ORIGINAL ARTICLE

Relative Productivity of Nurse Practitioner and Resident Physician Care Models in the Pediatric Emergency Department William M. McDonnell, MD, JD,* Pamela Carpenter, BA,† Kammy Jacobsen, BS,† and Howard A. Kadish, MD, MBA† Objectives: Duty hour restrictions limit the use of resident physicians in pediatric emergency departments (PEDs). We sought to determine the relative clinical productivity of PED attending physicians working with residents compared with PED attending physicians working with nurse practitioners (NPs). Methods: In a tertiary care PED with multiple care models (PED attending physicians with residents and/or fellows, PED attending physicians with NPs, PED attending physicians alone), we identified periods when care was provided concurrently and exclusively by a PED attending physician with 1 to 2 residents (resident pod) and a PED attending physician with 1 NP (NP pod). Billing records were reviewed to determine relative value units (RVUs) generated and patients seen by each PED attending physician. Emergency Severity Index (ESI) triage scores were used to compare patient acuities. Results: The NP pods generated 5.35 RVUs per hour and the resident pods generated 4.35 RVUs per hour, with a significant difference of 1.00 RVUs per hour (95% confidence interval, 0.19–1.82). The NP pods saw 2.18 patients per hour, whereas the resident pods saw 1.90 patients per hour. This difference of 0.28 was not statistically significant (95% confidence interval, −0.07 to 0.62). Patient acuity was similar. Thirteen percent of the NP pod patients had the highest triage severity levels of ESI-1 and ESI-2, whereas 19% of the resident pod patients were ESI-1 and ESI-2 (P = 0.06). Conclusions: Pediatric emergency department attending physicians in an NP care model had greater clinical productivity, measured by RVUs, than PED attending physicians in a resident care model while treating similar patient populations. Key Words: efficiency, organization and administration, residents, staffing, economic workforce (Pediatr Emer Care 2015;31: 101–106)

T

he traditional resident physician care model, consisting of resident physicians working alongside attending physicians to provide patient care, has served to facilitate resident medical education to provide appropriate trainee supervision and to help in delivering timely and efficient patient care.1 In 2003, the Accreditation Council for Graduate Medical Education instituted duty hour standards, restricting the amount of time that resident physicians could provide patient care.2 The Accreditation Council for

From the *Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE; and †Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Utah, Salt Lake City, UT. Disclosure: The authors declare no conflict of interest. Funding Source: No external funding was secured for this study. Reprints: William M. McDonnell, MD, JD, Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Nebraska Medical Center, 8200 Dodge St, Omaha, NE 68114 (e‐mail: [email protected]). Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0749-5161

Graduate Medical Education subsequently adopted even more stringent duty hour restrictions in 2011.1 Academic medical institutions quickly recognized that resident duty hour restrictions would reduce residents’ contributions to the overall patient care workload and that these institutions would have to consider alternative sources for some of the clinical services previously provided by residents.3 Some of these potential alternative sources of clinical work included shifting clinical work from residents to attending physicians,4 increased use of midlevel providers (MLPs) such as nurse practitioners (NPs) and physician assistants,5,6 and increasing the number of residency positions.7 Limitations on graduate medical education funding and objections from attending physicians experiencing increased workloads4 have increasingly led academic institutions to choose MLPs as an alternative work source in place of residents.8–11 In the face of steadily increasing volumes, emergency departments (EDs) and pediatric EDs (PEDs) historically relied heavily on the clinical assistance provided by resident physicians.12,13 However, as duty hour restrictions have limited their ability to rely on residents for clinical services, PEDs have increasingly turned to MLPs.14–16 Despite their increasing use, it remains unclear whether, and to what extent, MLPs improve clinical productivity in PEDs and whether PED attending physicians become more clinically efficient when unencumbered with the clinical teaching responsibilities of resident teams. Without a better understanding of residents’ and MLPs’ relative contributions to clinical productivity, it will be difficult for PEDs to make informed staffing decisions. Therefore, we sought to analyze the relative clinical productivity of PED attending physicians working within a resident care model and an NP care model, respectively. The results of this study will assist PEDs as they explore potentially viable alternative staffing strategies.

