How long should a first year ER stay after the shift ends...

[rckbnd]

I have a question for ER residents.

How long does one stay after your shift ends? Specifically, what's normal for someone that has been doing ER for one year (a PGY2 who's now at the end of his year.)

As you advance through your practice -- residency and then attending -- do you find yourself being able to get out any faster?

Any tips on getting out of the ER faster and more efficiently?

Thanks. Much appreciated.

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[southerndoc]

I'm not an EM resident (graduated last year), but I have experienced residency.

We signed out pretty quickly as residents. At shift change, you signed out whatever was pending to the next person and only hung around to either sign out a patient to the admitting team (to prevent a double signout), do any procedures that aren't done routinely (chest tube), or to document. I rarely stayed more than 30 minutes after a shift.

As an attending in a fee-for-service group, I rarely sign out patients. The person who makes the disposition is the one who gets paid. I routinely stay 1-3 hours after a shift to finish things up.

 

[rckbnd]

The time you quoted for residents -- about 30 minutes -- does that vary from program to program?

 

[Hard24Get]

The time you quoted for residents -- about 30 minutes -- does that vary from program to program?

How come you're an attending and you don't know this? Anyway, it varies depending on how good of a job the program does with shift overlap, as well as the psychological makeup of the program and its residents

 

[Arcan57]

I have a question for ER residents.

How long does one stay after your shift ends? Specifically, what's normal for someone that has been doing ER for one year (a PGY2 who's now at the end of his year.)

As you advance through your practice -- residency and then attending -- do you find yourself being able to get out any faster?

Any tips on getting out of the ER faster and more efficiently?

Thanks. Much appreciated.

Never have more than 3 undictated charts on your dispositioned patients. During the last 2 hrs (depending on lab turnaround time) dictate the H&P/medical decision making right after you walk out of the room. If it's a gyn patient, get on the nurse/tech/chaperone to set up the pelvic because you can't sign those out. When your shift does end, if you have multiple charts left to dictate, find someplace outside of the main work area to do them. That way you won't be tempted/compelled to follow up on the labs that come back 30 minutes after your shift. Which then avoids waiting another half hour for the admitting doc to call back.

 

[BADMD]

I'm going to take a different view.

An intern is there to learn. Thus an intern (and other residents) should stay until the work is done. Procedures should rarely be signed out. Labs and basic xrays should be mostly back and clear disposition plans made. While residents have to learn to move the meat, they also have to how the results of the labs/imaging interplay with their clinical impression. I'm not saying that a resident should hang back 2+ for oral contrast to traverse the gut, but waiting for an xray to rule a foreign body and then closing the laceration is appropriate.

There are few things worse then trying to admit a patient that is a sign out. One of those few things are having to disposition a signed out patient who has mildly abnormal labs. Frankly, if my colleague signs out an undispositioned patient to me that doesn't even have basic labs and xrays back, then why did they see the patient? I'm doing the decision making and will likely have to go back and repeat most of what they did.

If the physician is in the ED when the results of studies come back, it should be the responsibility of that physician to finish that patient. This is good practice and good patient care. The doctor that saw the patient is in the best position to make decisions. Hand offs, especially handoff with incomplete information, lead to errors. Not to mention it prevents people from dumping their work on others.

Though the ED is shift work, it is not factory work. We are not clock punchers.

 

[beyond all hope]

As residents, certain truisms apply for signout.

1) Make sure you have a plan, the simpler the better
eg. admit after labs, consult after CT, etc. If the dispo is uncertain, I prefer to give guidelines, eg. admit if K >6, DC if troponins neg, etc. Nebulous signouts: 'just check labs' are annoying. Make sure the attending is on board with your plan.

2) make sure the case is wrapped up as much as possible, eg never sign out rectals, pelvics, lumbar punctures or other necessary procedures

3) spend the last hour wrapping stuff up rather than picking up new patients. For me, I'd prefer to have several patients waiting to be seen than really bad signout. Bad signout can really burn you.

