The Enemies of Flow

[Arcan57]

As a tangent to the 3 vs 4, the discussion of a lack of adequate training on flow and metrics came up. The general consensus seems to be that most residencies are very good at imparting medical knowledge and poor at preparing community docs for the realities they face after graduation. This thread is an attempt to look at the things that cause a lack of flow, and how to remedy them. The simple truth is that most of us won't have adequate nursing or ancillary (esp. techs) support to brute force good metrics and without engaging with nursing leaders and hospital administration we will end up being blamed when the metrics are poor. It's much easier to fire a doc or even a group then it is to replace an ED's worth of nurses. Also, in many situations there are not adequately trained nurses available to be hired even if admin is willing to foot the bill for extra help.

This discussion will (mostly) presuppose that your practice pattern for a given patient complaint is already solidified (early PGY-3 and above), and will focus on what we as docs can do to improve flow including adjustments to nursing work flow. Possible topics for expansion would include the pros and cons of a doc out in triage, direct bedding (pull to full), an intake model, etc.

The topic I wanted to touch on first (because of its ubiquity as well as being something we can change in our own habits) is batching.

Batching is the devil.

Batching naturally occurs in almost every ED process because it involves the least amount of effort from the person batching.

Batching guarantees down-stream problems even in otherwise well-run systems.

We all saw this every day in residency, so the following scenario should be immediately recognizable:

5 patients check into triage within 30 minutes of each other at 10 am. The ED isn't at capacity yet, so all of them could come back at any time. The triage nurse(s) triages all 5 and then has the tech walk back with a stack of charts and a line of patients trailing to put them all in rooms essentially simultaneously (none are critically ill). You're mid morning Starbucks cup gets quickly drained and you start seeing patients. They're presenting with non-complex symptoms that still require a work-up. You're being pretty efficient and are taking roughly 7 minutes to see each patient. Which means the last patient you get to has been in the room 35 minutes by the time you walk in.

Things aren't great, but what you do nowcan make a big difference later:

1) Do you put in orders on the patient as you see them, dealing with the hassle of logging in or going back to the computer each time?
2) Do you wait until you've seen everyone and then log into the EMR to put in orders?

In most systems, option 2 is easier for the doc since we feel like option 1 is wasting our time walking back to the charting area or logging back into the system.

And in almost every case, option 2 leads to significant prolongations in length of stay (LOS) not just for the current group of patients but for patients you won't see for several hours.

While it takes less of our time to put in the orders all at once, now you've given your nurses (1 or more of which has just gotten two patients put back into their rooms) a batch of work to do. This means the nurses have been waiting 7-35 minutes to find out what they need to do on the patient. Once they get your orders, it's likely the phlebotomy will be batched (in fact it's guaranteed if lab draws the blood). This will lead to additional delays due to the multiple patients' samples being sent to lab at the same time, meaning the first patient's blood sat in the bag for 5-10 minutes while the second patient's sample was collected.

Once the blood's in lab, batching disappears as a problem for a while because the lab is built to batch. It then rears it's ugly head again as at least 3-4 of your patients are going to become ready for dispo simultaneously. This means spending the time explaining to the patient what just happened and what happens next (skipping this step guarantees poor patient sat scores and is medico-legally risky) and then generating their discharge instructions and scripts. With the advent of EMR, the amount of time the last step takes is non-trivial.

By the time this wave of patients is being discharged, it's early afternoon and the ED is full and the waiting room is starting to accumulate. The nurse now has to chart on two patients leaving, and will likely keep them on the board until they have finished charting on both. This means that 4 rooms now become available simultaneously and the cycle continues until sometime in the early am when the backlog is finally processed (if at all).

So you personally can help things by not routinely batching patient orders. Even if it takes a little longer to see that 5th patient initially, you more than make it up on the back end by not getting as large of a second bolus once the ED is full. It also makes life easier for the nurses (who are usually the rate limiting step in patient flow), and the patients are happier because they have less wasted time once they are seen by the doc.

From an ED level, get your nursing and physician leadership thinking about this issue as it makes intuitive sense to us but the science behind queue theory isn't widely appreciated by the C-suite. If you have lab currently drawing your blood (because of some BS about unacceptable hemolysis rates is the typical excuse), unless the hospital is willing to staff an adequate number of phlebotomists for the ED (which is vanishingly rare since the number required to keep up with flow is ridiculous) that would be the first battle I'd fight. Having worked in both systems (lab vs. nurse draw) as well as having experienced a cross-over (lab to nurse) at my last shop, this change alone is worth a good 45 minutes off of LOS. The lab doesn't care about your flow, and the numbers they generate on their turn-around times are essentially voodoo for everything but the analytical time. See what numbers they quote administration (U-Preg in 5 minutes?) and if they don't match up to your daily experience ask how they came up with that. Often they are just quoting the time on the instrument, but at my current shop lab was claiming times that were 30-40 minutes better then what we were seeing. When I asked how they generated the time in lab, it was when the tech reached into the bin and logged the sample as being in lab. Which interestingly enough was taking them about 30 minutes from when the sample was tubed to lab to do.

Hopefully this was useful. If anyone has a counter-argument I'd love to hear it or if you have tips that you've noticed have improved either your flow or the ED's flow please keep this thread alive.

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[gro2001]

Great Post Arcan! What do you think about batching notes? When you sit down and log in to place orders, should you also take another 3 minutes to bang out that patient's note? I did notice it takes less time per note for me to do that (after batching a few patients I spend longer on each note trying to recall which detail of the history went with which patient), but its hard to say which model fits in better with down time.

 

[jonmadden]

Check the raw data too, plenty of these data pulls have garbage in garbage out issues. A patient in the waiting room for 6 months or door to bed in -12 minutes

And dont get lost in the data, anything you can do you can usually see yourself during a shift to improve. If their is.

 

[jonmadden]

Check lab requirements for your state, "point of service" lab devices are small and dont require much training or a cert so a tech can do and will cut down on time and money for many common labs

 

[alreadylernd]

Excellent post. I have always felt that if there are empty beds in the ER, just bring patients back to rooms and triage them back in the ER. Hey, if it's not busy, I'll be in the room with the nurse during triage, and we can dispo a patient in the time it takes to register them (for quick complaints especially), the patient won't have to tell the same story a bazillion times to two nurses (one at triage, one back in the ER) and the doc, and I feel that from a documentation/medical legal standpoint, there's less likely to be surprises on the triage note that the MD may not see and not address. What happens at my shop is that a bunch of patients will come in, they'll get triaged one at a time (creating a bottleneck), then they'll all sit out in triage for 45 minutes even though there are open beds in the ER! Then, at some arbitrary point, probably at the whim of the charge nurse, they will all be brought into the department simultaneously. Then, all the problems of batching that Arcan wrote about ensue.

However, it has been my experience (both during residency and now out in the community) that there is strong push-back from staff and their management about avoiding the patient "bolus" into the department. I'm not sure if it is just being resistant to change, or protecting "turf".

The irony is, there really is no need for triage in the literal sense of the word when the bottleneck or limiting factor is triage itself!

 

[Arcan57]

Great Post Arcan! What do you think about batching notes? When you sit down and log in to place orders, should you also take another 3 minutes to bang out that patient's note? I did notice it takes less time per note for me to do that (after batching a few patients I spend longer on each note trying to recall which detail of the history went with which patient), but its hard to say which model fits in better with down time.

For the attendings using EMR, get a scribe. They help compensate for some of the loss of efficiency and can be starting the record (in my shop electronic T-sheets) while I'm entering orders. From a patient perspective, the time spent documenting is wasted time. With a scribe and electronic t-sheets, I typically only go over the charting when there's nothing else to do (pod-locked and waiting for lab results) or at the end of my shift while waiting to disposition that last patient.

When I was doing paper t-sheets without a scribe, I do the H&P section at the same time I was doing orders because I was better at documenting when it was fresh. It would take an extra 90 second or so but tended to be worth it downstream.

I haven't done documentation as attending with a non T-sheet system but maybe others can offers tips for what they do for dictating or the other common EMRs.

