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Impact of scribes on emergency medicine doctors’ productivity and patient throughput: multicentre randomised trial

BMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l121 (Published 30 January 2019) Cite this as: BMJ 2019;364:l121

Opinion

It’s time to think hard about how clinicians work in a digital age

  1. Katherine Walker, director of emergency medicine research, adjunct clinical associate professor12,
  2. Michael Ben-Meir, director of emergency medicine, adjunct senior lecturer12,
  3. William Dunlop, head scribe, medical student13,
  4. Rachel Rosler, director of clayton emergency medicine4,
  5. Adam West, director of paediatric emergency medicine4,
  6. Gabrielle O’Connor, emergency physician5,
  7. Thomas Chan, director of emergency medicine, adjunct associate professor56,
  8. Diana Badcock, director of emergency medicine7,
  9. Mark Putland, adjunct senior lecturer, clinical director of emergency medicine, director of emergency medicine478,
  10. Kim Hansen, emergency physician, director of emergency medicine910,
  11. Carmel Crock, director of emergency medicine11,
  12. Danny Liew, chair of clinical outcomes research12,
  13. David Taylor, professor, director of emergency medicine research613,
  14. Margaret Staples, adjunct senior research fellow, biostatistician214
  1. 1Emergency Department, Cabrini Hospital, Malvern, VIC 3144, Australia
  2. 2Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
  3. 3Australian National University, Canberra, ACT, Australia
  4. 4Emergency Department, Monash Health, Dandenong, Melbourne, VIC, Australia
  5. 5Emergency Department, Austin Health, Heidelberg, VIC, Australia
  6. 6University of Melbourne, Melbourne, VIC, Australia
  7. 7Emergency Department, Bendigo Health, Bendigo, VIC, Australia
  8. 8Emergency Department, Melbourne Health, Parkville, VIC, Australia
  9. 9Emergency Department, Prince Charles Hospital, Chermside, QLD, Australia
  10. 10Emergency Department, St Andrews War Memorial Hospital, Brisbane, QLD, Australia
  11. 11Emergency Department, Royal Victorian Eye and Ear Hospital, East Melbourne, VIC, Australia
  12. 12School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
  13. 13Emergency Medicine, Austin Health, Heidelberg, VIC, Australia
  14. 14Biostatistics, Cabrini Institute, Malvern, VIC, Australia
  1. Correspondence to: K Walker katie_walker01{at}yahoo.com.au
  • Accepted 7 January 2019

Abstract

Objectives To evaluate the changes in productivity when scribes were used by emergency physicians in emergency departments in Australia and assess the effect of scribes on throughput.

Design Randomised, multicentre clinical trial.

Setting Five emergency departments in Victoria used Australian trained scribes during their respective trial periods. Sites were broadly representative of Australian emergency departments: public (urban, tertiary, regional referral, paediatric) and private, not for profit.

Participants 88 physicians who were permanent, salaried employees working more than one shift a week and were either emergency consultants or senior registrars in their final year of training; 12 scribes trained at one site and rotated to each study site.

Interventions Physicians worked their routine shifts and were randomly allocated a scribe for the duration of their shift. Each site required a minimum of 100 scribed and non-scribed shifts, from November 2015 to January 2018.

Main outcome measures Physicians’ productivity (total patients, primary patients); patient throughput (door-to-doctor time, length of stay); physicians’ productivity in emergency department regions. Self reported harms of scribes were analysed, and a cost-benefit analysis was done.

Results Data were collected from 589 scribed shifts (5098 patients) and 3296 non-scribed shifts (23 838 patients). Scribes increased physicians’ productivity from 1.13 (95% confidence interval 1.11 to 1.17) to 1.31 (1.25 to 1.38) patients per hour per doctor, representing a 15.9% gain. Primary consultations increased from 0.83 (0.81 to 0.85) to 1.04 (0.98 to 1.11) patients per hour per doctor, representing a 25.6% gain. No change was seen in door-to-doctor time. Median length of stay reduced from 192 (interquartile range 108-311) minutes to 173 (96-208) minutes, representing a 19 minute reduction (P<0.001). The greatest gains were achieved by placing scribes with senior doctors at triage, the least by using them in sub-acute/fast track regions. No significant harm involving scribes was reported. The cost-benefit analysis based on productivity and throughput gains showed a favourable financial position with use of scribes.

