Improving Efficiency

[EthylMethylMan]

Hey guys. I'm a PGY-3 about to graduate. My medical knowledge and procedural skills are fine, but I find that I'm one of the slower residents in my class in terms of throughput. I do my best to triage my patients appropriately, and I frequently review results so that I can dispo as fast as possible, but I still find most of my classmates to be noticeably quicker than me. Are there some general tips I could implement to improve my efficiency?

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[HoosierdaddyO]

Hey guys. I'm a PGY-3 about to graduate. My medical knowledge and procedural skills are fine, but I find that I'm one of the slower residents in my class in terms of throughput. I do my best to triage my patients appropriately, and I frequently review results so that I can dispo as fast as possible, but I still find most of my classmates to be noticeably quicker than me. Are there some general tips I could implement to improve my efficiency?

Well to be perfectly honest… what are some of the reasons if you had to look in the mirror and be honest with yourself as to why you think you’re slower than the rest!!!

I find that most people who pose this question, they can come up with a laundry list of things that they do during the shift that they feel slows them down, but they are sometimes a little hesitant to look hard at themselves and critique themselves with true unbiased perceptions. (Ps obviously not saying this is you).

But I know sone people that when they sit back down they don’t at least throw in the HPI/ROS/PE. I find that it’s an easy way to keep things moving and get the note started. Also, if I’m picking or clicking in multiple patients at 1 time. I’ll triage them both in my head and make little mental notes and go see one right after the other and then get back to the computer and put orders and notes in!!

Another thing I see with residents is if they are discharging patients. They will discharge one patient and walk all the way to the other side of the ER and then walk back to the doc box to then realize they needed to walk all the way back to the other side again to reevaluate a patient. So I find spatial and temporal mapping in your head saves minutes here and there which add up.

Ultimately it takes time… and experience and introspection to see what you can do in a shift to make more time for yourself to get tasks done!

 

[GassYous]

Well to be perfectly honest… what are some of the reasons if you had to look in the mirror and be honest with yourself as to why you think you’re slower than the rest!!!

I find that most people who pose this question, they can come up with a laundry list of things that they do during the shift that they feel slows them down, but they are sometimes a little hesitant to look hard at themselves and critique themselves with true unbiased perceptions. (Ps obviously not saying this is you).

But I know sone people that when they sit back down they don’t at least throw in the HPI/ROS/PE. I find that it’s an easy way to keep things moving and get the note started. Also, if I’m picking or clicking in multiple patients at 1 time. I’ll triage them both in my head and make little mental notes and go see one right after the other and then get back to the computer and put orders and notes in!!

Another thing I see with residents is if they are discharging patients. They will discharge one patient and walk all the way to the other side of the ER and then walk back to the doc box to then realize they needed to walk all the way back to the other side again to reevaluate a patient. So I find spatial and temporal mapping in your head saves minutes here and there which add up.

Ultimately it takes time… and experience and introspection to see what you can do in a shift to make more time for yourself to get tasks done!

I just realized from reading your post that I do spatial and temoral mapping in my head to decrease how much walking I have to do a day. Mostly because I'm lazy.

 

[thegenius]

Hey guys. I'm a PGY-3 about to graduate. My medical knowledge and procedural skills are fine, but I find that I'm one of the slower residents in my class in terms of throughput. I do my best to triage my patients appropriately, and I frequently review results so that I can dispo as fast as possible, but I still find most of my classmates to be noticeably quicker than me. Are there some general tips I could implement to improve my efficiency?

Hey man. Honestly this should be the least of your worries. If you come out of residency with strong training and you thoroughly assess and workup patients for EMCs, your efficiency will improve.

I was like you. I used to ask every single patient the following set of questions, regardless of their complaint:
- what are your medical problems
- what meds do you take
- any major surgeries

Obviously I cut that out for the majority of the patients I see now.

You will get better at pattern recognition. For instance…I used to scan a lot of young people < 40 who had nonsense abdominal pain. After getting 50 of 50 neg CTs, I stopped doing it.

You will learn to be more efficient. Don’t worry about it

 

[CajunMedic]

I'm in the same boat, I've finally figured a few things out that save time and clicks. @HoosierdaddyO's advice is solid.

As soon as I walk back into the fishbowl and sit down, I put in whatever orders haven't been entered yet (we have a huge boarding issue, so 90% of the workup is started in the waiting room and orders are protocoled by triage nurse)

Once orders are in, I start the note and put everything in but my MDM. If i'm fairly certain of the dispo, I'll even drop in my specific MDM template.

Then, I look and see what's back, and if I can dispo someone. I try to know what the minimum data set my admtting doc needs, and make the call as soon as that's back. If there is someone that likely will be D/C'd, but I'm watiting on something, I'll put in any follow up, patient education, Rx, etc.

I figured out I wasted a lot of time and steps leaving the fishbowl without a plan. When I walk out, I plan my route. I also try to be aware of what the rate-limiting steps are that particular day (UA's, CT, etc.) and try to keep an extra eye on them.

 

[The Knife & Gun Club]

How do y’all deal with the nursing interruptions? I feel like I spend an inordinate amount of time dealing with nursing BS even at our community site.

“Hey doc, bed 12 needs a new dressing on their chronic ulcer, I’m not comfortable dressing it”

“hey doc, I need you to reorder the ABG on bed 15, I printed the label but forgot to collect it.”

“Hey doc, I saw you ordered a foley on bed 42. I need you to call the nursing admin to get approval for a foley, and go get if from their office. Leave it at bedside and I’ll put it in”

“hey doc i saw you ordered a lactic. Do we really need that? You can’t put it as an add on? Are you sure? Why don’t you call the lab, they can sometimes I think”

“Hey doc, can you place an IV on bed 7? I heard he’s a hard stick. No I haven’t tried yet, he told me he’s a hard stick. No I don’t want to bother the charge nurse with this first. No it has nothing to do with his HIV/HCV.” *Annoyed attitude when I tell nurse they need to attempt a stick*

“Hey doc, the patient in bed 3s sister wants to talk to you. I know you already spoke to his wife and the other sister but she’s demanding she speak to-you right now”

 

[CajunMedic]

How do y’all deal with the nursing interruptions? I feel like I spend an inordinate amount of time dealing with nursing BS even at our community site.

If it's an order that needs to be put in, i'll put it in if I'm in that chart already. If not, i'll write it on the notepad I keep by me and do it when I'm finished with whatever I'm doing. Unless they need it for a CTA, critical meds, etc.; US IV's will wait until one of the other nurses have tried, and I've got the time to do it. Same thing goes for talking to families if I've already talked to someone else in the room.

 

[BoardingDoc]

How do y’all deal with the nursing interruptions? I feel like I spend an inordinate amount of time dealing with nursing BS even at our community site.

“Hey doc, bed 12 needs a new dressing on their chronic ulcer, I’m not comfortable dressing it”

“hey doc, I need you to reorder the ABG on bed 15, I printed the label but forgot to collect it.”

“Hey doc, I saw you ordered a foley on bed 42. I need you to call the nursing admin to get approval for a foley, and go get if from their office. Leave it at bedside and I’ll put it in”

“hey doc i saw you ordered a lactic. Do we really need that? You can’t put it as an add on? Are you sure? Why don’t you call the lab, they can sometimes I think”

“Hey doc, can you place an IV on bed 7? I heard he’s a hard stick. No I haven’t tried yet, he told me he’s a hard stick. No I don’t want to bother the charge nurse with this first. No it has nothing to do with his HIV/HCV.” *Annoyed attitude when I tell nurse they need to attempt a stick*

“Hey doc, the patient in bed 3s sister wants to talk to you. I know you already spoke to his wife and the other sister but she’s demanding she speak to-you right now”

I honestly can't tell if your post is hyperbole or if you have literally abysmal nursing staff.

1: doesn't happen. I would ask them to explain what they were uncomfortable with exactly. I would then explain how to do the dressing PRN.

2: Fine. Ordered.

3: What? What? This is not a thing.

4: "I can't add on lactates. You're welcome to call the lab if you think they can."

5: "Once 3 people have tried and failed, I'll be there."

6: "No."

 

[thegenius]

How do y’all deal with the nursing interruptions? I feel like I spend an inordinate amount of time dealing with nursing BS even at our community site.

“Hey doc, bed 12 needs a new dressing on their chronic ulcer, I’m not comfortable dressing it”

“hey doc, I need you to reorder the ABG on bed 15, I printed the label but forgot to collect it.”

“Hey doc, I saw you ordered a foley on bed 42. I need you to call the nursing admin to get approval for a foley, and go get if from their office. Leave it at bedside and I’ll put it in”

“hey doc i saw you ordered a lactic. Do we really need that? You can’t put it as an add on? Are you sure? Why don’t you call the lab, they can sometimes I think”

“Hey doc, can you place an IV on bed 7? I heard he’s a hard stick. No I haven’t tried yet, he told me he’s a hard stick. No I don’t want to bother the charge nurse with this first. No it has nothing to do with his HIV/HCV.” *Annoyed attitude when I tell nurse they need to attempt a stick*

“Hey doc, the patient in bed 3s sister wants to talk to you. I know you already spoke to his wife and the other sister but she’s demanding she speak to-you right now”

Thank god I don't get much of that. It would drive me nuts. Especially the IV stuff

 

[Fox800]

Funny how in residency the nurses needed all the residents to get ultrasound IVs after giving up after 2 attempts. They refused to learn how to do US-guided IVs, the RN training classes magically never got scheduled or "didn't have enough people sign up".

