Decision-making for end-of-day relief of anesthesiologists based on equity can decrease group productivity: Historical cohort study from a hospital with both anesthesia residents and nurse anesthetists

Background: Multiple departments use relief dashboards to increase anesthesiologists' equity of late afternoon relief. In our historical cohort study, we quantify the extent to which productivity could have been increased at one such hospital had decisions to relieve anesthesiologists been based on productivity, specifically relieving anesthesiologists with single cases when that case was suitable for relief (e.g., emergence was not underway). Methods: Time based anesthetics of any type except labor epidurals were included. We studied cases that were ongoing at 5:00 PM, 5:30 PM, 6:00 PM, and 6:30 PM during the 252 workdays July 2020 through June 2021. A stepwise algorithm for relief that maximized cases per anesthesiologist incorporated different supervision ratios for nurse anesthetists (1:3) and anesthesia residents (1:2). Results reported are means (standard errors). Results: From 5:00 PM to 6:30 PM, anesthesiologists' productivities were 57.0% (0.6%) to 60.4% (0.4%) of the maximum possible productivity. There were 46.7% (0.8%) to 54.4% (0.9%) of the cases with anesthesiologist permanent relief. Such decisions made based on increasing productivity differed from such decisions made to achieve equity of recent late afternoon workload (all four P <= 0.0001). No such conflict would have existed had all the anesthesiologists supervised only anesthesia residents and fellows, supervised only nurse anesthetists or only anesthesiologist assistants, or all personally administered care. There were 8.1% (0.6%) to 10.7% (0.5%) of the ongoing cases that were staffed by an anesthesiologist with one room and without a constraint on relief. Increases in productivity were achievable by targeting those anesthesiologists for relief by other anesthesiologists also with one case: 9.6% (0.3%) to 11.8% (0.6%). Conclusions: Among departments with anesthesiologists supervising a mixture of anesthesia residents and nurse anesthetists, the long-term goal of achieving equity of late afternoon workload among anesthesiologists conflicts with the short-term (daily) goal of maximizing their productivity.