Emergency department (ED) overcrowding, defined as “a situation in which the demand for emergency services exceeds the ability to provide quality care within a reasonable time,” was first described nearly 20 years ago and continues to pose a significant barrier to the current day delivery of timely emergency care [
The UF Health Emergency Department is a Level 1 Trauma Center that averages over 95,000 visits per year across three physically distinct sites: an adult emergency department, a pediatric emergency department, and a free-standing community emergency department. In September 2012, the UF ED implemented a rapid assessment zone (RAZ) concept to improve patient flow within the adult emergency department (AED). The implementation of the RAZ effectively reduced door to room, door to provider, and door to disposition time but not door to exit time. In addition, extended analysis showed a slight increase in the number of patients who left without being seen [
One such method was the implementation of an ED Scribe Program to decrease the amount of time that providers spend with documentation as well as to increase the speed and accuracy of medical charting. Scribes in the UF Health AED work in all areas of the department, including the 14-bed unit known as RAZ with 10 overflow beds into a subwaiting location, the 13-bed unit known as Core 1, and the 15-bed unit known as Core 2. The scribes are responsible for the documentation of information including the history of present illness (HPI), review of systems (ROS), physical exam (PE), lab results, and pertinent medical decision making (MDM) for the providers. A study published by the AMA and RAND Corporation in 2013 revealed that electronic medical records were a major factor contributing to physician dissatisfaction [
The aim of this study is to investigate the several measures of throughput that impact clinical productivity and to assess clinician satisfaction through the implementation of an emergency department Scribe Program.
This study was performed at the UF Health Adult Emergency Department (ED) with proposal approval by the University of Florida Institutional Review Board (IRB). The quantitative arm of this study assessed the impact of the implementation of the Scribe Program on measures of Adult ED throughput and was conducted using retrospective data analysis. Administrative data was abstracted retrospectively from the University of Florida Decision Support Services (DSS) for the timeframe between June 1, 2012, and April 30, 2013, (prescribe) and June 1, 2013, and April 30, 2014 (postscribe). Variables compiled included daily number of registered visits, number of admitted, discharged, and left without being seen (LWBS) patients, and median time interval data for all patients, admitted patients, and discharged patients. Upon careful consideration, researchers decided not to include the month of May 2013, due to crossover and inconsistency during this month, while the Scribe Program was being implemented. Outcome measures were then compared between pre- and postscribe data. A secondary, qualitative arm of this study assessed the impact of the Scribe Program on providers and was conducted using a survey created with UF Qualtrics Online Survey Software.
The Adult ED at UF Health is an academic institution that registered 66,514 patients in 2013, which translates to approximately 182 patients per day. Thirty-two percent of daily patients arrive by ground or air ambulance. The admission rate is 33.1% and the vast majority of medical services are available at UF Health, so patients are rarely transferred out of our health system. During a shift, the scribe provides medical documentation services to all providers working in their designated area excluding the first year resident (PGY1). The scribe completes charting of the emergency medical record (EMR) either in the room with the provider or via dictation after encounter, but does not complete order entries. Scribes are assigned to work 10-hour shifts in various areas of the ED.
The primary aim of this study was to assess the impact of the implementation of a Scribe Program on measures of AED throughput. Throughput was assessed using the following commonly evaluated ED objective measures: door to triage time: the time elapsed from when the patient arrives in the ED until the patient is triaged; door to room time: the time elapsed from when the patient arrives in the ED until the patient arrives in the room; door to provider time: the time elapsed from when the patient arrives in the ED until the provider (physician) signs on to the patient’s chart; door to disposition time: the time elapsed from when the patient arrives in the ED until the provider decides the patient’s disposition; door to exit time: the time elapsed from when the patient arrives in the ED until the patient exits the ED; provider to disposition time: the time elapsed from when the provider (physician) signs on to the patient’s chart until the provider decides the patient’s disposition; disposition to exit time: the time elapsed from when the provider decides the patient’s disposition until the patient exits the ED; The number of patients who left without being seen (LWBS).