 

[Arcan57]

Excellent post. I have always felt that if there are empty beds in the ER, just bring patients back to rooms and triage them back in the ER. Hey, if it's not busy, I'll be in the room with the nurse during triage, and we can dispo a patient in the time it takes to register them (for quick complaints especially), the patient won't have to tell the same story a bazillion times to two nurses (one at triage, one back in the ER) and the doc, and I feel that from a documentation/medical legal standpoint, there's less likely to be surprises on the triage note that the MD may not see and not address. What happens at my shop is that a bunch of patients will come in, they'll get triaged one at a time (creating a bottleneck), then they'll all sit out in triage for 45 minutes even though there are open beds in the ER! Then, at some arbitrary point, probably at the whim of the charge nurse, they will all be brought into the department simultaneously. Then, all the problems of batching that Arcan wrote about ensue.

However, it has been my experience (both during residency and now out in the community) that there is strong push-back from staff and their management about avoiding the patient "bolus" into the department. I'm not sure if it is just being resistant to change, or protecting "turf".

The irony is, there really is no need for triage in the literal sense of the word when the bottleneck or limiting factor is triage itself!

So true, triage should only take place when there are insufficient resources to deliver immediate care. Yet almost every day the slow down of care and build up of the waiting room in the early afternoon is a result of the batching done in triage when "we're not busy".
Direct bedding (or pull-to full) is something that's been implemented at my last two shops with minimal success. It tends to work in early part of the day shift when the ED is mostly empty, but as soon as the ED is almost full the triage nurse stops doing it and never restarts even if we get caught up.

The main barrier I've seen is that the triage nurse gets brutalized by their colleagues in the back because they want the patient fully triaged because it's easier for them. It also helps excuse them not going in immediately to see the patient because they've already been assessed. Most nurses will try and tell you it's safer for the patient to be in the waiting room than to be brought back without having vitals done. Which is nonsense, but the nurses are very aware of the switch from the hospital's liability for events in the WR to their liability once a patient is back in their room.

The nurse and doc simultaneous assessment is a patient satisfier, but is difficult to pull off logistically because the amount of time it takes to perform our tasks is quite different. My last shop had serious back end problems and implemented an intake system where level 3s (in reality anyone that wasn't actively dying) got seen by either an MD or MLP then assigned to immediate discharge, a results waiting area, or one of the main ED areas. The MD would keep patients they thought would be discharged (immediately or from WR), otherwise they'd start the t-sheet and hand off to their colleagues in the back. We tried to do team assessment, but even with 3 nurses they couldn't keep up when things were busy since it took me 3-4 minutes to see the patient and it took them 10-30 minutes to do their work.

The general path for any of these process improvements is that you will see immediate improvement in the part of flow you concentrated on, and often a min to moderate overall improvement in flow. Within 3-6 months, these gains are typically attenuated because in the absence of constant vigilance from nursing leadership people go back to doing things the easy way. It's much easier for a nurse to batch and then have their rooms locked up then it is to be constantly faced with a new patient to assess and an old patient to discharge. Very few nurses are incentivized to maintain this level of work-flow, and in systems were the patient is moved from intake to results waiting even identifying who the nurse responsible for the bulk of the patients care is difficult. We recently switched out of a system where almost every patient changed beds at least once, which resulted in very little getting done since the nurse was constantly waiting to hand off the patient and the list of tasks needing done to the nurse in the next area. We were having major quality of care issues, and it always turned into a he-said, she-said between the nurses regarding who was supposed to have done the work.

 

[AmoryBlaine]

So true, triage should only take place when there are insufficient resources to deliver immediate care. Yet almost every day the slow down of care and build up of the waiting room in the early afternoon is a result of the batching done in triage when "we're not busy".
Direct bedding (or pull-to full) is something that's been implemented at my last two shops with minimal success. It tends to work in early part of the day shift when the ED is mostly empty, but as soon as the ED is almost full the triage nurse stops doing it and never restarts even if we get caught up.

The main barrier I've seen is that the triage nurse gets brutalized by their colleagues in the back because they want the patient fully triaged because it's easier for them. It also helps excuse them not going in immediately to see the patient because they've already been assessed. Most nurses will try and tell you it's safer for the patient to be in the waiting room than to be brought back without having vitals done. Which is nonsense, but the nurses are very aware of the switch from the hospital's liability for events in the WR to their liability once a patient is back in their room.

At places where I have worked we have tried all sorts of different iterations of the things you mentioned. The bottom line is that any RN policy has to revolve around their not feeling too busy. Bedside triage is simple (1/2 page at my current shop) but to them it is another task. No flow process that asks bedside nurses to do more work has ever or will ever succeed in my opinion and observation.

Batching is a disaster, you are correct about that. We routinely got 9-10 patients at a time. By the time you are on patient #8 patient #1 is almost always hopping mad that no one has been back in to talk to them so you have an automatic fire to put it esp since they can often see the MD(s) doing other work.

 

[Greenbbs]

I think that the system that my shop uses gets it right most of the time.

We see upwards of 115k/year (usually between 350-400 a day). All Docs have a scribe. Midlevels in the Triage area have scribes as well for increased efficiency.

In our walk-in triage (our EMS triage is a different beast), there's an MLP from 7a-3a, and a physician from 10-10 (and rumblings that an extra doc will be there from 12-10). There are 2-3 nurses, 2 techs, and a registrant. In our Triage area, there are 4 Triage rooms, an EKG machine, a lab draw area, 3 subacute rooms and a host of geri-chairs that we use.

Anyone who walks in through the front door (adult and child- our peds ED runs the same system) goes through the Triage area and is seen by either an MLP or a doc. Patients are triaged, usually within a few minutes and seen by one of the providers. Patients are sorted whether they can be treated and released (rashes, med refills, simple lacs that can be repaired immediately), can go back to the waiting room (waiting for simple things like x-rays, US legs for DVT's, simple labs like UA's, etc) prior to discharge; to a subacute room (for basic labs and IV fluids for dehydration, undifferentiated abdominal pain in younger folks, kidney stones, uncomplicated vag bleeding, etc), or back to the main ED for more acute things (chest pain, AMS, etc) and get orders put in and head to a lab draw station in the back part of the ED to get the ball rolling. Uber acute things get immediatley given to a doc for immediate processing.

If you work in Triage, you keep the simple things (treat and street, subacute things) to yourself and send the stuff that needs the bigger workups to the back. It's not unusual to treat and release 50 patients by yourself in a 12 hour triage shift. Charting is done by the scribes at the time of the patient encounter, so by the time you walk out of the room, the chart is done, and all you have to do is review it. You only chart on the ones you keep. You put in a basic provider triage note on the ones you sent back (in addition to the nursing triage note)

Our door-to-doc time has markedly gone down with this system. Satisfaction has gone up because most people get seen within a few minutes of walking in the front door. Labs and imaging get done faster b/c the orders are put in. If things are bogged down in the back (which happens frequently), at least the ball is moving on these patients so that by the time a doc sees them, most things are done and they can be dispo'd. Anyone that needs urgent attention will get it, but a lot of the time, people wait a bit to see a doc in the back part of the ED. Most are very understanding because we usually tell them in our triage area that things are busy, but by seeing a provider in triage gets a basic exam, and orders going so it speeds their process up.

Suprisingly, even with our high volumes, when you come in for a day shift, there are plenty of open beds in the main ED because we have this system in place. All that crap that would ordinarily sit in the waiting room to come back to the main ED in most places gets dispo'd from Triage and most of those are done within an hour. ~Half our ED volume (adult and peds) gets sent home from the triage area, so usually on the adult side, only ~175 of ~280 patients a day go to the back part of the ED (which has 40 beds --> ~roughly 4 patients/day per bed), while on the Peds side, more get dispo'd from triage because all those non-urgent ear aches and ankle sprains never make it back.

Our ED admission rate for May was about 33%, and our average total time in the ED was about 5.5 hours long (usually the dispo'd patients are there an avg of 2.5-3 hours), while we board a decent amount of admitted patients for 6-8 hours). The inpatient side has decent flow, so even on our busy days, people still get beds, but we're usually busier than they can dispo inpatient wise.

All in all, pretty efficent, I think.

 

[Arcan57]

At places where I have worked we have tried all sorts of different iterations of the things you mentioned. The bottom line is that any RN policy has to revolve around their not feeling too busy. Bedside triage is simple (1/2 page at my current shop) but to them it is another task. No flow process that asks bedside nurses to do more work has ever or will ever succeed in my opinion and observation.

Batching is a disaster, you are correct about that. We routinely got 9-10 patients at a time. By the time you are on patient #8 patient #1 is almost always hopping mad that no one has been back in to talk to them so you have an automatic fire to put it esp since they can often see the MD(s) doing other work.