METHODS This retrospective, correlated groups study was designed to compare the relative clinical productivity of PED attending physicians when they worked in a traditional resident-supported care model, with their productivity when working in an NP-supported care model. The study was conducted at an urban, tertiary care, free-standing children’s hospital affiliated with an academic institution, with an annual PED census of 43,000 patient encounters. The study hospital PED uses multiple care models, including PED attending physicians working with residents and/or pediatric emergency medicine fellows, PED attending physicians working with NPs, and PED attending physicians working alone. All PED attending physicians work in all care models. Different care models are used based on time of day and also vary by seasonality. In the study hospital PED, as in many pediatric hospital EDs, NPs do not practice independently, and all of the NPs’ patients are staffed with a PED attending physician. Emergency department staffing records were reviewed to determine all time intervals during a 12-month period from May 1, 2011 through April 30, 2012 in which the PED was staffed concurrently and exclusively by a

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PED attending physician working with 1 or 2 resident physicians (resident pod) and by a PED attending physician working with 1 NP (NP pod). Pediatric ED patient tracking records were reviewed to identify all patients evaluated in the PED during these study periods. Departmental billing records were analyzed to determine the relative value units (RVUs) coded and billed for care provided by resident pods and NP pods during the study periods. Individual patients and their associated RVUs were attributed to resident pods and NP pods, respectively. All patients were seen by PED attending physicians; coding and billing was determined by professional coders and based on PED attending physician care, and no independent care or billing was provided by residents or NPs. Standard practice in the study hospital PED is to assign patients to pods and to examination rooms according to room and nursing availability, without regard to presenting complaint or acuity. The pod system is geographically based, with distinct patient care areas. Both pods contain designated resuscitation rooms for managing high-acuity trauma and medical resuscitation patients, and the pods have similar structures and resources. To compare the acuities of the patient populations seen by the resident pod and the NP pod, we reviewed the Emergency Severity Index (ESI) score assigned to each patient during PED triage. The ESI scale is used as a standard triage tool in the PED and uses a 5level triage algorithm based on patient acuity and need for hospital resources.17 We distinguished high-acuity patients as those

meeting criteria for ESI-1 and ESI-2 because the ESI tool itself defines high-risk patients as ESI-1 or ESI-2, regardless of the particular underlying disease or injury.17 The proportion of high-acuity patients among all patients seen in each pod was determined. Approval was granted by the appropriate university institutional review board and hospital privacy board. Because the primary unit of analysis was RVUs generated by PED attending physicians, informed consent was obtained from all PED attending physicians who cared for patients in the PED during the study periods. Comparisons between paired, continuous, normally distributed variables (RVUs per hour, patients per hour, and RVUs per patient) were analyzed using the correlated t test (paired t test). We selected the correlated t test rather than an independent samples t test such as the Student t test because the productivity data from the respective pods were matched by date and time, and constituted a correlated groups design intended to eliminate confounding differences between patient populations.18 The categorical variable of ESI triage level was analyzed with the χ2. Data analysis was performed using JMP 9.0.3 (SAS Institute, Inc, Cary, NC).

RESULTS Twenty-eight 4-hour periods were identified between May 1, 2011 and April 30, 2012, during which the PED was staffed exclusively by a resident pod attending physician (with 1–2 residents)

TABLE 1. Clinical Productivity by Date of Service RVUs Coded and Billed Per Hour Date of Service 6/11/2011 7/2/2011 7/3/2011 7/10/2011 7/13/2011 7/14/2011 7/15/2011 7/18/2011 7/19/2011 7/28/2011 7/30/2011 7/31/2011 8/4/2011 8/6/2011 8/7/2011 8/11/2011 8/12/2011 8/17/2011 8/18/2011 8/19/2011 8/25/2011 8/26/2011 8/27/2011 9/1/2011 9/7/2011 9/9/2011 9/16/2011 9/28/2011 Mean