Now in the community I almost never have to do a US-guided IV, our RNs are expected to do them on their own. I won't agree unless at least 2 RNs have tried 4+ times, with US.

 

[Groove]

Hey guys. I'm a PGY-3 about to graduate. My medical knowledge and procedural skills are fine, but I find that I'm one of the slower residents in my class in terms of throughput. I do my best to triage my patients appropriately, and I frequently review results so that I can dispo as fast as possible, but I still find most of my classmates to be noticeably quicker than me. Are there some general tips I could implement to improve my efficiency?

You'll get better with time. You should be able to comfortably move 2pph upon graduation from residency. If you can't do this, your residency program is doing you a great disservice as this will be expected in most jobs out in the community. Optimizing your multitasking simply takes practice and some of it depends on the EMR, shop layout (open ED vs pod), whether you have a scribe or not, acuity of the pt population, etc.. In general, if you have computers in the room, or a mobile COW/WOW, you can enter orders and even do brief HPI/ROS/PE in the room with the pt which improves pt satisfaction and saves time wasted by walking all the way back to your workstation.

Probably the most important aspect of decreasing LOS, is stopping yourself from overworking patients which is very common in new grads (but not all). I think this gets better with time. I seem to remember overworking patients earlier in my career but after you get a better clinical gestalt and pattern recognition, you will be better able to identify the pt's that are low yield. Why order a plethora of tests when the pt doesn't really need them? The more tests you order, the more time is required to address each (often non emergent) abnormal result. Potassium 3.1? Repleted, educated pt on dietary changes and/or brief supplementation. Sodium 130? Beer potomania in a chronic alcoholic (presenting with ankle pain). Do either of those pt's have an emergency? You get the picture. If they are there for something non metabolic, are eating/drinking/voiding/stooling normally, do they really need chemistries in the first place? The better you get at easily identifying the "non sick" pt population and minimizing their order set, the faster you will get. COVID sx? Again, eating/drinking/voiding/stooling normally? Stable VS? I swab them for flu/COVID and immediately discharge with a dx of "suspected COVID 19" and educate them on how to retrieve their test results from the online portal. You add up enough of these patients and that's serious decreased LOS.

Don't expect yourself to be as fast as you will be in 5, 10 or 20 years. You won't. Always practice in a comfortable zone without pushing yourself to where you feel uncomfortable in discharging a pt. As long as you try to optimize your flow, minimize non essential work ups and constantly work at it...you'll get faster with time. It may seem to pander to CMG/hospital metric requirements but optimizing LOS is essential in EM. Especially in the state of healthcare as it stands today where most ED's are overwhelmed and hospital resources are maxed out.

Another often not thought of element is figuring out what you need personally to be able to fire on all thrusters for each shift. Sleep, nutrition, exercise, asking the scheduler to optimize your nights in a single block, etc.. Not picking up too many hours for the month, decreasing fatigue, etc.. (Don't forget to take a few vacations!) All these things are important to ensure you are optimized mentally, psychologically, physically to be operating at your absolute best during each shift.

 

[The Knife & Gun Club]

I honestly can't tell if your post is hyperbole or if you have literally abysmal nursing staff.

1: doesn't happen. I would ask them to explain what they were uncomfortable with exactly. I would then explain how to do the dressing PRN.

2: Fine. Ordered.

3: What? What? This is not a thing.

4: "I can't add on lactates. You're welcome to call the lab if you think they can."

5: "Once 3 people have tried and failed, I'll be there."

6: "No."

I don’t think it’s bad nursing staff, just used to working with residents. We tend to be pushovers (I’m very much guilty of this), and nurses learn quickly what tasks they can force on the resident.

Whenever we have travelers come who are used to working with attendings directly, these behaviors are mysteriously absent.

 

[The kitchen sink]

Funny how in residency the nurses needed all the residents to get ultrasound IVs after giving up after 2 attempts. They refused to learn how to do US-guided IVs, the RN training classes magically never got scheduled or "didn't have enough people sign up".

Now in the community I almost never have to do a US-guided IV, our RNs are expected to do them on their own. I won't agree unless at least 2 RNs have tried 4+ times, with US.

At my IM program, the floor nurses were so notorious at not trying IVs that it started interfering with workflow. It escalated to the point that we made nursing implement a policy that stated a minimum of 3x documented attempts, plus an attempt by the charge RN. Those pages decreased dramatically.

 

[Angry Birds]

You need to run the ER like a McDonalds. Here is what I do:

1) Review the vital signs and chief complaint. From this alone 90% of the time you know what to order. Order it.

2) For the non-sick patients, I divide them into simple and complex. It's counter-intuitive, but I actually only first eyeball the complex patients, looking at them from the door, looking at their vital signs and just how they look. I put in orders for them and then go and blitz to see the simple patients who are discharged on site. I try as hard as possible not to have to go into a room more than once. By the time the work-up is back on the complex patients, I've already discharged the simple patients, so now I can go into the complex patients' rooms and even let them know their results in the same visit.

3) Sick-as-sh** patients are different. They obviously require all your attention so they don't die on you. Those I keep a very close eye on and alert nursing staff to, often moving them to more acute rooms if necessary.

4) I literally think about throughput all the time. This means coordinating with nurses (especially charge nurses) and giving them an order-of-operations. I also call radiology techs to let them know what order I want scans done in, and also, to push them to take the patients now.

5) Order less CT scans. Ask yourself: Do I already know it's going to come back negative? Then why the hell am I ordering it?

6) Never order a test unless it will change your plan.

7) Be decisive. Don't hedge all the time. Make a plan and stick to it. Don't nickle-and-dime nurses with orders. That's annoying. Also, I usually am very aggressive with pain meds on my first volley of orders. This breaks the patient's pain and gets rid of the need to constantly order piss doses of pain meds repeatedly.

8) Don't waste time with psych patients. Snow them when possible. If they are willing, then give them Ativans and Benadryls across the board. If they are being belligerent, let nursing staff try deescalation strategies. Once you get involved, it's time for one last warning to the patient and then chemical sedation time. I consistently find doctors wasting precious time negotiating with psych patients when they KNOW it's going to all end with the same end point: sedation. It's your choice whether or not to waste five hours of back-and-forth and sedating at the end of your shift, or just doing it at the front end and then not having to deal with that patient for most of your shift. Keep in mind that I am NOT saying to chemically restrain patients who don't need it. That would be unethical. But, from your clinical experience, you will know those patients who WILL end up getting sedated. If that's the case, then just do it earlier.

9) Constantly follow up with nurses to make sure orders are being done. Why aren't labs back? Were the labs sent over? Why isn't the patient in scan yet? I always stress to the patient from the very first step in their room, "We really need your urine as soon as you can give it to us." Then, I bug the nurse about it and the tech.

10) I don't care if people get annoyed that I bug them. I always do closed loop communication with nurses and techs, and I push them to get orders done.

11) Don't ask stupid medical student level questions to patients. I remember one of my attendings made fun of me during intern year when I started talking about what color the patient's sputum was. He asked me, "Was it violet fuscha or more of a lime green?" I never asked that question again.

12) Ask the pan-positive review of systems patients, "What is your worst symptom?" I also ask, "If I had a magic wand and could get rid of one symptom for you, what would it be?"

13) Procedures take a lot of time. If you have a PA or NP, try to get them to do the lac repairs. That's a huge time suck. As for US-guided peripheral IVs, once the nurses know you can do this, they will suddenly not be able to establish IVs and your time will be wasted constantly... That's at least 20 minutes of your time. I don't care what anyone says-- it's 20 minutes from decision time to completion of the task, regardless of whether or not the actual procedure is "two minutes."

14) Discharge, discharge, discharge. Refer to PCP. Only do EM, not FP.

15) Eliminate any unnecessary steps in whatever you are doing. Throughput is king. Get faster. I disagree with those who say it's ok to be slow in residency. It's not.

FINALLY, focus your time and energy on the SICK patients. If they have unstable vital signs, obsess over them. Don't delay their evaluation, treatment, ressuss, central line, etc. The ENTIRE reason you are following the above rules is so that when these sick-as-sh** patients come to your ER, you have the time to dedicate your entire self to them so that they don't die on you. I can't tell you how many times I've seen the "compassionate ER docs" -- who spend oodles of time on the non-sick patients ordering them MRIs and whatever the hell else they want -- panic and ignore the sick patients, leaving them for sign-out, not getting central lines in them, etc. Intubate, central line, etc. early in the course of their stay... and never leave those to the next guy. That's weak.

