mean, 0.95 FTE part-time staff per 10,000 visits; range, 0 to 25 per 10,000 visits). Public hospitals tended to use more part-time staffing, with 1.2 * 3.0 versus 0.82 f 1.2 FTEs per 10,000 visits (P = .19). When total FTE full-time and part-time staffing were combined, hospital EDs averaged 2.7 FTEs per 10,000 visits, but large differences b were still noted between institutions. Despite such vari-
ANNALS
OF EMERGENCY
MEDICINE
21:l
JANUARY1992
PHYSICIAN STAFFING Holley, Kellermann & Andrulis
ability, mean overall levels of attending staff at public hospital EDs were not significantly different than those at private institutions (3.1 + 4.8 vs 2.9 +_3.0 FTEs per 10,000 visits; P = .72). The use of PAs and nurse practitioners does not appear to be common among surveyed hospitals. Use of nonphysician primary care providers to supplement attending physician staffing was reported by only 33% of responding EDs. Thirty-one (12.7%) use nurse practitioners, 36 (14.8%) use PAs, and 5.3% use both. Twenty-seven percent of responding public hospitals use PAs compared with only 16% of responding private hospitals (P = .03). Fifteen percent of public hospitals use nurse practitioners in their EDs compared with 27% of private institutions (P = .03). In addition to staffing with attending physicians, 6.5% of the hospital EDs that responded to our survey use the services of rotating physicians-in-training. Thirty-five percent are staffed by postgraduate year (PGY)-I residents (mean, 0.60 FTEs per 10,000 visits), and 35% are staffed by PGY-2 or higher residents (mean, 0.96 FTEs per 10,000 visits). Twenty-one percent are staffed by both intern s and residents at higher levels of training. When we compared the 82 hospitals that reported supporting emergency medicine residency programs with the remaining 175 institutions that did not, we found that emergency medicine residency hospitals averaged significantly higher levels of staffing by housestaff (2.1 + 1.6 vs 1.1 + 2.0 FTEs per 10,000; P < .3) than hospitals without emergency medicine residency programs. However, staffing levels for attending physicians were comparable among residency-affiliated and nonresidencyaffiliated hospitals. Hospitals with emergency medicine residency programs staffed 2.76 + 1.7 attending per 10,000 visits, whereas hospitals not affiliated with an emergency medicine residency staffed 2.79 + 1.9 attending per 10,000 visits (P = .96).
BISCUSSION The patterns and characteristics of physician staffing of hospital EDs have evolved considerably over the past 20 years. Initially, many EDs were staffed by variations of the Pontiac Plan, through which physicians in the community united to staff the ED by each serving several shifts per month.2 At teaching hospitals, housestaff-in-training were often the exclusive providers of care, with little or no direct faculty supervision. With the emergence of the specialty of emergency medicine, these haphazard approaches to ED staffing were steadily (albeit slowly) replaced by the recognition that patients are better served by physicians specifi-
JANUARY 1992
2 1 : 1 ANNALS OF EMER6ENCY MEDICINE
cally trained to meet the unique demands of this clinical environment. Despite recognition that levels of physician staffing have profound impacts on both the quality and costs of emergency care, few guidelines have been published. No group has previously published information about the patterns or levels of staffing in a substantial number of US hospitals. In 1984, the American College of Emergency Physicians endorsed the concept that hospital EDs should be staffed 24 hours a day by specialists trained to practice emergency medicine on a full-time basis, but ACEP provided no specific guidance regarding the number of physicians necessary to meet various levels of demand. 3 van de Leuv suggested that hospital EDs treating 20,000 to 30,000 patients per year be staffed by five emergency physicians; one additional physician is recommended for every 5,000 annual visits above that number. 4 Mills concluded that one physician is needed for every 5,000 to 7,000 patient visits. 