It Just Takes a Minute!

[docB]

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I want to point out something about Emergency Physician productivity and the additional tasks we are being forced to take on. This is vitally important because productivity directly correlates to the money you get paid as an EP. Every additional task we must do that is not compensated or poorly compensated costs us money. All of the attendings already know this. Students and residents are less attuned to it. Because they don't yet equate time spent to less $$$ they are more accepting of new tasks. Here I attempt to explain why we have to be skeptical about adopting these tasks.

Lets look at a typical EP. Assume a 10 hour shift with 3 patients per hour for a total of 30 patients. What happens if we introduce a new task that takes 1 minute per patient (or averages to 1 minute per patient)? That is 30 minutes per day. That is 1.5 patients worth of lost productivity per shift per EP. If you're making $175/hour that's $87.50 you lose. If your ED sees ~120/day and has 4 EP shifts for 40 hours of coverage you are losing 6 patients per day of productivity. If your CPV (cash per visit = the average amount of actual money you take in per patient seen, this relates directly to your payer mix) is $125 that's $187.50 of lost income per doc per day. In the 4 shift example that's $750 per day or $22,500 lost per month or $270,000 lost per year.

So there it is. Adding a 1 minute task costs about half as much as it costs to employ an EP.

Let's take a look at some of the tasks or changes we have had to adopt in recent years:

• Medication reconciliation - totally unreimbursed, not our job, stuck to us by the Joint Commission because they can't make the PMDs do it as they don't fall under their purview.
  
  
• Supradiaphragmatic central lines only - More time consuming than femorals and you have to use ultrasound. The data on this seemed good but now there's contradictory data saying femorals were ok all along.
  
  
• Gowning for lines - Back in the day I could place a fem line in <5 min. Now doing fully gowned, US guided IJs it's a 30 minute process not counting waiting for and checking the CXR.
  
  
• CPOE - Computer Physician Order Entry has caused a loss of much more than a minute per patient. It is totally unreimbursed.
  
  
• EMR - Say whatever you want about quality or even billing these are much more time consuming than paper.
  
  
• Ultrasound - Do we really make back the time loss of doing our own untrasounds by billing for them?
  
  
• Deferral of Care - Screening out a nonemergent patient is much more time consuming than just treating and/or streeting them. Unless your hospital pays you extra for these it's lost time.
  
  
• Obs vs. Admit - Do you have to discuss/argue this with your admit docs? Do you have case managers who take your time to talk to you and "recommend" that you change the status? If so you are losing time for no additional money.
  
  
• No Drinks - Are you prohibited from having drinks at your desk? That means you will need to swing by the pantry or office every hour or so for a sip or just dry out. That's time lost to the drink nazis

.

All of these are either not reimbursed or poorly reimbursed. They all cost us money. Now some of them we have adopted based on data telling us it's the right thing to do clinically (supra diaphragmatic central lines). Others are purely to benefit some other stakeholder (Obs. vs. Admit) and others are just spiteful silliness (drink nazis). The point is not that we should never change. It is that change comes with a cost, a higher cost than many people realize. To be a good EP in your future groups you MUST be cognizant of these issues. You need to be skeptical (not obstinate, just skeptical) when told you need to do something new and you shouldn't mind because it only takes a minute.

 

[BADMD]

I'm with you, except for:

-Supradiaphragmatic central lines only

-Gowning for lines

I think there is very clear patient safety improvement with these two. The others are administrative BS. I'm not as convinced regarding the data on US guidance, but we have seen a significant reduction in CLABSI hospital wide with rigid adherence to putting in non-crash line in a completely sterile fashion. Yes it takes time, however for central lines, these practices are absolutely best PHYSICIAN practice.

 

[alreadylernd]

Nice post. The one thing I would add is that with EMR, charting is better (T-sheets are quick, but for sometimes for procedures not so helpful) which could help "productivity" and medical-legally as you can document MDM much better.

I want to point out something about Emergency Physician productivity and the additional tasks we are being forced to take on. This is vitally important because productivity directly correlates to the money you get paid as an EP. Every additional task we must do that is not compensated or poorly compensated costs us money. All of the attendings already know this. Students and residents are less attuned to it. Because they don’t yet equate time spent to less $$$ they are more accepting of new tasks. Here I attempt to explain why we have to be skeptical about adopting these tasks.

Lets look at a typical EP. Assume a 10 hour shift with 3 patients per hour for a total of 30 patients. What happens if we introduce a new task that takes 1 minute per patient (or averages to 1 minute per patient)? That is 30 minutes per day. That is 1.5 patients worth of lost productivity per shift per EP. If you’re making $175/hour that’s $87.50 you lose. If your ED sees ~120/day and has 4 EP shifts for 40 hours of coverage you are losing 6 patients per day of productivity. If your CPV (cash per visit = the average amount of actual money you take in per patient seen, this relates directly to your payer mix) is $125 that’s $187.50 of lost income per doc per day. In the 4 shift example that’s $750 per day or $22,500 lost per month or $270,000 lost per year.

