Physician workload and the Canadian Emergency Department Triage and Acuity Scale: the Predictors of Workload in the Emergency Room (POWER) Study

Abstract

The Canadian Emergency Department Triage and Acuity Scale (CTAS) is a 5-level triage tool used to determine the priority by which patients should be treated in Canadian emergency departments (EDs). To determine emergency physician (EP) workload and staffing needs, many hospitals in Ontario use a case-mix formula based solely on patient volume at each triage level. The purpose of our study was to describe the distribution of EP time by activity during a shift in order to estimate the amount of time required by an EP to assess and treat patients in each triage category and to determine the variability in the distribution of CTAS scoring between hospital sites. Research assistants directly observed EPs for 592 shifts and electronically recorded their activities on a moment-by-moment basis. The duration of all activities associated with a given patient were summed to derive a directly observed estimate of the amount of EP time required to treat the patient. We observed treatment times for 11 716 patients in 11 hospital-based EDs. The mean time for physicians to treat patients was 73.6 minutes (95% confidence interval [CI] 63.6-83.7) for CTAS level 1, 38.9 minutes (95% CI 36.0-41.8) for CTAS-2, 26.3 minutes (95% CI 25.4-27.2) for CTAS-3, 15.0 minutes (95% CI 14.6-15.4) for CTAS-4 and 10.9 minutes (95% CI 10.1-11.6) for CTAS-5. Physician time related to patient care activities accounted for 84.2% of physicians' ED shifts. In our study, EPs had very limited downtime. There was significant variability in the distribution of CTAS scores between sites and also marked variation in EP time related to each triage category. This brings into question the appropriateness of using CTAS alone to determine physician staffing levels in EDs.