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Chapter 3

N of 1 -- The World’s Most Efficient ED?

Michael White, MD and Rob Orman, MD
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Once a patient is placed in an ED room and bed, it can feel like time slows down. Unless they're dying, most systems don't have a rush order on getting things done. Florida emergency physician Michael White says things don't have to be that way. He has re-worked his ED's flow so that discharge length of stay is less than 80 minutes, patients are happier, and docs more satisfied.

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Don Z. -

Hi. Did he mis speak when he said his docs see 1.8 and apps see 1.4 with this efficient system. i work in a 80 thousand per year level two trauma center and altho we use apps in triage we dont do anything like what he touts and yet our docs see 1.9 and midlevels 1.6 and i believe our acuity is much higher- very elderly complex patients.

Rob O., MD -

Hey Don! See Response from Dr. White below...

Michael W. -

Don Z

Thank you for the question. I apologize for the lengthy response but often one response begets another question. I figured I'd address some of the more common questions I encounter.

My ER is staffed with 36 hours doc and up to 52 hrs APP per day. Staffing has increased over the years in accordance with volumes. I use APPH (pt/day divided by the sum of 0.5*APP/day plus physician coverage) and have averaged APPH staffing >2.25 since 2015. Absolute patient per hour per provider is variable depending on shift (nights versus day) and location (main versus triage). As a rough number midlevels average 1.8 pt/hr, docs in main 1.6 pt/hr and triage docs 2.1 pt/hr.

Judging ER acuity is difficult and is one of the common responses when I present my data. It is hard to imagine such numbers without some trick. However the key is a shared common departmental vision. That aside, at our facility our admit rate is just below 20%, a 6% transfer rate, and a 6% critical care rate (based on physician documentation). We receive rare transfers in so our critical care represents actual traffic. The location is more remote with basic specialists (general surgery, cardiology, nephrology - no available neurology, vascular, ENT, etc). We are heavily weighted at both ends of the age spectrum - in 2019 we saw 16% peds and significant percent of folks > 65. The facility is actually one of a handful who receives special federal reimbursement due to our high percent of medicare visits. Given our more rural location we receive our fair share of blunt and penetrating trauma as well as precipitous deliveries, etc. State trauma designation is frozen until 2023 but I fully expect our conversion after that is lifted.

My ER had a single expansion 4 years ago. In 2019 we averaged 3000 ER visits per available clinical room and had >30% hold rate since 2015.

Before 4 kids I had successfully deployed this model in various ERs ranging for > 85K trauma II to less than 30 K. In my experience size and acuity does not impact near as much as efficiency and positioning of providers (ie early, streamlined patient/provider interface). I am not arguing a level I trauma response is not time intensive, but simply an efficient evaluation, processing and disposition can be achieved within a highly functioning department. However, the key to any ER involves maximal handling of the most common patient presentations.

Another way to look at this is to consider my current shop. Overall ER volume as well as admission per day have both doubled from 2015 to 2019 with more than a 6 fold increase based on critical care. During the same time our throughput metrics have steadily improved from over an average of 150 minutes per visit (arrive to depart including all discharges and transfers) to averaging less than 70 minutes for the last 8 months. Arrive to admit disposition has been < 90 minutes for last two years.

Beyond staffing and acuity, the model has allowed us to provide excellent bedside care. I believe that is why we each went into ER. Last year our severe sepsis plus septic shock mortality rate averaged less than 2% and our LWBS (LPT plus LPMSE) was a total of 3 with a total of less than 130 AMA.

This is not achieved alone. I cannot give enough thanks to the entire team from our nurses, techs, administrators and other ancillary services. I realize all of this sounds far fetched and that is why I originally reached out to Rob. I felt it was unethical to have developed such a system and to not share it with others.

I hope this helps!


Don Z. -

Thanx for your considered response. Your tatd is great. But I have trouble following the rest of the logic to be honest. I would think that the productivity pet provider would be higher. Does this affect your bottom line much?

Michael W. -

Sorry for later response.
Productivity can be viewed in different ways. I've traditionally employed APPH where physician productivity is viewed as twice midlevel. This is calculated as APPH = ER volume / (doc hours plus 1/2 midlevel hours). For example an ER that has 135 patient visits per day and is staffed with 36 hour physician and 50 hour midlevel per day would have an APPH of 2.21. However patients seen per provider hours worked would be 135 divided by 36 plus 50 or an average of 1.57 patients seen per provider hour worked. Most ERs run around at an APPH of 2.1 but I've seen them as low as 1.8. The lower the APPH the higher the total staffing. My shop has an annual average APPH north of 2.25 since 2015.
Other views on productivity involve RVUs generated and cost per provider per patient seen. As stated in the podcast I am not a fan of RVU. RVU, especially tied to incentive, can lead to aggressive test ordering, over admitting and up-coding. My focus is simply proving the best care to the individual seated in front of me.
Do you know what your shops APPH is?
Take care

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2.25 AMA PRA Category 1 Credits™ certified by Hippo Education (2020)