I believe nurses should be incentivized on performance, since they are the ones that are actually providing health care in most cases and whenever you have a flat hourly rate the incentive is to minimize work. I understand in states with unionized nurses that this isn't going to happen, but I don't understand why it doesn't happen in non-union shops.

 

[Arcan57]

I think that the system that my shop uses gets it right most of the time.

We see upwards of 115k/year (usually between 350-400 a day). All Docs have a scribe. Midlevels in the Triage area have scribes as well for increased efficiency.

In our walk-in triage (our EMS triage is a different beast), there's an MLP from 7a-3a, and a physician from 10-10 (and rumblings that an extra doc will be there from 12-10). There are 2-3 nurses, 2 techs, and a registrant. In our Triage area, there are 4 Triage rooms, an EKG machine, a lab draw area, 3 subacute rooms and a host of geri-chairs that we use.

Anyone who walks in through the front door (adult and child- our peds ED runs the same system) goes through the Triage area and is seen by either an MLP or a doc. Patients are triaged, usually within a few minutes and seen by one of the providers. Patients are sorted whether they can be treated and released (rashes, med refills, simple lacs that can be repaired immediately), can go back to the waiting room (waiting for simple things like x-rays, US legs for DVT's, simple labs like UA's, etc) prior to discharge; to a subacute room (for basic labs and IV fluids for dehydration, undifferentiated abdominal pain in younger folks, kidney stones, uncomplicated vag bleeding, etc), or back to the main ED for more acute things (chest pain, AMS, etc) and get orders put in and head to a lab draw station in the back part of the ED to get the ball rolling. Uber acute things get immediatley given to a doc for immediate processing.

If you work in Triage, you keep the simple things (treat and street, subacute things) to yourself and send the stuff that needs the bigger workups to the back. It's not unusual to treat and release 50 patients by yourself in a 12 hour triage shift. Charting is done by the scribes at the time of the patient encounter, so by the time you walk out of the room, the chart is done, and all you have to do is review it. You only chart on the ones you keep. You put in a basic provider triage note on the ones you sent back (in addition to the nursing triage note)

Our door-to-doc time has markedly gone down with this system. Satisfaction has gone up because most people get seen within a few minutes of walking in the front door. Labs and imaging get done faster b/c the orders are put in. If things are bogged down in the back (which happens frequently), at least the ball is moving on these patients so that by the time a doc sees them, most things are done and they can be dispo'd. Anyone that needs urgent attention will get it, but a lot of the time, people wait a bit to see a doc in the back part of the ED. Most are very understanding because we usually tell them in our triage area that things are busy, but by seeing a provider in triage gets a basic exam, and orders going so it speeds their process up.

Suprisingly, even with our high volumes, when you come in for a day shift, there are plenty of open beds in the main ED because we have this system in place. All that crap that would ordinarily sit in the waiting room to come back to the main ED in most places gets dispo'd from Triage and most of those are done within an hour. ~Half our ED volume (adult and peds) gets sent home from the triage area, so usually on the adult side, only ~175 of ~280 patients a day go to the back part of the ED (which has 40 beds --> ~roughly 4 patients/day per bed), while on the Peds side, more get dispo'd from triage because all those non-urgent ear aches and ankle sprains never make it back.

Our ED admission rate for May was about 33%, and our average total time in the ED was about 5.5 hours long (usually the dispo'd patients are there an avg of 2.5-3 hours), while we board a decent amount of admitted patients for 6-8 hours). The inpatient side has decent flow, so even on our busy days, people still get beds, but we're usually busier than they can dispo inpatient wise.

All in all, pretty efficent, I think.

My old shop ran a similar system that helped quite a bit, and it would be common to see 40-50 pts during an intake shift. The issue we had was that we had a very small population of level 4-5s, usually in the 10-20% range. So the main ED would be full from ambulance traffic and we'd be starting patients on BiPap in intake because we had no place to put them. This was a tremendous nursing dissatisfier, and a couple of months after I left led to the ED director resigning after having a blow up fight with one of the nurse managers during an intake shift.

I tried to get a similar system implemented at my current shop, but we are RVU with no base and our billing company can't/won't split RVUs between providers.

 

[Zanegray]

Great Post Arcan! What do you think about batching notes? When you sit down and log in to place orders, should you also take another 3 minutes to bang out that patient's note? I did notice it takes less time per note for me to do that (after batching a few patients I spend longer on each note trying to recall which detail of the history went with which patient), but its hard to say which model fits in better with down time.

yes yes yes! plus each note doesn't take much time, but you will be 1-2 hours after your shift if you don't do this - wish I didn't know this from experience

 

[The White Coat Investor]

It turns out I'm most efficient with about 4 patients. If lab is slow, make it five. X-ray is slow too, then make it 6. The slower those I work with get, the more patients I can handle at a time. Otherwise, I'm ready to dispo the first one after I've picked up about 3. The key is to ramp up in the first hour, then stagger your work throughout the shift, with a slight increase in picking up 1.5-2.5 hours before the end of your shift, then taper from there, hopefully not starting any new non-fast track patients in the last hour.

Staggering means pick up a new one, start the chart, put in the orders, then dispo a patient, then pick up a new one, then dispo an old one. You don't want to pick up pick pick up, then dispo dispo dispo, then pick up pick up pick, then dispo dispo dispo.

And prioritize dispos to improve flow. That frees up your nurse to help you with your next pick up.

As far as managing my own time, it's much better if I see the patient, write the orders, start the note, then go on to the next one. When results are back, I talk to the patient, finish the note, print the disposition, then go on to the next one. Two step process per patient. Then I get to the end of my shift and voila, I'm out the door. All charts done. I think it's better care too since doing the charting helps me remember things I would otherwise forget, both to consider in the initial differential and also to address at disposition time. Sometimes there's too many new patients waiting to do this, but that's what I do 95% of the time.

 

[deleted109597]

I agree. Batching makes everything happen at once, and if you have a hospitalist group, they really hate to hear you say "I've got 3 to admit to you." Not saying it doesn't happen anyway sometimes, but it shouldn't be standard (unless they want you to call them less often with more patients, and some are that way).

That being said, I can't for the life of me figure out why the charge nurse always asks the nurses if they're "ready for more patients" but never asks me. I spent the better part of a year trying to get them to pull people out of the lobby, or discharge people as I do it instead of waiting for multiple people to send home. And invariably, you discharge someone, and that same nurse is calling report, so instead of putting people in their "zone" one at a time, they just wait and reload from empty to full. Nothing pisses off patients more than waiting 2 hours to be put in a room and wait another hour or more.

And while the doc in triage concept may be functional, I really hate working up there. Nothing like seeing 6 pph and having to discharge half of them.

 

[la gringa]

i worked for 2 yrs at 2 shops where nearly everyone was triaged at the bedside. i loved this - about half the time i saw the pt with the nurse, plan was clear to everyone, we both got the same story, etc... door to doc and door to dispo times were exceptional.

my current shop uses physician in triage 10 hrs a day. i am relatively new and have yet to work this shift, and honestly i don't want to. i'm meticulous and excel at patient satisfaction and well, being thorough. i'd rather take care of pts in "the back" who need a workup any day!!

only problem is that the triage shift generates an inordinate amount of RVU's compared to the back, and with much much less risk and whatnot. i believe this is about to change due to a change in our compensation model.

as far as charting - i try to get the HPI done right away and any complicated physical exam findings. i do usually stop to do orders at least every 2 pts, but usually after each one.

our worst batching problem is that often when i show up to a shift, there are 3-6 pts in my "area" waiting to be seen... due to no overlap in shifts and the fact that one area is semi-closed 6 hrs a day. still don't have that down pat, as it wasn't like that anywhere i've been previously.

thanks for the good discussion arcan and all posters!

 

[AmoryBlaine]

I agree. Batching makes everything happen at once, and if you have a hospitalist group, they really hate to hear you say "I've got 3 to admit to you." Not saying it doesn't happen anyway sometimes, but it shouldn't be standard (unless they want you to call them less often with more patients, and some are that way).

That being said, I can't for the life of me figure out why the charge nurse always asks the nurses if they're "ready for more patients" but never asks me. I spent the better part of a year trying to get them to pull people out of the lobby, or discharge people as I do it instead of waiting for multiple people to send home. And invariably, you discharge someone, and that same nurse is calling report, so instead of putting people in their "zone" one at a time, they just wait and reload from empty to full. Nothing pisses off patients more than waiting 2 hours to be put in a room and wait another hour or more.