 

[Angry Birds]

How do y’all deal with the nursing interruptions? I feel like I spend an inordinate amount of time dealing with nursing BS even at our community site.

“Hey doc, bed 12 needs a new dressing on their chronic ulcer, I’m not comfortable dressing it”

No, I need you do it or find another nurse who can.

“hey doc, I need you to reorder the ABG on bed 15, I printed the label but forgot to collect it.”

OK, put the order in and I'll co-sign it.

“Hey doc, I saw you ordered a foley on bed 42. I need you to call the nursing admin to get approval for a foley, and go get if from their office. Leave it at bedside and I’ll put it in”

No I'm not going to do that. You need to do the foley. Otherwise, you can straight cath. One or the other. I'll let you figure it out but I need you to get the urine.

“hey doc i saw you ordered a lactic. Do we really need that? You can’t put it as an add on? Are you sure? Why don’t you call the lab, they can sometimes I think”

I'm not going to call the lab. If you're busy, then you can call the lab to see if they will do it. But I need you to make sure it gets done.

“Hey doc, can you place an IV on bed 7? I heard he’s a hard stick. No I haven’t tried yet, he told me he’s a hard stick. No I don’t want to bother the charge nurse with this first. No it has nothing to do with his HIV/HCV.” *Annoyed attitude when I tell nurse they need to attempt a stick*

No. I can't do that right now. I need you to try to get the IV. But if you can't get it after 4 attempts, then ask the charge nurse. If the charge nurse still can't get it, then circle back to me.

“Hey doc, the patient in bed 3s sister wants to talk to you. I know you already spoke to his wife and the other sister but she’s demanding she speak to-you right now”

You can let her know I am simply not available right now. You can either take a message or I'll get to her when I can, which might not be for some time.

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Always give less or no explanation. Short, curt responses. Don't raise your voice. Don't yell. But don't budge. Don't use words like 'please' and 'thank you,' or 'i'm sorry', etc. Don't ask nurses. Tell them. Do NOT be scared to say NO. Be firm. Get your nurses in line.
I think based on your list of questions, you are probably way too nice to nurses.
A little bit of fear goes a long way. People respect leaders who they fear a little bit. Not surgeon level yelling and berating people, etc. But, don't be the "compassionate doc" that everyone walks over.

Also, if you are having this problem, then maybe you are socializing with nurses too much. I have a rule: I only socialize with those nurses who I know won't take that as a sign that they can flout my authority. Once in awhile I have had nurses who try to exploit such friendship, but then I set them right.

 

[Angry Birds]

Oh, another tip: If a patient is hedging or going back-and-forth with a family member about a decision step of what to do, don't just stand there like an idiot listening and taking part in that. For example, the perennial dilemma of the patient who wants to go home AMA and the wife who wants him to stay... I just say, "OK, I'm going to let you two discuss this and I'll come back in 15 minutes or so for your answer." Then I walk away. Every minute counts. Don't waste your time.

This leads me to my overall tip: Don't waste time arguing. Don't argue with patients. Don't argue with nurses. (That's why I say don't give explanations, just orders.)

Also, learn to become a patient whisperer. This means you have to think in your head with every encounter, "What is this person here for? What is their motivation? What do they want from me?" If you can give it to them, give it. Sometimes it's literally just a work note. You know how many times I've realized that a patient just came in for a cold or man-flu and just wanted a work note? Learning this right away means saving yourself the IV fluids, meds, useless labs, etc. So, my number one tip is: learn patient psychology. That's the name of the game. It also means less arguing.

"I want an MRI."
You know how many times I've seen ER docs get in a fighting match with patients over something like this? All I say is, "Ah, I agree with you -- an MRI would be great to get right now. It's actually no radiation, so I actually prefer it. So, you and I are on the same page here. Problem is that the MRI team is not available right now in the middle of the night [or whatever the situation is]... But, I'll make sure to write it on your discharge paperwork for your PCP to consider ordering one on an urgent or semi-urgent basis."
I validate the crap out of patients. Validation is a huge part of patient psychology. Don't just say, "it's just constipation." Say, "Constipation can result in peristaltic pain, which can be very severe and painful." And then offer a solution.

Also, whenever I give pain meds--even if they are NSAIDs--I always say, "I am going to give you some very powerful meds to help you with your pain. I'm confident you are going to feel better." Planting the idea in their head. It really works.

 

[RustedFox]

Oh, another tip: If a patient is hedging or going back-and-forth with a family member about a decision step of what to do, don't just stand there like an idiot listening and taking part in that. For example, the perennial dilemma of the patient who wants to go home AMA and the wife who wants him to stay... I just say, "OK, I'm going to let you two discuss this and I'll come back in 15 minutes or so for your answer." Then I walk away. Every minute counts. Don't waste your time.

This leads me to my overall tip: Don't waste time arguing. Don't argue with patients. Don't argue with nurses. (That's why I say don't give explanations, just orders.)

Also, learn to become a patient whisperer. This means you have to think in your head with every encounter, "What is this person here for? What is their motivation? What do they want from me?" If you can give it to them, give it. Sometimes it's literally just a work note. You know how many times I've realized that a patient just came in for a cold or man-flu and just wanted a work note? Learning this right away means saving yourself the IV fluids, meds, useless labs, etc. So, my number one tip is: learn patient psychology. That's the name of the game.

Which is antithetical to what we all were trained to do in school/residency.
You're not wrong. I'm not disagreeing.
I'm pointing out that this is part of the mechanism of how these MS3/4s think: "EM is the best; this is the only thing I can see myself doing" and then in the real world, EM is a completely different beast.

 

[Jabbed]

Excellent tips from @Angry Birds . To current residents, I would only add that these are the skills that you’re forced to cultivate in your first year as an attending. Many of the throughput strategies are probably ineffective at most residency programs when you’re waiting 2+ hrs for CT and you’re generally seeing higher acuity patients more than quick dispos.

Never let them see you do an ultrasound IV.

 

[bougiecric]

• Truth is, it takes 1-3 years (maybe more) to reach peak efficiency. Academics is nothing like the community and no matter how fast you are as a resident, there's a significant learning curve for everyone.
• You only need to do enough work up necessary to determine if a patient requires admission or urgent intervention. The ER is not the place to whittle down to the exact diagnosis in every patient. If you know they need admission, and you're comfortable they won't deteriorate, then admit and move on. Know what diagnostics must be done the the ER versus what can be done by the admitting services.

I have a couple points that aren't as palatable, but they are true in my experience:

• Going against the above, sometimes it's more efficient just to order the CT. Sure, a CT may make a patient's LOS longer, but it may be more efficient for you and the ER in general. Yes, the right thing to do is discuss risks/benefits, do shared decision making, make sure they understand return precautions and follow up (in place of a CT). But if the picture's unclear, or the patient is concerned, sometimes it's easiest just to do the CT and go do your other tasks.
• Here's the dirty truth: the most time consuming part of this job is talking to patient's and their families. It's also (in my opinion) maybe the most rewarding and important thing we do. I've seen incredibly efficient docs essentially stand in the doorway, say a line or two to the patient, then walk away. It genuinely makes them very fast. Do I agree with this approach? Not to this extreme. But it's helpful to find ways to have meaningful conversations with patients/family while also keeping them reasonably short.
• To help with the point above, you really should have 2 encounters per patient per visit. Sometimes 3, very rarely more. The 2 encounters should be on presentation and at disposition. Stick to this as best you can.

 

[Angry Birds]

In an addendum to my post about what to respond to those pesky nurse requests, what I would add to that is something I read in a book about being a director/manager of a non-profit organization. Employees under you will constantly try to pass the buck to you. All of my responses are designed to pass the buck right back to them. Delegate them with completion of the task and you can sometimes add a choice in there to make them feel like you helped them out. But, ultimately, they get the buck passed back to them. Otherwise, you as the manager of the ER will be overwhelmed with bucks and that's buckin' terrible.

Some of the nurses praise this one doc in our practice who prints out all the discharge paperwork himself, does all his own pages, sets up his own materials for a procedure, etc. Guess what? That's terribly inefficient as the leader/manager of the ER. You should delegate, delegate, delegate. Streamline so you are just a floating brain walking around commanding people and moving the pace along.

 

[emergentmd]

It takes some time, some longer than others and some/many on here may disagree but

1. Figure how to chart quickly. Most EMRs sucks but they all can be gamed to create a quick chart. This will date me but we used Dos Based Meditech for 17 years. Yeah, that EMR where you had to type everything and created before browser based. I gamed it where I could create a chart on avg in 2-3 minutes. I timed myself and completed 20 charts in 50 minutes. My charts were, IMO, top echelon for the group.

2. ORDER all studies ONCE. Do not nickle and dime. If someone with belly pain comes in, ORDER all the labs at one. Don't order a cbc and BMP then come back to add on LFTs when they are all normal, then come back and add a UA if everything is normal. If pt has a tender belly and you think a CT will be necessary then order it with Labs. If you are iffy about a CT, then make yourself a note

3. At the beginning of every shift, get a white blank sheet of paper. I put stickers of every pt I see with the room number and all labs/studies I ordered. If I am iffy about a CT, then I make a note to add one after labs back. This keeps you from constantly looking at the board and wondering what you are missing. This prevents me from missing anything. When all the boxes are checked, then pt gets discharged vs admitted.

