Quality Improvement & Patient Safety

QIPS TIPS #31 To Scribe or Not to Scribe

Shari Welch , MD, FACHE, FACEP

Shari WelchThere is now a growing body of literature surrounding the use of scribes in clinical practice. The deployment of scribes has spread from its origins in the ED to a whole array of clinical settings including urology offices, cardiology clinics and primary care settings. A number of very positive things have been noted regarding the utilization of scribes in medicine: Physician satisfaction is improved, chart completion is expedited, documentation time is reduced and redirected to patient care, and some studies show improvement of the bottom line. One academic site reported that despite a significant increase in volume, the LOS was maintained and LWBS reduced, with RVUs going up after scribe integration into the practice.

Of all the benefits that may accrue to offset the cost of scribes, the physician satisfaction piece, particularly in this age of physician shortages, may be the most important element in the plus side of the scribe equation. Anecdotally, at San Gabriel Medical Center the introduction of scribes kept some senior physicians practicing when they had planned to retire!

Even if the only reason that your group decides to utilize scribes is for physician satisfaction, the question must be answered, when and where to deploy them to optimize the department’s efficiency? The answer may be counter-intuitive. The introduction of scribes into very inefficient departments with long lengths of stay may result in no changes in performance metrics. The department becomes an inefficient one with long LOS AND scribe support!

When looking for the most bang for the buck with scribes, consider deploying them on the busiest shifts, and in the areas with the most rapid patient turnover. If a geographic zone has little bed turnover, high admission rates and long lengths of stay, there should be time to manage the documentation. On the other hand, in Fast Track, Physician in Triage or Vertical Flow areas, rapid turnover is supported by the introduction of scribes into workflow.

The Anderson Emergency Center at Rhode Island Hospital was a poor performer on most time metrics, despite having scribes for each physician in every area and on every shift. The ED was re-engineered and scribes were strategically placed in the Physician in Triage which allowed the physicians to move patients through in less than 10 minutes, with the work-up begun and the bulk of the documentation completed up front.

The accompanying table summarizes the remarkable results. The table shows the baseline, the rapid cycle testing data (RCT) and the data to date showing consistent improvement. Door to Doc medians which began at 52 minutes were reduced to 22 minutes and LWBS which was 4.6% was reduced to 1.87 %!

So as you consider to Scribe or Not to Scribe, also consider the workflow most optimized by scribe deployment.

Chart of Volume and Admit Rate

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