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Patient Volumes Per Hour

RVUs Per Patient

NP Pod

Resident Pod

NP Pod

Resident Pod

NP Pod

Resident Pod

4.43 2.35 6.87 3.58 7.30 5.27 1.68 3.50 8.22 5.47 5.75 2.32 4.79 4.58 2.77 4.39 2.92 3.80 4.36 5.84 6.78 6.68 8.02 8.22 8.70 2.90 8.81 9.49 5.35

5.55 4.59 6.36 5.95 4.62 3.11 1.98 1.96 3.57 4.18 6.45 2.63 4.78 4.31 3.85 4.83 2.90 3.98 4.99 4.93 3.63 5.03 4.58 4.40 4.47 4.16 5.07 4.80 4.35

2.25 1.75 2.50 2.25 2.5 3.00 1.25 1.50 2.50 2.00 2.00 1.50 1.75 2.25 1.75 1.75 1.50 1.50 1.75 1.50 2.00 2.75 3.00 2.75 3.25 1.25 4.25 3.00 2.18

3.00 2.00 2.00 3.50 1.75 1.50 1.25 1.00 1.75 2.00 2.75 1.50 2.00 1.25 1.50 2.00 1.25 1.00 3.75 1.50 1.50 2.50 2.00 2.00 1.50 1.50 2.00 2.00 1.90

1.97 1.34 2.75 1.59 2.92 1.76 1.35 2.34 3.29 2.73 2.87 1.54 2.74 2.04 1.58 2.51 1.95 2.53 2.49 3.89 3.39 2.43 2.67 2.99 2.68 2.32 2.07 3.16 2.42

1.85 2.29 3.18 1.70 2.64 2.07 1.58 1.96 2.04 2.09 2.34 1.75 2.39 3.45 2.57 2.41 2.32 3.98 1.33 3.28 2.42 2.01 2.29 2.20 2.98 2.77 2.54 2.40 2.39

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NP and Resident Physician Care Models in PED

FIGURE 1. Relative value units per hour.

and by an NP pod attending physician (with 1 NP). At all other times during the year, the PED was staffed with additional care models, including PED attending physicians working with fellows and PED attending physicians caring for patients alone without resident or NP support. All resident pod and NP pod PED attending physicians were board certified or board eligible in pediatric emergency medicine by the American Board of Pediatrics. A total of 1085.36 RVUs were coded and billed for care provided in the PED during the 28 study periods (Table 1). Nurse practitioner pod PED attending physicians accounted for 55% (n = 598.95) of the total RVUs, and resident pod attending physicians accounted for 45% (n = 486.41). Billing data showed a significant difference between the 2 care models in RVUs generated. Nurse practitioner pod PED attending physicians generated a mean of 5.35 RVUs per hour and resident pod attending physicians generated 4.35 RVUs per hour, with a mean difference of 1.00 RVUs per hour (95% confidence interval [CI], 0.19-1.82) (Fig 1). During the 28 study periods, 457 patients were seen in the PED (Table 1). Nurse practitioner pod PED attending physicians evaluated and treated 53% (n = 244) of these patients, and resident pod attending physicians saw 47% (n = 213). Pediatric ED attending physicians with 1 NP saw a mean of 2.18 patients per hour, whereas resident pod attending physicians saw a mean of 1.90 patients per hour, with a mean difference of 0.28 patients per hour (95% CI, −0.07 to 0.62). This difference was not statistically significant. Nurse practitioner pod PED attending physicians generated a mean of 2.42 RVUs for each patient seen, and resident pod attending physicians generated a mean of 2.39 RVUs per patient (Table 1). The mean difference of 0.03 RVUs per patient was not significantly different (95% CI, −0.24 to 0.31). Patient acuity was similar among the patient groups seen by the NP pod and the resident pod. When patients were grouped into high acuity (ESI-1 and ESI-2) and low acuity (ESI-3, ESI-4, and ESI-5), 16% (n = 72) of all patients were high acuity and 84% (n = 385) were low acuity. Distribution of the high-acuity

patients between the pods was similar, as 13% (n = 31/244) of NP pod patients were high acuity, whereas 19% (n = 41/213) of resident pod patients were high acuity (P = 0.06) (Table 2).