4. Never read the nurses notes other than vitals/PMH/Meds. The rest is a waste of time 99% of the time and causes more things to worry about. My history/exam is better than the nurses.

5. ORDER all meds at once and do not nickle and dime it. See #2. A gastroenteritis comes in. I order 2L NS, Phenergan, zofran. After labs back and normal, they likely will go home. IF they are no better/worse they get admitted b/c I have given the college try of 2LNS and 2 doses of antiemetics. I rarely order meds more than twice before DC vs admission. I see too many docs doing 3-4 rounds of meds before making a decision. STOP this.

6. STOP seeing complicated pts or actually anything but a quick xray or zpak pt 2 hrs before your shift ends. I want to leave when my pay clock ends. No one pays me to stay extra or bring charts home so I am not working for free. If I leave at 9pm, then my last pt will be seen at 7pm. If there are some quick putts, then I may pick them up if its busy. Yes, I will cherry pick the last 2 hrs. This only works if you are fast and efficient, otherwise docs/staff will complain that you are slacking. But I am always seeing the most pph in my group and the rare times that someone sees more pph then they are staying back 2-3+ hrs to chart. I walk in, pick up 5-10 pts the 1st hour if busy, then float the rest of the shift seeing a leisure 2 pph which works out to 2-3pph but they are all front loaded.

7. 90% of the pts should have a H&P in less than 5 minutes. If you are regularly spending 10-15min a pt, then figure it out. Fix it. If you are spending 15 min a pt, then you will never be efficient.

8. U/S - unless you are looking for a baby or a DVT, it is NEVER 1st line. U/S for some reason takes so long. I get a CT first and U/S if needed. Almost never the other way around. Learned my lesson ordering a GB US which takes 3 hrs for a read. Then a CT after b/c US was neg. I go straight to CT and reduced my US rates drastically.

9. Batch charting. Its is just faster knocking them out in blocks than right after each pt. Its not only inefficient but pts pile up when busy.

10. Your time is just as valuable as any specialist. Invariably shift comes to an end and I call in an admission. I used to wait after my unpaid shift for their call. No more, learned my lesson. I page, leave the clerk my cell, and they can call me while I am driving home.

11. Last 2 hr of the shift is used to clean up all lose ends. Don't let a lose end linger right before your shift ends. Look at the rate limiting factor for you leaving on time and make it happen. Belly pain comes in and its 90 min til shift ends, then I ponder if I should pick it up but the ER is packed and so I pick it up. 1st thing I do, is go tell the nurse to please draw labs. Too many docs forget about it and at the end of their shift figure out nothing has been done. All the staff knows when my last 2 hrs is b/c everything is stat. My time is valuable. I will call/go to the rad box 30 min b/f my shift and tell them to bump it up b/c I need a read ASAP = I need to go home. Don't do this and you will turn around looking down at the barrel of another shift leaving late. Did I mention unpaid?



Do all of this and you will be at the top 1/4 of efficiency, leave on time, have high pph numbers, and be able to go to the cafeteria as often as you want. My partners never complains that emergentmd went to get coffee again b/c they know my pph is ridiculous and the board typically has my name on most of the pts. I have seen 48 pts in an 9 hr shift and left 1 hr after my shift ended with all charts done. Irritate that I gave the CMG an extra hr of free work.

 

[p1acebo]

You need to run the ER like a McDonalds. Here is what I do:

1) Review the vital signs and chief complaint. From this alone 90% of the time you know what to order. Order it.

2) For the non-sick patients, I divide them into simple and complex. It's counter-intuitive, but I actually only first eyeball the complex patients, looking at them from the door, looking at their vital signs and just how they look. I put in orders for them and then go and blitz to see the simple patients who are discharged on site. I try as hard as possible not to have to go into a room more than once. By the time the work-up is back on the complex patients, I've already discharged the simple patients, so now I can go into the complex patients' rooms and even let them know their results in the same visit.

3) Sick-as-sh** patients are different. They obviously require all your attention so they don't die on you. Those I keep a very close eye on and alert nursing staff to, often moving them to more acute rooms if necessary.

4) I literally think about throughput all the time. This means coordinating with nurses (especially charge nurses) and giving them an order-of-operations. I also call radiology techs to let them know what order I want scans done in, and also, to push them to take the patients now.

5) Order less CT scans. Ask yourself: Do I already know it's going to come back negative? Then why the hell am I ordering it?

6) Never order a test unless it will change your plan.

7) Be decisive. Don't hedge all the time. Make a plan and stick to it. Don't nickle-and-dime nurses with orders. That's annoying. Also, I usually am very aggressive with pain meds on my first volley of orders. This breaks the patient's pain and gets rid of the need to constantly order piss doses of pain meds repeatedly.

8) Don't waste time with psych patients. Snow them when possible. If they are willing, then give them Ativans and Benadryls across the board. If they are being belligerent, let nursing staff try deescalation strategies. Once you get involved, it's time for one last warning to the patient and then chemical sedation time. I consistently find doctors wasting precious time negotiating with psych patients when they KNOW it's going to all end with the same end point: sedation. It's your choice whether or not to waste five hours of back-and-forth and sedating at the end of your shift, or just doing it at the front end and then not having to deal with that patient for most of your shift. Keep in mind that I am NOT saying to chemically restrain patients who don't need it. That would be unethical. But, from your clinical experience, you will know those patients who WILL end up getting sedated. If that's the case, then just do it earlier.

9) Constantly follow up with nurses to make sure orders are being done. Why aren't labs back? Were the labs sent over? Why isn't the patient in scan yet? I always stress to the patient from the very first step in their room, "We really need your urine as soon as you can give it to us." Then, I bug the nurse about it and the tech.

10) I don't care if people get annoyed that I bug them. I always do closed loop communication with nurses and techs, and I push them to get orders done.

11) Don't ask stupid medical student level questions to patients. I remember one of my attendings made fun of me during intern year when I started talking about what color the patient's sputum was. He asked me, "Was it violet fuscha or more of a lime green?" I never asked that question again.

12) Ask the pan-positive review of systems patients, "What is your worst symptom?" I also ask, "If I had a magic wand and could get rid of one symptom for you, what would it be?"

13) Procedures take a lot of time. If you have a PA or NP, try to get them to do the lac repairs. That's a huge time suck. As for US-guided peripheral IVs, once the nurses know you can do this, they will suddenly not be able to establish IVs and your time will be wasted constantly... That's at least 20 minutes of your time. I don't care what anyone says-- it's 20 minutes from decision time to completion of the task, regardless of whether or not the actual procedure is "two minutes."

14) Discharge, discharge, discharge. Refer to PCP. Only do EM, not FP.

15) Eliminate any unnecessary steps in whatever you are doing. Throughput is king. Get faster. I disagree with those who say it's ok to be slow in residency. It's not.

FINALLY, focus your time and energy on the SICK patients. If they have unstable vital signs, obsess over them. Don't delay their evaluation, treatment, ressuss, central line, etc. The ENTIRE reason you are following the above rules is so that when these sick-as-sh** patients come to your ER, you have the time to dedicate your entire self to them so that they don't die on you. I can't tell you how many times I've seen the "compassionate ER docs" -- who spend oodles of time on the non-sick patients ordering them MRIs and whatever the hell else they want -- panic and ignore the sick patients, leaving them for sign-out, not getting central lines in them, etc. Intubate, central line, etc. early in the course of their stay... and never leave those to the next guy. That's weak.

This is an excellent summary, every graduating resident should read this.

One thing I do (that I think bougiecric mentioned), is sometimes just ordering the CT is quicker in the long run depending on the situation. We risk stratify, if an old person comes in with belly pain and had previous surgery, recent post op, or history of SBO, unless the patient refuses there is no reason not to order the CT (even with a benign exam). Old people can’t be trusted, they don’t articulate history well, they don’t anyways have consistent exams, and they don’t always mount an appropriate immune response.

 

[Angry Birds]

This is an excellent summary, every graduating resident should read this.

One thing I do (that I think bougiecric mentioned), is sometimes just ordering the CT is quicker in the long run depending on the situation. We risk stratify, if an old person comes in with belly pain and had previous surgery, recent post op, or history of SBO, unless the patient refuses there is no reason not to order the CT (even with a benign exam). Old people can’t be trusted, they don’t articulate history well, they don’t anyways have consistent exams, and they don’t always mount an appropriate immune response.

I agree with you. I freely order the CT scans in the first volley of orders if I think the patient fits my criteria for that, which includes old age and any number of other things including what the patient looks like from the door. It is almost never a problem with patients and is better for throughput, I agree.

