as a cross over on the subject of senior staffing in Emergency Departments from the Australian e-med line I am sending this from Drew Richardson in Canberra
John Vinen in Sydney had estimated that 15 specialists are necessary to provide comprehensive specialist presence but that is clearly some years off (although I see that the Brigham and Women's Hospital in Boston has 21 staff specialist for patient load of 40,000 + patients - many will be part time)
Drew has produced the best calculations I have seen for some time and reached the conclusion that 10-11 is the optimal number for good cover balanced with a good lifestyle
I would agree with this and have been stating this loudly for some years to our management (i.e. myself mainly!)
We have gone from 1 to 5 over the past 4 years but it is bloody hard covering 16/7 plus on call every day plus all the other commitments with 5 FTE - but we are doing this and it is starting to show results in terms of patient care and our profile as speciality
In NZ our manpower planning is being reviewed but an 11 FTE minimum formula for major hospitals is taken as definite and there are enough trainees in the system to get there by 2010.
Please read the e-mail below very very carefully it offers a framework for the entire future of the speciality of Emergency Medicine if it is to survive and provide the service required.
JohnC
TOIL means time of in lieu(? spelling!)

-----Original Message-----
From: Richardson, Drew [mailto:[log in to unmask]]
Sent: Tuesday, 5 November 2002 12:34 p.m.
To: Emed-Aus
Subject: RE: Weekend cover


I must disagree again: in the real world it is true that no administrator
will pay 15 FACEMS to cover 14 shifts a week.  The reasonable minimum to
avoid burnout and adequately renumerate us is:

4 x 10 hour shifts per week
Maximum 1 in 4 evening/weekend/call
TOIL - 25% weekday evenings, 50% Sat, 100% Sunday
25% non-clinical time (more for director)
10% Leave (add more for sabbatical)

Now even within this, there are problems with definitions - do I mean 1 in 4
weekends in the year, or 1 in 4 whilst you are there?  Can your TOIL be
taken as hours (shorter shifts) or must it be taken as whole days?  Can your
TOIL be taken on Non-Clinical Days thus increasing your proportion of
clinical time actually worked?  Depending on how you answer these questions,
you come up with 9-11 FTE, and on reasonable answers get 10 clinical FTE
(probably 11 with director).  For example, here are two possible rosters for
8 people (need 10 to account for leave) that cover two day shift, two
evening shift weekdays, one of each weekednds (24 clinical shifts/week) that
work 34 hours per week, 40.13 including TOIL, one using hours, one using
shifts for TOIL.  Both give 7 days off in a row once in 8 weeks, maximum of
6 days clinical in a row.

(1) Non Clinical Shift every Week 
MON TUE WED THU FRI SAT SUN
D08 D08 E10 N08
    E10 N06 D08 D08
E10 N08 D08 E10
            N08 E10 E08 E08
D08 D08 E10 N08
    E10 N06 D08 D08
E10 N08 D08 E10
            N08 E10 D08 D08

(2) Exclusively 10 hour shifts (reduced non-clinical shifts - some weekday
time after handover to be non-clinical)
MON TUE WED THU FRI SAT SUN
D10 D10 E10
    E10 N10 D10 D10
E10     D10 E10
            N10 E10 E08 E08
D10 D10 E10
    E10 N10 D10 D10
E10     D10 E10
            N10 E10 D08 D08


If the director helped out with some weekends, that makes it about 10
weekends worked each year (definitely less that 1-in-4 whilst there), only
half of them requiring on-call overnight.  That is the sort of life we are
looking at.  As both an administrator and clinician, I'd rather be paid than
take TOIL.  

Loking to the future, if it is night cover you want, then you can easily
cover one shift x 24 hours with the 10 FTE AMWAC suggested, but (1) you
would need at least 15 bodies doing that 10 FTE to keep nights down to 2 per
month and (2) that is not when the patients come - it is far more important
to have multiple FACEMs during day and evening shift than one at night and
(3) the penalty loadings should make TOIL not an option - it has to be
money.

Drew Richardson


-----Original Message-----
From: John Vinen [mailto:[log in to unmask]]
Sent: Monday, 4 November 2002 8:55
To: Tim Green; John Chambers; Robert Dowsett; Emed-Aus
Subject: Re: Weekend cover


Sorry to say but you are all wrong in relation to the number of EP's
required to staff an ED.
I refer to my previous calculations using the NSW "award" for staff
specialists.
In any calculations you need to factor in leave entitlements and TOIL for
after-hours work.
Leave entitlements annually are:
5 weeks annual leave
5 week TESL
TOIL entitlements vary a little but should be standardised to prevent
administrators playing games.
To cover 2 shifts/day one EP at any one time [many sites need two on duty
during busy periods] 7 days a week you require [excluding the HOD]:

This means that you require to cover 14 shifts per week.

If you do the mathamatics you require a minimum of 15 FTE's.

If you replace TOIL with payment fewer are required.

You also require enough EP's to ensure that they are not overworked
especially on weekends.

The US experience clearly demonstrates that after-hours work dramatically
increases burnout and the other adverse effects of shift work [relationship
breakdown,ill health,suicide,etc].
JV


----- Original Message -----
From: "Tim Green" <[log in to unmask]>
To: "John Chambers" <[log in to unmask]>; "Robert Dowsett"
<[log in to unmask]>; "Emed-Aus"
<[log in to unmask]>
Sent: Thursday, October 31, 2002 1:19 AM
Subject: Re: Weekend cover


> John,
>
> I presume you only have one EP on day shift.  At RPA and I'm sure other
big
> Australian  centres we need 2 EPs each weekday day to cover the load.  On
> that basis we need 9-10 FTE to cover 16 hours x 7 days
>
>
> Tim Green
>
> 30/10/02 14:11, "John Chambers" <[log in to unmask]> wrote:
>
> > we provide 16 hr cover 7 days a week with 5 FTE
> > could just about do with 6.5 though
> > John
> >
> > -----Original Message-----
> > From: Robert Dowsett [mailto:[log in to unmask]]
> > Sent: Wednesday, 30 October 2002 2:58 p.m.
> > To: [log in to unmask]
> > Subject: Re: Weekend cover
> >
> >
> >
> > We have 6 FTEs providing day time coverage only. Weekend shifts tend to
be
> > about 2 shifts every 5 weeks on average. We need 16 hour coverage but
will
> > need a minimum of 10 FTEs to do that.
> >
> >>>> Tony Nocera <[log in to unmask]> 28/10/2002 20:28:30 >>>
> > We are being offered funding for two staff specialist positions provided
> > we go to providing seven day a week 0800-2300 with seven EFT positions
> > meaning our weekend roster will be one in three most of the year.  Is
> > anyone working less than one in four weekends?
> >
> >
> >
> > Tony
> >
> >
> >
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