It’s 8 pm and I’m 9 hours into a 10-hour shift when four new patients walk in. Even though I’m feeling drained, I smile warmly as each passes my workstation. I “eyeball” them each as they walk by; my grin persists because they all seem stable and my “TUR” for this shift in the emergency department is now only 45 minutes away.

TUR (or “time until relief”) is a metric I continuously track with ruthless precision when working in the ED. After all, it is the most important figure to know in that position—like a batter knowing the count when he’s at the plate.

Shifts in urgent care are different. In the ED, there’s always a fresh, well-caffeinated, fully rested colleague arriving as my shift comes to an end. There’s tremendous solace in that. For example, I explained to those four patients who came in at the end of my day that it was shift change and we’d check their vitals while they’re waiting for the next physician who was about to start work.

This is standard practice in the ED. It’s a practice not born out of laziness, but out of a sense of duty to patient safety. Most patients are quite understanding when provided this explanation for a slightly longer wait. Nobody wants to be cared for by an exhausted clinician. Furthermore, patients deserve a comparable assessment whenever they choose to present for care. And there’s a stark difference in the mental crispness of the provider wrapping up their shift and the one who’s just getting ready to start.

Unlike in the ED, the vast majority of UC’s have fixed hours of operation. They open and they close. In the ED, the patients arriving in the last hour of a shift simply wait a bit longer as shift change approaches. During a day in the urgent care, TUR is not on my mind because there’s no relief scheduled. Consequently, I don’t greet patients arriving at the end of my UC shifts as warmly. I’m sure I’m not alone in this attitude towards last minute walk-ins. Whether we admit it openly or not, we all feel this way to a certain extent—and we needn’t feel guilty about it.

This is the essence of the last hour problem: the demoralizing threat of having an uncertain amount of work looming when we are in our most exhausted, ego-depleted state. In ED shiftwork, TUR is a reassuring figure to follow because I know the intensity of work will wind down in parallel with my mental energy. “Time until close” (TUC), however, is a terror-inspiring countdown because there’s no guarantee that closing time will mark the end of the workday. It’s like running a marathon knowing that there’s a very real possibility that the finish line might be moved a few miles down the road just as it comes into sight. After seeing 50 patients over 12 hours, elation understandably turns to despair when several patients stroll in during the last 10 minutes before close.

Clinicians are not the only ones affected by the last hour problem. Patient experience is often suboptimal when presenting near closing time. In addition to the increased risk of medical errors, these patients commonly face palpably unwelcoming attitudes from UC staff . This is just human nature.

You’ve probably had this experience if you’ve ever shown up at a restaurant just as they’re getting ready to lock the doors. In this scenario, you probably noted the subtle (or not so subtle) vibes of disgust and frustration from the employees who were tired and eager to go home.

From a brand perspective, however, we want patients to feel they can be seen and treated with kindness and high-quality care whether they walk in 5 hours or 5 minutes before closing.

The last hour problem isn’t going to go away, either. In fact, the situation seems to be getting worse. While unfortunate, there is an increasing trend among patients to expect the same convenience from UC as would be expected from a grocery store. I’ve had many patients show up from 7:55 to 7:59 pm with complex complaints who look at me quizzically when I politely suggest that they’d be better served if they come in a bit earlier next time. Patients want convenience and quality in their UC experience, but rarely consider the clinician’s perspective when presenting in the literal 11th hour (or more) of their shift.

For the medical directors and administrators reading, it’s essential to recognize that pretending the last hour problem doesn’t exist is not a viable option. In fact, I am convinced the stress around closing time is driving much of the provider burnout and turnover plaguing UC organizations nationwide. This is because of the moral injury associated with the false summit of closing time and the unpredictability of unscheduled additional work when there are last minute walk-ins.

While I’m sure some UC centers have solved for this issue, I have heard from many providers that the prevailing “solution” offered to the last hour problem is to “suck it up” and accept that it’s “just part of the job.” If provider retention is among your priorities, I strongly discourage this strategy.

Conversely, I’ve seen UC organizations “cap” and stop registering patients significantly before posted closing times. While this approach offers tangible recognition for the inevitable fatigue your staff experience with high volumes, it can be profoundly dissatisfying for a would-be long-term patient of your UC to be turned away when the clinic is “open.”

I’d like to offer a nonexhaustive list of strategies to combat the last hour problem that I’ve seen implemented with some success in various centers and that would be worth a trial in your organization.

1. Bring in Relief—In baseball, when the starting pitcher is wavering, the manager brings in the reliever so someone with a fresh arm can “save” the game. Similarly, having a second clinician come in for the last 2-3 hours the center is open can unburden a weary provider and allow them to know the time until relief with more certainty. And for the clinician-administrators, you’ll achieve instant hero status if you’re the one who shows up to manage the end-of-day rush.

2. Incentivize Them—As the economist and co-author of Freakonomics, Steven Leavitt commonly says, “People respond to incentives. If you can figure out what people’s incentives are, you have a good shot at knowing how they’ll behave.” And there’s nothing more universally incentivizing than money. Clearly UC clinicians are not only in it for the money, but what they are paid does speak volumes about how much they are valued. Therefore, offering and extra $20-$30 per patient seen in the last hour and beyond, for example, communicates recognition for how much harder it is seeing the last patients of the day.

3. Rotate Clinicians Between Busy and Less-Busy Clinics—Most UC networks have a few slow(er) centers. These can serve as reprieves from the nonstop hustle of busier sites. Try scheduling providers at a less-busy clinic for the shifts following days when they’ve worked at the most predictably hectic centers.

4. Set Expectations to Stay (and Pay) Beyond Closing Time—Satisfaction = Outcome – Expectations. So, if you want more satisfied providers, dispel the notion that they will get to go home the moment the center closes. The best way to set this expectation in a nonoffensive way is to pay them for an hour after closing time, regardless of whether they need to stay late or not. With this approach, they’ll be overjoyed when the clinic is miraculously empty at closing time and content when they stay the extra hour or so that they’d already mentally budgeted for.

While the last hour problem may seem like a minor one, it is far from that. There is an epidemic of providers feeling underappreciated and burned out. Recruiting and training new providers is extremely costly. So, facing the “last hour problem” head-on is as much a sound business decision as it is a moral one. If you’re looking for a simple strategy to ensure both your patients and providers feel better cared for, invest in solving this problem in your UC center and let everyone know that relief is on the way. Furthermore, if you have a “last hour problem” solution that works, please share your success story with the JUCM audience by submitting an article. You can find instructions on doing this at https://www.jucm.com/submit-an-article/.

The Last Hour Problem

Joshua Russell, MD, MSc, FAAEM, FACEP

Quality and Provider Education, Legacy - GoHealth Urgent Care, is affiliated with the University of Chicago Medical Center in Vancouver, WA, and is Editor-in-Chief of JUCM.
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