The only nickle-and-dime I do is I order a BMP instead of CMP, since our lab's CMP takes FOREVER, thereby delaying CT scan waiting for the GFR. (I also do this for DKA patients so I get the K back sooner). I try to push radiology techs to take the patients without that coming back but they usually win, especially since they can just drag their feet. So, I order BMP, wait for that to come back and then call the lab to add on the LFTs.
The bottom line is that virtually every decision I make is based on throughput.

 

[Angry Birds]

It takes some time, some longer than others and some/many on here may disagree but

1. Figure how to chart quickly. Most EMRs sucks but they all can be gamed to create a quick chart. This will date me but we used Dos Based Meditech for 17 years. Yeah, that EMR where you had to type everything and created before browser based. I gamed it where I could create a chart on avg in 2-3 minutes. I timed myself and completed 20 charts in 50 minutes. My charts were, IMO, top echelon for the group.

I agree. This might even include taking a typing class for those people who can't type.

2. ORDER all studies ONCE. Do not nickle and dime. If someone with belly pain comes in, ORDER all the labs at one. Don't order a cbc and BMP then come back to add on LFTs when they are all normal, then come back and add a UA if everything is normal. If pt has a tender belly and you think a CT will be necessary then order it with Labs. If you are iffy about a CT, then make yourself a note

I agree with all of this although I would just order the CT if you are iffy. I think it's better to be decisive and decide one way or the other on the first go around.

3. At the beginning of every shift, get a white blank sheet of paper. I put stickers of every pt I see with the room number and all labs/studies I ordered. If I am iffy about a CT, then I make a note to add one after labs back. This keeps you from constantly looking at the board and wondering what you are missing. This prevents me from missing anything. When all the boxes are checked, then pt gets discharged vs admitted.

Here I disagree. When I see someone with one of these sheets I usually think 'medical student.'
EDIT: On the flip side, I do it myself occasionally when the ER is an absolute zoo. So, maybe your shop is always like that.

4. Never read the nurses notes other than vitals/PMH/Meds. The rest is a waste of time 99% of the time and causes more things to worry about. My history/exam is better than the nurses.

I disagree here too. I look at chief complaint and vitals, which is enough for me to enter in my first volley of orders, saving me precious time.
I don't waste time with a long history myself. Plus, if I ever do need a long history, I'd rather do it when all my labs and imaging are back, so that I can ask more targeted questions.

5. ORDER all meds at once and do not nickle and dime it. See #2. A gastroenteritis comes in. I order 2L NS, Phenergan, zofran. After labs back and normal, they likely will go home. IF they are no better/worse they get admitted b/c I have given the college try of 2LNS and 2 doses of antiemetics. I rarely order meds more than twice before DC vs admission. I see too many docs doing 3-4 rounds of meds before making a decision. STOP this.

This I agree with 10000%.
For migraines, for example, I order a whole volley of meds, all given at once, with a note to nurse, "discharge after patient is feeling better from these meds."

6. STOP seeing complicated pts or actually anything but a quick xray or zpak pt 2 hrs before your shift ends. I want to leave when my pay clock ends. No one pays me to stay extra or bring charts home so I am not working for free. If I leave at 9pm, then my last pt will be seen at 7pm. If there are some quick putts, then I may pick them up if its busy. Yes, I will cherry pick the last 2 hrs. This only works if you are fast and efficient, otherwise docs/staff will complain that you are slacking. But I am always seeing the most pph in my group and the rare times that someone sees more pph then they are staying back 2-3+ hrs to chart. I walk in, pick up 5-10 pts the 1st hour if busy, then float the rest of the shift seeing a leisure 2 pph which works out to 2-3pph but they are all front loaded.

Agreed. You can, however, order up the work up for the next doc but slyly remove your name from the chart, depending on your EMR.

7. 90% of the pts should have a H&P in less than 5 minutes. If you are regularly spending 10-15min a pt, then figure it out. Fix it. If you are spending 15 min a pt, then you will never be efficient.

Agreed. Five minutes might even be generous in some patients. For example, you see a patient writhing in pain to the RLQ, why do you need a history when you know a CT scan will tell you everything?

8. U/S - unless you are looking for a baby or a DVT, it is NEVER 1st line. U/S for some reason takes so long. I get a CT first and U/S if needed. Almost never the other way around. Learned my lesson ordering a GB US which takes 3 hrs for a read. Then a CT after b/c US was neg. I go straight to CT and reduced my US rates drastically.

Or you can order both at the same time.

9. Batch charting. Its is just faster knocking them out in blocks than right after each pt. Its not only inefficient but pts pile up when busy.

Ah, I disagree here. I made a rule after residency that I never pick up another patient until the chart is done on the current patient.
EDIT: On the flip side, I do this myself sometimes when it is zoo. So, again, maybe your shop is a zoo and you are forced to do this.
I feel like it just increases pressure and a huge headache afterward to have to do multiple charts in a row.

10. Your time is just as valuable as any specialist. Invariably shift comes to an end and I call in an admission. I used to wait after my unpaid shift for their call. No more, learned my lesson. I page, leave the clerk my cell, and they can call me while I am driving home.

Yes, that's fine. I've done that before. But, you just can't dump it on the next guy.

11. Last 2 hr of the shift is used to clean up all lose ends. Don't let a lose end linger right before your shift ends. Look at the rate limiting factor for you leaving on time and make it happen. Belly pain comes in and its 90 min til shift ends, then I ponder if I should pick it up but the ER is packed and so I pick it up. 1st thing I do, is go tell the nurse to please draw labs. Too many docs forget about it and at the end of their shift figure out nothing has been done. All the staff knows when my last 2 hrs is b/c everything is stat. My time is valuable. I will call/go to the rad box 30 min b/f my shift and tell them to bump it up b/c I need a read ASAP = I need to go home. Don't do this and you will turn around looking down at the barrel of another shift leaving late. Did I mention unpaid?

Excellent advice.

Do all of this and you will be at the top 1/4 of efficiency, leave on time, have high pph numbers, and be able to go to the cafeteria as often as you want. My partners never complains that emergentmd went to get coffee again b/c they know my pph is ridiculous and the board typically has my name on most of the pts. I have seen 48 pts in an 9 hr shift and left 1 hr after my shift ended with all charts done. Irritate that I gave the CMG an extra hr of free work.

Same.
You earn respect by nurses as well when you are hyper efficient.


BUT THE NUMBER ONE TIP I HAVE FOR PEOPLE IS: Try finding the job with the highest pay and lowest patient per hour. You will thank yourself.

 

[lucid_leprechaun]

I agree. This might even include taking a typing class for those people who can't type.


I agree with all of this although I would just order the CT if you are iffy. I think it's better to be decisive and decide one way or the other on the first go around.


Here I disagree. When I see someone with one of these sheets I usually think 'medical student.'
EDIT: On the flip side, I do it myself occasionally when the ER is an absolute zoo. So, maybe your shop is always like that.



I disagree here too. I look at chief complaint and vitals, which is enough for me to enter in my first volley of orders, saving me precious time.
I don't waste time with a long history myself. Plus, if I ever do need a long history, I'd rather do it when all my labs and imaging are back, so that I can ask more targeted questions.



This I agree with 10000%.
For migraines, for example, I order a whole volley of meds, all given at once, with a note to nurse, "discharge after patient is feeling better from these meds."



Agreed. You can, however, order up the work up for the next doc but slyly remove your name from the chart, depending on your EMR.


Agreed. Five minutes might even be generous in some patients. For example, you see a patient writhing in pain to the RLQ, why do you need a history when you know a CT scan will tell you everything?



Or you can order both at the same time.


Ah, I disagree here. I made a rule after residency that I never pick up another patient until the chart is done on the current patient.
EDIT: On the flip side, I do this myself sometimes when it is zoo. So, again, maybe your shop is a zoo and you are forced to do this.
I feel like it just increases pressure and a huge headache afterward to have to do multiple charts in a row.

Yes, that's fine. I've done that before. But, you just can't dump it on the next guy.

Excellent advice.


Same.
You earn respect by nurses as well when you are hyper efficient.


BUT THE NUMBER ONE TIP I HAVE FOR PEOPLE IS: Try finding the job with the highest pay and lowest patient per hour. You will thank yourself.

Personally love batch charting, with dragon can knock out 30-40 charts in the last hour of the shift. Usually will do admitted patients at TOS mainly to make sure I am not missing something.

 

[southerndoc]

It takes some time, some longer than others and some/many on here may disagree but

1. Figure how to chart quickly. Most EMRs sucks but they all can be gamed to create a quick chart. This will date me but we used Dos Based Meditech for 17 years. Yeah, that EMR where you had to type everything and created before browser based. I gamed it where I could create a chart on avg in 2-3 minutes. I timed myself and completed 20 charts in 50 minutes. My charts were, IMO, top echelon for the group.

2. ORDER all studies ONCE. Do not nickle and dime. If someone with belly pain comes in, ORDER all the labs at one. Don't order a cbc and BMP then come back to add on LFTs when they are all normal, then come back and add a UA if everything is normal. If pt has a tender belly and you think a CT will be necessary then order it with Labs. If you are iffy about a CT, then make yourself a note

3. At the beginning of every shift, get a white blank sheet of paper. I put stickers of every pt I see with the room number and all labs/studies I ordered. If I am iffy about a CT, then I make a note to add one after labs back. This keeps you from constantly looking at the board and wondering what you are missing. This prevents me from missing anything. When all the boxes are checked, then pt gets discharged vs admitted.

