how do you assign patients in your ED?

Panacea Financial Contract Review
This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
1

12R34Y

Full Member
15+ Year Member
20+ Year Member
Joined
Apr 6, 2000
Messages
1,678
Reaction score
6
Members don't see this ad.
Howdy,

I've got a question for all of you in various EM residencies.

How do you divide up/assign/distribute the patient load in the ED amongst residents?

Our system is incredibly frustrating and I'm looking for different models.

any thoughts or just telling me about your system would be helpful in taking it to our faculty in trying to improve our current system.

thanks!

later
 
Well, briefly...

Our ED is divided into two sides, A and B. The resuscitation bays are not included in either. Side A is run by a senior resident, with help from other residents that may be working on side A (often rotators that report to the seniors/attendings). Side B is run by a second year with an intern on the team that reports directly to the attendings. The charts are placed in a rack between the two sides, alternating sides with each patient. No acuity preference is given for which side the patients are placed. If you see a chart, and you have time, you pick it up. If there are a lot of them, you pick up faster. In the beginning of intern year they will watch to make sure you don't bite off more than you can chew, and will sometimes throw you a bone if it is educational. Otherwise, you pick up what you can manage with little "cherry picking"...next one to be seen is yours if you happen to be passing the rack when it comes in. There is no pressure to see many patients as an intern, they prefer quality to volume. Also, as interns, we are allowed to pick up high acuity, we just get help from the attendings/residents as needed. Any procedures on your patient are yours (of course, upper level residents throw us procedures all the time).

Resuscitations: These go directly to the resuscitation rooms. A tweeter goes off (a horribly loud, annoying tweeter) The team that is "up" goes to the resusc bay. The resusc teams alternate just as the charts do. There is a cross covering shift that will also be in on this rotation at times for relief, but it rotates between senior (A), 2nd year (B), and "power shift" (picks up a chart from either side) if present. The intern is required to attend all resuscitations and trauma alerts and manages the airway, regardles if it is an A, B, or Power resuscitation. The 2nd year and seniors each run their respective resuscitations with the attending on their team.

There are a few intricacies I am sure I am missing, but this is the gist of it. It is simple, fair, and it evenly divides the patients and traumas. Of course, if your side is full, there is little recourse other than to work faster...they do not redistribute charts because the nurses would be incensed. The attendings roam around and pitch in a great deal when it is busy.

Some find it a little chaotic. It was actually a draw to the program for me as I get a chance to see higher acuity patients during my intern year without getting the "leftovers" from seniors. I am never left unsupervised with a very sick patient, yet, I am allowed to manage these patients with my attending and learn from them.

Let me know if this is clear and I'll try to clarify when I've had a bit of rest.


ditch
 
Our residents work on teams. Each team consists of a resident, nurse, and tech. The resident knows which nurse to go to for meds/IV's and so forth for their patients, and the nurse knows which resident to go to.

The ED is divided into two areas (north and south), with each area having a critical care area. Patients are assigned to teams on an alternating fashion. During peak times, there is usually an overlapping resident/PA that will pick up patients from both teams in the "central" area (but never in the critical care area).

North and south sides each have two central teams (green and purple) and one critical care team (blue). The critical care team differs from other teams by having two or three nurses instead of the usual one nurse.

Attending coverage is pretty good. Each side has an attending (except from 2a-7a on the south side), and the critical care areas have dedicated attendings during peak times (11a-8p).

As an intern, I initially thought the volume was too much. Now as a fourth year I'm glad I had the volume. It taught me to be incredibly efficient with my time, and as a fourth year I can now see a good number of patients per hour.
 
A light goes on on the electronic greaseboard. If you're not too busy you pick it up. If you're too busy it waits or someone else picks it up.
 
OK. this is precisely the thing that I believe my program is scared of....if it is up to the individual resident what is the incentive to pick up a chart if it is a "free for all"? Is there anyway from preventing or monitoring if resident A is a gunner and seeing all of the patients and resident B just carries 2 at a time and rarely picks up new charts when the "light" goes off?

