How to get RN and MD to assess patient at the same time

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Jackson18

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My ED is under pressure to improve our throughput metrics. Nursing has fixated on the idea that all patients should be assessed by the MD and RN at the same time once they hit a room in the back. I've seen this done successfully with a single doc and 1-2 RN's in triage but we've struggled to conceptualize how this would work in a pod based system with a doc and 3 residents covering 15 rooms. Obviously we are an academic center but if you're in the community i'm sure you work with midlevels to cover a pod.

Has anyone been able to consistently make it so the provider and RN are able to be in the room of new patients at the same time and in a reasonable time from when the patient hits the room?
 
Nursing wants different information from patients than physicians (and vice versa). It wastes each others time and generally doesn't work.

You can just put a doc at triage during peak hour to "stop the clock" and put in obvious orders that can get started before the pt even gets a room.
 
Doc-RN swarm/SWAT models work well when you have 1 doc and 2 nurses +/- a tech and the doc is only doing the initial assessment, not responsible for following up on or dispo'ing the patient. Trying it in the pod tends not to work well because RN and MD cycle times don't naturally sync up and so usually the doc is waiting for the nurse to be available or is being interrupted from a crucial task to assess a low priority patient. If you think about what the swarm actually does, it's main benefit is getting the nurse and MD on the same page in terms of type and urgency of work-up. There are other ways then swarming to accomplish this, but swarming is the only way it's (almost) guaranteed to happen.
 
Depends on if you want to interrupt your doctors every time a new patient is roomed. Also our nurses have a bad habit of taking a bad version of a thorough history plus the 10 minutes of additional not overly useful questions and flowsheets, often done on the only computer I could use to put in orders or review the chart.
 
I think I figured this one out.

You know how in order to launch a nuclear missile, 2 different Air Force missile (insert rank here...I have no idea) have to insert their keys, turn them and then push the "Nuke Gorbachev Now" button at the same time?

Same idea. Room a patient and then double lock the door. Only keys from an MD and an RN will unlock the door (as a bonus, it keeps the turkey sammich cries at a minimum). To prevent the ED tech from sneaking the RN in, don't allow anyone to log into the EMR from within the room unless both an RN and MD re present and login within 30 seconds of each other.
 
TooMuchResearch said:
Depends on if you want to interrupt your doctors every time a new patient is roomed. Also our nurses have a bad habit of taking a bad version of a thorough history plus the 10 minutes of additional not overly useful questions and flowsheets, often done on the only computer I could use to put in orders or review the chart.
Click to expand...
We did actually try this...We might still do it at times of the day (?), but I don't. One of the nurses interrupted my evaluation to ask a low speed MVC patient "but you lost consciousness, right?" Then proceeded to type the patient's response of a several minute LOC. And my discharge paperwork turned into a head CT. And I was pulled away from my lunch. And I finally realized that some nurses intentionally slow down flow by writing everything down and trying to force expansion of the workup. I was in a bad mood that day, and it clearly left an impression.
 
Angry Birds said:
Walk into the room. Listen to lungs and heart. Feel belly. Glance at vitals. Place orders. Clock stopped. Now return later once nurses are done and you've been able to read the chart. Shrug this is how I do it.
Click to expand...
You listen to the lungs and heart?
 
TooMuchResearch said:
We did actually try this...We might still do it at times of the day (?), but I don't. One of the nurses interrupted my evaluation to ask a low speed MVC patient "but you lost consciousness, right?" Then proceeded to type the patient's response of a several minute LOC. And my discharge paperwork turned into a head CT. And I was pulled away from my lunch. And I finally realized that some nurses intentionally slow down flow by writing everything down and trying to force expansion of the workup. I was in a bad mood that day, and it clearly left an impression.
Click to expand...
do nurses ever get positive reinforcement incentives for increasing throughput?
 
Thanks for the responses everyone. I figured as much but wanted see if there was some unicorn department out there that had made this work
 
This is coming from a former scribe and current med student so take it with a grain of salt.

