A before-after single centered, non-randomized study.
Study setting and population
This study was carried out from June to August 2018 at the ED of Kungälv Hospital, an emergency hospital, treating approximately 31 000 patients annually, where 10 000 being further admitted11.
All patients visiting the emergency department and requiring healthcare during the period of scribes’ presence, were eligible. Both the physician and the patient could refuse the presence of a scribe during the consultation. The patient would then be excluded from the study. However, neither a patient nor any physician refused the presence of a scribe during any consultation.
Due to the lack of a Swedish translation and understanding of the title ‘’Scribe’’; all physicians presented the scribes in the beginning of the consultations as assistant colleagues who document the consultation. One scribe was allocated for each physician. A scribe could interchange between physicians if a physician was appointed to do another task outside the ED.
A physician allocated his/her name to a patient by using our electronic medical triage and registration system (ELVIS). The scribe was expected to attend all consultations with the physician, regardless the complexity of the case.
We compared the productivity of the physicians together with scribes (scribed) during the summer of 2018 versus the productivity of the physicians without scribes (non-scribed) during summer of 2017. Physicians’ productivity was measured by assessed patients per hour per physician.
Selection of participants
In this study, emergency physicians were physicians working at the emergency department regardless of their specialty. The physicians who participated were selected by the clinical supervisor of the emergency department. Those who provided the clinical supervisor with a verbal consent had a scribe allocated behind them during their routine shifts. Participation was voluntary. All the licensed physicians, except one, agreed to participate in the study. Most of the physicians were residents in either internal medicine or emergency medicine.
The usual routine for the physicians when assessing patients is to document manually at bedside and later dictate with a dictaphone or manually type in the information in the electronic health record (EHR) system. The physicians were offered one day of training with the new scribe. For routine purposes, every time a physician received a new scribe, one day of training was provided which was subsequently excluded from the study.
The scribes were medical students under clinical rotation in their 6-8th semesters of their studies. They were handpicked from a student emergency medicine group. They were salaried employees who were paid per month and entitled physician’s assistants/scribes.
All scribes were familiar with the medical chart and software system used at the hospital as all medical students use the same systems during their clinical rotations. They received one day of administrative training with the medical secretaries for questions and further familiarization of the system. The training was delivered one week before the study.
The total number of scribes were five, all employed at once and rotated between physicians according to their work schedule.
The scribes performed all medical documentation for each patient they attended together with the physicians. If demanded by the physicians, they ordered the investigations, wrote the medical referrals and completed the EHR for further admission. The physicians reviewed, edited and signed off all the documents. The scribes followed and documented all patient consultations including triage assessment, immediate assessment – trauma and regular consultations in the patient waiting room at the ED.
The scribes could work three possible shifts from Monday-Friday 8:00 AM - 4:30 PM, 9.30 AM. - 6:00 PM or 1:00 PM. - 9:00 PM. If the physician needed to work overtime, the scribe followed and documented the extra time in the sheet. The hours were included in the study. If a scribe was reported sick, that particular day would be excluded from the study.
Weekends, public holidays and night shifts after 9:00 PM. were excluded. If the appointed physician was sick, the scribe followed another colleague with the similar level of experience and was included in the study.
The ED is divided in three major treatment teams; Medical, Surgical and Orthopedic teams. During the majority of the study period the medical scribes worked in the medical teams. However, emergency medicine residents and senior consultants assessed patients in all teams.
The scribes followed their physicians during their whole shifts. The scribes used a mobile laptop computer on wheels or carried them around into the examination room where tables were set for support. They were in the room during the whole consultation while the physician assessed the patient.
Physicians’ productivity was compared between scribed and non-scribed workdays. These workdays included different shifts and physicians. From the data collected we extracted the physician work hours and number of patients seen by each physician during each shift to calculate patients per hour per physician. The mean patients per hour per physician was later calculated from the shifts of each workday. The mean result was compared with the matched non-scribed workday of 2017.
Total patients from the study period of 2018 and from the comparing period of 2017 were first registered in table sheets. Having in mind that a date of a weekday may differ between the years, we approached it by extracting data from the matched weekdays of each year. The included workdays were from week 26 to week 34. We could collect the total number of patients signed-off by the working physician each shift. In order to make an accurate comparison with the data of 2017, we extracted data from the matched shifts and hours as in 2018. If the shifts of the comparative years did not match in working hours, we extracted shifts with the closest working hours during that weekday.
One shift was usually worked by one physician. If a scribe happened to work with two physicians during one shift, it was counted as one physician. The physicians in the study group of 2017 were different and unrelated to the physicians in the study group of 2018.
The total number of patients were calculated by counting all the registered patients from June 26th to August 24th, 2018. The corresponding days of 2017 were from June 27th to August 25th.
All patients were given an identity number which was neither correlated to their Social Security number nor to their reason for visit.
- Data collection during 2017
We collected 2017 year’s data digitally from the ELVIS system. This system does not register which patients were overhanded to or from a physician. It only registers the assessed and finished patients. There were no scribes during 2017 which made it easier to extract data from the physicians’ log file. In addition, triage consultations by a physician were not registered during 2017. The physicians working at the emergency department during 2017 were senior consultants, residents in internal medicine or interns.
We extracted the data of 2017 from shifts where the physicians were either on the same or near the same level of competence as the comparing physicians of 2018. Competence was measured by looking at the physicians’ career-levels (Table 1). 2018 was the first year Kungälv Hospital implemented residents in Emergency medicine. The closest comparison to these residents were physicians specializing in Internal medicine.
- Data collection during 2018
The scribes collected the data for 2018 manually by logging on paper sheets (Appendix). The manual approach was used since it was less time consuming, easier to track in comparison to the complex data management systems used at the hospital and also avoiding entering our data-base and putting patient’s integrity at risk. Manual approach made it possible for the scribes to log both overhanded triage patients and patients that their respective physicians had already started assessing but not finished.
Table 1: Career level of physicians in 2017 and 2018
||End of residency,
|End of residency,
||2nd year of residency,
|2.5 y of residency,
||2nd year of residency,
|2nd year of residency,
|Physician Five, Six and Seven
||1st year of residency,
|1st year of residency, Emergency Medicine
Statistical data and analysis
Mean result of patients per hour per physician for each scribed and non-scribed workday were tabulated into Microsoft Excel worksheet. Patients per hour per physician were calculated in Excel according to above explanation (see Measurements). The means for the variables were calculated for each day of 39 days. For statistical analysis we used IBM SPSS Statistics Version 27. Significance was set at p < 0.05. Independent- sample t tests were used to compare the mean values for both data set. For significance levels, we did a Levene’s Test for Equality of Variances. We assessed the data distribution with Q-Q plots, Outliers and Histograms.
Permission to conduct this study was granted by the operations manager of the emergency department. All registered data could not be tracked to any patient. A patient and a physician were able to deny a scribe’s presence. Due to no involvement of patients’ personal information and medical records, no other agreements were needed for ethical purpose.