Here is a synposis of our system:

We have 3 EM residents on at all times (always at least one third year and the other two can be either 3rd or 2nd years). we have 3 shifts, with 3 EM residents on each shift. (7a-3p, 3p-11p, 11p-7a).

there are 3 boxes in one location in the enormous ED. Each of the 3 EM residents has their own box with their name tag on it. So, charts gets placed in the box and a clip gets moved to the next box and so the next chart goes on the box with the clip on it and it gets moved to the next box etc....So, there is no sorting of acuity/type of patient/location of patient in ED. It is totally random. If the clip is on your box you get the next patient chart. Fair enough.

In the ED there are EM interns, rotating interns, medical students as well, but the ED interns do not have their own box. Only the 2nd and 3rd years have their own box. The EM interns and medical students pull from the 3rd year box (usually only 1 third year at a time, along with 2 2nd years, but sometimes 2 third years and one second year).

If the intern or medical student checks out to the attending then essentially the 3rd year just gets a chart reduction because there are two people pulling from the one box. occasionally the intern checks out the EM 3rd year on as well.

The problem is the physical layout of our ER as well as the problem of ED boarding of inpatients.

We are a busy, inner city ED and frequently have a waiting room with 20-50 deep (like many EM residencies). We unfortunately, like others , are often holding anywhere from 10-30 inpatients for 1-3 days at a time, essentially jugger-knotting our ED flow as we only have 56 beds.

So, a typical shift I see 16 patients in my 7.5 hours of shift time.

3 new residents come on shift and we may have 3 charts in each of our boxes, all in various locations and different acuities.

All of my patients may be in different pods that are quite a walk between each. This is horribly inefficient. You don't see the same nurses all shift because you are always wandering about to different pods.

Also, when a code or trauma comes in and you respond your box continues to fill. so, when you are done with your 30-40 minutes or (more) of resuscitation you come out to a box that is full of charts.

We have thought about having a "pod" system where we would put one resident in each pod, but the problem with that is that one pod may be totally full of admits the whole shift and that resident would therefore do nothing or maybe only have one room in a pod that isn't full of admits so they'd be nice a slow working up their complaint one at a time, while the other residents may have an empty pod and get 6 patients all at once.

So, we're fighting the physical plant, holding on inpatients, and being punished for staying with a sick patient because your box is constantly filling up.

I know all EM residencies are plagued with their inefficiencies, but I hear about others with teams that involve a nurse/tech etc... and I immediately fall in love because I would love something like that.

Any more ideas?

thanks!


later
 
Both of our EDs have a critical care (includes resus + high-risk CP, SOB, etc) and a non-critical care area.
CC: always one attending and one R2 or R3 (one ED has 2 upper-levels from 3p-MN). There are occasional rotators/students/EM interns. You are primarily responsible for this area (15-20 beds) but can cross over to the "other side" when it's not busy. Rarely, a non-CC R2/R3 will come over to help out if there is a rush of really sick pts. If you move a pt from non-CC to CC (mistriage, etc), you follow them.

non-CC: obviously the larger of the two areas. 1-3 attendings depending on time of day. 1-2 R2/R3 and a hodgepodge of students/rotators/EM interns. Typically, the upper levels are expected to "carry" this side, but there isn't usually much pressure to really move the meat. As above, when CC isn't busy, that resident will help out, mostly because they want something to do.

With this setup, you're geographically near the pts, nurses, etc, so communication isn't too hard. As for cherry-picking, it's not usually a problem, and our computerized pt board automatically lists pt by triage level and then by length of stay. Most of the time you pick up whoever is on top of the list. The exception would be picking up (hopefully) quick pts at the end of your shift to help move things or seeing multiple patients that are right next to each other in order to increase efficiency.
 
We have two residents on at a time. Typically the upper-level resident sees all of the critical care and trauma patients.

Unfortunately we have yet to work out an adequate system of patient assignment, and typically one resident is a gunner and sees most of the patients while the "slower" one takes their sweet time.