4) try not to spend >1 hour at signout (I was the king of long signouts, I would regularly spend 2-3 hrs after a shift wrapping work up bc I didn't trust anyone else)

I've worked at places where signout was five minutes on the board, other places where you walk around and see every patient and then wrap up. As an attending, signout rarely takes more than 20-30 minutes unless you're in a group that doesn't sign out, in which case you're probably making way more money than me....🙂

 

[southerndoc]

I'm going to take a different view.

An intern is there to learn. Thus an intern (and other residents) should stay until the work is done. Procedures should rarely be signed out. Labs and basic xrays should be mostly back and clear disposition plans made. While residents have to learn to move the meat, they also have to how the results of the labs/imaging interplay with their clinical impression. I'm not saying that a resident should hang back 2+ for oral contrast to traverse the gut, but waiting for an xray to rule a foreign body and then closing the laceration is appropriate.

There are few things worse then trying to admit a patient that is a sign out. One of those few things are having to disposition a signed out patient who has mildly abnormal labs. Frankly, if my colleague signs out an undispositioned patient to me that doesn't even have basic labs and xrays back, then why did they see the patient? I'm doing the decision making and will likely have to go back and repeat most of what they did.

If the physician is in the ED when the results of studies come back, it should be the responsibility of that physician to finish that patient. This is good practice and good patient care. The doctor that saw the patient is in the best position to make decisions. Hand offs, especially handoff with incomplete information, lead to errors. Not to mention it prevents people from dumping their work on others.

Though the ED is shift work, it is not factory work. We are not clock punchers.

Your philosophy works great for 8 hour shifts, but not for 12 hr shifts which are at the limit of what the RRC allows. In fact, residents aren't supposed to stay 1 minute over after a 12 hr shift.

Residents can learn just as much from following up on an x-ray that was signed out to them as they can from following up on an x-ray of their own patient.

 

[Arcan57]

If the physician is in the ED when the results of studies come back, it should be the responsibility of that physician to finish that patient. This is good practice and good patient care. The doctor that saw the patient is in the best position to make decisions. Hand offs, especially handoff with incomplete information, lead to errors. Not to mention it prevents people from dumping their work on others.

Though the ED is shift work, it is not factory work. We are not clock punchers.

That philosophy works quite well if you only take jobs where you never sign out patients. Signing out safely is a skill that requires practice, just like carrying a heavy patient load. Giving good sign-outs, receiving good sign-outs, and dealing with bad sign-outs are going to be a daily occurence for most EPs. If you don't develop these skills in residency, the learning curve as an attending can be brutal and expensive.

 

[BADMD]

Your philosophy works great for 8 hour shifts, but not for 12 hr shifts which are at the limit of what the RRC allows. In fact, residents aren't supposed to stay 1 minute over after a 12 hr shift.

Yes. Stick adherence to RRC guidelines, for 12 hour shifts, creates a situation where residents aren't even allowed to sign out. I guess all those programs are in violation of work hours or they don't have their residents sign out. Frankly, I think they should be abandoned. What ends up happening is that for the last hour, only easy cases or serious emergencies are seen.

Residents can learn just as much from following up on an x-ray that was signed out to them as they can from following up on an x-ray of their own patient.

I strongly disagree. Medicine is a process. From history to disposition. Reading xrays on a patient you haven't seen goes from "I think that patient has X because of Q,R,P and S and I see Y on the film" to "My colleague thinks the patient has X and I see Y on the film." Much of the clinical context, decision making and all physical findings are lost. Sure, in straight forward cases it isn't an issue. Medicine isn't about learning the straight forward presentations. Leaving unfinished business does teach that one doesn't need to own one's patients.

 

[Seaglass]

My personal opinion is that sign-out is a necessary evil and an art as previously mentioned and should be practiced. I don't think interns should stay more than an hour after a shift - they are already working a lot of shifts and deserve their time off. I am fully in favor of slowing down in that last hour so that sign out is neat and efficient. I also agree that you should not be signing out procedures or invasive exams. On the flip side - you should not have to stay more than 15 minutes for charting - if you are you need to learn how to chart more efficiently. Personally I think you should chart each visit after you see the patient and then you just have to fill in the details as the case wraps up. Now certainly there are times where you have to see 2-3 patients in a row but usually that leaves you with a little breathing room to chart. If you can't learn this you are in for trouble as an attending - I had one partner who was trying to get paid for the hour and a half he spent after every shift charting (the answer was no).