We trialed a team assessment and team discharge system in low-acuity area with one doc and 2 midlevels, so similar to what you describe with the residents. It was supposed to be both a patient satisfier (not getting asked the same question 2-3 times), and increase efficiency (again, less overlap in the assessments). We had the doc do their thing first with RN and scribe watching and charting. Then scribe asks a few more questions, with RN charting. The RN then theoretically has most of their charting done and just needs to ask a few questions and do their assessment. Theoretically.

I'm not sure if they decided to keep this system because I left for med school, but about half of the docs "went rogue" and would just go to the room without the nurse because they were tired of waiting. 90% of the time the nurse would interrupt or go before the scribe, so the scribe would get stuck waiting for the nurse to ask all their questions. The doc would be waiting and ready to go to the next patient and the scribe would get behind. It was messy.

We also had some trials without the dual assessment, but we would just end up outpacing the nurses and have patients waiting an hour or more for their discharge paperwork because nurses were trying to catch up with all their patients initial assessments, interventions, etc. Its hard to say what the rate limiting step in the process was, but the rate limiting factor in the zone seemed to be the nurses-both lack of staffing and personality/speed issues.

There were some shifts I remember when the right combination of doc and nursing team resulted in a very efficient and patient-satisfying system. So maybe if you are in shop with great nurses (which seem to be the places they test out these ideas before deciding everybody else should do the same thing...) it can work. But it is definitely annoying to the doc having to wait for/ask for a nurse all the time...or having a couple nurses hanging around them ready to see more patients while they are busy doing other things.

Edit: I think by the end, the best practice was for the doc to "announce" that they are going to see a new patient, and if any nurses were sitting around and/or ready for a new patient, they do a team assessment. But if no nurse is ready the doc just goes ahead. I would guess 30-50% of the time it ended up being a team assessment.
 
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I like to go in the room with the RN, when I can. I find it actually speeds up my departmental flow. That said, I find I work with our RN staff well and neither side interrupts, we tend to understand each other's needs and do a little give and take.

A lot of caveats--
(1) If you work with RNs who must go through their 24 question template in strict order and interrupt you to achieve it, it won't work.
(2) It works very well with easy stuff. Say an ankle sprain, we can go in together, I can ask the 3 questions I need to ask, then I can ask "any medical problems?" and "any meds you take?" while I look at the ankle and poke it a bit. I tell them I'm going to order an Xray, and walk out of the room while the RN finishes their questions. We haven't wasted each other's time.
(2) It works very well with critically ill patients. We all feel good hitting the door together, getting the initial stuff going, getting on the same page. And if they are sick, I don't mind being in the room for 5 minutes for all of the nursing questions.

It falls apart with moderate illness especially if you and the nurse don't have a solid working relationship. I typically try to get my 2-3 questions in about the chief complaint, do a cursory exam and vital check, and then tell them I'm going to go look at their records, or order some initial stuff, and then come back by myself later to finish my questioning.

Often if the RN is doing their mandatory questions, I'll take the time to chat up a family member (often good source of history) in parallel, or do the thing where you pull up a seat and gently smile and stare. Makes the patient feel like you spent 8 hours in their room 😉
 
Remember, nurses think they're the ones being patient advocates. If you've made the mistake of having any as your friends on facebook, you'll see. All they do all day is save lives by preventing idiot doctors from killing people and also while diagnosing things said idiot doctors never thought of. Of note, their tests are really hard apparently. And they're smarter than their friends.
 
Dr.McNinja said:
Remember, nurses think they're the ones being patient advocates. If you've made the mistake of having any as your friends on facebook, you'll see. All they do all day is save lives by preventing idiot doctors from killing people and also while diagnosing things said idiot doctors never thought of. Of note, their tests are really hard apparently. And they're smarter than their friends.
Click to expand...

Did you know that the guinness book of world records ranked nursing as the hardest out of all majors? Nurses take 295960 hours of classes and do 50743 projects and take 15927 tests during their schooling, like and share if you think nurses are the best!!!
 
