From, US Acute Care Solutions, Canton, OH, USA.
the, Department of Emergency Medicine, Allegheny Health Network, Pittsburgh, PA, USA.
Acad Emerg Med. 2020 Nov;27(11):1089-1099. doi: 10.1111/acem.14077. Epub 2020 Jul 31.
We examined emergency department (ED) advanced practice provider (APP) productivity and how APP staffing impacted ED productivity, safety, flow, and experience.
We used 2014 to 2018 data from a national emergency medicine group. The exposure was APP coverage: APP hours as a percentage of total clinician hours at the ED-day level. Multivariable regression was used to assess the relationship between APP coverage and productivity outcomes (patients/clinician hour, relative value units [RVUs]/clinician hour, RVUs/visit, and RVUs/salary-adjusted hour), flow outcomes (length of stay and left without treatment), safety (72-hour returns, incident reports), and experience (Press-Ganey scores), adjusting for patient and facility characteristics.
In 13.02 million patient visits in 105,863 ED-days across 94 EDs from 2014 to 2018, nurse practitioners and physician assistants managed 5.4 and 18.6% of visits independently, 74.6% by emergency physicians alone, and 1.4% jointly. APP visits had lower RVUs/visit (2.8 vs. 3.7) and lower patients/hour (1.1 vs. 2.2) compared to physician visits. Higher APP coverage (by 10%) at the ED-day level was associated with lower patients/clinician hour by 0.12 (95% confidence interval [CI] = -0.15 to -0.10) and lower RVUs/clinician hour by 0.4 (95% CI = -0.5 to -0.3). There was no impact of increasing APP coverage on RVUs/salary-adjusted hour or RVUs/visit. There was also no effect of increasing APP coverage on flow, safety, or patient experience.
In this group, APPs treated less complex visits and half as many patients/hour compared to physicians. Higher APP coverage allowed physicians to treat higher-acuity cases. We found no economies of scale for APP coverage, suggesting that increasing APP staffing may not lower staffing costs. However, there were also no adverse observed effects of APP coverage on ED flow, clinical safety, or patient experience, suggesting little risk of increased APP coverage on clinical care delivery.
我们研究了急诊科（ED）高级执业医师（APP）的生产力，以及 APP 人员配备如何影响 ED 的生产力、安全性、流程和体验。
我们使用了 2014 年至 2018 年来自一家全国性急诊医学组的数据。暴露因素是 APP 覆盖率：ED 日水平的 APP 小时数占总临床医生小时数的百分比。使用多变量回归评估 APP 覆盖率与生产力结果（患者/临床医生小时数、相对价值单位[RVU]/临床医生小时数、RVU/就诊次数和 RVU/薪酬调整小时数）、流程结果（住院时间和未治疗离开）、安全性（72 小时复诊、事故报告）和体验（Press-Ganey 评分）之间的关系，同时调整患者和医疗机构特征。
在 2014 年至 2018 年间，105863 个 ED 日中的 1302 万患者就诊中，护士执业医师和医师助理独立管理 5.4%和 18.6%的就诊次数，单独由急诊医师管理 74.6%，联合管理 1.4%。与医师就诊相比，APP 就诊的 RVU/就诊次数（2.8 比 3.7）和患者/小时数（1.1 比 2.2）更低。ED 日水平上 APP 覆盖率每增加 10%，患者/临床医生小时数减少 0.12（95%置信区间[CI]为-0.15 至-0.10），RVU/临床医生小时数减少 0.4（95% CI 为-0.5 至-0.3）。增加 APP 覆盖率对 RVU/薪酬调整小时数或 RVU/就诊次数没有影响。增加 APP 覆盖率对流程、安全性或患者体验也没有影响。
在这个组中，APP 治疗的就诊患者复杂性较低，每小时治疗的患者数量也较少，与医师相比，APP 治疗的就诊患者复杂性较低，每小时治疗的患者数量也较少。更高的 APP 覆盖率使医生能够治疗更高病情严重程度的病例。我们没有发现 APP 覆盖范围的规模经济效应，这表明增加 APP 人员配备可能不会降低人员配备成本。然而，APP 覆盖范围也没有对 ED 流程、临床安全性或患者体验产生不利影响，这表明 APP 覆盖范围的增加对临床护理服务的提供几乎没有风险。
