1. 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.

2. E.D. Personnel Types Requiring Separate Scheduling ƒE. M. residents ƒRotating residents from other services ƒE. M. faculty ƒNurses ƒOther patient care personnel –E.M.T.'s –Nursing assistants ƒMedical students

3. E. M. Residency Review Committee (RRC) Scheduling Requirements for E.M. Residents ƒNo more than 12 hours clinical duty at one time ƒAt least 12 hours off between shifts ƒAt least one day off in every seven days ƒNo more than 72 work hours per week ƒMust attend at least 70 % of scheduled conferences, so must have other coverage arranged for conference time ƒ"Moonlighting" time must be monitored by the Program Director

4. Advantages of 12 Hour Shifts ƒMuch simpler scheduling for the scheduler ƒMore full days off in a week ƒFewer "transition pickups" for staff coming on-duty ƒLess time spent in commuting to work ƒAll assigned personnel can attend a conference at shift "overlap" time

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

6. Two Shift Workday with Different Shift Lengths ƒApproach 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

7. Different Scheduling Patterns to Consider for 12 Hour Shifts ƒ5 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 ƒOther 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

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

9. Options for Different Overlapping Work Shifts for E.D. Personnel ƒ1 person 0700 to 1700 or 1900 ƒ1 person 1000 to 2200 ƒ1 person 1700 or 1900 to 0100 or 0300 ƒ1 person 1900 or 2200 to 0700 ƒMay need to "double up" additional available personnel on the second or third shifts to provide the most "overlap" during the higher census times

10. 1990 A.C.E.P. Recommendations for Physician Coverage for E.D.'s Visits Per Year Shift Length (hours) CoverageRecommended Number M.D.'s < 800024 Single 3 fulltime plus moonlighters 8000 to 1200012 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

11. Other Options for "Overlap" E.D. Coverage ƒHave 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 ƒMost 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

12. General Scheduling Rules to Remember to Keep Personnel Happy ƒAdvance from day shift to evening shift to overnight shift to days off duty ƒBalance assignment to weekends and holidays ƒAllow at least one full day off when transitioning from overnight shift to day shift ƒA month of all night shifts is often better tolerated than frequent switching between day and night shifts

13. Other Options for Night Shift Scheduling ƒConsider paying extra per hour for night or evening shifts ƒMay 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

14. Options for Prescheduling E.M. Faculty and Residents ƒSimplest 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 ƒThis rigidity usually does not work well for academic E.M. physicians because of their need to schedule attendance at other events (conferences, etc.)

15. Options for Scheduling E.M. Faculty and Residents (cont.) ƒCan 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 ƒScheduler then matches requests to give each person the maximum number of requests possible

16. Options for Scheduling E.M. Faculty and Residents (cont.) ƒCan 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

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

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

19. Different Resident Scheduling Options Tried at Hershey ƒ3 day - 3 night - 3 off ƒ4 day - 2 off - 4 night - 2 off ƒ4 day - 2 off - 4 eve - 2 off - 4 night - 2 off ƒ"Overlap" resident from 1000 or 1100 to 2200 or 2300 5 days a week with coverage of same time slot on weekends with moonlighters ƒ"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

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