Without physically handing charts to the interns, we have no method in place to make sure they are seeing enough.

Hopefully this will change. I too would also like to see some solutions that others are using to address this.
 
We have three 'team centers.' Sounds like your 'pod' idea. Each one has a faculty doc, a resident in charge of just that unit, and a few interns and students. Rotating residents can take the place of, or reinforce, the EM resident in any team center. RNs and techs are scheduled to one team or another for a half- or a whole shift. (Note, this is a center with volume of like 80k/yr, so I don't know how well it would scale down.)

A = highest acuity (all beds have telemetry monitors). A cases tend to need more resources and monitoring, and A patients tend to be sicker.

B = lower acuity, plus Ortho, plus a Pelvic and a Procto room. A couple of the B rooms have monitors. One room has a door that shuts, and a monitor, and lots of floor space, so that's the procedure room. B cases are either really fast, or really labor-intensive (reductions, I&Ds, pelvics).

C = Peds and (to a lesser extent) Fast Track. C cases generally move faster, although there is a fair bit of waiting around for labs.

The resusc/ trauma/ burn bays are seperate, but the Team B R-3 = pit boss, with faculty oversight in the room. Team A's R-3 will take the second case, if there is one. Team C's takes the third, if there is one. R-2s do airways, central lines, etc, with R-1 backup. DRE tends to be a R-1 thing.

To prevent unfair distribution of workload, the Charge RN and Team A faculty decide what changes, if any, to make based on volume. And since all residents rotate from team to team, it all works out.

The key difference between this "pod" thing and your present system is that because it's divided up by team, each R-3 has specific duties, and R-3s never compete with one another for the same cases. There's no way to slack; if your area is covered and the other guy's is swamped, then the next heavy rock will go into YOUR wheelbarrow.
 
I've never seen one of these elaborate patient assignment systems in use so I can't comment on that. I can tell you that's not how it works in the real world so I question the utility of training people that way.

The "free for all" system previously described works well for the most part. Certainly some residents see more than others and sometime you do have an internal groan when you see that you're going to be on with the slow guy but generally over 3-4 years of training people get up to a comparable level. There is a lot of upper level resident and faculty feedback to the slower folk that tends to get them to improve. The nice thing is that every waiting patient is seen by the next available physician - no one waits because any particular "team" is overloaded.
 
One important point is that an "elaborate" system would almost certainly be doomed to failure; as Seaglass says, there are much more low-tech (and ultimately reliable) ways to identify who's slow and who's fast. The best a system can do, IMHO, is to spread things out in a consistent way, and make sure that specific people have specific spheres of responsibility. Break up a complex system into a number of smaller, relatively simpler ones.
 
Oh, definitely. And the whole department knows who's who... even as a tech, I could tell if my day would involve a lot of bed-stripping and IV care, or a lot of waiting.

There seems to be a sweet spot where things don't move so quickly there's no time to breathe, but things aren't so slow that the board is filling up to a ludicrous degree. One sign that you have a good assignment system is that it works equally well at different levels of volume.
 
Our ED is divided into 12-15 bed modules (in addition to the resus room, the fast-track, prisoner module, and the observation unit). All modules are essentially the same except that two (or three depending on time of day) of the modules respond to the medical codes going directly to the resuscitation room and one of the modules respond to the trauma codes (alerts/activations... whatever you call them at your institution). Patients are distributed to each module on a rotating basis as they come in so there is no cherry-picking between modules. Medical codes going directly to resus are also rotated amongst the modules.

EM-2s and EM-3s run their own modules. An EM-1 may be assigned to their own module (working with an attending directly) or an EM-3 module but I don't get the impression that the seniors are cherry-picking. One of us is supposed to establish contact with a patient within a half hour of their arrival to the module unless we're in a code situation or two come in at about the same time, then obviously see what's going on with the potentially sicker patient. Rotating patient distribution amongst the modules helps alleviate this problem most of the time. A key component of this set-up to alleviate confusion is that after patients are triaged and assigned to a module, they are brought directly back to the module and not back out to the waiting room. If anything, I have found that the seniors tend to keep us (the interns) away from the non-educational cases.