So there it is. Adding a 1 minute task costs about half as much as it costs to employ an EP.

Let’s take a look at some of the tasks or changes we have had to adopt in recent years:

• Medication reconciliation - totally unreimbursed, not our job, stuck to us by the Joint Commission because they can’t make the PMDs do it as they don’t fall under their purview.
  
  
• Supradiaphragmatic central lines only - More time consuming than femorals and you have to use ultrasound. The data on this seemed good but now there’s contradictory data saying femoral were ok all along.
  
  
• Gowning for lines - Back in the day I could place a fem line in <5 min. Now doing fully gowned, US guided IJs it’s a 30 minute process not counting waiting for and checking the CXR.
  
  
• CPOE - Computer Physician Order Entry has caused a loss of much more than a minute per patient. It is totally unreimbursed.
  
  
• EMR - Say whatever you want about quality or even billing these are much more time consuming than paper.
  
  
• Ultrasound - Do we really make back the time loss of doing our own untrasounds by billing for them?
  
  
• Deferral of Care - Screening out a nonemergent patient is much more time consuming than just treating and/or streeting them. Unless your hospital pays you extra for these it’s lost time.
  
  
• Obs vs. Admit - Do you have to discuss/argue this with your admit docs? Do you have case managers who take your time to talk to you and “recommend” that you change the status? If so you are losing time for no additional money.
  
  
• No Drinks - Are you prohibited from having drinks at your desk? That means you will need to swing by the pantry or office every hour or so for a sip or just dry out. That’s time lost to the drink nazis

.

All of these are either not reimbursed or poorly reimbursed. They all cost us money. Now some of them we have adopted based on data telling us it's the right thing to do clinically (supra diaphragmatic central lines). Others are purely to benefit some other stakeholder (Obs. vs. Admit) and others are just spiteful silliness (drink nazis). The point is not that we should never change. It is that change comes with a cost, a higher cost than many people realize. To be a good EP in your future groups you MUST be cognizant of these issues. You need to be skeptical (not obstinate, just skeptical) when told you need to do something new and you shouldn't mind because it only takes a minute.

 

[docB]

I'm with you, except for:


I think there is very clear patient safety improvement with these two. The others are administrative BS. I'm not as convinced regarding the data on US guidance, but we have seen a significant reduction in CLABSI hospital wide with rigid adherence to putting in non-crash line in a completely sterile fashion. Yes it takes time, however for central lines, these practices are absolutely best PHYSICIAN practice.

Duly noted. However it is a totally unreimbursed practice that we have adopted. The reimbursement for central lines did not go up when this became dogma. We were simply forced to absorb the cost, i.e. take a pay cut to do it.

 

[Birdstrike]

I want to point out something about Emergency Physician productivity and the additional tasks we are being forced to take on. This is vitally important because productivity directly correlates to the money you get paid as an EP. Every additional task we must do that is not compensated or poorly compensated costs us money. All of the attendings already know this. Students and residents are less attuned to it. Because they don't yet equate time spent to less $$$ they are more accepting of new tasks. Here I attempt to explain why we have to be skeptical about adopting these tasks.

Lets look at a typical EP. Assume a 10 hour shift with 3 patients per hour for a total of 30 patients. What happens if we introduce a new task that takes 1 minute per patient (or averages to 1 minute per patient)? That is 30 minutes per day. That is 1.5 patients worth of lost productivity per shift per EP. If you're making $175/hour that's $87.50 you lose. If your ED sees ~120/day and has 4 EP shifts for 40 hours of coverage you are losing 6 patients per day of productivity. If your CPV (cash per visit = the average amount of actual money you take in per patient seen, this relates directly to your payer mix) is $125 that's $187.50 of lost income per doc per day. In the 4 shift example that's $750 per day or $22,500 lost per month or $270,000 lost per year.

So there it is. Adding a 1 minute task costs about half as much as it costs to employ an EP.

Let's take a look at some of the tasks or changes we have had to adopt in recent years:

• Medication reconciliation - totally unreimbursed, not our job, stuck to us by the Joint Commission because they can't make the PMDs do it as they don't fall under their purview.
  
  
• Supradiaphragmatic central lines only - More time consuming than femorals and you have to use ultrasound. The data on this seemed good but now there's contradictory data saying femoral were ok all along.
  