 

[kungfufishing]

As residents, certain truisms apply for signout.

1) Make sure you have a plan, the simpler the better
eg. admit after labs, consult after CT, etc. If the dispo is uncertain, I prefer to give guidelines, eg. admit if K >6, DC if troponins neg, etc. Nebulous signouts: 'just check labs' are annoying. Make sure the attending is on board with your plan.

2) make sure the case is wrapped up as much as possible, eg never sign out rectals, pelvics, lumbar punctures or other necessary procedures

3) spend the last hour wrapping stuff up rather than picking up new patients. For me, I'd prefer to have several patients waiting to be seen than really bad signout. Bad signout can really burn you.

4) try not to spend >1 hour at signout (I was the king of long signouts, I would regularly spend 2-3 hrs after a shift wrapping work up bc I didn't trust anyone else)

I've worked at places where signout was five minutes on the board, other places where you walk around and see every patient and then wrap up. As an attending, signout rarely takes more than 20-30 minutes unless you're in a group that doesn't sign out, in which case you're probably making way more money than me....🙂

Another sign out point and one that will help you get faster is to evaluate which patients really are at "branch" points in their care - if the lab or image is truly a dealmaker/breaker in their disposition, by all means have everything else done so that the accepting doc can perform dispo A or B. However, if this is a 70 year old obese lady with diabetes, copd, chf, etc. and is going to be admitted any way you slice it, those consultant residents have both computers and fingers. Taking a sign out just so you can give the medicine resident a laundry list of lab is annoying.

Have all the procedures done and the physical exam done. If there are consultants to be called, call them.

My point is to try and set your oncoming doc up with one essential thing to do. If it is really important, he won't forget it, and if it is just one thing, it isnt much burden. Sort of like the idea that a good EP does everything so the consulting specialist has only to show up and do what he does best.

Now that I'm out in the real world, I probably sign something out once a month. Usually an image that will define dispo.

 

[Hard24Get]

My personal opinion is that sign-out is a necessary evil and an art as previously mentioned and should be practiced. I don't think interns should stay more than an hour after a shift - they are already working a lot of shifts and deserve their time off. I am fully in favor of slowing down in that last hour so that sign out is neat and efficient. I also agree that you should not be signing out procedures or invasive exams. On the flip side - you should not have to stay more than 15 minutes for charting - if you are you need to learn how to chart more efficiently. Personally I think you should chart each visit after you see the patient and then you just have to fill in the details as the case wraps up. Now certainly there are times where you have to see 2-3 patients in a row but usually that leaves you with a little breathing room to chart. If you can't learn this you are in for trouble as an attending - I had one partner who was trying to get paid for the hour and a half he spent after every shift charting (the answer was no).

Wow, Seaglass, I am loving seeing your little one grow up. He is getting cuter and cuter by the minute!

Frankly, I think they should be abandoned. What ends up happening is that for the last hour, only easy cases or serious emergencies are seen.

Actually, my class just voted on a schedule with 1hr overlap for our R2 shifts, expanding our hours from 8hrs to 9-10. This allows for those at the end of their shift to finish up while the fresh people pick up new ones. I really pushed for this because I felt it was best for patient care. I think it is possible to have it both ways.

 

[Norman]

I have a question for ER residents.

How long does one stay after your shift ends? Specifically, what's normal for someone that has been doing ER for one year (a PGY2 who's now at the end of his year.)

As you advance through your practice -- residency and then attending -- do you find yourself being able to get out any faster?

Any tips on getting out of the ER faster and more efficiently?

Thanks. Much appreciated.

Stop seeing patients the last hour of your shift and dispo everyone. I tried to get out at shift change.

 

[Jeff698]

Stop seeing patients the last hour of your shift and dispo everyone. I tried to get out at shift change.

More difficult to do with single coverage, even for patients that triage doesn't think are sick. I just hate it when patients stare at me with that "aren't you gonna come see me" look. I can just feel the group's PG scores dropping.

Take care,
Jeff

 

[Norman]

More difficult to do with single coverage, even for patients that triage doesn't think are sick. I just hate it when patients stare at me with that "aren't you gonna come see me" look. I can just feel the group's PG scores dropping.

