How Many Anvils Can You Juggle?

[southerndoc]

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I thought this was an excellent article. The guy's sarcasm is what makes the article interesting, but there is truth in his words.

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How Many Anvils Can You Juggle?

Guest Editorial

ACEP News
March 2006

By David f. Baehren, MD

The triage nurses and I have a love-hate relationship.

I love to give them the business when I am working, and they hate me when I do it.

Really, it's not all that bad, but I do sometimes take issue with them about some of the decisions that flow my way--always downhill.

Possibly in your practice you have had similar experiences. If you have not seized the opportunity to take the triage nurse to task--or better yet the charge nurse--you should try it.

The next time they send you a stubbed toe that could have gone to the fast track but didn't because the diastolic blood pressure was 95, call them on it. Say it right out loud. You'll feel better.

It's best to try this late in your shift, because you will enjoy every drunk, hypochondriac, and drug seeker for the remainder of your day. Be prepared, because these special thanks can flow into the next day or two as well.

I'll say right now that the triage nurse has a tough job, and I'm glad I don't do it. It takes a seasoned and skilled nurse to do it well. That said, I'm typing away.

Whoever thought up the "30-minute guarantee" unknowingly sent what little joy there was in triage to the same black hole that consumes manners, common sense, and lost socks.

Now every nurse manager in the universe is under the gun from the CEO to "do something about waiting times--or else."

The "or else" implies either unemployment or the institution of their local version of the 30-minute guarantee. Patients could be guaranteed free movie tickets, free gasoline, or 10% off a colonoscopy if the doctor fails to meet the 30-minute goal.

Of course, everyone knows that patients wait because the doctor is not working fast enough. The solution is to give the doctor more patients to see simultaneously.

Never mind that one-third of the department is full of admitted patients, and the rest are waiting for the lab to get around to calling to say that the dreaded hemolysis happened in the tubes of blood sent 2 hours prior. Arrrgh! And the CEO couldn't find ... never mind.

So, the immediate solution to this thorny problem seems to be to shoehorn as many patients as possible into the hallway.

For a thousand years, I will maintain that patients are relatively happy in their blissful ignorance in the lobby. Move them back to the patient care area where they can be ignored in person, and they really start to get annoyed.

Their ringside seat also makes them instant experts on what the nurses and doctors should be doing with their time. Apparently, talking to consultants on the telephone and reviewing a chart while seated are not acceptable activities. God help you if you eat a handful of nuts to prevent starvation while your lunch from 2 days before grows mold in the refrigerator in the break room.

I believe that patients with 3 months of constipation are best served by a comfortable seat in the lobby, a magazine that was printed since their last haircut, and a tall glass of Metamucil. Sometimes that is the best you can do until a bed (in an actual room with a door) becomes available. (My apologies to those who still practice in places that have treatment areas without four walls and a door.)

As others have commented, I never took the boards for hallway medicine. And there is never a group of Boy Scouts to stand with their backs to the patient in a semicircle, fingers in their ears, when you need them. This would be nice, because it would solve the problem of taking a sexual history and doing a rectal examination.

So, you try to get things started on the 20-year-old ambulance rider who has been vomiting at home for an entire 3 hours. You do this while you should be trying to discharge the patient with the ankle sprain who could have waited in the lobby to go to the fast track when it opened. But no, this patient would be seen "faster" if he came right back to see you.

Of course, he would already be home by now watching ESPN if he "waited" for the fast track. Instead he's watching ESPN on the TV in his exam room and eating a sandwich while the 20 year-old vomits in a pink bucket in the hall.

Did you ever have one of those days when you kept the lobby empty and had no more than eight patients at any one time? I remember a day in 1992 ... it was great. Everything clicks on days like that, and you can see a lot of people. Everyone is happy, and the patients say "thank you" and write nice letters about you. The nurses smile and think you are smart.

There is a reason for that. Any circus juggler will tell you that there are a finite number of balls that can be put in the air simultaneously. Three are easy; things get hairy with more than 10. Problems and mistakes happen when someone tosses in an anvil (patient with acute coronary syndrome and ventricular arrhythmias), and all the other balls drop to the ground. A few roll under the Pyxis.

Everyone has a threshold where productivity falls as the number of active patients goes up. I think mine is 8.6, give or take a tenth. I could make you a graph, but that kind of thing makes my brain hurt (as my third grader likes to say). I've tried to communicate this thought. Possibly you could do better.

What sense does it make to pile more nonacute patients into the treatment area when the physician says (in a pleasant and reasoned manner) that it will slow him or her down?

Putting these patients there may make the triage nurse feel better, improve the "door-to-doctor" time, and keep the CEO off the nurse manager's back, but it doesn't help the patient. And it doesn't help the doctor.

But this antiquated idea is not often spoken of these days. Emergency patient flow is complicated. Few understand it, and those who don't will continue to try to "improve" it by driving you to distraction unless there is reasoned discussion with someone who makes a lot more money than the poor triage nurse.

They had a discussion like this about bloodletting once.

Dr. Baehren is the author of "Roads to Hilton Head Island" and practices emergency medicine in Toledo, Ohio.

 

[doctawife]

Ralph Feigin et al could use a look at that article. We have an incredibly busy ED with routine 4 hour waits (6+ if it's winter and RSV has hit). We also have medical hallway beds A-G and respiratory hallway beds A-E.

So good for patient care, so good.