  
• Gowning for lines - Back in the day I could place a fem line in <5 min. Now doing fully gowned, US guided IJs it's a 30 minute process not counting waiting for and checking the CXR.
  
  
• CPOE - Computer Physician Order Entry has caused a loss of much more than a minute per patient. It is totally unreimbursed.
  
  
• EMR - Say whatever you want about quality or even billing these are much more time consuming than paper.
  
  
• Ultrasound - Do we really make back the time loss of doing our own untrasounds by billing for them?
  
  
• Deferral of Care - Screening out a nonemergent patient is much more time consuming than just treating and/or streeting them. Unless your hospital pays you extra for these it's lost time.
  
  
• Obs vs. Admit - Do you have to discuss/argue this with your admit docs? Do you have case managers who take your time to talk to you and "recommend" that you change the status? If so you are losing time for no additional money.
  
  
• No Drinks - Are you prohibited from having drinks at your desk? That means you will need to swing by the pantry or office every hour or so for a sip or just dry out. That's time lost to the drink nazis

.

All of these are either not reimbursed or poorly reimbursed. They all cost us money. Now some of them we have adopted based on data telling us it's the right thing to do clinically (supra diaphragmatic central lines). Others are purely to benefit some other stakeholder (Obs. vs. Admit) and others are just spiteful silliness (drink nazis). The point is not that we should never change. It is that change comes with a cost, a higher cost than many people realize. To be a good EP in your future groups you MUST be cognizant of these issues. You need to be skeptical (not obstinate, just skeptical) when told you need to do something new and you shouldn't mind because it only takes a minute.

Great post. You are a great asset to this forum. I couldn't have said it better.

 

[Zanegray]

I want to point out something about Emergency Physician productivity and the additional tasks we are being forced to take on. This is vitally important because productivity directly correlates to the money you get paid as an EP. Every additional task we must do that is not compensated or poorly compensated costs us money. All of the attendings already know this. Students and residents are less attuned to it. Because they don’t yet equate time spent to less $$$ they are more accepting of new tasks. Here I attempt to explain why we have to be skeptical about adopting these tasks.

Lets look at a typical EP. Assume a 10 hour shift with 3 patients per hour for a total of 30 patients. What happens if we introduce a new task that takes 1 minute per patient (or averages to 1 minute per patient)? That is 30 minutes per day. That is 1.5 patients worth of lost productivity per shift per EP. If you’re making $175/hour that’s $87.50 you lose. If your ED sees ~120/day and has 4 EP shifts for 40 hours of coverage you are losing 6 patients per day of productivity. If your CPV (cash per visit = the average amount of actual money you take in per patient seen, this relates directly to your payer mix) is $125 that’s $187.50 of lost income per doc per day. In the 4 shift example that’s $750 per day or $22,500 lost per month or $270,000 lost per year.

So there it is. Adding a 1 minute task costs about half as much as it costs to employ an EP.

Let’s take a look at some of the tasks or changes we have had to adopt in recent years:

• Medication reconciliation - totally unreimbursed, not our job, stuck to us by the Joint Commission because they can’t make the PMDs do it as they don’t fall under their purview.
  
  
• Supradiaphragmatic central lines only - More time consuming than femorals and you have to use ultrasound. The data on this seemed good but now there’s contradictory data saying femoral were ok all along.
  
  
• Gowning for lines - Back in the day I could place a fem line in <5 min. Now doing fully gowned, US guided IJs it’s a 30 minute process not counting waiting for and checking the CXR.
  
  
• CPOE - Computer Physician Order Entry has caused a loss of much more than a minute per patient. It is totally unreimbursed.
  
  
• EMR - Say whatever you want about quality or even billing these are much more time consuming than paper.
  
  
• Ultrasound - Do we really make back the time loss of doing our own untrasounds by billing for them?
  
  
• Deferral of Care - Screening out a nonemergent patient is much more time consuming than just treating and/or streeting them. Unless your hospital pays you extra for these it’s lost time.
  
  
• Obs vs. Admit - Do you have to discuss/argue this with your admit docs? Do you have case managers who take your time to talk to you and “recommend” that you change the status? If so you are losing time for no additional money.
  
  
• No Drinks - Are you prohibited from having drinks at your desk? That means you will need to swing by the pantry or office every hour or so for a sip or just dry out. That’s time lost to the drink nazis

.

All of these are either not reimbursed or poorly reimbursed. They all cost us money. Now some of them we have adopted based on data telling us it's the right thing to do clinically (supra diaphragmatic central lines). Others are purely to benefit some other stakeholder (Obs. vs. Admit) and others are just spiteful silliness (drink nazis). The point is not that we should never change. It is that change comes with a cost, a higher cost than many people realize. To be a good EP in your future groups you MUST be cognizant of these issues. You need to be skeptical (not obstinate, just skeptical) when told you need to do something new and you shouldn't mind because it only takes a minute.

