1. Scheduling for Emergency
Department Personnel
Jim Holliman, M.D., F.A.C.E.P.
Professor of Military and Emergency Medicine
Uniformed Services University of the Health Sciences
Clinical Professor of Emergency Medicine
George Washington University
Bethesda, Maryland, U.S.A.

2. E.D. Personnel Types Requiring Separate Scheduling
E. M. residents
Rotating residents from other services
E. M. faculty
Nurses
Other patient care personnel
E.M.T.'s
Nursing assistants
Medical students

3. E. M. Residency Review Committee (RRC)
Scheduling Requirements for E.M. Residents
No more than 12 hours clinical duty at one time
At least 12 hours off between shifts
At least one day off in every seven days
No more than 72 work hours per week
Must attend at least 70 % of scheduled conferences, so must have other coverage arranged for conference time
"Moonlighting" time must be monitored by the Program Director

4. Advantages of 12 Hour Shifts
Much simpler scheduling for the scheduler
More full days off in a week
Fewer "transition pickups" for staff coming on-duty
Less time spent in commuting to work
All assigned personnel can attend a conference at shift "overlap" time

5. Disadvantages of 12 Hour Shifts
Do not divide evenly into 40 hours (the standard American workweek)
More tiring if E.D. is busy
Cannot do other work duties on the same day
Technically violates the RRC rule of at least 12 hours off between shifts if any other academic duties or conferences required between shifts

6. Two Shift Workday with Different Shift Lengths
Approach taken by some E.M.S. organizations (especially where the day shift is usually very busy and the night shift usually quiet) :
8 to 10 hour day shift
14 to 16 hour night shift
Should be considered only if night shift personnel are likely to be able to sleep for part of their shift

7. Different Scheduling Patterns to Consider for 12 Hour Shifts
5 days (0700 to 1900) work followed by 4 days off, followed by 5 nights (1900 to 0700) work, followed by 6 days off
This results in average of 180 work hours per month or 45 hours per week
Other common pattern is to do 3 day shifts followed by 3 night shifts and then have 3 days off
This results in average work week of 60 hours

8. Effects of E.D. Census on Personnel Scheduling
In the U.S.A., majority of E.D. patients present in the afternoon and evening
Many U.S. E.D.'s have much greater census on weekends and holidays (when other offices and clinics are closed)
So to match personnel numbers to E.D. patient loads, non-even scheduling of E.D. personnel is usually required

9. Options for Different Overlapping Work Shifts for E.D. Personnel
1 person 0700 to 1700 or 1900
1 person 1000 to 2200
1 person 1700 or 1900 to 0100 or 0300
1 person 1900 or 2200 to 0700
May need to "double up" additional available personnel on the second or third shifts to provide the most "overlap" during the higher census times

10. for Physician Coverage for E.D.'s
1990 A.C.E.P. Recommendations
for Physician Coverage for E.D.'s
Visits Per Year
Shift Length
(hours)
Coverage
Recommended
Number M.D.'s
< 8000 24
Single
3 fulltime plus
moonlighters
8000 to 12000 12
Single
4 fulltime plus
moonlighters
12000 to
20000 12
Double at
peaks
4 fulltime plus
moonlighters
20000 to
30000
8 to 10
Double at
peaks
5 fulltime plus
moonlighters
> 30000
8 to 10
Double and
triple
5 FT + 1 FT per 5000 visits

11. Other Options for "Overlap" E.D. Coverage
Have personnel assigned to less than a 40 hour work week but they are also assigned to have beeper or phone availability for 12 to 36 hours per week to be called in to the E.D. if it gets busy
Most hospitals using this system pay a small amount per hour on-call and then pay the person's usual hourly salary for the time they are actually called in

12. General Scheduling Rules to Remember to Keep Personnel Happy
Advance from day shift to evening shift to overnight shift to days off duty
Balance assignment to weekends and holidays
Allow at least one full day off when transitioning from overnight shift to day shift
A month of all night shifts is often better tolerated than frequent switching between day and night shifts

13. Other Options for Night Shift Scheduling
Consider paying extra per hour for night or evening shifts
May have permanent designated night shift staff
Consider not expecting these staff to meet the same academic or conference attendance expectations as for the other staff
Will still need other staff to cover vacation times for the permanent night shift staff

14. Options for Prescheduling E.M. Faculty and Residents
Simplest system is to predesignate a shift pattern (e.g., 3 days on & 3 days off) for the entire year and then require each person to make shift trades if they need to alter this schedule
This rigidity usually does not work well for academic E.M. physicians because of their need to schedule attendance at other events (conferences, etc.)

15. Options for Scheduling E.M. Faculty and Residents (cont.)
Can require time-off requests a certain period in advance (one to three months)
Should also require each person to volunteer for a specified "even" number of holidays and weekends
Scheduler then matches requests to give each person the maximum number of requests possible

16. Options for Scheduling E.M. Faculty and Residents (cont.)
Can use a "lottery" system :
Staff get together and sign up for shifts in "rounds"
Start each selection "round" with staff with higher seniority
Continue "rounds" until all shifts have been filled
Each person may not "skip" a round in order to maintain fairness

17. Scheduling Limitations for "Off-Service" Residents in the E.D.
Internal Medicine and Family Practice RRC's require their residents to do "continuity clinics" each week
May need to schedule off for department Grand Rounds
Probably best if "even" conference time trades with the E.M. residents

18. Scheduling Options to Cover Personnel Illness
Can require each person to arrange their own coverage if ill
Or can have a predesignated "at risk" person to be called to fill in
Other consideration is if the ill person will have to "pay back" the shift to the covering person

19. Different Resident Scheduling Options Tried at Hershey
3 day - 3 night - 3 off
4 day - 2 off - 4 night - 2 off
4 day - 2 off - 4 eve - 2 off - 4 night - 2 off
"Overlap" resident from 1000 or 1100 to 2200 or days a week with coverage of same time slot on weekends with moonlighters
"Irregular" overlapping shifts (0700 to 1700, 1000 to 2200, 1700 to 0100, 2200 to 0700, with "extra" assigned residents doubled up on day or eve shifts

20. E.D. Personnel Scheduling Summary
Scheduling should be matched to E.D. census
General pattern of "day to night to off" should be followed
Scheduler should strive for even distribution of nights, weekends, and holidays
Schedule should be arranged well in advance, but should have mechanism for covering for illness