DISCUSSION Because resident duty hour restrictions have progressively reduced the availability of residents for clinical work, it has become essential that academic institutions assess workforce productivity and be prepared to implement alternative clinical models. Nevertheless, many institutions have not yet assessed the financial impact or efficacy of their residents and of incorporating MLPs into their practices.8 Our finding that the NP pod showed a significantly greater productivity than the resident pod, measured by total RVU production per hour, may help guide academic institutions as they explore these alternative clinical models in their own workplaces. Several studies have examined ED and PED resident productivity, consistently noting that resident productivity increases as residents progress through their training.13,19,20 Other studies have examined MLP productivity.21–23 Direct comparisons between resident and MLP productivity in the ED have also begun to emerge.24,25 Hamden et al compared the RVUs generated by TABLE 2. Patient Acuity ESI Level ESI-1 resuscitation ESI-2 emergent Total ESI-1 and ESI-2 ESI-3 urgent ESI-4 semiurgent ESI-5 nonurgent Total ESI-3, ESI-4, and ESI-5

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NP Pod

Resident Pod

2 (1%) 29 (12%) 31 (13%) 170 (67%) 40 (16%) 3 (1%) 213 (87%)

5 (2%) 36 (17%) 41 (19%) 138 (65%) 28 (13%) 6 (3%) 172 (81%)

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independently practicing MLPs with those generated by residents working with attending physicians during different shifts in a community hospital ED.24 That study found that MLPs saw more patients per hour yet generated fewer RVUs per patient, resulting in similar overall RVU generation between MLPs and residents. The study results were limited in that the authors did not compare the relative acuities of the patient populations seen by the MLPs and the residents. Jeanmonod et al25 also compared the productivity of independently practicing MLPs with residents working with attending physicians, but in a low-acuity area of an ED. They found that the MLPs saw more patients per hour and generated more overall RVUs per hour than the residents. That study was also limited by an inability to directly compare the 2 groups’ respective patient populations. Even those studies that have sought to directly compare resident and MLP productivity in the ED are limited in that they address the productivity of the residents and MLPs themselves, rather than their effect on the productivity of the supervising (and billing) physician. The training and the clinical practices of MLPs and residents may be quite different, which might impact diagnostic test utilization and other clinical care characteristics, and potentially have a significant impact on the RVU coding for their respective work. Our results are important because they demonstrate the relative contributions of MLPs and residents to the overall productivity of the attending physician and of the PED, rather than focusing on the MLPs and residents in isolation. Academic institutions that participate in the Medicare and Medicaid programs are generally unable to seek reimbursement for clinical services provided by residents, but rather must bill for the supervising physician’s services.26 Even where MLPs are licensed independent providers, many pediatric institutions have made the policy decision that every patient is under the direct care of the attending physician. For those institutions in which every patient is evaluated by an attending physician, the relative impact of resident and MLP support on attending physician productivity is the relevant inquiry. Therefore, our study was deliberately designed to compare only the respective productivity of the PED attending physicians who practiced in the 2 models. All patients in both pods were seen by attending physicians. Attending physicians placed into the patients’ charts complete notes documenting history, physical examination, ED course, medical decision making, diagnoses, and treatment plans. Relative value unit determinations were made from the attending physicians’ documentation. Several potential markers might have been used to measure productivity. We chose RVUs as most representative of the economic productivity of the PED in a fee-for-service reimbursement environment. Relative value unit generation is the most commonly used metric in studies evaluating ED productivity because it incorporates both the complexity of the patient encounter and the number of patient encounters, thereby best representing the total billable work performed by the physician.19,24,25,27,28 Alternative measures, such as numbers of patient encounters, or other velocity markers, such as time-to-discharge metrics, can be distorted by procedures and patient acuities. However, RVUs account for both complexity and patient care velocities, providing a more comprehensive measure of productivity. Therefore, relative RVU production was our primary outcome measure. The total productivity measured by RVUs is a function of the complexity of each patient and of the number of patients seen. As the number of patients seen increases, or as the complexity per patient increases, the number of RVUs also increases. It may be useful for institutions to understand how each of these 2 components of attending physician RVU production was affected by the respective care models. Therefore, we not only assessed the overall difference in RVUs between the NP and resident models,