I think our system works well and I'm satisfied with it. Interns can be seeing high-acuity cases and at the same time are not expected to move the module. If the EM-3 is seeing more high-acuity cases than I am it's only because they are able to see more patients than I can get to. Seniors generally run the codes but I've been given opportunities to do it as well to get my feet wet before 2nd-year. And if things are going okay in the module, interns should be going to each code.
 
southerndoc said:
Honestly, you're going to deal with slow and fast people throughout your career. Even attendings grown when they are working with other attendings who are slow.
Click to expand...

That is absolutely true.
 
12R34Y said:
We have thought about having a "pod" system where we would put one resident in each pod, but the problem with that is that one pod may be totally full of admits the whole shift and that resident would therefore do nothing or maybe only have one room in a pod that isn't full of admits so they'd be nice a slow working up their complaint one at a time, while the other residents may have an empty pod and get 6 patients all at once.

So, we're fighting the physical plant, holding on inpatients, and being punished for staying with a sick patient because your box is constantly filling up.

I know all EM residencies are plagued with their inefficiencies, but I hear about others with teams that involve a nurse/tech etc... and I immediately fall in love because I would love something like that.

Any more ideas?

thanks!


later
Click to expand...

In addition to my post above. I think the pod/module system works great if your department/hospital can find a way to not board patients for insane periods of time. We are also a high-volume, inner-city ED (saw 94,000+ pt visits last year, essentially adults since kids go next door) so it is possible. Our patients that are admitted/waiting for bed or on "cruise control" gets moved to our observation unit (with it's own nurses) so that they're not taking up space and resources away from the module. Each of our modules have their own nurses. Attendings staff 1-2 modules at a time. The nurses have to work as a team within the module as well so that there's no "that's not my patient" mentality. Basically, you always know who to go to during your shift. Sure, there have been times (rarely) when a particular module is full of patients and another module doesn't have as much going on. It shouldn't be a problem if patients are being moved away from the module (to the observation unit or somewhere else in the hospital) and patients are still being seen within an acceptable period of time. Eventually, everything evens out again. Part of our solution is that during our peak hours, there is also another module that opens up for ten hours. There's also a mentality here that each module is really an "ER" within the ED so what happens to a particular "ER" that shift is the responsibility of the team assigned to that "ER" versus the mentality that all modules should always have equal patient loads. Besides, as an intern I've floated to an adjacent module to help out with procedures when our module was relatively slow-going. We also have an EM-2 each month on our ED-critical care rotation that floats around for about 10 hours each day that acts as a extra set of eyes and hands helping out as requested.

Also an electronic tracking system (our ED is pretty much paperless) helps to do away with the boxes and having to walk back and forth for the charts. Plus, everyone can see who's taking care of whom and you'll know if the senior is cherry-picking the charts.
 
awdc said:
In addition to my post above. I think the pod/module system works great if your department/hospital can find a way to not board patients for insane periods of time. We are also a high-volume, inner-city ED (saw 94,000+ pt visits last year, essentially adults since kids go next door) so it is possible. Our patients that are admitted/waiting for bed or on "cruise control" gets moved to our observation unit (with it's own nurses) so that they're not taking up space and resources away from the module. Each of our modules have their own nurses. Attendings staff 1-2 modules at a time. The nurses have to work as a team within the module as well so that there's no "that's not my patient" mentality. Basically, you always know who to go to during your shift. Sure, there have been times (rarely) when a particular module is full of patients and another module doesn't have as much going on. It shouldn't be a problem if patients are being moved away from the module (to the observation unit or somewhere else in the hospital) and patients are still being seen within an acceptable period of time. Eventually, everything evens out again. Part of our solution is that during our peak hours, there is also another module that opens up for ten hours. There's also a mentality here that each module is really an "ER" within the ED so what happens to a particular "ER" that shift is the responsibility of the team assigned to that "ER" versus the mentality that all modules should always have equal patient loads. Besides, as an intern I've floated to an adjacent module to help out with procedures when our module was relatively slow-going. We also have an EM-2 each month on our ED-critical care rotation that floats around for about 10 hours each day that acts as a extra set of eyes and hands helping out as requested.