And while the doc in triage concept may be functional, I really hate working up there. Nothing like seeing 6 pph and having to discharge half of them.

Nurse will get new patient when: below ratio, feeling happy, fed, coffee'ed, caught up, facebook updated, upcoming wedding/weekend plans discussed, overall satisfied with the alignment of the planets

Doctor will get new patient when: breathing

 

[EvoDevo]

Outstanding discussion. Thanks for starting this thread, Arcan.

With respect to charting at the bedside or just after the patient encounter, does anyone have any thoughts as to how much impact your EMR (or not) can have?

I've used Medhost, Meditech with Dragon dictate (at our community site), and Epic. I feel that with Medhost I was pretty fast but the charts looked awful from a records standpoint. RVU billing was great.

I really liked the Meditech/Dragon combo because I could clearly and cogently dictate a solid chart in no time. Lately we used Epic...boy, that was slow as molasses (but also had a wealth of info available, especially old charts for your complicated patients.

My new shop has PICIS and I wondered if anyone has had any experience with it?

Anyway, I've often said that Apple needs to do an EMR the right way, from the Physician perspective. If they did it and it was smooth and intuitive...it would be an overnight hit.

 

[Arcan57]

i worked for 2 yrs at 2 shops where nearly everyone was triaged at the bedside. i loved this - about half the time i saw the pt with the nurse, plan was clear to everyone, we both got the same story, etc... door to doc and door to dispo times were exceptional.

my current shop uses physician in triage 10 hrs a day. i am relatively new and have yet to work this shift, and honestly i don't want to. i'm meticulous and excel at patient satisfaction and well, being thorough. i'd rather take care of pts in "the back" who need a workup any day!!

only problem is that the triage shift generates an inordinate amount of RVU's compared to the back, and with much much less risk and whatnot. i believe this is about to change due to a change in our compensation model.

as far as charting - i try to get the HPI done right away and any complicated physical exam findings. i do usually stop to do orders at least every 2 pts, but usually after each one.

our worst batching problem is that often when i show up to a shift, there are 3-6 pts in my "area" waiting to be seen... due to no overlap in shifts and the fact that one area is semi-closed 6 hrs a day. still don't have that down pat, as it wasn't like that anywhere i've been previously.

thanks for the good discussion arcan and all posters!

Having worked a couple of years at a place where I'd walk into 14 waiting to be seen if I was the early am doc, I found that sticking with the one at a time approach was still better than trying to see everyone for 2 min then going back. In many cases the nurses had started a work-up or it was the typical early morning walking well so I could usually dispo 75% of the patients immediately after I finished my exam.

So I'd typically end up picking up 6 the first hour and dispo'ing 5 of them during that same hour. The second hour ran much like the first, and then it would settle into a more normal flow once I was seeing pts that hadn't had labs sent off or were starting to need cross-sectional imaging.

Which leads me to another axiom of patient flow:
If you can discharge a patient immediately after seeing them, do so.

Once you are done with a patient, get them out of the ED ASAP. This is the group that will get PG surveys and it's also the group that has the least tolerance for waiting. If you walk out of a room after having explained what's going to happen in the ED and the details of the after care plan to the patient's satisfaction they are usually quite eager to leave. If you then see 3 other patients and now it's an hour since you told them they were going home they are pissed and start consuming nurse and doc time again dealing with their complaints. If their primary nurse is busy, then I'll grab the first nurse in the area that's not doing something and get them to discharge the patient. They're never happy about it, but they also rarely refuse. Note: if you're doing this but didn't explain to the patient what's going on then you're a jerk and are probably wondering why you're in the single digits on your PG surveys.

The corollary to the immediate discharge axiom is:
Don't work up patients that don't need a work up

Remember all the old-school docs (Greg Henry comes to mind) that talk about history/physical/physician judgement being of primary importance that you thought were clueless and out of touch when you were a resident? They're actually right.

The problem is that in residency, essentially everything gets worked up. How many hundreds of negative CXRs did you order on pt's with URIs? How many U/S got ordered on patient's with previously confirmed IUPs with 1st trimester bleeding? How many normal sets of electrolytes got ordered on patients with less than a day of vomiting and diarrhea (that you weren't planning on scanning)?

And there's a good reason for that, because most residents (especially junior) don't have a sufficient n of patients to feel comfortable telling the patient that our tests won't show why the patient is sick.

I'm not saying don't work-up patients, but if you KNOW that the patient's ED eval is going to be unremarkable then you're wasting everyone's time. And just as importantly, it's not going to make the patient more satisfied. How many patients have you seen claim they had a prior ED visit were nothing was done and when you get the records the patient had a full lab work-up, a negative CT +/- U/S? If you want the patient to leave on amicable terms you're going to need to tell them what the next step in care is, and that's going to take time. So if the tests you have available aren't going to give an answer, tell the patient up front and give them a referral to the appropriate outpatient doc. It's the same amount of time for you (maybe a little less because you're not wasting time checking results), but the patient is out the door in 30 minutes rather than 2-4 hours. And if you give them time and action specific follow up instructions (thanks again Dr. Henry), you're probably as protected medicolegally as if you ordered the useless work-up.

 

[Arcan57]

Outstanding discussion. Thanks for starting this thread, Arcan.

With respect to charting at the bedside or just after the patient encounter, does anyone have any thoughts as to how much impact your EMR (or not) can have?

I've used Medhost, Meditech with Dragon dictate (at our community site), and Epic. I feel that with Medhost I was pretty fast but the charts looked awful from a records standpoint. RVU billing was great.

I really liked the Meditech/Dragon combo because I could clearly and cogently dictate a solid chart in no time. Lately we used Epic...boy, that was slow as molasses (but also had a wealth of info available, especially old charts for your complicated patients.

My new shop has PICIS and I wondered if anyone has had any experience with it?

Anyway, I've often said that Apple needs to do an EMR the right way, from the Physician perspective. If they did it and it was smooth and intuitive...it would be an overnight hit.

We're using TEV (electronic t-sheets) and the log-in time to the server is prohibitive (~3 min) with a relatively quick time out so our scribes push around COWs so they don't have to keep logging in. When I don't have a scribe I run back to the central work area so TEV doesn't log off (I also have a sign warning not to use my computer so I don't get accidently logged off), and will dash out the H&P then do the clinical course and dispo at the same time I used Firstnet to create the Rx and discharge instructions.

The main point for EMR is : Get a scribe

At my first job I was one of the fastest docs in the group, and when we went to using scribes I started seeing 33% more patients/shift. Typically 1-2 extra patients/shift pays for a scribe, but it's hard to put a price on leaving a shift on time and not being continuously pissed off about how much your EMR sucks.

 

[la gringa]

it's hard to put a price on leaving a shift on time and not being continuously pissed off about how much your EMR sucks.

a-friggin-men. had scribes at my last job... was skeptical at first, but came to love most of them and it was kinda fun being able to teach them little tidbits here and there when i had the time. they're like med students who are paid to help you and aren't trying to kiss your butt.

my current gig doesn't consider them to be worth the $$$... holy hell do i disagree!!! i wish i could choose to have one and pay for them myself. i'm up to my eyeballs in debt, but the increase in sanity and being able to get out on time would easily be worth it.

i have a few partners who produce the most useless charts ever. they always leave on time, but if the patient returns or you have to read their chart for any reason, you get zero from it b/c they just click boxes and don't chart an HPI that resembles what you'd actually say. they document literally nothing in MDM other than results. then there are a few who don't proofread their Dragon dictations... makes for funny reading, but medicolegally scary and painful to the reader. SDNers, don't be that guy!!!

to whomever just started using Picis - had it at my last job, really liked it. very ED focused and user friendly. sucks as a printed chart but great on the computer. would be IDEAL if also used w/ Dragon or the like. as stated above - we had scribes at those shops.

 

[CraftyMed]

Until recently, I worked the shift that opened one of our "areas" at 10am on a Saturday morning. You know, the witching hour when the masses start to wake up. I would be the only doc for a few hours before a resident came in in the afternoon. The problem was that the triage nurse would save up patients for the area, then plop back 6-8 patients. Each nurse would get 2-3 un-vitaled, un-triaged new patients at once. You would have no idea who was actually sick, other than what you could see in the half-sec as they went by you into their room. I can say that every week there was a patient who was a lot sicker than what they wrote on the complaint form out front. I also was part of the rate-limiting step since there was only one of me and 6-8 new patients. Kind of unsafe, IMHO.

