I think I have the fastest turnaround and disposition times in my new group (surprisingly). If not the fastest then definitely the top 3. Everybody is different and in some ways all the recommendations in the world won't replace experiencing the process at your own pace and learning your own individual and unique ways to improve efficiency. That being said, here's what I do:
1) I'm one of the few that doesn't use any handwritten notes at all. I remember patients by room number and associate everything by memory, visualizing the room and even the patient's face sometimes, odd peculiarities, etc.. That way I'm not constantly scribbling on paper and I "run the board" in my head constantly as I see patients so it doesn't get lost out of short term memory. I've done this since residency but seem to be in a minority as most docs I've worked with carry around a folded up piece of paper and are constantly scribbling.
2) I see patients and then put in orders and do a brief HPI/ROS/PE. If you have a computer in the room with the patient or have WOW's, take advantage of them. If there's a computer in the room, I always use it to log in with my badge and put in orders and will even type as much of the HPI as possible while I'm talking to the patient. It makes you spend more time in the room and patients perceive that you've spent more time with them than you actually have... Improves patient satisfaction. I'll even talk out loud telling the pt what orders I'm putting in, they seem to get a kick out of that. If you have a medical dictation system, load the mobile app on your phone and using the clipboard function I will briefly dictate the HPI either in or outside the pt's room. If I don't put in orders immediately, I enter them every 2-3 patients, never more than that. Preferably, I enter them after each encounter as that maximizes time efficiency. Remember...the nurses, techs, ancillary staff can't do anything until you place orders unless they have standing order sets and the clock is ticking as you're seeing other people.
3) As soon as you see the pt, you really should have already formulated a disposition plan and have a very good sense as to whether they are staying or going home and identify each and every hurdle that needs to be overcome to establish the disposition. This takes time, patience, practice and pattern recognition and will come with time. This should be a critical skill that's fairly well developed by the time you finish residency. The old EM adage "Sick or NOT sick?!"
4) Don't over order. Every single order you place should be necessary to rule out emergent pathology and ultimate successfully disposition the patient. Refrain from ordering superfluous testing that really doesn't change management. Every time you order something...ask yourself "Does this change my management?" If not, then you probably shouldn't be ordering it. Do you really need that UA in the penile discharge pt? Do you really need chemistries on that healthy 23yo with anxiety presenting for palpitations with a normal EKG and VS? Do you really need a CXR on that costochondritis with "chest pain"? Probably not. Don't play PCP. You're an EM physician and the ER is not the place for some things. Learning how to re-set patient's expectations while maximizing their experience in the ED and giving them a positive perception of the encounter is an art and takes a long time to master. (I had a pt with weight loss yesterday brought in by hysterical family convinced that he has cancer...and he might. Rather than do a full body CT scan with a million labs like they requested, I re-set their expectations, educated them on why an outpatient work up with a PCP was the absolute best way to proceed and then called up a PCP that I knew could see them in a few days and got them an appt). We avoided an almost guaranteed 2-3 hour work up and they were very grateful for all my assistance even though I was basically telling them that it's not my job to work them up for occult malignancy. This kind of stuff takes practice but is important to learn.
5) Every 2-3 patients, run the board in your head or at the computer and identify hurdles preventing you from disposition. I.E. "I'm waiting on labs for 16...if normal, will dc home", "need CT A/P for 10, rule out diverticulitis, if no concerning path, will dc home", "need EKG and cardiac enzymes on syncope guy in 46...hx of CHF, sounded suspicious..needs obs tele to r/o arrhythmia...once back will consult hospitalist for admission", "18 is taking forever to get labs drawn...difficult stick? Check with nurse while I'm nearby that nursing station seeing 16..."etc..
6) Your last 1.5 hours, you should become more selective in the patients you pick up unless signing out patients is not an issue. Only pick up patients you can easily and quickly disposition. Do not pick up belly pain, pelvic pain, dizziness, pregnant pt's, etc.. during this time or you'll regret it. Identify any remaining hurdles such as US, CT, etc.. and address them. I will identify obstacles at 1.5 hours and if some of these tests are still pending at 1 hour before the end of my shift, I will call the tech and ask where the pt is on their queue or ask if they can expedite the study. If there are labs still pending, I will get up and assist the nurse with getting the labs, etc. Finish your charts during this time period. Nobody should have 2 hours of charting to do after their shift. How this has become an accepted norm, I have no idea. I have a colleague who spends an entire day off catching up on charts. Don't be that person.
7) Don't sit on lacs or I&Ds. Just knock them out as soon as possible. These patients often languish on the board due to procrastination and kill throughput. Once the procedure is done they are quick dispositions.
8) Don't be afraid of the waiting room. If I have no patients to pick up due to bed holds or gridlocked ED, I will get up, grab a WOW and go out into the waiting room and see patients there. I will pull them into a cubby, registration room, anywhere. I'll get a history, do a quick cursory physical and drop in orders. I'll do this anytime the board is locked and flow is at a stand still preventing patients from getting rooms. I'll also do this near the end of my shift. If the pt is complex, I just dump in screening orders for the next doc on shift. If it's something easy that I can disposition quickly, I start the note and discharge them after tests are complete.
Just relax. Efficiency comes with time. Nobody is great at it starting out as a PGY2 but you should be pretty savvy by the end of residency and will pick up additional polish on the first few years post graduation. The earlier you can reinforce good habits and get rid of the bad habits, the better you will be in the long run.
