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

STUDY OBJECTIVE: We assess the effect of emergency department (ED) operational stressors on clinician scheduling and throughput. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

Procedural Experience With Intubation: Results From a National Emergency Medicine Group.

STUDY OBJECTIVE: Although intubation is a commonly discussed procedure in emergency medicine, the number of opportunities for emergency physicians to perform it is unknown. We determine the frequency of intubation performed by emergency physicians in a national emergency medicine group. METHODS: Using data from a national emergency medicine group (135 emergency departments [EDs] in 19 states, 2010 to 2016), we determined intubation incidence per physician, including intubations per year, intubations per 100 clinical hours, and intubations per 1,000 ED patient visits. We report medians and interquartile ranges (IQRs) for estimated intubation rates among emergency physicians working in general EDs (those treating mixed adult and pediatric populations). RESULTS: We analyzed 53,904 intubations performed by 2,108 emergency physicians in general EDs (53,265 intubations) and pediatric EDs (639 intubations). Intubation incidence varied among general ED emergency physicians (median 10 intubations per year; IQR 5 to 17; minimum 0, maximum 109). Approximately 5% of emergency physicians did not perform any intubations in a given year. During the study, 24.1% of general ED emergency physicians performed fewer than 5 intubations per year (range 21.2% in 2010 to 25.7% in 2016). Emergency physicians working in general EDs performed a median of 0.7 intubations per 100 clinical hours (IQR 0.3 to 1.1) and 2.7 intubations per 1,000 ED patient visits (IQR 1.2 to 4.6). CONCLUSION: These findings provide insights into the frequency with which emergency physicians perform intubations.

Prescription Drug Shortages: Implications for Ambulatory Pediatrics.

OBJECTIVE: To describe contemporary drug shortages affecting general ambulatory pediatrics. STUDY DESIGN: Data from January 2001 to December 2015 were obtained from the University of Utah Drug Information Service. Two pediatricians reviewed drug shortages and identified agents used in ambulatory pediatrics. Shortage data were analyzed by the type of drug, formulation, reason for shortage, duration, marketing status, if a pediatric friendly-formulation was available, or if it was a single-source product. The availability of an alternative, and whether that alternative was affected by a shortage, also was noted. RESULTS: Of 1883 products in shortage during the study period, 314 were determined to be used in ambulatory pediatrics. The annual number of new pediatric shortages decreased initially but then increased to a high of 38 in 2011. Of the 314 pediatric shortages, 3.8% were unresolved at the end of the study. The median duration of resolved shortages was 7.6 months. The longest shortage was for ciprofloxacin 500-mg tablets. The most common class involved was infectious disease drugs. Pediatric-friendly dosage forms were affected in 19.1% of shortages. An alternative agent was available for 86% drugs; however, 29% of these also were affected. The most common reason for shortage was manufacturing problems. CONCLUSIONS: Drug shortages affected a substantial number of agents used in general ambulatory pediatrics. Shortages for single-source products are a concern if a suitable alternative is unavailable. Providers working in the ambulatory setting must be aware of current shortages and implement mitigation strategies to optimize patient care.