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BMJ. 2019 Jan 30;364:l121. doi: 10.1136/bmj.l121.

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

Author information

1
Emergency Department, Cabrini Hospital, Malvern, VIC 3144, Australia.
2
Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
3
Australian National University, Canberra, ACT, Australia.
4
Emergency Department, Monash Health, Dandenong, Melbourne, VIC, Australia.
5
Emergency Department, Austin Health, Heidelberg, VIC, Australia.
6
University of Melbourne, Melbourne, VIC, Australia.
7
Emergency Department, Bendigo Health, Bendigo, VIC, Australia.
8
Emergency Department, Melbourne Health, Parkville, VIC, Australia.
9
Emergency Department, Prince Charles Hospital, Chermside, QLD, Australia.
10
Emergency Department, St Andrews War Memorial Hospital, Brisbane, QLD, Australia.
11
Emergency Department, Royal Victorian Eye and Ear Hospital, East Melbourne, VIC, Australia.
12
School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
13
Emergency Medicine, Austin Health, Heidelberg, VIC, Australia.
14
Biostatistics, Cabrini Institute, Malvern, VIC, Australia.

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.

Conflict of interest statement

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.

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