These measures were analyzed before and after the implementation of the Scribe Program.
The secondary aim of this study was to assess the impact of the implementation of a Scribe Program on providers. An electronic, anonymous, password protected survey was constructed via the UF Qualtrics Online Survey Software. The link to the survey was administered via e-mail to all ED residents, physician’s assistants (PA), and nurse practitioners (NP) individually, who were employed within the UF Health Adult Emergency Department (see Figure
Survey questions.
(1) Do you think scribes are a valuable addition to this department? |
(2) From a shift stand point, have you seen an increase in work production/work flow while working with a scribe? |
(3) Before scribes, how many hours following your shift did you spend charting? |
(4) With a scribe, how many hours following your shift did you spend charting? |
(5) Does the use of a scribe increase the amount of time you spend with patients? |
(6) Do you enjoy working with a scribe? |
(7) Overall, does the use of scribes increase your workplace satisfaction? |
(8) Does the use of a scribe increase your quality of life? |
(9) Does the use of a scribe increase your level of focus at work? |
(10) Does the use of a scribe decrease your level of stress at work? |
(11) Does the use of a scribe decrease your level of stress at home? |
(12) Will the use of scribes extend your career as a physician/PA/NP? |
(13) Does the use of a scribe help you remember to ask the patient questions that you otherwise might have forgotten to ask? |
(14) Please discuss your thoughts about the use of scribes in RAZ |
(15) Please discuss your thoughts about the use of scribes in Core |
(16) Please discuss your thoughts about the use of scribes in the Trauma Bay |
(17) Please discuss your thoughts of the Scribe Program as a whole |
Survey demographics.
The primary aim of this study, effects of Scribe Program implementation on ED throughput, was assessed using retrospective statistical analysis methods on the pre- and postscribe data. Data was separated into prescribe (June 1, 2012, through April 30, 2013) and postscribe (June 1, 2013, through April 30, 2014) implementation cohorts, in order to assess the effects of scribe presence in the clinical areas (Table
Measures of ED throughput (medians except mean LWBS).
Variable | Mean prescribe (hours) | Mean postscribe (hours) | Difference (hours) |
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Registered visits | 181.68 | 180.69 | ↓ 0.99 | 0.468 |
% admittance | 0.31 | 0.35 | ↑ 0.04 | <0.0001 |
% LWBS | 0.05 | 0.05 | ↓ 0.00 | 0.382 |
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All patients (discharged and admitted) | ||||
Door to triage | 0.08 | 0.07 | ↓ 0.01 | 0.008 |
Door to room | 0.55 | 0.54 | ↓ 0.01 | 0.647 |
Door to provider | 1.34 | 1.28 | ↓ 0.06 | 0.073 |
Door to disposition | 4.16 | 3.89 | ↓ 0.27 | <0.0001 |
Door to exit | 5.62 | 5.76 | ↑ 0.14 | 0.021 |
Provider to disposition | 2.82 | 2.61 | ↓ 0.21 | <0.0001 |
Disposition to exit | 1.46 | 1.87 | ↑ 0.41 | <0.0001 |
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Discharged patients | ||||
Door to triage | 0.07 | 0.07 | 0.00 | 0.210 |
Door to room | 0.89 | 0.90 | ↑ 0.01 | 0.782 |
Door to provider | 1.67 | 1.61 | ↓ 0.06 | 0.220 |
Door to disposition | 4.57 | 4.41 | ↓ 0.16 | 0.029 |
Door to exit | 5.07 | 4.89 | ↓ 0.18 | 0.012 |
Provider to disposition | 2.89 | 2.80 | ↓ 0.09 | 0.021 |
Disposition to exit | 0.51 | 0.48 | ↓ 0.03 | 0.020 |
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Admitted patients | ||||
Door to triage | 0.10 | 0.08 | ↓ 0.02 | <0.0001 |
Door to room | 0.22 | 0.20 | ↓ 0.02 | 0.001 |
Door to provider | 0.91 | 0.91 | 0.00 | 0.996 |
Door to disposition | 3.63 | 3.25 | ↓ 0.38 | <0.0001 |
Door to exit | 7.61 | 8.27 | ↑ 0.65 | <0.0001 |
Provider to disposition | 2.72 | 2.34 | ↓ 0.38 | <0.0001 |
Disposition to exit | 3.98 | 5.01 | ↑ 1.03 | <0.0001 |
The implementation of the Scribe Program led to several statistically significant decreases in throughput variable measurements (see Table
Survey results.
