How can I go faster? Advice?

[suckstobeme]

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Hey Guys- I'm a PGY2 in a 2-4 so, I've bascially just started my residency, but even a few months in, i've noticed i'm slow as hell. I really want to see more patients, but I never really end up seeing a bunch. Honestly, I think the biggest bottleneck is charting- I'm always scared I'll not document something important on the chart and i'll get a lawsuit, and the attending will get sued and be like "why the heck didnt you document such and such?"

any advice on how to move faster- charting related or not, I could really use your advice? tips, tricks, etc?

 

[southerndoc]

As a PGY-2, you should concentrate on LEARNING, not speed. Yes, you should improve efficiency, but that shouldn't be your main concentration.

 

[doctawife]

As a PGY-2, you should concentrate on LEARNING, not speed. Yes, you should improve efficiency, but that shouldn't be your main concentration.

It's the attending's and senior resident's job to monitor flow. Anyone more junior should focus on learning. ED flow is something you will have to learn... eventually. But not yet.

 

[kungfufishing]

That you will become more efficient is a given. Keep reading and learning so you actually get better as you get faster.

 

[GeneralVeers]

That you will become more efficient is a given. Keep reading and learning so you actually get better as you get faster.

As a PGY-2 in a 2-4 program you are basically an intern and should focus on learning. That being said, you should see a steady increase in the number of patients you see as the year progresses. In most places if you finish your intern year seeing 1 or more patients per hour then you are doing well. In your second year you should be able to move 2 patients per hour.

 

[JackBauERfan]

As a PGY-2 in a 2-4 program you are basically an intern and should focus on learning. That being said, you should see a steady increase in the number of patients you see as the year progresses. In most places if you finish your intern year seeing 1 or more patients per hour then you are doing well. In your second year you should be able to move 2 patients per hour.

I think in residency, and maybe even afterwards, it makes a big difference how efficient your ER in general is towards how many patients per hour you can see. I mean in general if you are comparing yourself in the same place, just see more patients per hour would be a good estimate, but I know there are some places I'd see WAAAAY more patients per hour, and i'm sure there are places where my patients per hour would drop.

I can even see the difference between which nurses are working and which attendings are working on certain days as to how it changes my patients per hour.

and definitely i agree I think as a first year you should just work on getting good at the basics, then work on efficiency a lot more in second and third years; otherwise you're gonna be a third year and not know stuff haha.

 

[JackBauERfan]

oh and back to your original question on how to be faster...

I'm still kinda young, but an important thing is knowing how long its going to take to get things done in your particular ER.
Where I'm at, i try to see an abdominal pain, then a drunk guy, then something that will be taken care of fast, maybe even discharged. The abdominal pain would need labs so after seeing I would get that started, then seeing the drunk/psych case might or might not need labs; while those are cooking you can discharge the easy one, then rinse repeat; after a few cycles you will have decisions to make on the first few you got labs on.

if you have a mixed ER then you can throw in people who you know will need xrays; we have a surgical er part, sometimes i will see an abdominal pain there, get labs started; then go see the patient who needs an xray (like ankle/knee, traumatic leg/hand pain), while this one is in xray I'll go see the abcess that just needs an I&D, by the time you are done with that, the xray should be back and labs should be coming back for the abdominal pain; then rinse repeat again.

of course all this is mixed in with the very critical patients that come in so sometimes might not go soooo smooth, but you will get better at handling distractions.

i think in ER thats one of the hardest things to do is get better at handling the distractions; you'll be putting in orders for something and then bam the surgical consult wants to talk to you, in the middle of that one of your patients is screaming your name, by that time you've fogetting you were putting in some orders haah.

so as a diagram instead of going like this

patient 1 --------
patient 2 0000000 -----------
patient 3 000000000000000000 -------------

you should try to go like this

patient 1------------
patient 2 00-------------
patient 3 000--------------

and i think after awhiel you'll get better at picking what type of patients you can handle after you get your timing down.

hmm a few more tips i guess include what type of ancillary staff you have, and at a place thats good you may have a few folks that dont work and at a place that is bad you may have a few folks that work hard, once you get to know who is who, you'll know when things will get done faster; so you'll be able to delegate more stuff

but like everyons saying, in the end, just learn the basics during the first year haha.

 

[southerndoc]

i think in ER thats one of the hardest things to do is get better at handling the distractions; you'll be putting in orders for something and then bam the surgical consult wants to talk to you, in the middle of that one of your patients is screaming your name, by that time you've fogetting you were putting in some orders haah.