 

[Arcan57]

Until recently, I worked the shift that opened one of our "areas" at 10am on a Saturday morning. You know, the witching hour when the masses start to wake up. I would be the only doc for a few hours before a resident came in in the afternoon. The problem was that the triage nurse would save up patients for the area, then plop back 6-8 patients. Each nurse would get 2-3 un-vitaled, un-triaged new patients at once. You would have no idea who was actually sick, other than what you could see in the half-sec as they went by you into their room. I can say that every week there was a patient who was a lot sicker than what they wrote on the complaint form out front. I also was part of the rate-limiting step since there was only one of me and 6-8 new patients. Kind of unsafe, IMHO.

From an economics perspective this makes sense, you should be the rate limiting step. You are the most expensive server (borrowing the term from queue theory not the restaurant industry) in the department and should be being utilized at close to 100% capacity. The problem of course is that we almost never are being utilized at 100%, it's either 150%+ or less than 30%. In hospitals currently, the nurses are the rate limiting step most of the time. One of the discoveries made studying queue theory is that adding capacity at servers upstream of the bottleneck actually makes things worse. In English, as it applies to the ED, :If your ED's flow is limited by insufficient nursing resources, adding more docs worsens flow.

This is somewhat counterintuitive, but if you have overwhelmed your nurses' capacity then having more docs giving them orders and asking for updates just slows things further. Think about how ineffective getting work-ups started in the lobby is when you don't have a nurse to start those work-ups. It's good for door-to-doc times (which everyone is obsessed with despite how easy it is to game), but doesn't do a damn thing for LOS (which most people want to pretend isn't the real problem). That's not saying going to the lobby is always a bad idea (I'll talk more about back-end problems later), but unless you have a nurse with you to draw blood or are just screening out patients who don't need a workup then it's not going to help flow.

You're not going to get your C-suite to pay for appropriate nurse staffing (every hospital I've been at claims they used to do it and lost millions while still having crappy metrics), so you need to get them thinking about nurse extenders. The ED should be highly subscribed with techs (1:1 or 1:2 tech/nurse ratio preferably) to reduce the load on the nurses so they can drive patient flow. The techs need CLEAR JOB DESCRIPTIONS and work best in an environment that fosters teamwork. Of note, if you do hire a bunch of techs expect to have to fire at least a couple of nurses who will expect the tech to do all the unpleasant parts of the job even if the techs are overwhelmed with other tasks.

 

[CraftyMed]

You are the most expensive server (borrowing the term from queue theory not the restaurant industry) in the department

No no, we're also servers in the terms of the restaurant industry too.

Turkey sammich and mini-Shasta, anyone??

 

[la gringa]

last night, my section got totally constipated b/c all of the NA's on shift were tied up watching psych pts... add in 2 ICU players, one of whom was cared for by a green nurse and bam... total backup. i turned over the rooms i could, but it made for a painful night and a rough morning for my colleague who walked into new pts in nearly all of the rooms once the backlog let up. sorry dude

the issue of psych pts and lack of beds, delays, etc is a whole 'nother issue.... but also kills flow!

 

[Arcan57]

last night, my section got totally constipated b/c all of the NA's on shift were tied up watching psych pts... add in 2 ICU players, one of whom was cared for by a green nurse and bam... total backup. i turned over the rooms i could, but it made for a painful night and a rough morning for my colleague who walked into new pts in nearly all of the rooms once the backlog let up. sorry dude

the issue of psych pts and lack of beds, delays, etc is a whole 'nother issue.... but also kills flow!

Back end delays are so common in EM that I think we try and triage them out of our minds. Otherwise the systemic disregard for patient care that occurs once we've decided a patient needs to be admitted would drive us crazy. At my current shop, it was taking roughly 6hours from the time a physician discharged a floor patient until that bed was ready for the next patient. Add to that the common tactic of a floor nurse refusing to take report for any number of reasons and it's cousin, inventing arbitrary vital sign or lab criteria that would exclude a patient from coming to the floor. My current favorite being the floor refusing patients admitted for hyperglycemia solely because of the glucose being too high.

There unfortunately aren't a lot of interventions for improving flow on the back-end at the level of an EP on shift, and the ones I can think of are done by most R3s already:

1) Keep your charge nurse informed of patients that are going to need an ICU bed (+/- keeping them in the loop on step-down pts depending on hospital characteristiscs). They can start the house supervisor working on getting a bed assigned without waiting for all the info it will take to actually get the patient admitted.

2) If you're short on ICU beds, take the extra time to tune up the borderline cases. This doesn't mean holding patients in the ED unnecessarily, but a lot of ICU admits are for people on titratable drips. If you know they're going to be downstairs indefinitely, a PO dose of cardizem can change a patient into a telemetry player in a couple of hours.

3) If you have plenty of beds available, prioritize getting your patients upstairs. Every shop I've worked at has had the EP write holding orders, so I have direct control over that step. If the intensivist is in-house and the ICU has a bed, don't wait for everything to come back prior to getting the patient upstairs. Despite what we think of our own ability to resuscitate patients, the ICU has much better nursing ratios and in a lot of hospitals the ED won't have pressure transduction/PCO2 monitoring etc. available. If you are relying on a doc to come down and write admit orders, if the patient is stable ask if you can write some basic orders to get them upstairs.

4) If you hear a nurse getting push back from a floor nurse about sending a patient up, call the nursing supervisor and ask why they are refusing the patient. I've found some non-specific but moderate aggression (pretty much the only time I use it) tends to work well for getting things moving during these calls.

 

[alreadylernd]

Great discussion. I find it ridiculous that sometimes it feels that we are the only people fighting to do more work (move patients upstairs to re-fill our beds in the ED downstairs to see more patients) while everyone else is fighting to do less.

 

[Apollyon]

3) If you have plenty of beds available, prioritize getting your patients upstairs. Every shop I've worked at has had the EP write holding orders, so I have direct control over that step. If the intensivist is in-house and the ICU has a bed, don't wait for everything to come back prior to getting the patient upstairs. Despite what we think of our own ability to resuscitate patients, the ICU has much better nursing ratios and in a lot of hospitals the ED won't have pressure transduction/PCO2 monitoring etc. available. If you are relying on a doc to come down and write admit orders, if the patient is stable ask if you can write some basic orders to get them upstairs.

This is a good one. And get to know your guys/women in the unit. If they know you're not a screw-up, they will let you send a patient up even if every T isn't crossed and I dotted. They have a better feel for their unit with the charge nurse up there, so it works together (that is, they know if they have a bed, vs having to ask the charge nurse). At my last gig, it was not rare that I told them I had a septic or a DKA, nothing else, and they told me "send them up!". I guess they were used to earlier docs in the ED that sucked, so they assume that they're all un-worked-up. Hey, whatever it takes!

 

[docB]

From an economics perspective this makes sense, you should be the rate limiting step. You are the most expensive server (borrowing the term from queue theory not the restaurant industry) in the department and should be being utilized at close to 100% capacity.

This is complex. In many cases (mine for example) the doctor is the cheapest person in the department from the hospital perspective. Since the hospital doesn't pay me anything I'm free as far as they're concerned. They want more staffing and more tasks to be done by the docs. If they could get me to empty the trash they would. For the hospital the most expensive person around is a nurse on overtime. So they will frequently send home nurses when we're short to avoid the OT.

Back end delays are so common in EM that I think we try and triage them out of our minds. Otherwise the systemic disregard for patient care that occurs once we've decided a patient needs to be admitted would drive us crazy. At my current shop, it was taking roughly 6hours from the time a physician discharged a floor patient until that bed was ready for the next patient. Add to that the common tactic of a floor nurse refusing to take report for any number of reasons and it's cousin, inventing arbitrary vital sign or lab criteria that would exclude a patient from coming to the floor. My current favorite being the floor refusing patients admitted for hyperglycemia solely because of the glucose being too high.

The trick to this is getting a house sup who will crack the whip and move people despite the delay tactics. To get that you have to have an administration that #1 recognizes flow as a problem and #2 backs up the sup when the floor nurses start to make allegations because they don't like her. Those situations seldom last for a long time.

 

[8654Marine]

The trick to this is getting a house sup who will crack the whip and move people despite the delay tactics. To get that you have to have an administration that #1 recognizes flow as a problem and #2 backs up the sup when the floor nurses start to make allegations because they don't like her. Those situations seldom last for a long time.