This stuff really builds up. As a new attending I am really recognizing this now...

In my "community shop" we are still asked to put consults into the computer for the admitting doctor. We finally got to stop writing admission orders, but are asked to put in the consults "as a favor" to the admitting doctors. what? why are we doing them "favors"? They have remote access to the computers and can put them in themselves, just like the other orders. And - I got slammed once by my director for not consulting endocrine STAT on a DKA patient going to the unit. I had put "routine." Really - I didn't want the consult at all, managed the patient just fine on my own in the ED and as I saw it they were going to the unit who could consult or not consult as they saw fit. Argh! (anyway - just blowing off steam)
I don't see these metrics on the sheet they send me quarterly with my productivity -

 

[Arcan57]

This stuff really builds up. As a new attending I am really recognizing this now...

In my "community shop" we are still asked to put consults into the computer for the admitting doctor. We finally got to stop writing admission orders, but are asked to put in the consults "as a favor" to the admitting doctors. what? why are we doing them "favors"? They have remote access to the computers and can put them in themselves, just like the other orders. And - I got slammed once by my director for not consulting endocrine STAT on a DKA patient going to the unit. I had put "routine." Really - I didn't want the consult at all, managed the patient just fine on my own in the ED and as I saw it they were going to the unit who could consult or not consult as they saw fit. Argh! (anyway - just blowing off steam)
I don't see these metrics on the sheet they send me quarterly with my productivity -

I'd take having to enter them into the computer in a heartbeat compared to my current situation. Apparently all of the docs hate talking to each other because I'm stuck calling about 80% of the requested consults and it's mandatory that every ICU consult be called doc-to-doc (even non-emergent stuff like wound care or ID). Yesterday I had a good shift ruined by having to wait 45 minutes after having wrapped everything up just waiting for one of our less responsive intensivists to call back.

 

[la gringa]

i haven't done a billable ultrasound since residency. all of my sites have 24/7 diagnostic u/s. sometimes i'll do a look-see before cutting a questionable abscess or check underlying anatomy but it's not something i can bill as i'm not credentialed.

will use it to scout IJ and carotid but have trouble using it and doing the line w/o someone else to man the machine.

VERY glad we don't have drink hounds - most places the doc desk is in an area where it's never an issue. still not sure what the worst case scenario is for a doc having a bottle of water/gatorade or a cup of coffee, when pts have drinks or worse everywhere...

 

[glorfindel]

What a great post.

This one should get bumped approx once/month.

 

[WilcoWorld]

This one should get bumped approx once/month.

Yeah. After all, it only takes a minute.

 

[WilcoWorld]

In all seriousness, excellent points docB.

 

[Pharmavixen]

Delurking to comment on this one:

CPOE - Computer Physician Order Entry has caused a loss of much more than a minute per patient. It is totally unreimbursed.

Physicians have totally brought this on themselves by their complete intransigence regarding badly-written rxs that has been an issue for at least the 26 yrs I've been a pharmacist.

Maybe there wouldn't have been such a push for CPOE if the average dr's orders didn't look like you wrote them with your feet.

 

[KeyzerSoze]

Delurking to comment on this one:



Physicians have totally brought this on themselves by their complete intransigence regarding badly-written rxs that has been an issue for at least the 26 yrs I've been a pharmacist.

Maybe there wouldn't have been such a push for CPOE if the average dr's orders didn't look like you wrote them with your feet.

I could be wrong, but I think CPOE in this context is mainly as opposed to giving nurses verbal orders, so bad handwriting is pretty irrelevant.

Sent from my SCH-I535 using Tapatalk 2

 

[BJJVP]

Delurking to comment on this one:



Physicians have totally brought this on themselves by their complete intransigence regarding badly-written rxs that has been an issue for at least the 26 yrs I've been a pharmacist.

Maybe there wouldn't have been such a push for CPOE if the average dr's orders didn't look like you wrote them with your feet.

That prescription is unforgivable. BUT, 2 wrongs do not make a right.

Surgeons should not amputate the wrong leg, we should not give the wrong blood, and doctors should write legibly, etc. But the solution is not to make me, in the ED, fill out boat loads of anesthesia pre-op paperwork for sedation to reduce a shoulder in the ED. Documenting a time-out to do an emergent central line is silly. I shouldn't have 3 forms to fill out to do a central line. I shouldn't have to run to a computer to login, scroll down, click several times, override a tylenol-tylenol duplicate interaction (from when the pt was in the hospital last month), just to initiate an order for tylenol in a febrile child.

