Emergency Department Staffing Plan

ED of King Saud Hospital is one of the most busiest emergency in Qaseem region , where almost 252000 patients visit per year including both medical and surgical cases . In the vicinity of King Saud Hospital 14 PHCs are working from 8 am to 5pm , due to lack of proper communication and family education maximum number of cold cases turn towards King Saud Hospital emergency department where there is 24/7 medical and surgical cover is provided and the patient is taking it an easy access for medical service. The Emergency Department has male, female .pediatric and resuscitation room where Emergency Physicians are performing duties in three shifts, each shift is of 8 hours. Emergency Physician who are working in the male . female and Pediatric clinics are titled ED Resident ,while Physicians working in the Resuscitation room and looking recovery room are Specialist. The Chief of Emergency is consultant who is having exclusively managerial role. There is no established criteria to differentiate new or old cases, therefore all the cases are considered new and are being examined according to triage. Clinical decision making is the main work unit of the department , they make clinical assessment of the patient , decide on appropriate investigations , treatment and disposal..Most of the time ED Physician work autonomously ,especially in the management of routine cases. The level of autonomy and need for supervision is a function of a experience and training. This hospital is consultant base institution therefore their role is autonomous in patient management and the Specialist require supervision .while General Physician are largely autonomous in the care of routine cases. Due to non availability of consultant in the Emergency Department ,their role is performed by the Specialist. In the emergency department the Specialist has clinical manager and clinical decision making role during his shift. To meet 98% target an EM Department would need to be staffed at standard mentioned in document CEM (College of emergency medicine) and BAEM(British Association of Emergency Medicine) A method is designed to calculate the number of staff required to meet the standard.

According to BAEM the SHO sees 3000 patients per year , who works 44 clinical hours per week 6 weeks holiday per year ,one week study leave , this comes 1.5 patient per hour, we will take ED Physician as a SHO CONSULTANT : 5 (20 HOURS) programmed activities per week, 40 weeks per year =800 hours per year. ASSOCIATE SPECIALIST: 32 clinical hours per week,44 hours per year , 2800 patients per year.. minor injuries 4200 patients per year or 3 patients /hr. SPECIALIST REGISTRAR. 48 hours per week The best way to provide Emergency Department staffing will be for local care system to decide(BAEM) There should be consultant led ED which has adequate staff to produce all the outputs required (including teaching, management and research) In departments with average case mix one consultant per 12,000 patient attendance should be able to provide clinical leadership, clinical supervision training and management to the department, the major input to patient care will be the of other staff. To see 3000 patient per year is equal to 1 workload unit. Justification of numbers of patients seen by type of staff. Information provided by the British Association for Emergency Medicine shows variation in the numbers of patients various grades of staff will see per hour This variation will be explained by case mix and departmental procedures. WORK HOURS SHO/ED Physicians working hours per week are 48hrs. same for Specialist and for Consultant it is 800 hours/year. The standard workload 100,000 unit average case mix = 33 workload units (standard) 252,000 unit-average case mix = 82 workload units STAFFING WITH DEPARTMENT WITH AVERAGE CASE MIX

Total Patient SHO ENP 10,000

Work load Consultant 33

Middle grade 8

10

18

CLINICAL DECISION MAKERS ENP-(Emergency nursing Practioner)-2500 per year(minor injury) not applicable here. SHO- 3000 patients per year (full case mix) Middle Grade- 1800 patients per year(not applicable here) Consultant -500-1000 cases per year + direct supervision 2000 cases per year. Work load units per 10.000=33 Consultant 8x0.25wlu=2wlu Middle grade10X0.6WLU=6wlu SHO18x1wlu=18wlu ENP 9x0.8wlu+7wlu TOTAL = 33wlu. The emergency department of King Saud hospital is lacking the Physicians to full fill the standard mentioned in the document of British Association of Emergency Medicine. In view of above statement , Staff distribution could be SHO/ENP=ED Physician Middle grade= ED Specialist As per standard SHO/ED Physician 2 patient per hour and SpR/ED Specialist 1-2 patient per hour while Consultant 1 patient per hour will examine. The standard for distribution of staff in the different categories is as follows Average case mix -15-20% admission, Pediatric patients -25% Minor injuries 50% Resident and specialist both are sharing the patient and the filtered patients are seen and admitted by in patient specialist whereas the BAEM standard states filtering the patients for specialist and consultant. As this standard can not be implemented as such in this set up therefore we subtracted admission patients from main stream visits

For the emergencies where 100,000 patients are visiting 15-20% of them should have admission ,while in this emergency total number of average admission in one year is 24500 among 252000 visited patients that is 10% admission. This admission of patients is filtered by both resident and specialist. If we take SHO and ENP(emergency nurse practioner) as a ED physician there work load is 1 and 0.8 respectively in 100,000 patient unit, therefore 33wlu is needed to run the emergency to meet the standards. Whereas for 252000 patients 82wlu is needed to maintain the BAEM Standard Total Patient (Resident) 252000 46 Work load Consultant 82 20 Middle grade/SpR SHO/ENP 16

Among 63 ED Physician 8 will be on vacation or sick/education leave that counts 45days/year average. Similarly for specialist and consultant 2 will be on vacation. Therefore active staff available will be53 and 16 respectively. To overcome this deficiency we can hire staff on locum. DUTY ASSIGNEMNTS 25% of this staff will be assigned in the Pediatrics clinic and remaining in the adult and female side ,The Specialist will look after resuscitation and share his/her opinions for recovery patients with resident. The shift duties will be allocated according to the acuity and volume of the patient . PRESENT POSITION The present staff is having 23wlu that is for unit having 70.000 patients /year. and he/she are seeing almost 10200 patients /year or 13 patients/hr where as standard describes to see 1-2 patient/hr. Distribution work is according to the Job description of each staff that is already defined in the policy