We solved this problem at one our hospitals.

The previous nursing supervisors were lazy and had no clue about the ED. The regularly balked about admissions and delay was routine. 2 hour delay just for "room cleaning" was common. There were instances of calling for a bed for admission. The sups would say to hold the patient for several hours until a bed meeting could be done. Then would formally deny/accept the admit. The irksome thing was that the ED got blamed for delays. Yeah, that went over well.

A cadre of ED nurses vied for the job when several spots opened up. Having the ED connection really shortened the admission time. Now, I'll call for an admission. Things get done on a timely basis.

This opened my eyes about getting involved in hospital functions.

 

[Arcan57]

This is complex. In many cases (mine for example) the doctor is the cheapest person in the department from the hospital perspective. Since the hospital doesn't pay me anything I'm free as far as they're concerned. They want more staffing and more tasks to be done by the docs. If they could get me to empty the trash they would. For the hospital the most expensive person around is a nurse on overtime. So they will frequently send home nurses when we're short to avoid the OT.

Excellent point. For the non-employee crowd, part of the equation is going to depend on admin's perception of the availability of additional MD resources. If there is a dearth of EPs in the area, what I said should still hold true. If it's an area where docs are plentiful or an area that has become attractive to the CMGs then you are absolutely correct. If you want to hold onto a contract, you need to make administration feel like there is almost nothing that can be optimized on your end to improve flow.

The trick to this is getting a house sup who will crack the whip and move people despite the delay tactics. To get that you have to have an administration that #1 recognizes flow as a problem and #2 backs up the sup when the floor nurses start to make allegations because they don't like her. Those situations seldom last for a long time.

It's odd that nursing is so quick to eat its young, but is also so vicious about protecting its worst practitioners.

We've just hired someone who's job description, as far as I can tell, is to kick floor nurse a-- and who reports only to the COO. The COO also just changed the structure so our versions of the house sups report directly to the COO. I expect much wailing and gnashing of teeth, and to have the floor to retaliate by writing-up every single patient who deteriorates within 24 hours of admission from the ED. [RANT] Of course that last part already happens. I am continually amazed that people are suprised when pts sick enough to be in the hospital get worse. If we knew they were going to be fine, we wouldn't have admitted them! [/END RANT]

 

[AmoryBlaine]

Excellent point. For the non-employee crowd, part of the equation is going to depend on admin's perception of the availability of additional MD resources. If there is a dearth of EPs in the area, what I said should still hold true. If it's an area where docs are plentiful or an area that has become attractive to the CMGs then you are absolutely correct. If you want to hold onto a contract, you need to make administration feel like there is almost nothing that can be optimized on your end to improve flow.




It's odd that nursing is so quick to eat its young, but is also so vicious about protecting its worst practitioners.

We've just hired someone who's job description, as far as I can tell, is to kick floor nurse a-- and who reports only to the COO. The COO also just changed the structure so our versions of the house sups report directly to the COO. I expect much wailing and gnashing of teeth, and to have the floor to retaliate by writing-up every single patient who deteriorates within 24 hours of admission from the ED. [RANT] Of course that last part already happens. I am continually amazed that people are suprised when pts sick enough to be in the hospital get worse. If we knew they were going to be fine, we wouldn't have admitted them! [/END RANT]

Many hospitals have an insane rule where an ICU transfer within 24 hours gets automatically quality review. Doesn't that mean that the hospital worked?

Nursing supervisors tend to be among the most incompetent, petty people in the whole hospital.

We physicians spend considerably too much time back-biting each other. And then we're supposed to be surprised that we can't organize on things like tort reform and reimbursement?

 

[docB]

Arcan is correct about the problems with batching and so on. My biggest problem by far is hold patients. So here's my question:

Several studies and a large amount of ACEP writing holds that many positive ends are achieved by holding patients on the floors rather than in the ED. How do we get hospital administrators to buy into this?

 

[xaelia]

How do we get hospital administrators to buy into this?

...how do you get floor nurses to buy into hallway holds? It's hard enough to get them to take report on the patients with beds.

As far as administrators go, in theory, money saved via risk attenuation should get their attention. But, I'm not an administrator, nor do I meet with them on a consistent basis.

 

[southerndoc]

Many hospitals have an insane rule where an ICU transfer within 24 hours gets automatically quality review. Doesn't that mean that the hospital worked?

We review all rapid responses within 24 hours of admission (whether it leads to an ICU upgrade or not). We also review all return visits within 72 hours or a return visit that leads to an admission within 7 days. A physician will review the chart to see if it's a quality issue, but in almost all circumstances, everything was fine when the patient was dispositioned.

Just because we review them doesn't mean anything is wrong.

Our health system CEO is a big believer in our door-to-door/door-to-floor metrics and has gotten hospitalists and consultants on-board. Our weekly flow meetings are very productive (we even have environmental services involved and their schedules have been changed to staff during the highest turnover times for floor beds).

 

[NinerNiner999]

This is a great thread, and frankly central to the survival of the contract EM group in the community.

Batching orders can be alleviated by two additional easy ways - standard order sets requiring one click, and clearly defined nursing protocols entered by the nurse during triage when there is a wait in the main ED, or at the bedside when the physician and nurse are in the room at the same time. This keeps the physician free to see multiple patients while the orders are being entered by protocol.

I try to explain to the nurses that every time I order a CBC I have "bought" them at least 45 minutes to finish their charting and work for that patient. This is due to the draw, send, process, and result time from the lab. Further, there will be an increased trend in point of care testing in the next few years. This will be driven by the core measure of troponin result time. I anticipate that eventually, all of our basic labs will be drawn and resulted at the bedside within 15 minutes.

Batching Admissions is another interesting point, in that it can either help or hinder efficiency. One or two of the docs in my group have a tendency to know that 4 or 5 patients are being admitted to the same doctor, and wait until everything is back before calling that doctor for admission. They think this is more efficient and it is - for them. It causes tremendous back logs and delays.

Efficient admission batching involves proactive notification of the admitting physician when you know someone is going to be admitted. I may have 5 patients that are going to the same hospitalist. Instead of waiting for all 5 to be resulted, I'll call as soon as the first one is, and present the other 4 patients at the same time, assuring the admitting physician that I'll notify them of any irregularities should they present themselves. This saves much time on the back end. This approach clearly relies on an understanding between the ED group an the admitting physicians that nothing will slip through the cracks.

Niner's rule of admissions: As soon as you know someone needs to be admitted, start the process. As soon as you can present the patient to the admitting doctor, do it. Without delay.

Bridge or Transition Orders are another highly effective way to smooth the admission transition to the floor. These are clearly best used when there is no inpatient EMR (which should be on its way out).

Discharges are another HUGE opportunity for efficiency. As has been mentioned above, don't work up anything that doesn't require a workup and document why you feel comfortable sending the patient home.

Niner's rule of discharges: As soon as you can send a patient home, send them home. Do not pass Go (but do collect $200.). I have no problem seeing toothaches in the triage booth and printing their discharge instructions.

Not every patient needs a bed.

If you can walk in with an extremity injury, you will likely be walking out. Have a seat. If you have a cough and a sore throat, you were able to drive yourself to the ED. Have a seat. Beds are a commodity in our department and not everyone has an acuity that requires a bed. This includes minor sutures as well. Reclining chairs can serve just the same function. Further, we know when a patient is going home, and we know what their rate limiting step is for that to happen. Why does a patient need to wait in a bed to get their x-ray results? Can we splint patients in a chair?

Niner's Rule of Bed Assignment: If you don't need a bed, you get a chair, and it may be in the waiting room after you have been seen.

Corollary to Niner's Rule of Bed Assignment: This practice must be implemented throughout the entire day - even when the main ED is empty - to prevent disruptions of flow.

Patient satisfaction is by far the biggest hindrance to what we do, but also the most sincere reminder of why we do what we do. Opponents to flow will say "If you don't give them a bed, they will complain." or "You need to give everyone a prescription for something to keep them happy." or "If they don't see a nurse in triage, they will feel like we are discounting them."

Niner's Rule of Patient Satisfaction: Patients come to the ED for one reason and one reason only - to see a doctor. Period. End of Story. Anything that gets in the way or slows this process will make them unhappy.

Physicians should be able to compassionately explain to their patients why they are safe to wait in a bed, why they don't want them to eat or drink, and why it is safe for them to go home and be seen as an outpatient. Make them comfortable, keep them informed, tell them what to expect, and treat them with respect.