Sometimes, individuals screw up. We have to accept this in certain situations. This whole idea of changing a system just to avoid individual errors has been taken too far and has become almost crippling to the emergency department. Two nurses to double check blood before administering it in the ED? I agree. Marking the leg pre-operatively before the surgery? Great idea. BUT, when I was a resident, we couldn't get an abdominal stab wound with bowel evisceration to the OR because the nurse in the OR wouldn't accept the ED nurse's report. Apparently, they couldn't prep the OR until the pt was formally registered. The protocol didn't allow it. I realize this is an extreme example but numerous small delays and physician distractions that only "take a minute" do ultimately affect the doctor's ability to focus, handle multple pts, emergency physician longevity, and of course, pt care.

I remember being told once that most EKG's that are severely misread in the ED are not due to incompetence. It is usually due to the physician being distracted or rushed or pressured. I don't know if there was a study or this was anecdotal. But I believe most ER doctors would agree that this is very likely.

 

[docB]

Delurking to comment on this one:



Physicians have totally brought this on themselves by their complete intransigence regarding badly-written rxs that has been an issue for at least the 26 yrs I've been a pharmacist.

Maybe there wouldn't have been such a push for CPOE if the average dr's orders didn't look like you wrote them with your feet.

This is a case of the cure being worse than the disease. Many CPOE systems are very difficult and some even introduce safety issues. My system is good on some fronts but makes it very difficult to order certain things like drips. More than once I have been in the ED with the nurse standing next to me on the phone with pharmacy trying to order tPA or Levophed and none of us can make it happen.

 

[GeneralVeers]

CPOE actually saves me time. Before CPOE I used to spend at least 30 minutes of my day chasing down charts (usually with the RN in the room), double-checking that the Unit Support had put in the orders, and making sure they had been done. Now I can do all of this with a few moments of time.

I agree with the rest of the BS DocB pointed out. Most of it is chasing "never" events, that are impossible to actually make "never".

The one I still don't understand is food/drinks at the desk. I've had nursing administrators claim "infection control" but when I press them on the actual risk of infection brought about by food at my desk, as opposed to the food trays in patient rooms, they can't give me an answer.

 

[Flopotomist]

It is a miracle we haven't all died from the scourge of the coffee-spread bacterium that only JACHO seems to know about. Somebody should publish about this new bug - there is a serious lack of literature on it, and yet clearly the clinical importance is fundamental to the practice of medicine.

 

[deleted6669]

It is a miracle we haven't all died from the scourge of the coffee-spread bacterium that only JACHO seems to know about. Somebody should publish about this new bug - there is a serious lack of literature on it, and yet clearly the clinical importance is fundamental to the practice of medicine.

THE CURE FOR MANY STUPID RULES.....
work 100% nights.

no admin around EVER.
the joint commission never surveys at night.
I have an OPEN CUP OF COFFEE at my desk at work this very minute and every minute of every shift.
nurses at night know what happens on nights, stays on nights.

 

[la gringa]

CPOE actually saves me time. Before CPOE I used to spend at least 30 minutes of my day chasing down charts (usually with the RN in the room), double-checking that the Unit Support had put in the orders, and making sure they had been done. Now I can do all of this with a few moments of time.

totally agree... also can check that a med has been given, whether the lab has my specimens, etc etc.

no confusion about BMP vs BNP or med doses.

i think the good outweighs the bad for CPOE.

 

[la gringa]

It is a miracle we haven't all died from the scourge of the coffee-spread bacterium that only JACHO seems to know about. Somebody should publish about this new bug - there is a serious lack of literature on it, and yet clearly the clinical importance is fundamental to the practice of medicine.

sounds like a resident project! lmfao...

i wonder what grows in my bottle of water???

 

[Doctor Bob]

i wonder what grows in my bottle of water???

Giardia

 

[la gringa]

Giardia

well i'll just have to sprinkle some flagyl in my water...

 

[docB]

CPOE actually saves me time. Before CPOE I used to spend at least 30 minutes of my day chasing down charts (usually with the RN in the room), double-checking that the Unit Support had put in the orders, and making sure they had been done. Now I can do all of this with a few moments of time.

I agree with the rest of the BS DocB pointed out. Most of it is chasing "never" events, that are impossible to actually make "never".

The one I still don't understand is food/drinks at the desk. I've had nursing administrators claim "infection control" but when I press them on the actual risk of infection brought about by food at my desk, as opposed to the food trays in patient rooms, they can't give me an answer.

totally agree... also can check that a med has been given, whether the lab has my specimens, etc etc.

no confusion about BMP vs BNP or med doses.

i think the good outweighs the bad for CPOE.