but also sought to explore differences in these underlying components of the total RVU measurement: RVUs per patient and number of patients per hour. Our results demonstrate that the NP pod generated more total RVUs per hour than did the resident pod. This productivity difference necessarily resulted either from higher average levels of billing per patient (RVUs per patient) or from treating more patients per hour, or both. When we subanalyzed the underlying components of RVUs per patient and patients per hour, however, the differences between the NP pod and resident pod failed to reach statistical significance for either of these 2 components. The greater numbers of patients seen per hour by the NP pod approached statistical significance, but that difference did not exceed the 95% CI. Nevertheless, a larger sample size might well have demonstrated that more patients per hour accounted for the greater RVU productivity of the NP pod. The study was initially powered based on our primary outcome measure of relative productivity, measured by RVUs per hour. We performed poststudy power calculations for each of the 2 component measures, which demonstrated that the pods might well have important performance differences in these areas, which our study was unable to detect. The study had a power of only 27% to show a difference of 0.25 patients per hour between the pods. It had a power of only 11% to show a difference of 0.12 RVUs per patient (which would generate an approximately 5% increase in revenue). Our results show that the NP pod generated more RVUs per hour, but our study simply cannot definitively explain whether this increased productivity was due to the NP pod billing more RVUs per patient or whether it saw more patients per hour or both. Future studies that include more study periods might better distinguish the specific RVU generation components that account for the greater productivity of the NP pod that we observed. Nevertheless, this study was sufficiently powered to determine the essential issue—that the NP pod demonstrated greater productivity than did the resident pod. A potential confounder in this study was the possibility of significant differences in the patient populations evaluated by the 2 respective pods. If 1 team treated patients with more significant injuries or illnesses, it would be expected that the pod would generate higher level billings per patient, and perhaps generate greater total RVUs. On the other hand, if 1 pod treated patients with less complex injuries and illnesses, that pod might be able to treat more total patients per hour and thereby generate greater total RVUs. Therefore, we felt that it is important to compare the acuity levels of the patient populations treated by the 2 care teams. Comparing acuity levels of ED patient populations based on proportions of high-acuity patients identified by standardized triage scoring systems such as the ESI is a validated and widely accepted method.29–31 Our results, which show no significant differences in the acuities of the patient populations seen by the NP pod and the resident pod, suggest that the difference in productivity between the teams is a result of either medical evaluation (eg, frequency and types of diagnostic tests) and documentation practices, or number of patients seen, but not a result of a difference in the patient populations themselves. We note that the acuity of the resident pod approached a significant difference from the NP pod. Even if the resident pod patients had shown greater acuity, however, it is not clear whether such higher acuity would have resulted in higher RVUs due to higher RVUs per patient or whether it would have led to lower RVUs due to fewer patients per hour. A challenge to our study design was the fact that our PED uses multiple care models. We felt that it is important to limit our study periods to only those times during which both the NP pod and the resident pod were in operation, but also when no other models (including PED attending physicians working alone and PED attending physicians assisted by PEM fellows) were in use.