Emergency Medicine is a great field and will likely serve as a model for the efficiency and functioning of hospitals nationwide as volume driven "quality" metrics continue to rule the world. The hospitals are beginning to realize this, and finally are being held accountable by CMS to decrease their length of stays as a quality indicator. This means if they don't fix their flow, they won't get paid. This also means that if we as doctors don't contribute value to the process, we won't have a job in the future.

 

[deleted109597]

This means if they don't fix their flow, they won't get paid. This also means that if we as doctors don't contribute value to the process, we won't have a job in the future.

Correct. But many cannot see past the trees of nurses to see the forest of an ED. As Arcan correctly noted, more docs doesn't help. Sometimes they press us to see more patients, to which I respond "I see everyone that gets put in my rack. I can't go out and see them in the lobby, and if you don't have a place to put them, I can't see them."
At one point my prior medical director sent out an email saying he wanted us to "volunteer" to spend time up front so we could help out. But without a nurse, we can't do anything. I cannot discharge patients (only because I don't have access in the system to do the things they "need" to be discharged from the hospital's viewpoint).
Another thing they wanted is for us to run out front if a patient threatens to leave and convince them to stay. This is mind boggling to me. That shop was ridiculous for acuity at 10-20% critical care time, and 40% admissions. I can't stop putting lines in people to go tell the dental pain they need to stay.
Also, the PAs/NPs would often balk at seeing too many 4s and 5s, and start triaging everything as a 3 so they wouldn't have to see them. And since they weren't comfortable at seeing vaginas, eyes, and children, all of those got to wait while our hundreds of chest pain/neuro symptom patients at ESI 2 got brought back instantly. Or as close to instantly as possible. I often get to discharge chest painers instantly after seeing them because they've already had their two sets prior to getting a room.
Volume is another think. We increased by over 40% in a year. No new rooms were built. Only change is now we have "vertical patients" which actually helps, if you can get the midlevels to see them. So now we have a group of people that used to get to be in the Fast Track area that still wait in the lobby. But we don't have enough midlevels to cover all the shifts we already have, much less more, and if I've seeing 2pph in back, I can't also see 3pph in Fast Track. It isn't possible.

 

[Arcan57]

Correct. But many cannot see past the trees of nurses to see the forest of an ED. As Arcan correctly noted, more docs doesn't help. Sometimes they press us to see more patients, to which I respond "I see everyone that gets put in my rack. I can't go out and see them in the lobby, and if you don't have a place to put them, I can't see them."
At one point my prior medical director sent out an email saying he wanted us to "volunteer" to spend time up front so we could help out. But without a nurse, we can't do anything. I cannot discharge patients (only because I don't have access in the system to do the things they "need" to be discharged from the hospital's viewpoint).
Another thing they wanted is for us to run out front if a patient threatens to leave and convince them to stay. This is mind boggling to me. That shop was ridiculous for acuity at 10-20% critical care time, and 40% admissions. I can't stop putting lines in people to go tell the dental pain they need to stay.
Also, the PAs/NPs would often balk at seeing too many 4s and 5s, and start triaging everything as a 3 so they wouldn't have to see them. And since they weren't comfortable at seeing vaginas, eyes, and children, all of those got to wait while our hundreds of chest pain/neuro symptom patients at ESI 2 got brought back instantly. Or as close to instantly as possible. I often get to discharge chest painers instantly after seeing them because they've already had their two sets prior to getting a room.
Volume is another think. We increased by over 40% in a year. No new rooms were built. Only change is now we have "vertical patients" which actually helps, if you can get the midlevels to see them. So now we have a group of people that used to get to be in the Fast Track area that still wait in the lobby. But we don't have enough midlevels to cover all the shifts we already have, much less more, and if I've seeing 2pph in back, I can't also see 3pph in Fast Track. It isn't possible.

Volume is awesome, because it actually f%^s with the bonuses of C-suite. When we see 130 pts/day, our metrics are almost godlike. We've been routinely seeing 160+/day for the last several months. I can't think of another business where more customers and more profit actually means smaller bonuses for the people in charge (this is in places that turn a profit off most encounters even d/c's).

Sometimes it seems like we are balancing this rotating disc of misery, and our only real choices are who we piss off. We're taught in residency not to mess with the nurses. We learn (usually painfully) that administration and the patients both can snap back if provoked. For those in leadership positions, we learn there is only so far you can push the providers before they 1) leave or 2) stop caring (the second being more difficult to handle). A lot of us have the instinct to short ourselves (I have the worst or second worst schedule every month and I make the damn thing), but most of the problems we're facing can't be managed unilaterally.

Ninja, it sounds like your shop did a random sampling of "things that EDs that are being successful do". Unfortunately, porting the methods from another shop without porting the culture usually fails. If your nurses feel like their leadership doesn't care and admin is constantly low-balling them or your midlevels aren't heavily incentivized on productivity then aggressively changing the front-end flow model will fail. The shops were this works have an almost marriage level of partnership between the EP director and ED nursing director, and were willing to let go of people who didn't get the message.

On the individual doc side, Don't get married to one method of work-flow. Conditions change (new EMR, new triage model, increasing volume), and things that used to be great may not work as well or may even be counterproductive. Change is a constant in our environment, and even since I've graduated the rate of change is accelerating. The satisfied EP is an adaptable EP.

Also, as Ninja said "Keep vertical patients vertical" Pt's that get back to a bed have all sorts of expectations for what will happen once there and this violates Niner's law of discharging patients ASAP.

 

[EvoDevo]

Great discussion. This is exactly the type of conversation that I've been wanting to see for so long.

Our shop's numbers have started going through the roof, so we're adding MLPs with a physician or MLP in triage. I'll be interested to try this model out.

I also support the comment made about culture. IMO, it always comes down to the ED/Hospital/Organization's culture. If I could run an ED with a bunch of Navy Corpsman and Marines.....*sigh*

 

[Arcan57]

Corollary to Niner's Rule of Bed Assignment: This practice must be implemented throughout the entire day - even when the main ED is empty - to prevent disruptions of flow.

QFT. Just like the person driving 50 in the far left lane has no idea how far traffic is backing up, most of the people responsible for disrupting flow never feel the effects.

Once flow is disrupted, recovering requires additional capacity to catch up. Unfortunately, that additional capacity has already being consumed by the afternoon/evening bolus of patients. Like in my batching example, the lack of timely discharge at 10am set up an ugly afternoon despite the fact that the ED was nowhere near capacity at the time the disruption occurred. This leads to a rule of staffing: When adding shifts due to increasing volume, make the additional shift start at least an hour prior to when your arrival rate explodes. If you traditionally go from 3 pts/hr at noon to 8 pts/hr at 1pm, having the provider start at 1pm is going to encourage batching. Have them come in at noon and ramp up. You'd be amazed what having extra resources at 7pm does for the waiting room at 11pm.

Also, while its been implied multiple times in this thread, let me state explicitly: Physician and nursing resources must be kept in synch for optimum flow. If you have a swing doc coming in, but no additional nursing resources then the swing doc is going to have consistently poor productivity. In situations that are RVU based, it will become an issue with scheduling since nobody want to do a swing shift that also pays poorly. Also, the nursing support also has to be commensurate with the physician resources. In general, adding an additional nurse for the arriving doctor is going to be insufficient support. Even in triage/intake situations, it usually will take a couple of nurses and a tech to keep up.

There are some things that flow out of staffing to patient volume that are unpleasant for us, the main one being that actually staffing to meet patient arrival curves generates some really unpleasant shift times. Nobody (well almost) wants to come into a night shift at 6p and stay til 3p but in most EDs that is a very productive shift. My last hospital was flirting with a 4p-2a shift. One of the answers to this is to shorten shift times and just stack a couple of 8hr swings, but in every hospital I've worked at the docs were concerned that they'd be working too many days per month.

 

[deleted109597]

My pediatric hospital has double coverage only 13 hours per day. Those hours are 1p-2a. I hate that shift.
4p-2a is similar. You never see your significant other (or kids) because they aren't home from school/work when you leave, and they're asleep when you get home. You're asleep when they leave again. If I work 3 of those in a row, I feel like I went on vacation without my family.

They made a "staffing pool" at our hospital system that calls in nurses to work when places aren't staffed. Of course they're more highly paid than our regular nurses, which facilitates embitterment. They are also usually floor nurses, so they aren't as good with working in an ED. For the life of me, I can't figure out what a town this size, with two 4 year nursing degree mills, and two 2 year nursing degree mills, does with all the thousands of nurses that graduate each year. Where do they all go, that we can never fully staff a place?