Also an electronic tracking system (our ED is pretty much paperless) helps to do away with the boxes and having to walk back and forth for the charts. Plus, everyone can see who's taking care of whom and you'll know if the senior is cherry-picking the charts.
Click to expand...


Thanks for all of the thoughts and responses.👍

Our biggest problem is the boarding issue. We have 56 beds and on any given day (especially during this flu season) we could be holding 15-30 admits for 1-3 days. Frequently, patients are admitted and spend their whole inpatient stay in the ED and are discharged from the ED 1-3 days later. It is a problem I know is not only plaguing my ED, but still a huge mess when we try and do a "pod" system.

The pod system in theory would be great for us, but on any given shift or time you might see 7 chest pains in a row and admit them all to tele and then your pod would be full and BAM......full pod for 1-2 days. We just don't have enought inpatient beds and our turnover is so slow.

Many days during this winter flu stuff we'll have 50-60 in the waiting room from 1000-midnight and during your shift you'll see 5-6 patients because we've got nowhere to put people. That's even using hallway stuff at times.

There is no way the paperless, electronic thing will happen during my next 15 months of residency, but for those who have it I'm sure it is nice.

I'm just looking for ideas as to how to stop being so inefficient with tromping back and forth through a gajillion square foot ED to one place to grab my charts and have my patients being located all over the place.

thanks again for the help.

later
 
12R34Y said:
Our biggest problem is the boarding issue.

The pod system in theory would be great for us, but on any given shift or time you might see 7 chest pains in a row and admit them all to tele and then your pod would be full and BAM......full pod for 1-2 days. We just don't have enought inpatient beds and our turnover is so slow.
Click to expand...
It was before my time here but my understanding is that lots of things had to happen in order for our system to start working. It wasn't something the EM Dept was able to fix on its own because it's really a hospital-wide system problem. If there are people at your place serious about changing things, it needs serious backing from the hospital bosses and probably serious financial investment. Sorry, I don't know what else to tell you that would be of practical use for your next shift in dealing with this problem and with the chart issue.
 
We have teams. They are 'colored' because it makes the screen pretty (not based on acuity or anythign else) Green, Red, Blue, etc. Patients are literally assigned : green, red, blue, green, red, blue, green, red, blue. No difference in teams. Nurses and residents are assigned to each team. There are timers so we know the minutes someone walked in the door, triaged, sent back, etc. There is NO cherrypicking.
 
I'd like to hear from senior residents and/or faculty as to how they "motivate" residents who cherry pick or are lazy. We all have them in our programs.
 
Surprisingly, we don't have them in our program. We occasionally have someone but it becomes apparant REALLY fast. (we have a computerized system so you see who is seeing who, how often, how sick, etc). There is a HUGE (almost to much) internal pressure generated by the residents regarding seeing patients. Our volume does not allow residents to be lazy. It is dealt with almost immediately. And often by the residents themselves, which is perhaps more effective than anything else.

In essence, peer pressure.
 
It was also peer pressure for us.
 