Take care,
Jeff

It's much easier if you work at a place that has staggered shifts and isn't single coverage. That's something to look at when applying for a job.

 

[EM_Rebuilder]

I think 'getting out at shift change' become a art that we get better at with time. We works 12s, we arrive about 10 mins early to a shift pretty much as a courtest to the off-going folks. For the most part, my charts will be complete, with some labs/scans pending for signouts. Generally in our field, it is 'improper' to sign out a procedure, unless some other test MUST be returned before the procedure can be done.


I usually am out a few mins before shift change or at most 10-15 after. Occasionally you get screwed on the trauma or super sick medical patient that arrives 15-20 til. Although, thats what we are there for, it might hold you up an hour between gettng orders, chart, and then going back and tidying up your other patients...but even then maybe an hour at most?

Some of my class mates spend an hour or so with charts, or even finish charts at home. I think that becomes an efficency thing. I saw the most patients in my class for the year totals, and at any one time during the day, all my charts are 'caught up'. Other folks do not even open a chart until 6-8 hours into it.

Just find your niche and what works....

 

[beriberi]

In my group, we only take new patients for 7 hours and have 2 hours to clean up. We sign out virtually no one. The new doc comes in 1 hour before our shift is up (on a 7a-5p shift, the next shift is 4p-1a). During the last hour before the next doc come (3-4, for example), I say 'hi' to most of the non-critical patients who are roomed.

"I'm Dr. Beriberi. I understand you are having quite a bit of abdominal pain? You have had this before? Well -- Dr. Kwashikor is going to be your doctor and he'll be here in about 20minutes. I don't want you to have to wait that long for things to get started. So I am going to ask Nurse Scurvy to place an IV, send off some lab work and get you some pain and nausea medication. Can you go give us a urine sample?"

Good P-G, very little interruption in our workflow.

 

[DoctorMedic]

i like that, takes a few minutes, and get some stuff done, standard labs/tests you would run for anyone w abd pain i'm imagining. then the oncoming has most stuff done and can order anything else as pt condition/lab results require.

 

[NeuroSync]

It is a violation of residency work hour rules in EM to work a minute longer than 12 hours. If this happens, the residency could lose accreditation. That is one of the difficulties in having 12s -- how do you do sign-out and possibly have teaching rounds as well? It's not possible. Some people like 12s because they get more days off, but again...it likely causes lots of work hour violations (for EM).

 

[Jeff698]

It doesn't specifically address this question, but it might soon. An intern is blogging his EM residency from day one. May be insightful for some...

http://www.journeytomedicine.com/EM_Blog/EM_Blog.htmlhttp://www.journeytomedicine.com/EM_Blog/EM_Blog.html

Since you've posted this in two forums now, I'm curious.

That intern wouldn't happen to be you, would it?

Take care,
Jeff

 

[kungfufishing]

Crazy talk Jeff. Crazy talk.

 

[goonie890]

Staying after a shifts is talked about in this emergency medicine blog being written by a current intern...

http://www.journeytomedicine.com/EM_Blog/EM_Blog.html

 

[Doctor Bob]

I'm still learning when to stop seeing patients. I usually won't pick up a patient in the last 30 minutes of my shift unless it's something that looks simple... but I keep getting charts that I think are simple (dental pain, etc), and when I walk in the room they always tack on crushing chest pain, or shortness of breath to whatever they actually came in for.

 

[GeneralVeers]

Might as well learn to wrap up your patients.

Now that I get paid for each patient I see (in theory) I have incentive to stay and finish their disposition.

That being said, I put limits on it. In general if I know it's going to take longer than 30 minutes (excluding procedures) to dispo a patient I will probably sign them out.

During the last hour of my shift I divide patients into 3 categories:

1. Quickie patients that I can see and dispo in 5 minutes (sore throat, tooth pain, etc.)

2. Critically ill patients who have to be seen. Can be signed out if necessary.

3. Moderate acuity. I will usually start a workup, like labs, CT but leave the patient as a "to be seen" for the next guy. That was it's fair to your patient who at least is getting something done during the time before the next doctor shows up, but you're not sticking your colleague with a sign-out.