Respondent | Resident ( |
Physician’s assistant ( |
Nurse practitioner ( |
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(1) Do you think scribes are a valuable addition to this department? | |||
Yes | 100% | 100% | 100% |
No | 0% | 0% | 0% |
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(2) From a shift standpoint, have you seen an increase in work production/work flow while working with a scribe? | |||
Yes, large amount | 78% | 88% | 75% |
Yes, small amount | 22% | 12% | 0% |
No | 0% | 0% | 25% |
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(3) Before scribes, how many hours following your shift did you spend charting? | |||
0-1 | 13% | 12% | 0% |
1-2 | 56% | 25% | 25% |
2+ | 31% | 63% | 75% |
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(4) With a scribe, how many hours following your shift did you spend charting? | |||
0-1 | 82% | 63% | 75% |
1-2 | 12% | 37% | 25% |
2+ | 0% | 0% | 0% |
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(5) Does the use of a scribe increase the amount of time you spend with patients? | |||
Yes | 89% | 75% | 50% |
No | 11% | 25% | 50% |
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(6) Do you enjoy working with a scribe? | |||
Yes | 100% | 100% | 100% |
No | 0% | 0% | 0% |
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(7) Overall, does the use of scribes increase your workplace satisfaction? | |||
Yes | 67% | 88% | 100% |
No | 33% | 12% | 0% |
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(8) Does the use of a scribe increase your quality of life? | |||
Yes | 89% | 88% | 100% |
No | 11% | 12% | 0% |
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(9) Does the use of a scribe increase your level of focus at work? | |||
Yes | 78% | 88% | 75% |
No | 22% | 12% | 25% |
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(10) Does the use of a scribe decrease your level of stress at work? | |||
Yes | 83% | 88% | 75% |
No | 17% | 12% | 25% |
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(11) Does the use of a scribe decrease your level of stress at home? | |||
Yes | 78% | 50% | 75% |
No | 22% | 50% | 25% |
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(12) Will the use of scribes extend your career as a physician/PA/NP? | |||
Yes | 72% | 38% | 50% |
Maybe | 28% | 38% | 50% |
No | 0% | 24% | 0% |
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(13) Does the use of a scribe help you remember to ask the patient questions that you otherwise might have forgotten to ask? | |||
Yes | 61% | 63% | 75% |
No | 39% | 37% | 25% |
During the 11-month period following the implementation of the ED Scribe Program the majority of measures of AED throughput were improved. Overall, most time intervals were decreased from pre- to postscribe time periods. Although some did increase, such as time to exit among all patients, we see that when broken out into discharged and admitted patients, this difference appears to be in the admitted patients and may be due to other operational factors within the hospital. Specifically, when provider to disposition and disposition to exit times are examined in the admitted group, provider to disposition time is decreased, and it is the disposition to exit time that increases, indicating that the time that scribes impact is decreased, and it is the time a patient waits to be discharged or admitted that increases. A 0.3% (5.1% to 4.8%) decrease in the number of patients who leave without being seen was also observed. Despite being not statistically significant, utilizing the estimates of fiscal loss by Guarisco ($450,000 lost for every one percent LWBS), this has the potential to capture $135,000, in revenue, that otherwise would have been lost [
The increase in door to exit time of admitted patients is hypothesized to be secondary to extended holds of admitted patients. In a paper published in 2013 by Guarisco it was stated that “the major obstacle to throughput is output to the inpatient units of the hospital, most importantly due to constraints such as bed availability [
The impact of the ED Scribe Program was overwhelmingly positive on the 30 survey respondents. The researchers believe that the low amount of survey respondents (60%) was likely secondary to some advanced practice providers working part time, as well as the emergency department’s policy that PGY-1 residents are not permitted to use scribes. Approximately 18 total nonresponders to the survey met these criteria. If these providers were initially excluded, our survey completion would have been 96%.