Our ED is about 60 beds (haven't really counted). We divide up into pods with residents of different levels:

1. Resus bays (6)--All unstable patients and high acuity trauma. Run by the R3 with Attending A. All procedures done by the R2 (comes over from C pod)

2. Minor care (9 or 10 beds). Staffed by attending C with a resident of any level and a PA.

3. A pod: ~13 beds. Split between a PA during the day or any level resident at night AND the R3 (who also runs all resus stuff while having like 6 pod beds)

4. B pod ~ 18 beds: Attending B, R4 directly supervising 2-3 residents who are either EM interns, off service R1s or R2s. One box, all charts go into it the 1st half of the year. Your incentive is to "hit the box" so you don't look like a slacker (we have a tracking system so everyone sees which patients are being seen by who). You are not forced to "move the meat", but you shouldn't have 2 people when the other intern has 8! Generally the EM R1s just pick up slack for the off service residents. Second half of the year it is usually only 2 interns working. EM interns will "split the pod" so they each have their own box, if off service is present usually keep just one box that everyone takes from (and the EM intern, attending, or R4 helps the off service out if needed). When I have 8 patients and the off service resident has 3 I now wait until there are 2 charts in the box, pick them both up, chose mine (the sickest, most complicated) and give the other to the off service....otherwise I just keep picking one up at a time and they never pick one up!!!!

5. C pod ~8 beds: Attending B, solo R2 has the whole pod, plus all resus bay procedures, plus helicopter flight doc.

Patient acuity:
--all super sick to resus bay
--otherwise acuity split between Pods A, B, C based on bed availability. Pods still manage to get patients on a regular basis that end up in the ICU, so the acuity is not sheltered for EM interns. EM R1s keep their own procedures, otherwise R2 is the procedure doc. Towards the end of the year R2s/3s toss R1s lots of procedures.
--We really don't board many patient's so getting pods filled up with boarders isn't an issue unless all hell breaks loose and then everyone is a bit jammed up with boarders.
 
GeneralVeers said:
I'd like to hear from senior residents and/or faculty as to how they "motivate" residents who cherry pick or are lazy. We all have them in our programs.
Click to expand...

Our system for the most part doesn't allow cherry picking because in resus, A pod, C pod if they are in your room you see them. In B pod with one box and multiple interns our R4s encourage us EM interns to cherry pick the sick or quick patients from the off service (and will frequently hand us the chart before it hits the box)! That way the patients get better/faster care. Now, a few examples so we don't sound like mean EM people.....we are not leaving all the crap like pelvics and stuff to off service. If a chest pain patient that sounds like they have real disease, or HTN emergency or something like that they would rather us see that an take a 2 min history before activating cath lab, rather than have the medicine resident take the 20 minute history! Same thing with regulars who we know well. It is easy to get sucked in to some of those people if you don't know them already. I hope this isn't coming out too bad because I swear it isn't as bad as it probably sounds when you read this. The cherry picking is done to help the off service out, not to take all the good patients or procedures, or anything like that. They still end up with sick patients too.
 
Community EM in several hospitals:

University Medical Center - divided up into several areas, with single coverage in two, staggered coverage in another and 16 hours of double cover in the "intermediate" area. It's next chart off the rack.

Community hospital #1: One rack, and variability in skills/confidence/credentialing for the fast track person (optimal is another EM person). A lot of cherry picking (and, interestingly, there is one EM guy that only wants patients that don't need a workup, and one FM guy that works two Sundays a month, and is a MACHINE - takes the next chart off the rack, and churns them out like butter).

Community hospital #2: Just recently went to one rack, but patients are triaged to rooms rather efficiently (tending to be fast track spilling over into the higher acuity areas, not the other way). No cherry picking, unless the higher acuity side is slow and the EM doc can get the really quick ones out of the rack, leaving the balance for the fast track doc (like the lacs).

Freestanding ED: Virtually all low acuity, so it's next chart off the rack.
 
You must log in or register to reply here.

Similar threads

W
Dogs in the ED
Replies
15
Views
891
WorkNoteEmergency
W
Elbrus
  • Poll Poll
Are physical therapists working with you in the ED?
Replies
18
Views
1K
old_boy
old_boy
Jabbed
  • Poll Poll
How much of your income are you investing?
2
Replies
58
Views
4K
Janders
J
Angry Birds
How can we protect our patients against ICE?
2 3
Replies
119
Views
7K
Old_Mil
Old_Mil
miamidoc101
  • Question Question
How much do yall work?
2 3
Replies
144
Views
7K
doitalldoc
D
Top