Scheduling for Emergency Department Personnel Jim Holliman, M.D., F.A.C.E.P. Professor of Military and Emergency Medicine Uniformed Services University of the Health Sciences Clinical Professor of Emergency Medicine George Washington University Bethesda, Maryland, U.S.A.

E.D. Personnel Types Requiring Separate Scheduling E. M. residents Rotating residents from other services E. M. faculty Nurses Other patient care personnel E.M.T.'s Nursing assistants Medical students

E. M. Residency Review Committee (RRC) Scheduling Requirements for E.M. Residents No more than 12 hours clinical duty at one time At least 12 hours off between shifts At least one day off in every seven days No more than 72 work hours per week Must attend at least 70 % of scheduled conferences, so must have other coverage arranged for conference time "Moonlighting" time must be monitored by the Program Director

Advantages of 12 Hour Shifts Much simpler scheduling for the scheduler More full days off in a week Fewer "transition pickups" for staff coming on-duty Less time spent in commuting to work All assigned personnel can attend a conference at shift "overlap" time

Disadvantages of 12 Hour Shifts Do not divide evenly into 40 hours (the standard American workweek) More tiring if E.D. is busy Cannot do other work duties on the same day Technically violates the RRC rule of at least 12 hours off between shifts if any other academic duties or conferences required between shifts

Two Shift Workday with Different Shift Lengths Approach taken by some E.M.S. organizations (especially where the day shift is usually very busy and the night shift usually quiet) : 8 to 10 hour day shift 14 to 16 hour night shift Should be considered only if night shift personnel are likely to be able to sleep for part of their shift

Different Scheduling Patterns to Consider for 12 Hour Shifts 5 days (0700 to 1900) work followed by 4 days off, followed by 5 nights (1900 to 0700) work, followed by 6 days off This results in average of 180 work hours per month or 45 hours per week Other common pattern is to do 3 day shifts followed by 3 night shifts and then have 3 days off This results in average work week of 60 hours

Effects of E.D. Census on Personnel Scheduling In the U.S.A., majority of E.D. patients present in the afternoon and evening Many U.S. E.D.'s have much greater census on weekends and holidays (when other offices and clinics are closed) So to match personnel numbers to E.D. patient loads, non-even scheduling of E.D. personnel is usually required

Options for Different Overlapping Work Shifts for E.D. Personnel 1 person 0700 to 1700 or 1900 1 person 1000 to 2200 1 person 1700 or 1900 to 0100 or 0300 1 person 1900 or 2200 to 0700 May need to "double up" additional available personnel on the second or third shifts to provide the most "overlap" during the higher census times

for Physician Coverage for E.D.'s 1990 A.C.E.P. Recommendations for Physician Coverage for E.D.'s Visits Per Year Shift Length (hours) Coverage Recommended Number M.D.'s < 8000 24 Single 3 fulltime plus moonlighters 8000 to 12000 12 Single 4 fulltime plus moonlighters 12000 to 20000 12 Double at peaks 4 fulltime plus moonlighters 20000 to 30000 8 to 10 Double at peaks 5 fulltime plus moonlighters > 30000 8 to 10 Double and triple 5 FT + 1 FT per 5000 visits

Other Options for "Overlap" E.D. Coverage Have personnel assigned to less than a 40 hour work week but they are also assigned to have beeper or phone availability for 12 to 36 hours per week to be called in to the E.D. if it gets busy Most hospitals using this system pay a small amount per hour on-call and then pay the person's usual hourly salary for the time they are actually called in

General Scheduling Rules to Remember to Keep Personnel Happy Advance from day shift to evening shift to overnight shift to days off duty Balance assignment to weekends and holidays Allow at least one full day off when transitioning from overnight shift to day shift A month of all night shifts is often better tolerated than frequent switching between day and night shifts

Other Options for Night Shift Scheduling Consider paying extra per hour for night or evening shifts May have permanent designated night shift staff Consider not expecting these staff to meet the same academic or conference attendance expectations as for the other staff Will still need other staff to cover vacation times for the permanent night shift staff

Options for Prescheduling E.M. Faculty and Residents Simplest system is to predesignate a shift pattern (e.g., 3 days on & 3 days off) for the entire year and then require each person to make shift trades if they need to alter this schedule This rigidity usually does not work well for academic E.M. physicians because of their need to schedule attendance at other events (conferences, etc.)

Options for Scheduling E.M. Faculty and Residents (cont.) Can require time-off requests a certain period in advance (one to three months) Should also require each person to volunteer for a specified "even" number of holidays and weekends Scheduler then matches requests to give each person the maximum number of requests possible

Options for Scheduling E.M. Faculty and Residents (cont.) Can use a "lottery" system : Staff get together and sign up for shifts in "rounds" Start each selection "round" with staff with higher seniority Continue "rounds" until all shifts have been filled Each person may not "skip" a round in order to maintain fairness

Scheduling Limitations for "Off-Service" Residents in the E.D. Internal Medicine and Family Practice RRC's require their residents to do "continuity clinics" each week May need to schedule off for department Grand Rounds Probably best if "even" conference time trades with the E.M. residents

Scheduling Options to Cover Personnel Illness Can require each person to arrange their own coverage if ill Or can have a predesignated "at risk" person to be called to fill in Other consideration is if the ill person will have to "pay back" the shift to the covering person

Different Resident Scheduling Options Tried at Hershey 3 day - 3 night - 3 off 4 day - 2 off - 4 night - 2 off 4 day - 2 off - 4 eve - 2 off - 4 night - 2 off "Overlap" resident from 1000 or 1100 to 2200 or 2300 5 days a week with coverage of same time slot on weekends with moonlighters "Irregular" overlapping shifts (0700 to 1700, 1000 to 2200, 1700 to 0100, 2200 to 0700, with "extra" assigned residents doubled up on day or eve shifts

E.D. Personnel Scheduling Summary Scheduling should be matched to E.D. census General pattern of "day to night to off" should be followed Scheduler should strive for even distribution of nights, weekends, and holidays Schedule should be arranged well in advance, but should have mechanism for covering for illness