This is something you really have to master. I've been listening to presentations from junior residents and had a nurse come up to me, interrupt the junior resident, and ask questions.

I think this has been studied before. In a typical hour, I get interrupted countless times. If you aren't good at multi-tasking, or if you have a bad short-term memory, you'll be in trouble and should make every effort to work on it. Nothing is worse than putting in orders in a computer, getting sidetracked by a phone call, and stop putting in orders while you're on the phone. You have to multi-task, so you should be able to listen to the conversation and put in orders at the same time.

 

[GeneralVeers]

In my prior residency (grungy county hospital with no support) I could see 1-1.5 patients an hour as a PGY-2. This was because I was pushing patients to CT, giving my own IV contrast, my own consent forms etc.

At my current residency all of those ancillary tasks are done for me, and I can see 2 patients an hour without breaking a sweat.

Most people should aim for approximately 2 patients per hour, as the range in most jobs is typically between 1.6 to 2.5 per hour depending on the hospital.

 

[WilcoWorld]

JBF makes some good suggestions. And I would agree with everyone here that your 1st year in the ED is not when you should expect to be fast. However, it needs to happen some time. Here's another tip: Bundling tasks.

One of our fastest attendings told me it's less about multi-tasking than it is about completing tasks, then moving on. So if I am going to see a laceration, I'll bring the lido, suture kit, irrigation materials & our portable computer in the room. I take my H&P, numb them up, then chart on the ptient, and put in their discharge instructions - once that's done they're numb, so I sew 'em up & am done with them. When I'm going to see an elderly abdominal pain & it's clear they'll need t be admitted, I'll fill out the CT form, lab orders, nursing orders & admission form, all while I'm standing in their room answering questions.

Also, try to avoid having to go back to a room for anything but explaining results. Each trip back takes 2-5 minutes. As little as 3 trips/shift can decrease your patients by 1/shift.

 

[southerndoc]

Charting while talking to a patient is also a way to increase efficiency. Printing up discharge instructions during downtime in anticipation of discharges is an absolute must! Nothing can get you overwhelmed than sitting around during a slow period and doing nothing, but then having a nurse pester you about discharging a patient you knew 2 hours ago was going home, but now you don't have time to print discharge instructions because of so many patients coming through the door.

As Wilco said, you do need to plan to do everything while in a room. You should rarely need to go back into an exam room to get more history or do more of an exam. Yes, it will happen from time to time. However, if you have a patient with new onset A-fib, there is no reason to delay the guiaic exam. Do it while you're examining the patient the first time so you don't need to do it before you start heparinization. (The need for this is subject to debate. However, it is a standard of care in many hospitals.)

 

[JackBauERfan]

Charting while talking to a patient is also a way to increase efficiency. Printing up discharge instructions during downtime in anticipation of discharges is an absolute must! Nothing can get you overwhelmed than sitting around during a slow period and doing nothing, but then having a nurse pester you about discharging a patient you knew 2 hours ago was going home, but now you don't have time to print discharge instructions because of so many patients coming through the door.

As Wilco said, you do need to plan to do everything while in a room. You should rarely need to go back into an exam room to get more history or do more of an exam. Yes, it will happen from time to time. However, if you have a patient with new onset A-fib, there is no reason to delay the guiaic exam. Do it while you're examining the patient the first time so you don't need to do it before you start heparinization. (The need for this is subject to debate. However, it is a standard of care in many hospitals.)

Thats another thing i forgot to mention. Getting the follow up scheduled and discharge stuff ready way before you have to if you ar just sitting there waiting for something. Most of the time you know they are getting discharged and even if they end up not being, you can just rip it p and throw it away. But normally where I am it takes anywhere from 30 sec to 5 minutes for the tech to schedule certain appts, so usually i give them that before i go do the suture or abscess or whatever it is.

But every hospital is different so you have to get fast in your own first haha.

 

[bartleby]

Try to avoid unnecessary linearity of ordering and workups. There is a false economy in ordering tests in dribs and drabs, because you wind up decreasing your efficiency when you need to put in orders again and the patient needs repeat trips to radiology, etc. If you have an 80 year old who may have pneumonia, you should should send labs off at the same time, because if the xray is positive, they will undoubtedly be admitted. That way, all the information you need to arrange disposition, etc will come back at nearly the same time.