4. Never read the nurses notes other than vitals/PMH/Meds. The rest is a waste of time 99% of the time and causes more things to worry about. My history/exam is better than the nurses.

5. ORDER all meds at once and do not nickle and dime it. See #2. A gastroenteritis comes in. I order 2L NS, Phenergan, zofran. After labs back and normal, they likely will go home. IF they are no better/worse they get admitted b/c I have given the college try of 2LNS and 2 doses of antiemetics. I rarely order meds more than twice before DC vs admission. I see too many docs doing 3-4 rounds of meds before making a decision. STOP this.

6. STOP seeing complicated pts or actually anything but a quick xray or zpak pt 2 hrs before your shift ends. I want to leave when my pay clock ends. No one pays me to stay extra or bring charts home so I am not working for free. If I leave at 9pm, then my last pt will be seen at 7pm. If there are some quick putts, then I may pick them up if its busy. Yes, I will cherry pick the last 2 hrs. This only works if you are fast and efficient, otherwise docs/staff will complain that you are slacking. But I am always seeing the most pph in my group and the rare times that someone sees more pph then they are staying back 2-3+ hrs to chart. I walk in, pick up 5-10 pts the 1st hour if busy, then float the rest of the shift seeing a leisure 2 pph which works out to 2-3pph but they are all front loaded.

7. 90% of the pts should have a H&P in less than 5 minutes. If you are regularly spending 10-15min a pt, then figure it out. Fix it. If you are spending 15 min a pt, then you will never be efficient.

8. U/S - unless you are looking for a baby or a DVT, it is NEVER 1st line. U/S for some reason takes so long. I get a CT first and U/S if needed. Almost never the other way around. Learned my lesson ordering a GB US which takes 3 hrs for a read. Then a CT after b/c US was neg. I go straight to CT and reduced my US rates drastically.

9. Batch charting. Its is just faster knocking them out in blocks than right after each pt. Its not only inefficient but pts pile up when busy.

10. Your time is just as valuable as any specialist. Invariably shift comes to an end and I call in an admission. I used to wait after my unpaid shift for their call. No more, learned my lesson. I page, leave the clerk my cell, and they can call me while I am driving home.

11. Last 2 hr of the shift is used to clean up all lose ends. Don't let a lose end linger right before your shift ends. Look at the rate limiting factor for you leaving on time and make it happen. Belly pain comes in and its 90 min til shift ends, then I ponder if I should pick it up but the ER is packed and so I pick it up. 1st thing I do, is go tell the nurse to please draw labs. Too many docs forget about it and at the end of their shift figure out nothing has been done. All the staff knows when my last 2 hrs is b/c everything is stat. My time is valuable. I will call/go to the rad box 30 min b/f my shift and tell them to bump it up b/c I need a read ASAP = I need to go home. Don't do this and you will turn around looking down at the barrel of another shift leaving late. Did I mention unpaid?



Do all of this and you will be at the top 1/4 of efficiency, leave on time, have high pph numbers, and be able to go to the cafeteria as often as you want. My partners never complains that emergentmd went to get coffee again b/c they know my pph is ridiculous and the board typically has my name on most of the pts. I have seen 48 pts in an 9 hr shift and left 1 hr after my shift ended with all charts done. Irritate that I gave the CMG an extra hr of free work.

Epic post. Should be a sticky.

 

[HemorrhagicShock]

How do you all dictate a chart in 2-3 minutes? Let's assume you have access to Dragon and Cerner/Epic or some other fairly widespread EMR.

Sure I get how this happens with a simple ankle sprain, or some other urgent care level complaint, but how do you dictate the ESRD patient who presents short of breath and dizzy, with a headache (all documented in the triage note) that has a history of uncontrolled diabetes, an IVC filter, and a chronic lower extremity diabetic ulcer wrapped up in a bulky dressing (that's POD x 10 from a toe amputation on the same foot)

Those notes routinely take me around 7-9 minutes and when 75% of your patients are that, well I just don't get how to see 2.5 an hour and get out on time with my charts done!

 

[HemorrhagicShock]

I have seen 48 pts in an 9 hr shift and left 1 hr after my shift ended with all charts done.

Fantastic post, but I simply do not believe you are able to do this without the help of PAs. This makes no sense unless your ED is effectively an urgent care with a CT scanner and gets little to no acuity or complexity. Admit rate must be close to zero, and/or you have zero pushback from consultants or admitting teams.

 

[emergentmd]

Here I disagree. When I see someone with one of these sheets I usually think 'medical student.'
EDIT: On the flip side, I do it myself occasionally when the ER is an absolute zoo. So, maybe your shop is always like that.

Think Med student is fine but my sheet prevents me from having to look at the meditech dos based computer which is know what is back and what is pending. So I have my sheet with pt sticker, box for every lab/studies ordered, do a lab/xray run every hour. Once all boxes gets checked, the pt goes home/admitted. We didn't have the fancy color coded screen that turns all green when everything is back.

I disagree here too. I look at chief complaint and vitals, which is enough for me to enter in my first volley of orders, saving me precious time.
I don't waste time with a long history myself. Plus, if I ever do need a long history, I'd rather do it when all my labs and imaging are back, so that I can ask more targeted questions.

90% of the time I just look at VS and CC. But the complicated ones I will look at pmh/meds b/c I almost never ask for meds.

Or you can order both at the same time.

Disagree. CT takes less than an hr to get back sometimes and gives me the diagnosis. Then if I batched ordered the US, they could be in imaging pushing my dispo back b/c it will not add anything. Just a waste of resources b/c CT will 95% of the time make US unnecessary.

Ah, I disagree here. I made a rule after residency that I never pick up another patient until the chart is done on the current patient.
EDIT: On the flip side, I do this myself sometimes when it is zoo. So, again, maybe your shop is a zoo and you are forced to do this.
I feel like it just increases pressure and a huge headache afterward to have to do multiple charts in a row.

Seeing pts is my first priority. I rather see another pt than have them sit for 5 min charting. I chart so fast that it prob doesn't matter with efficiency so rather just do it when I have 15 min or my golden 2 hrs.

Yes, that's fine. I've done that before. But, you just can't dump it on the next guy.

I never dump on next guy. I tell the next guy everyone I have on the board waiting for admission. I tell the clerk to give the consultant my cell phone and I will give them report driving home. I knew most of the consultants and I had their cell, so I would just text them. But there were a few that I didn't and I sure am not waiting for them to call back in an hr after surgery.

Same.
You earn respect by nurses as well when you are hyper efficient.

Some may not believe its possible but I worked in a busy referral center seeing 2.5-3pph on many shifts. I still went to get coffee 2-3x/shift, never missed lunch/dinner. NEVER. It takes 15 min and lets me decompress alittle and sometimes talk nonsense with hospital staff. Working 8-10 straight without a break is miserable. I will leave with 10 pt on the board or waiting 2 hrs b/c I am a better doc taking breaks. No one ever complained b/c they knew I saw more pts than they did. Docs would be shocked when I am out the door when my relief came eventhough there are 10 people waiting. No one dared complained b/c my pph were either 1 or 2 and I was the ER chief at my hospital.

That ER chief deal was the one thing that I could never figure out too well. Sometimes the CEO would want to talk about something dumb or the CNO walked through asking me to do something. That would put a wrench in my flow to leave the dept for 30 min.

 

[southerndoc]

How do you all dictate a chart in 2-3 minutes? Let's assume you have access to Dragon and Cerner/Epic or some other fairly widespread EMR.

Sure I get how this happens with a simple ankle sprain, or some other urgent care level complaint, but how do you dictate the ESRD patient who presents short of breath and dizzy, with a headache (all documented in the triage note) that has a history of uncontrolled diabetes, an IVC filter, and a chronic lower extremity diabetic ulcer wrapped up in a bulky dressing (that's POD x 10 from a toe amputation on the same foot)

Those notes routinely take me around 7-9 minutes and when 75% of your patients are that, well I just don't get how to see 2.5 an hour and get out on time with my charts done!

I dictate the history as I'm clicking buttons. Have a macro for ROS and physical exam and then change what's needed. For example, I have physical exam macros for asthma-mild, asthma-distress, copd-mild, copd-distress, chf-mild, chf-distress, appy, diverticulitis, right flank pain, left flank pain, PE (that includes leg exam for calf tenderness), etc. I hit one of those while I'm dictating, then change what's needed or delete what I didn't examine. Then I move to MDM and discuss all the lab findings, imaging findings, reassessments, plans, etc. I also put reassessments in the ED Course as I work the patient up (i.e., abnormal labs, I click on the abnormal lab and then comment if I compared it to previous, treatment I'm doing, etc.). 2-3 mins for a very quick chart, 5 mins top for a complicated chart. For differentials, I simply say "macro differential appendicitis" and Dragon will place pre-canned text. I have differentials for a ton of things.