The survey concluded that 100% of all providers indicated that scribes are a valuable resource to the department and that they enjoy working with scribes. Furthermore, 90% of all providers indicated that scribes increase their workplace satisfaction and increase quality of life, while over 80% of all providers indicated that scribes increased levels of focus at work and decreased levels of stress at work. Coinciding with this data, 70% of all providers indicated that scribes decreased levels of stress at home which one can likely attribute to decreased time documenting in the electronic medical record after shift.
Although both this study and previous studies investigating Scribe Programs have concluded that the use of Scribe Programs is monetarily significant for emergency departments, it is this study which demonstrates the intangible benefits of a Scribe Program in an academic emergency department. Increased workplace satisfaction, decreased levels of stress at home, decreased levels of stress at work, and increased levels of focus at work for the strong majority of emergency medicine residents and advanced practice providers are all intangible benefits from the implementation of a Scribe Program in an academic emergency department which cannot be accounted for monetarily.
It is also of importance to note that 63% of all provider types indicated that the use of scribes will likely extend their careers. The use of scribes allows providers to practice medicine without the barriers of documentation which they face daily. One UF Health emergency medicine resident responded to a survey question asking residents to discuss their thoughts of the Scribe Program overall: “Scribes allow me to be a doctor.”
This study involved a retrospective data analysis which introduces selection bias. In addition, the PA and NP providers primarily work in the RAZ area, which has historically had more extensive scribe coverage, although the Scribe Program has expanded in other ED areas more recently. The AED residents primarily work in the Core but still utilize scribes services in RAZ when a scribe is available [
During the study period, other measures were also put into place to improve the overall efficiency of the AED, such as improved clinical guidelines and policies, efforts to enhance communications and working relationships with admitting and consulting medical services, and better EMR support tools. However, implementation of the Scribe Program was considered the most important departmental strategy in improving overall operational efficiency and was certainly the program with the highest level of personnel and financial resources assigned to it. Therefore, the researchers do believe that the demonstrated improvements in operational metrics are mostly attributable to the scribe program.
This study was conducted within an academic institution. Further experimentation needs to be conducted in order to assess if the findings generated from our Scribe Program can be generalized to other academic and nonacademic emergency departments. Additionally, scribes within our AED are assigned to one area of the ED and work with multiple providers, whereas most other models assign each scribe to an individual provider for the entire duration of the shift.
Implementation of a Scribe Program at our tertiary, academic emergency department, has led to statistically significant improvements in basic ED throughput measures, including door to disposition time for all patients, door to provider time for discharged patients, door to exit time for discharged patients, and door to room time for admitted patients. Additionally, a trend towards a decreased number of patients who leave without being seen was found, although this measure was not statistically significant.
Based on survey data obtained from ED providers, having a Scribe Program also leads to overall increased job satisfaction, which in turn would be very beneficial from the perspective of minimizing provider turnover and attrition. This is important when considering the costs associated with hiring and training new providers to replace those lost due to job dissatisfaction. Employee wellness is clearly enhanced by having a Scribe Program.
For emergency department directors and administrators considering the implementation of such a program, it is very possible to conduct an analysis of the cost of the program compared to the projected costs of hiring and training new providers to replace dissatisfied personnel, as well as the costs associated with inefficient ED bed turnover and patients who leave without receiving medical care. The data presented in this study may help in this analysis.
The authors declare that there is no conflict of interests regarding the publication of this paper.