5 In 1973, Hannas noted that three physicians are needed for fewer than 20,000 patient visits, four physicians for 20,000 to 35,000 patient visits, and additional physicians if the volume is more than 35,000 patient visits per year. 6 Although all these authors have based their recommendations on actual patient visit statistics, patient volume is not the sole determinant of physician work load. Different levels of patient acuity require different levels of physician care. Many patient groups and problems require more lengthy or complex evaluation and care. Teaching may also necessitate increased staffing levels because staffing medical students, interns, and residents takes time away from direct patient care. As a result, teaching EDs may require additional staffing at peak times to meet the twin demands for education and patient care. Furthermore, academic emergency physicians generally spend more of their time in pursuit of research or educationally related activities than their colleagues in private practice; actual clinical time per FTE may therefore vary widely. In addition, ED size may require different levels of staffing due to such varied factors as subspecialization and the physical plant. To date, there has been no published information regarding current levels of staffing in EDs. No comparison has been made between the private and academic practices of emergency medicine. In 1981, the Graduate Medical Education National Advisory Committee of the Department of Health, Education, and Welfare predicted that ED visits for 1990 would total 68,335,836 and concluded that 14,686 emergency physicians would be needed to provide care for these patients .7 This level of staffing is equal to 2.14 FTEs per 10,000 annual visits. However, b"
55/57
I
PHYSICIAN H&y,
this
STAFFING
Kellermann
study
grossly
actually
occurred
exceeded
89.7
million
& Andruh
underestimated in 1990. million,
in 1991.8
were
9,099
25,000
board-certified staffing
for all emergency than
Our hospitals
coverage
marked
variability
ization
and teaching
credentials
the pattern
differed
mean
of attending
levels
of full-
somewhat of FTE
between
staff
primary
patients,
adopted
but they
this
may
caregivers
strategy.
The
lack
were
providers
of care,
extended
of our subset
of institutions EDs
variation
in both
the number
their
EDs
is important apparently assigned
without
such
to note,
however,
the result
department
this
hospital
EDs
Second, responders
programs
also
in terms
this
does
standing
officer
the first
than
ownership,1
they
hospitals
in other
important
size,
may
differ
respects.
year
efforts
that
as many
as half
be filled residents
departments
and
of
by from
under-
physician
training
size,
and region
would
more
emergency
medicine
change
was
on a part-time
a clearer
in emergency
programs
and
could
in mind,
to develop
under-
by 1990
‘moonlighting’
type,
they
oversupply
by a serious
expected
emergency
Education
physicians,
to prevent
flawed
observations
EDs.
in emergency
nationwide
and
variations
training
further
staffing It
is
and
a larger
systematic
physician” The
former
current
be useful
health
physicians
work
schedules
than
those
care
from
reported. size,
nonresponding
and
non-
EDs may
require
a comparable
physician.”
to 37 to 40 hours
private
demanding.
teaching
more level
emergency
more
with major
future
than
of direct
and research one full-time patient
care.
CONCLUSION Carefully
designed,
are needed and
many
that are considerably
for faculty to provide
“a full-time
to be equal
however,
academic
before equivalent
study
community
resembled
community
attending
of NAPH
nonteaching
requirements
be needed
with
considered
number
hand,
will
as “a full-time
confused
is generally per week;
our
such
are commonly
work
of
of terms
Expressions
of clinical
hospital
First,
clarification
surveys.
interns
survey
teaching
institutions
institutions
of hospital
slots
the
the credentials,
Medical
of graduates per
but
our nation’s
emergency
of ED visits
by hospital
future
Last,
their
in staffing
respects.
in US private, different
on Graduate
at 400
staff
about
staffing
was badly
who
beds.
data
by the assumption
of current
residency
additional
the number
these
credentials
to target
as no surprise.
not reflect
and private
responding
hospital
With
acuity,
to define
constant
specialties
patient
of inpatient
physicians.
practitioners
basis”7
medicine
staffed
of residents
important
be quite
other
and
of house
increase
to the member
of staffing
although
walk-in
hospital-
emergency
physician
“semiretired
On the other
in several
may
all emergency
considerable
comes
number
represents
was ‘limited Levels
as as
for
scarcity
of trained
compromised
for
emergency
institutions
Council
analysis
impact
admitted
policy.
to be better
and
that
further
emergency
tend
that
the
unclear,
the high
of training
sponsoring
at US public
it is limited
COTH.
an undersupply
of the number
FTEs.
study
staffing
population
in 1980
a profound
surrogates
of physicians
projected
have
responding
seek
Although
the presence
or part-time
experience
estimate
as well.