 

[emergentmd]

Fantastic post, but I simply do not believe you are able to do this without the help of PAs. This makes no sense unless your ED is effectively an urgent care with a CT scanner and gets little to no acuity or complexity. Admit rate must be close to zero, and/or you have zero pushback from consultants or admitting teams.

This was Pre APCs and I remember the day well b/c it was my highest count. I never count APCs otherwise I would have some shifts seeing 10pph.

This was when we had a dedicated Fast Track, 9 hr shifts during a bad flu spike. Walked in, Board full of pts to be seen, Fast track full. Typically the outgoing doc runs the fast track last 2-3 hrs but he was either slow/bogged down. Anyhow, saw 15 pts my first hour. Prob a 2:1 mixture of Fast track:ER pts. Went to the Main ER which is where I typically started and saw the typical 3pph x 5hrs. That put me at 30 pts in 6 hrs. Last 3 hrs in Fast track and did another 18 pts which was more charting than anything else plus discharging my 5-6 main ER pts. Triage already swabbed them in Triage so my visit was either You have the flu and here is tamiflu or you are negative flu and here is a zpak.

Had about 20 fast track charts to do and finished it up in an hr. I new it was 48 pts b/c each side of my sheet held 20 stickers, back had 20 stickers and I had to use a 2nd sheet which was a rarity with 8 stickers.

Busy shift but less Critical care vs others shifts for sure. During the Flu season 60-75% of the pts are there for URIs.

No way I get close to 5pph now that APCs run the fast track and all I see are work ups.

 

[emergentmd]

How do you all dictate a chart in 2-3 minutes? Let's assume you have access to Dragon and Cerner/Epic or some other fairly widespread EMR.

Sure I get how this happens with a simple ankle sprain, or some other urgent care level complaint, but how do you dictate the ESRD patient who presents short of breath and dizzy, with a headache (all documented in the triage note) that has a history of uncontrolled diabetes, an IVC filter, and a chronic lower extremity diabetic ulcer wrapped up in a bulky dressing (that's POD x 10 from a toe amputation on the same foot)

Those notes routinely take me around 7-9 minutes and when 75% of your patients are that, well I just don't get how to see 2.5 an hour and get out on time with my charts done!

You need to fix your inefficiencies. No way it should take you 8 minutes to chart a pt. The last 5 yrs of my Hospital ER career, the APCs took Fast track and I was stuck doing all work ups. Charting still was 2-3 minutes. I had so many macros (my partners were shocked) and I literally copied/pasted with small changes b/c I had Macros for 95% of diagnosis. And if a new one came up, I just charted and created a new Macro. After Macros are done, its just copy and paste with minor changes.

If you are seeing 25 pts a shift and you are spending 5 minutes/pp more charting than me, that is over 2 HRS a shift. Its miserable staying back 2 hrs or bringing work home making your family miserable and not being paid. It took me a year figuring things out as an attending and I NEVER brought work home/stayed back more than an hr charting but on the very rare occasion prob once a yr. Bringing work home when the kids want to see you or your wife wants to hang out is miserable.

I have timed myself and in Meditech it took me 1 min to chart a simple bronchitis. Complicated pts took me 3 minutes. I never took more than 4 min doing a chart when I timed myself.

 

[emergentmd]

We had 6 shifts staggered with a new doc leaving about every 3 hrs during the busy times. I remember days when I came on shift 3, saw more than shift 2 doc, and walked out the door when my relief came who would say, "Shift doc 2 still here" while I am walking out the door shrugging my shoulder.

shift doc 2 is the epitome of getting burned out.

 

[Jabbed]

How do you all dictate a chart in 2-3 minutes? Let's assume you have access to Dragon and Cerner/Epic or some other fairly widespread EMR.

Sure I get how this happens with a simple ankle sprain, or some other urgent care level complaint, but how do you dictate the ESRD patient who presents short of breath and dizzy, with a headache (all documented in the triage note) that has a history of uncontrolled diabetes, an IVC filter, and a chronic lower extremity diabetic ulcer wrapped up in a bulky dressing (that's POD x 10 from a toe amputation on the same foot)

Those notes routinely take me around 7-9 minutes and when 75% of your patients are that, well I just don't get how to see 2.5 an hour and get out on time with my charts done!

Embrace the dirty secret that most of your note is designed for billing and 90% of ED notes are garbage.

I have Cerner and have 20-30 templated notes for all manner of chief complaints. HPI is prefilled based on the complaint but is mostly generic garbage (onset is gradual, severity is moderate, character is “pain”). ROS is also prefilled with CC-specific modifications (abdominal pain chart has “abdominal pain” and “nausea” circled already). PE is a doorway exam that would describe most human beings (awake, normal conjunctiva, regular rate and rhythm, no respiratory distress, etc). MDM is a ddx prepopulated based on CC. Between HPI/ROS/PE I’ll click maybe 5 things and dictate PE findings. With a totally nonsensical note that conveys no information you can bill a level 5 chart. At the bottom of my note I’ll dictate my diagnosis and then an abbreviated HPI/PE/MDM that’s meant to convey all the important information in my chart to any clinician that’s reviewing it. I don’t worry about meeting any billing criteria here because my chart is already a level 5.

I can do a quick chart in 2-3 minutes and a complex chart in 5 minutes.

 

[emergentmd]

Embrace the dirty secret that most of your note is designed for billing and 90% of ED notes are garbage.

I have Cerner and have 20-30 templated notes for all manner of chief complaints. HPI is prefilled based on the complaint but is mostly generic garbage (onset is gradual, severity is moderate, character is “pain”). ROS is also prefilled with CC-specific modifications (abdominal pain chart has “abdominal pain” and “nausea” circled already). PE is a doorway exam that would describe most human beings (awake, normal conjunctiva, regular rate and rhythm, no respiratory distress, etc). MDM is a ddx prepopulated based on CC. Between HPI/ROS/PE I’ll click maybe 5 things and dictate PE findings. With a totally nonsensical note that conveys no information you can bill a level 5 chart. At the bottom of my note I’ll dictate my diagnosis and then an abbreviated HPI/PE/MDM that’s meant to convey all the important information in my chart to any clinician that’s reviewing it. I don’t worry about meeting any billing criteria here because my chart is already a level 5.

I can do a quick chart in 2-3 minutes and a complex chart in 5 minutes.

The holy grail of charting.

Most CC H&P sounds the same except I change the age, sex, time of onset. Exam are all benign other than when it fits the narrative.

Change 3-5 items on the template and just copy/past away.

 

[Siggy]

The only nickle-and-dime I do is I order a BMP instead of CMP, since our lab's CMP takes FOREVER, thereby delaying CT scan waiting for the GFR. (I also do this for DKA patients so I get the K back sooner). I try to push radiology techs to take the patients without that coming back but they usually win, especially since they can just drag their feet. So, I order BMP, wait for that to come back and then call the lab to add on the LFTs.
The bottom line is that virtually every decision I make is based on throughput.

If you order a BMP and LFT at the same time instead of a CMP, will you get the BMP back prior to the LFT portion?

 

[Siggy]

How do you all dictate a chart in 2-3 minutes? Let's assume you have access to Dragon and Cerner/Epic or some other fairly widespread EMR.

Sure I get how this happens with a simple ankle sprain, or some other urgent care level complaint, but how do you dictate the ESRD patient who presents short of breath and dizzy, with a headache (all documented in the triage note) that has a history of uncontrolled diabetes, an IVC filter, and a chronic lower extremity diabetic ulcer wrapped up in a bulky dressing (that's POD x 10 from a toe amputation on the same foot)

Those notes routinely take me around 7-9 minutes and when 75% of your patients are that, well I just don't get how to see 2.5 an hour and get out on time with my charts done!

I can knock out a crit care consult note in 2-3 minutes with Cerner and Dragon... With Cerner, part of it is knowing the voice commands.

Saying "Next field" will bring you to the next set of brackets ([exam]).

"Next entry" will bring you to the next underscore ( _ ). I rarely use this one.

Most labs can be inserted by voice command ("insert blood gas" will populate the blood gas. "insert ventilation" will insert the vent settings if the RT has already documented it, etc).

"Next paragraph" gives you 2 lines. "Next line" gives you one.

The other thing is generous use of personalized power plans. I have a preset up power plan for ventilators that includes propofol, fentanyl, basic vent setting (rate 14, Vt 500, Fi 100, Peep 5), CXR, and ABG. Patient needs to be intubated? Anything short of a pure crash intubation and I'll have pharmacy already working on sedation.

Same thing with insulin drips... drip order, q1 hour accuchecks, hypoglycemia meds, and q6 hour BMP, mag levels get ordered in the span of 10 seconds.


Code blues? Cool, customized power plan by adding full set of labs and EKG to the vent power plan.

Frequently ordered things have their own folder. All the basic stat labs have their own entry in a "stat lab" folder (I do the same thing for AM labs, but that's not an ED issue).