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Pediatric Emergency Care • Volume 31, Number 2, February 2015

Other studies have been limited when they attempted to assess productivity using potentially disparate patient populations and different ED conditions. The ability to provide efficient emergency care is affected by a number of factors, such as ED census, availability of inpatient beds, and available ancillary staff. Even when the acuities of the 2 patient populations are equivalent, differences such as ED volume pressures or other unmeasured factors might alter the providers’ productivity.32 Therefore, we reviewed all PED schedules over a calendar year to find the days and times during which the PED was staffed concurrently and exclusively by the resident pod and the NP pod. In our study, every period matched resident pod care with NP pod care during the same period, under the same ED census and staffing conditions. Our methodology of including only those study periods in which resident pod care and NP pod care were matched under identical times and conditions, with no other care models to confound the findings, led to a disproportionate distribution of study periods during the summer months. This distribution likely occurred because during the lower census months of summer, additional care models are less often used by the PED. It is unclear how this disproportionate representation of study periods during lower census periods might have affected our results. It is important to note that our findings relate only to the relative productivity between the 2 care models. Because we examined only a limited set of clinical care periods, the absolute productivity in RVU generation and patients seen per hour cannot be generalized to our PED overall or to the respective care models. Rather, our results show that when a resident care model and an NP model were employed simultaneously and were treating similar patient populations under the same PED conditions, the NP model was more productive. Finally, our study only addressed economic productivity. The education provided to trainees by the resident care model unquestionably provides value in the form of physician workforce education that is beyond the scope of this study, but which should be considered when selecting care delivery models. We found that PED attending physicians working in an NP care model had greater clinical productivity, measured by RVUs per hour, than PED attending physicians working in a resident care model while treating similar patient populations. Nurse practitioner care models may be a useful alternative to traditional resident care models in the PED. Additional studies should assess the relative costs, as well as productivity, of these 2 models. REFERENCES 1. Accreditation Council for Graduate Medical Education (ACGME). The ACGME 2011 Duty Hour Standards: Enhancing Quality of Care, Supervision, and Resident Professional Development. Chicago, IL: Accreditation Council for Graduate Medical Education; 2011. 2. Accreditation Council for Graduate Medical Education (ACGME). Report of the ACGME Work Group on Resident Duty Hours. Chicago, IL: Accreditation Council for Graduate Medical Education; 2002. 3. Weinstein DF. Duty hours for resident physicians—tough choices for teaching hospitals. N Engl J Med. 2002;347:1275–1278. 4. Goitein L, Shanafelt TD, Nathens AB, et al. Effects of resident work hour limitations on faculty professional lives. J Gen Intern Med. 2008;23: 1077–1083. 5. Nuckols TK, Escarce JJ. Residency work-hours reform. A cost analysis including preventable adverse events. J Gen Intern Med. 2005;20:873–878. 6. Freiburg C, James T, Ashikaga T, et al. Strategies to accommodate resident work-hour restrictions: impact on surgical education. J Surg Educ. 2011; 68:387–392. 7. U.S. Department of Health and Human Services, Health Resources and Services Administration, Council on Graduate Medical Education.

