Effects of decision fatigue on throughput and resource utilization over 12-hour shifts in the emergency department

Abstract

Objectives: This study aims to understand how decision fatigue affects emergency department (ED) operations which is of paramount importance to improve patient flow through the ED and to minimize cognitive errors. It assessed admission rates and throughput metrics in relation to time into 12-hour ED shifts. It was hypothesized that there would be increased throughput and increased likelihood of admission toward the end of the shift as a result of accumulated fatigue. Methods: The retrospective cohort study assessed 9,848 patient visits to Blue Diamond (BD) and Green Valley Ranch (GVR) - two freestanding EDs - from January 1, 2020 to May 31, 2020. A chi-square analysis was performed to determine whether patients were more likely to be admitted in the first 8 hours versus the last 4 hours of the shift at the two EDs. Student’s t-tests were also performed to evaluate differences in decision-to-admit time, door-to-doctor time, throughput time, and average patients per hour. Results: More patients were seen per hour at both BD (p < 0.0001) and GVR (p < 0.0001) during the first 8 hours. From the first 8 hours to the last 4 hours, GVR had decreased admission rates from 6.18% to 3.91% (p < 0.0001) and increased throughput time from 109.9 minutes to 114.1 minutes (p = 0.02). BD had increased door-to-doctor time from 4.86 minutes during the first 8 hours to 6.2 minutes during the last 4 hours (p < 0.0001). There was no significant difference in decision-to-admit time at BD (p = 0.6774) or GVR (p = 0.2276). Conclusions: Decision fatigue has a significant effect on physician decision-making in the ED. Later in a physician’s shift, as decision fatigue accumulates, decision-making is altered in such a way as to lead to less efficient patient flow. The accumulation of decision fatigue, and its subsequent effect on patient flow and patient admissions, may be more related to the patient volume than shift length.