 

[BJJVP]

We have our dept split up into separate teams staffed by a physician in each team. Anybody have issues with certain doctors that don't discharge patients in a timely manner? In other words, they fill up their team and lock up their beds which backs up the new patients into either the waiting room or onto another team. I find this greatly impedes flow in the department, especially when the doctors do this as they are getting ready to go home. This sets up the on-coming physician for a bad shift instantly on his/her arrival.

 

[tkim]

22 bed community ed + 6 room FT. Just switched to a 2 pod system with one doc in each pod, a swing shift doc in the afternoon. MLP in FT.

The pod shifts are staggered so if/when the first pod is filled up or the other pod doc shows up, that other pod starts getting patients. Then the swing doc shows up at noon and helps out.

Only one pod has a 'pelvic room' so that kinda blows. There's a two hour overlap between the outgoing and oncoming pod docs, so for the docs starting out in the pod, you can throttle back and dispo patients and leave on time or early (!). For the later pod docs, not so much.

Too soon to tell if this will work.

 

[alreadylernd]

22 bed community ed + 6 room FT. Just switched to a 2 pod system with one doc in each pod, a swing shift doc in the afternoon. MLP in FT.

The pod shifts are staggered so if/when the first pod is filled up or the other pod doc shows up, that other pod starts getting patients. Then the swing doc shows up at noon and helps out.

Only one pod has a 'pelvic room' so that kinda blows. There's a two hour overlap between the outgoing and oncoming pod docs, so for the docs starting out in the pod, you can throttle back and dispo patients and leave on time or early (!). For the later pod docs, not so much.

Too soon to tell if this will work.

My shop has the pod system - I'm not a huge fan. I find the charge nurse (who triages all ambulance traffic and determines when patients come back from the waiting room), puts all the patients he/she doesn't like in the far away pod (the screaming MR patient, chronic pain etc.) to be someone else's problem. The closer pod gets all the chest pains, trauma etc (ie: rapid dispos). Then, with the pod system and this system of assigning beds, a faster doc in one pod who turns over beds more quickly continually gets re-loaded and pounded with patients, while the doc who doesn't see or dispo anyone, fills up his pod, and then sits on everyone (we don't have a strong productivity bonus). You have patients waiting to be seen in one pod who have been waiting hours, but in the other, everyone is seen.

The way around this (and how it worked where I was a resident) was that every other ambulance and every other walk in was assigned to each pod.

 

[Arcan57]

We have our dept split up into separate teams staffed by a physician in each team. Anybody have issues with certain doctors that don't discharge patients in a timely manner? In other words, they fill up their team and lock up their beds which backs up the new patients into either the waiting room or onto another team. I find this greatly impedes flow in the department, especially when the doctors do this as they are getting ready to go home. This sets up the on-coming physician for a bad shift instantly on his/her arrival.

While we are a little more "noble" than your average doc, we still obey basic economic principles. If your shop isn't basing a substantial (at least 30%?) of your compensation on RVUs then #$@ like this happens. At my old shop, we switched our twice yearly profit sharing from : your hours/everyone's hours to your RVUs/everyone's RVUs. Everyone in the group picked up at least a couple of extra RVUs per hour in productivity, and my income went up about $50k/yr with the switch. Our base income was strictly hourly, so it made no sense to have initially based the incentive on number of hours worked.

I think RVUs are a more fair way to distribute the money than straight "eat what you kill", although there needs to be a night differential if your place dies during the overnights. Any other compensation scheme reeks of communism and has most of the negative effects associated with collectivism. [/end channeling GV]

 

[southerndoc]

My shop has the pod system - I'm not a huge fan. I find the charge nurse (who triages all ambulance traffic and determines when patients come back from the waiting room), puts all the patients he/she doesn't like in the far away pod (the screaming MR patient, chronic pain etc.) to be someone else's problem. The closer pod gets all the chest pains, trauma etc (ie: rapid dispos). Then, with the pod system and this system of assigning beds, a faster doc in one pod who turns over beds more quickly continually gets re-loaded and pounded with patients, while the doc who doesn't see or dispo anyone, fills up his pod, and then sits on everyone (we don't have a strong productivity bonus). You have patients waiting to be seen in one pod who have been waiting hours, but in the other, everyone is seen.

The way around this (and how it worked where I was a resident) was that every other ambulance and every other walk in was assigned to each pod.

We have a pod type system, and I turn over patients very quickly in my pod. I could care less if the other doc isn't turning over patients quickly as long as there aren't a ton of patients in the waiting room. I'm paid on a 100% productivity model. I show up and see no patients, I get paid nothing. See lots of patients, get paid more. I do get aggravated when slower docs gridlock their pod while tons of patients pile up in the waiting room.

 

[The White Coat Investor]

If I could run an ED with a bunch of Navy Corpsman and Marines.....*sigh*

Been there, done that. Not fun. No incentive to move the meat or treat anyone nicely.

 

[StevieStud]

Been there, done that. Not fun. No incentive to move the meat or treat anyone nicely.

Your right, but when the stuff hits the fan the GI will go above and beyond to do what needs to be done. Compare the gung-ho attitude with Mrs. 220 lbs, Union Specialist who requires 3 donut, 7 cigarette, 9 coffee and a full 1 hour lunch break or she gets cranky and calls her delegate.

 

[StevieStud]

This leads to a rule of staffing: When adding shifts due to increasing volume, make the additional shift start at least an hour prior to when your arrival rate explodes. If you traditionally go from 3 pts/hr at noon to 8 pts/hr at 1pm, having the provider start at 1pm is going to encourage batching. Have them come in at noon and ramp up. You'd be amazed what having extra resources at 7pm does for the waiting room at 11pm.

BINGO.

Also learn the shift changes/issues with every ancilliary department from housekeeping to radiology because their staffing issues can become your staffing issues.

 

[Arcan57]

BINGO.

Also learn the shift changes/issues with every ancilliary department from housekeeping to radiology because their staffing issues can become your staffing issues.

Crap, I almost forgot about this. So our ED was having serious problems with flow and PG, so one of our attempts to right this a fact-finding mission to an ED that had ridiculous turn-around times (<2 hrs for admitted pts) with stupid high PG scores. It also was pretty high volume, and located in what is truly BFE (Tupelo, MS). So the entire leadership team from our ED is talking with their nursing director and we're all trying to figure out how the hell they're doing it. And she says,
"If we came across a department that disrupted flow, we took it over and fixed it."

It's horribly labor intensive for the management team, but along the way they acquired essentially every ancillary department that had a hand in ED flow. Housekeeping wasn't keeping rooms clean, they took it over. They couldn't get patients upstairs so they built the command center that controlled the entire hospital's flow and then staffed it with their people.

This isn't feasible (or even desirable) everywhere, but the principal is universal: Everyone that has a hand in flow has to have skin in the game. If lab and radiology delays are destroying your world, they need to feel your pain. At the minimum, there needs to be an ED service line meeting where labs, rads, RT, business office, and +/- housekeeping are sitting down with the ED leadership and the hospital's COO and CMO and explaining their metrics. "The lab takes too long" is unfocused whining. "Why was your turn-around times for BMPs last month 75 minutes and what are you going to do to get it down to 45 minutes?" is an actionable item and not a question that lab like to keep being asked in front of their bosses.

 

[southerndoc]

This isn't feasible (or even desirable) everywhere, but the principal is universal: Everyone that has a hand in flow has to have skin in the game. If lab and radiology delays are destroying your world, they need to feel your pain. At the minimum, there needs to be an ED service line meeting where labs, rads, RT, business office, and +/- housekeeping are sitting down with the ED leadership and the hospital's COO and CMO and explaining their metrics. "The lab takes too long" is unfocused whining. "Why was your turn-around times for BMPs last month 75 minutes and what are you going to do to get it down to 45 minutes?" is an actionable item and not a question that lab like to keep being asked in front of their bosses.

We have exactly these types of numbers reviewed during our monthly ED meetings where the hospital administrator, VPMA, etc. are present. Lab, radiology, etc. must answer for delays.

We have weekly flow meetings that involve nurse managers of floors, ICU's, etc. plus ancillary staff (registration, environmental services, etc.) to hash out disruptions to flow.

Although we have a long way to go, I must say that it's helped tremendously getting our metrics better.