Conclusions Scribes improved emergency physicians’ productivity, particularly during primary consultations, and decreased patients’ length of stay. Further work should evaluate the role of the scribe in countries with health systems similar to Australia’s.

Trial registration ACTRN12615000607572 (pilot site); ACTRN12616000618459.

Footnotes

  • Prospective registration 10 June 2015, ACTRN12615000607572: A pilot study of the relationship between Australian trained emergency department scribes and emergency physicians’ productivity. In 2015 the study group received enough philanthropic support to start training and evaluating the effect of Australian scribes, rather than relying on American scribes living in Melbourne for brief periods. This trial registration describes evaluation of the productivity of physicians working with and without scribes at our first site (Cabrini). These site data were combined with data from other sites in this paper. We reported some outcomes in other publications (number of clinical shifts needed to train a scribe, cost of training a scribe, productivity of physicians while working with trainee scribes1718). When scribes achieved competency (no longer trainees), productivity and throughput data were collected for this study. We did not measure or report data on the following secondary outcomes: staff and patient satisfaction (separate studies were done simultaneously and registered and reported elsewhere46); complaints (none were received and we report possible harms, collected via the Emergency Medicine Events Registry, in this manuscript instead); periods of time spent on ambulance bypass/diversion (not measured). Completion of this section of the study and demonstration that we had the capability to deliver the project allowed us to seek and achieve funding for an additional four study sites.

  • Prospective registration 12 May 2016, ACTRN12616000618459: A prospective, multicentre cohort study, evaluating emergency doctor productivity with medical scribe assistance. On 16 September 2016 we changed the sample size required in the registry in response to two updated data points. We determined, from newer datasets during scribe training, that medical productivity (without scribes) had decreased at Cabrini since our first sample size estimate, and we determined the cost of training scribes in Australia, which was previously unknown. This required a doubling of our sample size at each site from 50 to 100 scribed shifts. In this evaluation, we report the primary outcome (patients per hour per doctor) and secondary outcomes 2 and 3 (door-to-doctor and door-to-discharge/emergency department length of stay times). We evaluated the quality of scribes’ notes and report the evaluation elsewhere.9 We did not measure and do not report the following secondary outcomes (with and without scribes): door-to-medical triage times; stress levels of physicians; per patient revenues; comparison of dictation to scribe (patients per hour per doctor). We received enough funding to do the five site evaluation of productivity, but not enough to evaluate the remaining outcomes. This decision was made before data collection was done. We changed the trial registry outcomes on 13 June 2018 to remove the outcomes we did not evaluate.

  • Contributors: KW and MBM obtained funding. KW and WD obtained ethics approval. KW, MS, DT, DL, WD, MBM, KH, and CC developed the methods for the study. KW, WD, RR, AW, GOC, MP, and DB were responsible for site implementation and data collection. WD was responsible for data cleaning. KW, WD, MS, KH, CC, and MBM were involved in data analysis. KW, WD, MBM, MS, KH, CC, DT, and DL wrote the manuscript, and all authors revised it. All authors had access to all of the data (including statistical reports and tables) and can take full responsibility for the integrity of the data and the accuracy of the data analysis. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. KW is the guarantor.

  • Funding: The study was funded by Equity Trustees, the Phyllis Connor Memorial Fund, Cabrini Foundation, and Cabrini and supported by the Cabrini Institute. Funders had no role in study design or protocol, results, or write-up or manuscript submission decisions other than to provide funding. The researchers were independent of the funders.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icjme.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: support from the Cabrini Institute for the submitted work; KW is the director of the Cabrini scribe programme; WD is a head scribe and research assistant; the Phyllis Connor Memorial Fund has supported KW and WD to attend conferences to present scribe data; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: Human research ethics committee (Monash, Cabrini, Austin, Bendigo Health) approval numbers Monash HREC 16392L, Cabrini HREC 06-27-07-15. All scribes and physicians gave consent before participation in the study.

  • Data sharing: Medical researchers can obtain de-identified data by contacting the corresponding author.

  • Transparency: The lead author affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

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