I have found CPOE to be more time consuming than writing. The quality may be better and other aspects of the EMR such as data retrieval may be better but it is still more time consuming. Veers and I use different versions of the same product and I have found ordering drips and blood and certain tests to be really hard.

The point in general though is that everything we do takes time. If we devote that time to seeing another patient we make money. If we devote more time per patient for other things we lose money. Handing out business cards or surveys, "managing up," etc. all cost in raw dollars. They may be worth it in terms of back end money from HCAHPs or repeat business or warm fuzzies. But they cost.

 

[WilcoWorld]

well i'll just have to sprinkle some flagyl in my water...

But then you'd have to stop getting drunk at work.

 

[FSU2013]

But then you'd have to stop getting drunk at work.

decisions, decisions....

 

[Bostonredsox]

Ann Intern Med. 2012 Nov 20;157(10):JC5-8. doi: 10.7326/0003-4819-157-10-201211200-02008.
Review: Femoral and subclavian or internal jugular venous catheters do not differ for bloodstream infections.
Whalen F.

Relax, go back to putting in the fem lines, turns out the overall data is no increased risk of infection, if done under sterile conditions.

And I can throw a gown/mask/gloves on, slap a chloraprep on and a 3/4 sheet and still put in a fem line in <3 minutes so you should be ok there. All my ed docs have been doing this if they have time for a line, and if they couldnt put it in under sterile conditions for whatever reason I rip it out upstairs and put in an IJ, no biggy I have plenty of interns who need lines anyway. And if you do enough of them with a good nurse who knows how you like your stuff setup I can put in most US guided IJS in <8 minutes from gown to suture. Yeah your gonna wait atleast another 5+ for your xray though.

As for the med reconcilliation, our ED nurses do that.

I am assuming by US you mean the FAST scans? Not sure about the reimbursment there, but they are afterall, fast, and yes I understand the lost revenue with 1 extra minute, but your only doing them on your trauma pts and they can change management based on what you see. All the other US, transvag, DVT r/o, etc. are done by the US techs at our shop so you are just waiting on the rads read, which I know, can be far too long at times.

Agree on CPOE, we use it on the floors and it is horribly time consuming in my opinion.

Alot of the other stuff cant help you with. modern medicine = more time and paperwork to do the same crap we have been doing with less reimbursment for each.

I do make a point when I am on nights in the MICU to come down to the ED for their Codes and resp failures to take them over as they are coming to me anyway, and allow the ED doc to get back to the 14 pain seekers that need to be discharged, if things are quiet upstairs.

 

[Birdstrike]

Ann Intern Med. 2012 Nov 20;157(10):JC5-8. doi: 10.7326/0003-4819-157-10-201211200-02008.
Review: Femoral and subclavian or internal jugular venous catheters do not differ for bloodstream infections.
Whalen F.

Relax, go back to putting in the fem lines, turns out the overall data is no increased risk of infection, if done under sterile conditions.

And I can throw a gown/mask/gloves on, slap a chloraprep on and a 3/4 sheet and still put in a fem line in <3 minutes so you should be ok there. All my ed docs have been doing this if they have time for a line, and if they couldnt put it in under sterile conditions for whatever reason I rip it out upstairs and put in an IJ, no biggy I have plenty of interns who need lines anyway. And if you do enough of them with a good nurse who knows how you like your stuff setup I can put in most US guided IJS in <8 minutes from gown to suture. Yeah your gonna wait atleast another 5+ for your xray though.

As for the med reconcilliation, our ED nurses do that.

I am assuming by US you mean the FAST scans? Not sure about the reimbursment there, but they are afterall, fast, and yes I understand the lost revenue with 1 extra minute, but your only doing them on your trauma pts and they can change management based on what you see. All the other US, transvag, DVT r/o, etc. are done by the US techs at our shop so you are just waiting on the rads read, which I know, can be far too long at times.

Agree on CPOE, we use it on the floors and it is horribly time consuming in my opinion.

Alot of the other stuff cant help you with. modern medicine = more time and paperwork to do the same crap we have been doing with less reimbursment for each.

I do make a point when I am on nights in the MICU to come down to the ED for their Codes and resp failures to take them over as they are coming to me anyway, and allow the ED doc to get back to the 14 pain seekers that need to be discharged, if things are quiet upstairs.

The way I always looked at it was like this: If a patient truly needs a line for an "emergency" (see thread on if that even means anything anymore) then I'm going to put it in as fast as possible by whatever route possible to decrease the life or limb threat from whatever it is. If I had time to fumble-fart around with surgical draping, getting the ultrasound, getting the sterile US-probe condom-thingy, threading that over the probe sterile with a non-sterile assistant, etc, etc, etc, then the line no longer is emergent at that point. Once the "emergency" is stabilized, the admitting team can take all the time in the world to put in their utopian ultrasound-guided, surgical-prepped and draped line in their controlled, non-chaotic setting and then promptly remove the life-saving yet rushed, femoral line that was put in, if they want to prevent a line infection (which takes time to manifest).

