The Effects of Implementing a "Waterfall" Emergency Physician Attending Schedule.

Lindsey Spiegelman,Alisa Wray,Saadat Soheil,Sangeeta Sakaria,Shannon Toohey,Maxwell Jen,Ryan Gibney,Danielle Matonis

doi:10.5811/westjem.2021.2.50249

Abstract

IntroductionIncreases in emergency department (ED) crowding and boarding are a nationwide issue resulting in worsening patient care and throughput. To compensate, ED administrators often look to modifying staffing models to improve efficiencies.MethodsThis study evaluates the impact of implementing the waterfall model of physician staffing on door-to-doctor time (DDOC), door-to-disposition time (DDIS), left without being seen (LWBS) rate, elopement rate, and the number of patient sign-outs. We examined 9,082 pre-intervention ED visits and 8,983 post-intervention ED visits.ResultsThe change in DDOC, LWBS rate, and elopement rate demonstrated statistically significant improvement from a mean of 65.1 to 35 minutes (P <0.001), 1.12% to 0.92% (P = 0.004), and 3.96% to 1.95% (P <0.001), respectively. The change in DDIS from 312 to 324.7 minutes was not statistically significant (P = 0.310). The number of patient sign-outs increased after the implementation of a waterfall schedule (P <0.001).ConclusionImplementing a waterfall schedule improved DDOC time while decreasing the percentage of patients who LWBS and eloped. The DDIS and number of patient sign-outs appears to have increased post implementation, although this may have been confounded by the increase in patient volumes and ED boarding from the pre- to post-intervention period.

Highlights

IntroductionEmergency department (ED) crowding and boarding have increased in recent years, a concern that has gained the attention of the media, physicians, and patients
Increases in emergency department (ED) crowding and boarding are a nationwide issue resulting in worsening patient care and throughput
This study evaluates the impact of implementing the waterfall model of physician staffing on door-to-doctor time (DDOC), door-to-disposition time (DDIS), left without being seen (LWBS) rate, elopement rate, and the number of patient sign-outs

Summary

Introduction

Emergency department (ED) crowding and boarding have increased in recent years, a concern that has gained the attention of the media, physicians, and patients It has been deemed a serious health issue[1] because patients depend on the ED for access to care for urgent or emergent issues especially when other healthcare options are unavailable.[2] boarding and crowding have significantly strained physicians, healthcare staff, and ED beds, leading to worsened patient outcomes attributed to increased wait times, elopement, and leaving against medical advice.[3] An issue closely tied to ED crowding is the increase in patient hand-off events that occur when patients remain in the ED for a prolonged period of time (ie, longer than any individual physician’s shift duration). This is problematic as transfers of care have been shown to be the highest risk event for errors in patient care.[4,5]

Methods

Results

Discussion

Conclusion