How often are you ordering a unit of pRBC for HgB <7? Save that non-bleeding transfusion plan with a time of "now" and the drop down box for reason already set to "HgB <7." Now ordering pRBC takes 10 seconds.

 

[RustedFox]

I can knock out a crit care consult note in 2-3 minutes with Cerner and Dragon... With Cerner, part of it is knowing the voice commands.

Saying "Next field" will bring you to the next set of brackets ([exam]).

"Next entry" will bring you to the next underscore ( _ ). I rarely use this one.

Most labs can be inserted by voice command ("insert blood gas" will populate the blood gas. "insert ventilation" will insert the vent settings if the RT has already documented it, etc).

"Next paragraph" gives you 2 lines. "Next line" gives you one.

The other thing is generous use of personalized power plans. I have a preset up power plan for ventilators that includes propofol, fentanyl, basic vent setting (rate 14, Vt 500, Fi 100, Peep 5), CXR, and ABG. Patient needs to be intubated? Anything short of a pure crash intubation and I'll have pharmacy already working on sedation.

Same thing with insulin drips... drip order, q1 hour accuchecks, hypoglycemia meds, and q6 hour BMP, mag levels get ordered in the span of 10 seconds.


Code blues? Cool, customized power plan by adding full set of labs and EKG to the vent power plan.

Frequently ordered things have their own folder. All the basic stat labs have their own entry in a "stat lab" folder (I do the same thing for AM labs, but that's not an ED issue).

How often are you ordering a unit of pRBC for HgB <7? Save that non-bleeding transfusion plan with a time of "now" and the drop down box for reason already set to "HgB <7." Now ordering pRBC takes 10 seconds.

I wish we had any of that.
Even at the shop where I had Cerner/Dragon, we had none of those capabilities.

 

[Angry Birds]

If you order a BMP and LFT at the same time instead of a CMP, will you get the BMP back prior to the LFT portion?

No. The lab switches it to a CMP and then I have to wait 90 min.
So, what I do is wait for the BMP to switch to pending and only then order the LFT so they can’t do that to me. I don’t know why our CMP takes so many absurdly long. The lab denies it but it’s been my consistent experience.

 

[emergentmd]

Two more points

1. Learn to read your own Xrays and feel confident to send them home before the official read. You will save upwards of an hr many times. ER docs read better plain films than radiologist who have no history.
2. Learn to do procedures quickly.

 

[thegenius]

I agree with you. I freely order the CT scans in the first volley of orders if I think the patient fits my criteria for that, which includes old age and any number of other things including what the patient looks like from the door. It is almost never a problem with patients and is better for throughput, I agree.

The only nickle-and-dime I do is I order a BMP instead of CMP, since our lab's CMP takes FOREVER, thereby delaying CT scan waiting for the GFR. (I also do this for DKA patients so I get the K back sooner). I try to push radiology techs to take the patients without that coming back but they usually win, especially since they can just drag their feet. So, I order BMP, wait for that to come back and then call the lab to add on the LFTs.
The bottom line is that virtually every decision I make is based on throughput.

Angrybirds I don't want this to be intreperted in the wrong way. I find the bolded statement upsetting. I don't know if you literally mean that, I hope that isn't the case.

Note as well that I don't expect any ER doc to make decisions solely on EBM or what's best for the patient. We would have a non-functioning ER. We would be spending on average 30 minutes per patient trying to get a good history, a good exam, calling family, etc.

ER can be hard because 1 of every 4 patients have symptoms that don't fit into a "workup bucket". And one could argue in those cases just do more and order it all at once, but I posit that actually taking some extra time to review the chart, talk to the family, or review the prior CTs give valuable information that can hasten disposition.

Just my opinion

 

[thegenius]

Fantastic post, but I simply do not believe you are able to do this without the help of PAs. This makes no sense unless your ED is effectively an urgent care with a CT scanner and gets little to no acuity or complexity. Admit rate must be close to zero, and/or you have zero pushback from consultants or admitting teams.

I don't think this happens on a regular basis

 

[Angry Birds]

Angrybirds I don't want this to be intreperted in the wrong way. I find the bolded statement upsetting. I don't know if you literally mean that, I hope that isn't the case.

Note as well that I don't expect any ER doc to make decisions solely on EBM or what's best for the patient. We would have a non-functioning ER. We would be spending on average 30 minutes per patient trying to get a good history, a good exam, calling family, etc.

ER can be hard because 1 of every 4 patients have symptoms that don't fit into a "workup bucket". And one could argue in those cases just do more and order it all at once, but I posit that actually taking some extra time to review the chart, talk to the family, or review the prior CTs give valuable information that can hasten disposition.

Just my opinion

Let me put it this way: I always have throughput in mind, but this is with meeting the standard of care.

I agree with you about reviewing the past chart. I find this more useful than talking to family.
I generally leave "extensive history taking" (which includes talking to family) to a last step if I still can't figure out what's going on.
I would put it at 1 out of every 10 instead of 1 of every 4.

 

[HemorrhagicShock]

Thank you for all the tips everybody!

One of my personal "inefficiencies" is my risk tolerance and the need to document a lot in my MDM for various items that I perceive as risky. For me, it's about being able to sleep at night and part of that is knowing that I've fully documented my individualized decision-making process.

I do need to move on from this to some extent because ultimately you're damned if you do and damned if you don't!

 

[Angry Birds]

Thank you for all the tips everybody!

One of my personal "inefficiencies" is my risk tolerance and the need to document a lot in my MDM for various items that I perceive as risky. For me, it's about being able to sleep at night and part of that is knowing that I've fully documented my individualized decision-making process.

I do need to move on from this to some extent because ultimately you're damned if you do and damned if you don't!

I don’t give any d/d and plan to say, “I always consider XYZ…”

 

[lucid_leprechaun]

I don’t give any d/d and plan to say, “I always consider XYZ…”

I agree. I comment on why they’re here, pertinent labs/imaging, reevaluation, interventions, and disposition. If it’s complicated I may try and explain in more detail my decisions. I think a boxed ddx is kind of a waste of time, never all inclusive and is can literally be copy/pasted based on chief complaint.

 

[emergentmd]

Hem,

It’s ok to not include many if not most of what the other says.

If they came to the Er for abd pain then they don’t get to complain about the back pain 3 months ago, or the chronic headache for 2 yrs, or the knee pain for 3 yrs.

Sorry but my history and emr will not mention the other junk history if I am not working up.

If u think about every possible issue then u will make lots of mistakes

 

[thegenius]

Thank you for all the tips everybody!

One of my personal "inefficiencies" is my risk tolerance and the need to document a lot in my MDM for various items that I perceive as risky. For me, it's about being able to sleep at night and part of that is knowing that I've fully documented my individualized decision-making process.

I do need to move on from this to some extent because ultimately you're damned if you do and damned if you don't!

On that note...this is what I do. Note that I have scribes as well:
When I dictate / sign charts I ask myself
1) is this a low risk chart? - I literally dictate 1 or 2 sentences. I immediately hit sign without reviewing it the chart for accuracy. I don't even care if it's downcoded. I don't really care if the chart is accurate or the scribe makes a mistake. The reason is I spend ~2 minutes with the patient. These low risk charts have about a 0% chance of ending up in a lawsuit. e.g. med refills, woman wants Abx for UTI, covid testing, coryza w/ kid running around, etc.

2) is this a med risk chart - I dictate a few more sentences and review the exam. still a pretty low chance of a lawsuit.

3) is this a high risk chart - I'll spend as much time as I want to make sure I feel protected. This happens about 1/shift.

 

[BoardingDoc]

I don't even care if it's downcoded.

You either don't have a large portion of your salary based on productivity, or you care about money a lot less than I do.

I had a chart review done by our coding agency a few years ago. I was having a lot of lvl 4 charts downcoded to a 3 because of charting BS reasons. E.g. I didn't check that I reviewed old records or somesuch. I started doing that for every single patient visit (adds maybe 30 seconds) and the problem largely went away. The following year I made a solid 40k more. All of my BS patients have a chart written that will qualify for a lvl 4 visit, even if there's no way they ultimately get billed that way. All real patients I chart so that they will qualify for lvl 5 if they ultimately get coded that way.

 

[thegenius]

You either don't have a large portion of your salary based on productivity, or you care about money a lot less than I do.

I had a chart review done by our coding agency a few years ago. I was having a lot of lvl 4 charts downcoded to a 3 because of charting BS reasons. E.g. I didn't check that I reviewed old records or somesuch. I started doing that for every single patient visit (adds maybe 30 seconds) and the problem largely went away. The following year I made a solid 40k more. All of my BS patients have a chart written that will qualify for a lvl 4 visit, even if there's no way they ultimately get billed that way. All real patients I chart so that they will qualify for lvl 5 if they ultimately get coded that way.

I’m RVU.

On these low risk charts….they are most likely 99282 and 99283. The RVUs for those are 1.2 and 1.7 respectively. Even though I code all charts to a 99285, I don’t go over the details of the low risk ones because it’s not worth my time. The lost pay here is about 0.5 or $15 based on my multiplier.