Yeah, I know, silly and old fashion talking about "emergencies" and stuff.


EMERGENCY = Quick and insured Level 3, that's been waiting longer than a 15 minute "door-to-greet" time, who is checking the competitions "door-to-greet" time on their mobile app.

 

[deleted109597]

Time for some IO action. Saves time. No reason not to use it if you're trying to manage multiple sick people at once.


Oh, CPOE and EMR aren't the panacea we hoped they would be. Sure, some systems work better than others. But now we have the OIG claiming that we are being fraudulent because EMR systems have higher billing codes than non-EMR. Sure, some people might be documenting more than they do, but they probably did that on paper too. It's probably more along the lines of the fact that EMR are easier to code from.

Our secretary used to sit at the desk and enter orders, and it would sometimes take a long time if 3-4 charts poapped up at once. Now she sits at the desk and talks to people, while docs put the orders in. Because the nurses don't know how to look for orders, we had to put the charts in the "orders in" rack for awhile, so the time to medication delivery really didn't change, just the speed at which the order went from my brain to the computer.

Also, because the system isn't user friendly, we don't know what is in our pyxis vs what's in the pharmacy, and since there are ~8 options for each med (dose, volume, concentration, etc), about half the time we order the wrong one and it takes longer to get to us. Or we have to change the order. Which just takes a minute.

 

[docB]

I think I have failed in the original intent of my post. By citing examples of time consuming practices I have inadvertently started a debate about those specific practices rather than a discussion of the fact that additional tasks results in lost productivity.

Ann Intern Med. 2012 Nov 20;157(10):JC5-8. doi: 10.7326/0003-4819-157-10-201211200-02008.
Review: Femoral and subclavian or internal jugular venous catheters do not differ for bloodstream infections.
Whalen F.

Relax, go back to putting in the fem lines, turns out the overall data is no increased risk of infection, if done under sterile conditions.

And I can throw a gown/mask/gloves on, slap a chloraprep on and a 3/4 sheet and still put in a fem line in <3 minutes so you should be ok there. All my ed docs have been doing this if they have time for a line, and if they couldnt put it in under sterile conditions for whatever reason I rip it out upstairs and put in an IJ, no biggy I have plenty of interns who need lines anyway. And if you do enough of them with a good nurse who knows how you like your stuff setup I can put in most US guided IJS in <8 minutes from gown to suture. Yeah your gonna wait atleast another 5+ for your xray though.

As for the med reconcilliation, our ED nurses do that.

I am assuming by US you mean the FAST scans? Not sure about the reimbursment there, but they are afterall, fast, and yes I understand the lost revenue with 1 extra minute, but your only doing them on your trauma pts and they can change management based on what you see. All the other US, transvag, DVT r/o, etc. are done by the US techs at our shop so you are just waiting on the rads read, which I know, can be far too long at times.

Agree on CPOE, we use it on the floors and it is horribly time consuming in my opinion.

Alot of the other stuff cant help you with. modern medicine = more time and paperwork to do the same crap we have been doing with less reimbursment for each.

I do make a point when I am on nights in the MICU to come down to the ED for their Codes and resp failures to take them over as they are coming to me anyway, and allow the ED doc to get back to the 14 pain seekers that need to be discharged, if things are quiet upstairs.

The studies that discredited femoral lines came out in ~2002. We weren't forced to abandon them until we got ED ultrasound in about 2009. We currently have a policy that if a femoral line is placed the doctor must document why an IJ or SC was not used. Now that the literature has reconsidered it will likely be 7 years until I am allowed to do femorals again.

I'm not trying to be confrontational but your description of how little time these tasks take and how quickly you can do them speaks to my point about doctors justifying these uncompensated tasks. Saying that you can do a fully gowned central line in 8 minutes is great. That means that if you are an EP and you do 2 in a shift (not unusual for my shop) you will lose ~1 patient of productivity. This is not to be taken lightly.

In my area nurses are prohibited from doing the med recs. The Joint Inquisition wants doctors to do them.

Time for some IO action. Saves time. No reason not to use it if you're trying to manage multiple sick people at once.


Oh, CPOE and EMR aren't the panacea we hoped they would be. Sure, some systems work better than others. But now we have the OIG claiming that we are being fraudulent because EMR systems have higher billing codes than non-EMR. Sure, some people might be documenting more than they do, but they probably did that on paper too. It's probably more along the lines of the fact that EMR are easier to code from.