of a larger
or attending
Although physician
should
and
hospitals
physician
However,
level
hospitals
programs
to the
of faculty
EDs,
that
training
counterparts
surveys
full-
as diverse
to provide
and
requiring
as rough
be held
the commitment
education,
is not surprising.
was noted
observation
residency
of their
Issues
the need
can
important
of ED patients
by a general
Their
use of off-site
resident
cited
be affected
medicine
housestaff
Given
reported and
are
staffing.
beds
percentage
the percentage
by 1990.
care
of nonphysicians
of junior
to medical that
in their
Our
for this
of operation.
coverage staffing
reasons
recom-
ambulatory
responding
or widespread
hours
of US hospitals
proportion
few
use
has been acute
of acceptance
setting,10
with
providers
relatively
in the ED
alternative clinics
but
include
care
way to provide
one of many
for physician
we did not ask
Future
public
coverage
and
recommended
as a cost-effective
to “walk-in”
can
training,
versus
The
are often
by board-certified
in the levels
Although
coverage
hospitals,
Use of nonphysician
68156
that
care
both
covered
is just
inpatient
needs.
intensive
the same.
mended
of available
on staffing
10,000
likely
of the need
(or lack)
on these
it appears
of US public
EDs.
physician
virtually
I
there
per
volume
as the acuity of the patient population, . specialized services (eg, trauma,.burns),
of an estimated FTEs
patient
determinants 90
that
Based
to be 2.77
were
sample
in their
private
have
physicians
annual
Fourth,
of a large
revealed
part-time and
visits
Third,
physicians.
study
staff
of these
reported
nationwide.’
However,
that
to surpass
ACEP
appear
physicians.
half
emergency
levels
visits
ED visits
is expected
1991,
EDs
of ED
nationwide
total
emergency
staffing
current
fewer
In 1989,
and this
As of January
physicians
totals,
the number
prioritize gency residency which
to guide efforts
surveys
allocation
of emergency
to expand
medicine,
recognition
and support
programs. to assess
quantitative
their
ED
adequacy
ANNALS
more
directors
of ED
of staffing
OF EMERGENCY
patterns resources,
of the specialty
of emer-
widespread need
staffing
physician
development
reference
data
relative
MEDICINE
to other
21:l
of
with )
JANUARY1992
PHYSICIAN
STAFFING
Holley, Kellermann & Andrulis
hospital EDs with similar characteristics. Our survey suggests that there is widespread variability. The reasons for such variations and their implications for patient care must be explored carefully. • The authors thank Ms Carol Conway for her assistance in the preparation of this manuscript.
REFERENCES 1. And@is DP, Kellermann AL, Hint EA: Emergencydepartments and crowding in United States Leaching hospitals. Ann EmergMed1991; 20: 980-986. 2. van de LeuvJH: Physicianstaffing, in van de LeuvJH (ed): Managementof Emergency Services. Rockville, Maryland, Aspen Publishing. 1987, p 33. 3. American College of EmergencyPhysicians: Guidelines for emergencydepartment physician staffing. Ann EmergMad 1984;13:1165-I186 4. van de Leuv JH: Physicianstaffing, in van de LeuvJH (ed): Managementof Emergency Services. Rockville, Maryland, Aspen Publishing, 1987, p 34. 5. Mills JP: The emergencydepartment: Organizationand staffing, in Schwartz GR (ed): Principles and Practiceof EmergencyMedicine, ed 2. Philadelphia,WB Saunders,1986, p 623, 8. Hannas RR: Staffing the emergencydepartment. Hospitals1973:43; 83-86. 7. Graduate Medical Education National Advisory Committee to the Secretary, US Department of Health, Education,and Welfare: The EmergencyMedicine Specialty. 1981,Washington. OC, Health ResourcesAdministration, vol 2, 1981. 8. American Hospital Association: HospitalStatistics. Chicago,American Hospital Association, 1990. 9. American College of EmergencyPhysicians: Faotsheet. January 1991, p 3. 10. Sturmann KM, Ehrenberg K, Salzberg MR: Physician assistants in emergencymedicine. Ann EmergMad 1990;19:304-308.
Address for reprints: Joseph E Holley, MD, Emergency Department, 877 Jefferson, Room G071, Memphis, Tennessee 38103
JANUARY 1992
21:1
ANNALS OF EMERGENCY MEDICINE
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