 

[Hawkeye Kid]

I just read this article this afternoon while watching my NCAA brackets go to crap. I agree--the sarcasm makes it easy reading and it sheds an interesting light on the kind of EM that most of us will practice.

 

[southerndoc]

Unfortunately it will probably never reach the persons who would most benefit from reading it: the hospital CEO's.

 

[bulgethetwine]

Unfortunately it will probably never reach the persons who would most benefit from reading it: the hospital CEO's.

I'm at a major academic center that is currently at critical level with regard to the lack of nursing, lack of beds, and slow admissions. But you know what? Everytime we get a "VIP' patient, they have no trouble surfing through triage, being seen, and sent to their bed in a timely manner. No wonder things never change!

Next time a CEO's relative or big-wig him/her-self visits the ED, they should wait like everyone else, have the same delays in being admitted, and suffer the indignity of 24 hours + in the waiting room waiting for a bed.

Let's see some letters get written and some action occur THEN

 

[JiffyGriff]

An ACNP can do wonders for moving non-acute patients through the system and out of everyone's way.

 

[southerndoc]

bulgethetwine, I have a feeling that if a charge nurse made a hospital CEO or big wig wait in the waiting room, he/she as well as the physician would be answering for this.

 

[EctopicFetus]

bulgethetwine, I have a feeling that if a charge nurse made a hospital CEO or big wig wait in the waiting room, he/she as well as the physician would be answering for this.

I think the only waiting the charge nurse would be doing is in the unemployment line. It is obvious that there is a double standard but it has nothing to do with insurance and money.

 

[Apollyon]

An ACNP can do wonders for moving non-acute patients through the system and out of everyone's way.

Not a "diss" on NP's - not at all - but our ACNP (n=1) in a world of PA's turns "Fast Track" into "Track".

 

[Apollyon]

I'm at a major academic center that is currently at critical level with regard to the lack of nursing, lack of beds, and slow admissions. But you know what? Everytime we get a "VIP' patient, they have no trouble surfing through triage, being seen, and sent to their bed in a timely manner. No wonder things never change!

Next time a CEO's relative or big-wig him/her-self visits the ED, they should wait like everyone else, have the same delays in being admitted, and suffer the indignity of 24 hours + in the waiting room waiting for a bed.

Let's see some letters get written and some action occur THEN

VIP medicine kills. Period.

What drives me nuts is that putting people in our evaluation unit and having them be "VIP" and "attending only" implies that we have different levels of care, when I strive to treat every patient - annoying drug-seeking homeless, rich businessman, university bigwig professor, housewife, ED-abusing 20something - the same.

 

[McDoctor]

Great article. I think its sad that our hospitals strive to deliver medicine in the same fashion that Dominoes delivers pizza. These thirty minute guarantees more than ever foster an environment that encourages misuse of ER's by the public. All of this excessive customer service definitely instills an unhealthy sense of entitlement to people presenting to the ED with clearly non-emergent health issues. I don't know how you EM docs do it.

 

[ERMudPhud]

VIP medicine kills. Period.

What drives me nuts is that putting people in our evaluation unit and having them be "VIP" and "attending only" implies that we have different levels of care, when I strive to treat every patient - annoying drug-seeking homeless, rich businessman, university bigwig professor, housewife, ED-abusing 20something - the same.

I worked at two hospitals in NYC that had whole VIP floors. They were fine for the housewife with "status migranus" or somebody in for an elective hernia repair but for patients that really needed telemetry or step down we used to call them the valley of death. The nurses there were better at catering to their every need and whim than they were at recognizing and dealing with medical badness.

As for the original post. There are some hospitals where the CEO's etc are going to bat for the ED. Ours has started at policy of having every patient upstairs within 30 minutes of a bed request being put in. They have even discussed "hallway" medicine on the floors as an alternative to "hallway" medicine in the ED as having someone parked next to the nurses station upstairs really motivates them to find a bed. We still have days when few beds are available and we are stuck boarding patients in the ED but it seems to be getting better. I have a few survival strategies in those cases.

1. For any patient who has completed workup and is waiting a bed I give the nurse fairly detailed orders of what meds(diabetic meds are a good example as its bad form for your stable patient to develop DKA while boarding in the ED) should be given up until the end of my shift and any routine labs that need to be done and tell them to notify me with the results. Then I treat the patient as if they were somewhat out of sight/out of mind. That way I don't feel like I'm keeping 20 balls in the air.

2. Expedite care and make some triage decisions based on how fast you can get people out of the ED. So if you have three people waiting for ankle films and 1 guy with a fairly low risk chest pain story get everybodies ankle films before the CXR. After all its going to be hours before the troponin comes back and most of the time the CXR isn't going to change a thing if it takes an hour to get. Obviously if life threatening stuff like dissection, tension PTX, massive PE, are high on your list you probably shouldn't be doing the CXR anyway but jumping right to treatment or more definitive imaging. This sort of triage based on speed of discharge can keep your nurses from having too many balls in the air and bogging down which is sometime even worse than when the doc bogs down.

3. Swing by the rooms of patients who are still waiting for the workup to be completed for a few seconds every hour or so and just tell them you haven't forgotten them but you are just waiting for the lab/radiologist/social worker/morgue/pcp/whoever to call you back.

4. When introducing yourself to somebody who has been waiting hours apologize for the wait but explain that the whole place has been crazy and you personally have been deeply involved in a cardiac arrest/ stroke/ child with septic shock/ heart attack/ case of ebola/ etc... for the last hour and couldn't get away until now.