Our secretary used to sit at the desk and enter orders, and it would sometimes take a long time if 3-4 charts poapped up at once. Now she sits at the desk and talks to people, while docs put the orders in. Because the nurses don't know how to look for orders, we had to put the charts in the "orders in" rack for awhile, so the time to medication delivery really didn't change, just the speed at which the order went from my brain to the computer.

Also, because the system isn't user friendly, we don't know what is in our pyxis vs what's in the pharmacy, and since there are ~8 options for each med (dose, volume, concentration, etc), about half the time we order the wrong one and it takes longer to get to us. Or we have to change the order. Which just takes a minute.

My main reason not to do IOs is that I'll have to go back and do a gowned, US guided IJ later anyway. May as well get it over with.

Your point about what preparation of drug is in the Pyxis is right on. We use a lot of COPE favorites and plans. If you enter, for example, your CAP plan and the rocephin has been changed from the vial to the 50cc bag the whole process comes to a crashing halt while you and nursing and pharmacy try to pick up the pieces. We recently had a shortage of Nitro paste. We had to switch to the patches. That meant that every CP plan you launched you had to go back and change it to the patch which was a pretty inconvenient task.

 

[deuist]

I shouldn't have 3 forms to fill out to do a central line.

We don't fill out any. The chair of my department has stated that every central line placed in the ED is considered emergent. All of our procedure notes begin with, "Central line placed under emergent conditions that precluded obtaining informed consent," even on awake patients.

 

[Bostonredsox]

I also fill out no paperwork for any line i place. I sign a dotted line on consent sheet that nurse fills out and I dictate a 30 sec procedure note. thats it.

And Docb, wasnt tryign to show 'line prowess' was just saying they are a bit faster than 30min after repitition with the US. But yes, they slow ED docs down alot given ed volume. At my shop I am on ED-ICU admit process team and we came up with a system where unless there is an inordiante amount of time in ED, or their is a credentialed resident on the ED service that month that can be an extra set of hands, if a pt needs emergent line, ED doc throws in fem and I chaneg it if needed upstairs. No reason to waste any extra time putting in IJ or subclav when your that busy in ED. they are not going to get infected in 90 minutes. plus atleast at my shop, the CCU nurses are far more equipped at assisting in procedures and I prefer them to our ed nurses by a substantial amount.

 

[southerndoc]

Not to derail the thread, but effective October 2012 Medicare no longer reimburses for iatrogenic pneumothoraces. We're getting a push to place more IJ's instead of subclavians even though the rate of iatrogenic PTX is pretty low at my institution.

 

[Bostonredsox]

Not to derail the thread, but effective October 2012 Medicare no longer reimburses for iatrogenic pneumothoraces. We're getting a push to place more IJ's instead of subclavians even though the rate of iatrogenic PTX is pretty low at my institution.

This, will finally get my horrible administration to buy us our own ultrasound for the unit. One of our surgical attendings was floored when he found out they wouldnt buy us one. He said, stop doing IJs, start putting in sublclavians, drop a few lungs and theyll buy you what you need. Well, they dont care about outcomes it seems here, just $, so maybe this will get me my standard of care equipment. And then as bonus I can do bedside echo.

 

[EM2BE]

Another is "I know you are leaving, but can you do ____ really quick before you go? I know you signed out..." I hide for this reason and I still get found and bothered about patients I signed out and have another person's name there next to the pt in the system so they know who to bother. I'm getting better at saying "Go ask _____" but it's still yet another interruption while I'm trying to finish up dictations to leave.

Often, the "really quick" task is to talk to family. This is never fast.

 

[docB]

This post from another thread points out another way we will be forced to slow down.

To be quite honest, had I known that Obamacare was going to become law and be supported by the court, I would have probably gone into family medcine. Although you can open an urgent care as an EM guy, it is probably easier to break free of the system and open a cash concierge practice if you are in one of the chronic care fields. Also, although the ACEP position that we only consume x% of healthcare dollars as a speciality is correct, as acute care physicians we do provide expensive care because we have to make up for a lack of knowledge about a given patient obtained over time with testing. In a cost controlled world this is going to become increasingly unacceptable and will probably increase our malpractice risk as we will be less able to order what we need to order without any changes in the standard of care to which we are held.

Something to consider.

Sent from my A110 using Tapatalk 2

Old_Mil is spot on with this. We will have to spend more time searching through records to see if the patient has had similar testing recently. This wasn't even an option in the past with paper records. Now with EMRs we'll be expected to know if they had a CT at a sister hospital last week. And if they did we'll be forced to justify a new one or the hospital won't get paid. Once we get to that point I will guarantee the process for ordering stuff will become really difficult and time consuming.