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Physician workforce policy guidelines for the United States, 2000–2020. Washington, DC: HRSA; 2005. 8. Moote M, Krsek C, Kleinpell R, et al. Physician assistant and nurse practitioner utilization in academic medical centers. Am J Med Qual. 2011; 26:452–60. 9. Lundberg S. Attaining resident duty hours compliance: the Acute Care Nurse Practitioners Program at Olive View-UCLA Medical Center. Acad Med. 2006;81:1021. 10. Pastores SM. The Accreditation Council for Graduate Medical Education resident duty hour standards: history, changes, and impact on staffing of intensive care units. Crit Care Med. 2011;39:2540–2549. 11. Pezzi C. The present and future use of physician extenders in general surgery training programs: one response to the 80-hour work week. J Am Coll Surg. 2009;208:587. 12. Committee on Pediatric Emergency Medicine, American Academy of Pediatrics. Overcrowding crisis in our nation’s emergency departments: is our safety net unraveling? Pediatrics. 2004;114:878–888. 13. Debehnke D, O’Brien S, Leschke R. Emergency medicine resident work productivity in an academic emergency department. Acad Emerg Med. 2000;7:90–92. 14. Varghese JR, Silvestri A, Lopez P. Reaching new heights: development of the emergency department nurse practitioner fellowship program. Pediatr Emerg Care. 2012;28:6–7. 15. Tsai VW, Sharieff GQ, Kanegaye JT, et al. Rapid medical assessment: improving pediatric emergency department time to provider, length of stay, and left without being seen rates. Pediatr Emerg Care. 2012;28:354–356. 16. Wood C, Wettlauger J, Shaha SH, et al. Nurse practitioner roles in pediatric emergency departments: a national survey. Pediatr Emerg Care. 2010;26: 406–407. 17. Gilboy N, Tanabe T, Travers D, et al. Emergency Severity Index (ESI): A Triage Tool for Emergency Department Care, Version 4. Implementation Handbook 2012 Edition. AHRQ Publication No. 12–0014. Rockville, MD: Agency for Healthcare Research and Quality; 2011. 18. Munro BH. T Tests: Measuring the differences between group means. In: Statistical Methods for Health Care Research. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005:137–150. 19. Brennan DF, Silvestri S, Sun JY, et al. Progression of emergency medicine resident productivity. Acad Emerg Med. 2007;14:790–794. 20. Dowd MD, Tarantino C, Barnett TM, et al. Resident efficiency in a pediatric emergency department. Acad Emerg Med. 2005;12:1240–1244. 21. Brook C, Chomut A, Jeanmonod RK. Physician assistants contribution to emergency department productivity. West J Emerg Med. 2012;13: 181–185. 22. Arnopolin SL, Smithline HA. Patient care by physician assistants and by physicians in an emergency department. JAAPA. 2000;13:39–40, 49–50, 53–54. 23. Silberman M, Jeanmonod D, Hamden K, et al. Mid-level providers working in a low-acuity area are more productive than when working in a high-acuity area. West J Emerg Med. 2013. Available at: http://www. escholarship.org/uc/item/9dv1d950. Accessed May 13, 2013. 24. Hamden K, Jeanmonod D, Gualtieri D, et al. Comparison of resident and mid-level provider productivity in a high-acuity emergency department setting. Emerg Med J. 2014;31:216–219. 25. Jeanmonod R, Delcollo J, Jeanmonod D, et al. Comparison of resident and mid-level provider productivity and patient satisfaction in an emergency department fast track. Emerg Med J. 2013;30:e12. 26. U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services. Medicare Carriers Manual, Part 3—Claims Process. Transmittal 1780 (November 22, 2002). Available at: https://www.cms.gov/ Regulations-and-Guidance/Guidance/Transmittals/downloads/R1780B3.pdf. Accessed May 13, 2013.

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27. Pershad J, Whitley M, Herman M. Visit-level acuity and resource-based relative value unit utilization in a pediatric emergency department. Pediatr Emerg Care. 2006;22:423–425. 28. Arya R, Salovich DM, Ohman-Strickland P, et al. Impact of scribes on performance indicators in the emergency department. Acad Emerg Med. 2010;17:490–494. 29. Green NA, Durani Y, Brecher D, et al. Emergency severity index version 4: a valid and reliable tool in pediatric emergency department triage. Pediatr Emerg Care. 2012;28:753–757. 30. Casalino E, Wargon M, Peroziello A, et al. Predictive factors for longer length of stay in an emergency department: a prospective multicenter

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study evaluating the impact of age, patient’s clinical acuity and complexity, and care pathways. Emerg Med J. 2013. (electronic publication ahead of print). 31. Lee JY, Oh SH, Peck EH, et al. The validity of the Canadian Triage and Acuity Scale in predicting resource utilization and the need for immediate life-saving interventions in elderly emergency department patients. Scand J Trauma Resusc Emerg Med. 2011;19:68. 32. Jeanmonod R, Brook C, Winther M, et al. Resident productivity as a function of emergency department volume, shift time of day, and cumulative time in the emergency department. Am J Emerg Med. 2009;27: 313–319.

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Relative productivity of nurse practitioner and resident physician care models in the pediatric emergency department.

Duty hour restrictions limit the use of resident physicians in pediatric emergency departments (PEDs). We sought to determine the relative clinical pr...
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