Adjusting can be difficult as EDs endure or brace for the surge.
Dear Director,
Our volumes are markedly down since everyone began social distancing during the COVID pandemic. Are you making staffing adjustments?
My department averages about two acute appendicitis cases a day. When I talk to our surgeons, they tell me they have only seen one in the last two weeks. I greatly appreciate all of the non-emergency patients who are staying out of the ED. We also have seen some declines in volume since children are not getting hurt at sports practices or at school, people aren’t going out to bars and getting in fights or falling downstairs, and MVCs are down since so many are working from home.
As I’ve talked to friends and colleagues around the country, it seems like volumes are down 20-50% from baseline. That’s a rapid change and one that draws the attention of CFOs. On the other hand, patients are sicker, donning and doffing takes time, and we all feel the surge is coming and that we’re about to be overrun with patients.
There are a few reasons to consider making some changes to the schedule. The first, and potentially most important, is to minimize the risk to providers of getting sick from a patient. Every time we’re in the hospital, we have a risk of getting exposed so in theory, you’d like to limit the risk to your staff. As people do end up unable to work, we need to have enough healthy staff to cover the schedule.
Secondly, most of us want to at least be a little busier. Having a really slow shift is nice during a blizzard, but after a couple of weeks of significantly decreased productivity, many docs are telling me they want to feel like their time at work was useful. Finally, as managers, we need to consider the fiscal responsibility we have to our organization.
As I’ve considered staffing changes, I’ve tried to keep in mind the following: how many docs does it take to staff our COVID and non-COVID zones, how many high acuity patients can a doc manage per hour as well as in total and how can we make temporary staffing changes that allow us to be flexible and elastic so that we can rapidly adjust to volumes in a given day or over a period of several days? Previously, I felt pretty comfortable staffing for two patients/hr but with these patients, I know it’s lower.
I also have always felt that docs should be able to manage 8-10 active patients, but with COVID, I think that number is lower. Therefore, you need to staff for new parameters and understand how many active patients you have in your department throughout the day. While it’s tough to predict exactly when the dam will break and we’ll be flooded with patients, it is possible to track your daily volume and admissions to look for trends.
We pretty easily developed an Epic report to track daily COVID isolation patients and those admitted. We’ve always tracked daily ICU admission and volume. I’d be surprised if our COVID isolation patients doubled overnight (they’ve stayed about the same for a week), but changing our current schedule to one that is appropriate for a markedly reduced volume has to be able to rapidly expand if our volume returns overnight.
Most docs I’ve spoken to have made the decision to adjust the schedule. This is especially important if you’re in a productivity-based pay model but just as important if you’re in a small group that is worried about making payroll. I’ve spoken to a lot of non-EM docs who feel like they’ll take a huge cut to pay over this time period as patients cancel appointments or surgeries are cancelled. Some have told me they won’t generate enough revenue this month to cover rent and pay their support staff. Some have put their staff on furlough. I’ve also spoken to colleagues who are employees of large systems and at least for now, pay and schedule remain unchanged.
For most of us, I think it really comes down to three options.
Option 1: Drop shifts and lengthen remaining shifts, which reduces the number of providers potentially exposed each day and also allows a bench in case someone is sick for a week or two.
Option 2: Shorten shifts to minimize overlap. This helps to account for the high stress and fatiguing nature these shifts seem to be compared to a “normal” day in the ED.
Option 3: Formalizing a go home early policy; although on paper I love this, I’ve never seen this managed really effectively.
Many people I’ve spoken with are doing a hybrid of options 1 and 2. I’ve found that we don’t need to start our double coverage shift nearly as early as we did a month ago. Therefore, it’s a bit shorter. Many are dropping a shift and keeping the provider on call for those hours in case volume picks up.
The new normal is a bit crazy. As chairs, we need to be honest with our group, listen to their concerns and ideas, and ask everyone to be flexible and creative as we work through this pandemic. It won’t be over in a week like a bad winter storm and we’ll need to make adjustments as we go.