BAM! said:
You listen to the lungs and heart?
Click to expand...

hilarious, this just reminded me of the "universal auscultation point"- the epigastrium- can hear both lungs, the stomach and the heart with one touch of the stethoscope....

PS - the nurse and doc together thing works for urgent care but not the ER
 
Dr.McNinja said:
Remember, nurses think they're the ones being patient advocates. If you've made the mistake of having any as your friends on facebook, you'll see. All they do all day is save lives by preventing idiot doctors from killing people and also while diagnosing things said idiot doctors never thought of. Of note, their tests are really hard apparently. And they're smarter than their friends.
Click to expand...

Agreed.

Without turning this into a nursing griping thread, these people wear shirts like this:
prod_d7a2cf74-d962-4959-a446-c05845a4a743.jpeg


I know throughput is important. But nursing 25 point checklists, asking patients if they have allergies to latex, what their religious denomination is etc is absolutely useless and bad patient care. You are the physician. You should assess the patient, make sure they are stable and get the diagnostic process underway. Everything else the RN wants to do can wait.

The only exception to this is starting IV access, administering medications, getting the patient on the monitor. That's the only time IMO that the RN and MD need to be doing things simultaneously.

Our nurses do great work. But nursing management and hospital policies can really impede patient care (despite what an RN thinks about how they are advocating for a patient). Sometimes as the physician, you have to get the process going because it's in the best interest of the patient (and the other patients in the ED who are waiting for you to evaluate them).
 
I love the fact that the administrators making these idiotic decisions continue to double down on their failing ideas.

maybe throughput wouldn't be such an issue if staffing and facility size were appropriate for average patient volume. but that would take away from their bottom line and counteract the profits they seek by advertising and incentivizing the use of the ER for any and all complaints regardless of how chronic and benign they are.

continuing to sell out to these unrealistic expectations will kill the specialty. There is no end to this "lean"ing process and by going along with it, we are going to ultimately contribute to our own undoing.
 
erdoc00 said:
I love the fact that the administrators making these idiotic decisions continue to double down on their failing ideas.

maybe throughput wouldn't be such an issue if staffing and facility size were appropriate for average patient volume. but that would take away from their bottom line and counteract the profits they seek by advertising and incentivizing the use of the ER for any and all complaints regardless of how chronic and benign they are.

continuing to sell out to these unrealistic expectations will kill the specialty. There is no end to this "lean"ing process and by going along with it, we are going to ultimately contribute to our own undoing.
Click to expand...

We can only pray that one day hospitals will not be paid and or financially punished for metrics such as throughput and PS.
You never know, but I'm not holding my breath.

We are SOL with regard to having to go along with the nonsense. Unless you would like your group to loose the contract.
 
The pertinent history and exam can easily be accomplished in under 1 minute. Simple need to gather enough information to get a workup started and the nurse on the same page. If you drive the boat and manage your own needs and throughput, and the hospital admin is firmly committed to dual evaluation, grab a nurse as you go into each room. Done. You need to decide how to handle the nurses that give pushback, because they will sink the program. This is almost always a process that needs to be nursing-driven and enforced as a culture change by nurse leadership. The sad part is that there are too many nurse leaders who are afraid to ruffle the feathers of their hen house.

The problem is that the concept of "triage" is held onto until the last breath by nurses who have no ability to conceptualize that once the patient has been seen by the doctor, there is no need to sort illness- only perform "charting."
 
Dr.McNinja said:
Remember, nurses think they're the ones being patient advocates. If you've made the mistake of having any as your friends on facebook, you'll see. All they do all day is save lives by preventing idiot doctors from killing people and also while diagnosing things said idiot doctors never thought of. Of note, their tests are really hard apparently. And they're smarter than their friends.
Click to expand...

Is acute sandwich-deficiency a diagnosis? Hang on, what is this thread about again?
 
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