Strategies for working more efficiently in the ED

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https://efficientmd.com/8-strategies-to-help-you-leave-your-shift-on-time/

 

[RustedFox]

Strategies for working more efficiently in the ED:

1. Kill the administrators.
2. See Rule 1.
3. Increase staffing to reasonable ratios to actually achieve good outcomes.
4. Ban Press Ganey and similar items.
5. Respect that the physician is the one making the medical decisions, and allow he/she time to "think".

I got more. Gotta go to the store.

 

[GeneralVeers]

Allow me to eat at my desk. My food IS NOT a direct threat to any patients, perhaps less so than the hospital meal tray. This way I can use those 15-20 minutes to take calls from consultants, view labs that are coming back, and order new things if necessary. Otherwise I have to take a 30 minute break from the ED to go eat, which means everything grinds to a halt in the meantime.

 

[thegenius]

dump emtala

efficiency has new meaning then.

 

[bravotwozero]

I don't think EMTALA should be dumped. You will see a crap ton of patient dumping by hospitals if we get rid of EMTALA. Your volume will also drop, and you will make less money.

 

[smokn]

This thread has the potential to be useful, but there’s already a strong whiff of it devolving into the irrelevant. @OP, interesting article.

 

[Paperman]

Strategies for working more efficiently in the ED:

1. Kill the administrators.
2. See Rule 1.
3. Increase staffing to reasonable ratios to actually achieve good outcomes.
4. Ban Press Ganey and similar items.
5. Respect that the physician is the one making the medical decisions, and allow he/she time to "think".

I got more. Gotta go to the store.

Classic RF!

 

[GeneralVeers]

This thread has the potential to be useful, but there’s already a strong whiff of it devolving into the irrelevant. @OP, interesting article.

When I see patients I open a note, and put the greet time. That way it's locked in. When I'm read to discharge or admit a patient, I put in the discharge/admit info in the note at the bottom (this is Cerner). When the next doc comes on or I get a break, I will sit and finish up the middle portions of the chart. This way I'm not delaying care by working on charting, and I'm not staying after shift to finish everything.

 

[TheComebacKid]

I find many nursing practices to be quite frankly, obstructionist, and detrimental to patient care, and waste my time.

"Place a foley"

"I can't get in"

"Use a coude"

"It's against the policy. Nurses aren't allowed to place coudes. MD has to."

In today's day and age, if a nurse "feels uncomfortable" they are basically absolved of all responsibility for doing a particular task. Furthermore, if you call them out on it, you are stuck taking workplace anger management classes because they start crying and report you to their supervisor.

And for god sake, just get the goddamn urine sample. You know the urine is important, why are you letting this dude piss all over himself in the bed.

For working at a "magnet" hospital, I find the nursing administration and their policies to be reprehensible, and overall, slow down my workflow. While a good nurse is invaluable, so many of them are so, so bad.

 

[deleted547339]

I find many nursing practices to be quite frankly, obstructionist, and detrimental to patient care, and waste my time.

"Place a foley"

"I can't get in"

"Use a coude"

"It's against the policy. Nurses aren't allowed to place coudes. MD has to."

In today's day and age, if a nurse "feels uncomfortable" they are basically absolved of all responsibility for doing a particular task. Furthermore, if you call them out on it, you are stuck taking workplace anger management classes because they start crying and report you to their supervisor.

And for god sake, just get the goddamn urine sample. You know the urine is important, why are you letting this dude piss all over himself in the bed.

For working at a "magnet" hospital, I find the nursing administration and their policies to be reprehensible, and overall, slow down my workflow. While a good nurse is invaluable, so many of them are so, so bad.

Heaven forbid an uncomfortable nurse....

 

[TheComebacKid]

Heaven forbid an uncomfortable nurse....

I'm not sure if you are agreeing with me or mocking me.

Our jobs involve us being uncomfortable. That doesn't absolve you of doing what's right for the patient. Stepping out of your comfort zone is part of working in the ED whether you are a physician or a nurse.

But throwing your hands up and saying "I'm uncomfortable! Not doing this!" without trying or learning and pawning it off to someone else is pretty weak sauce in my book, especially when the patient needs an intervention.

 

[emergentmd]

1. It is OK not to order everything just bc you can
2. Order everything at the beginning to dispo the pts. Don't nickle and dime. It pains me when a doc orders labs for RLQ pain and then orders the CT if the WBC is high or even normal. Just order the CT at first and it saves you 2 hrs.
3. Learn to chart fast. you need to figure this out yourself. I can do an EMR chart in 2-3 minutes. Create Templates, copy and past. 99% of the charts all reads the same anyhow. There is just very little variation in a bronchitis and the variations matter little.
4. 2 hrs before your shift ends bug the nurse, rad tech to get the stuff done. Don't think it is done and 10 min before your shift figure out labs weren't drawn. The squeaky gets the grease.
5. If you are double covered, don't pick anything complicated 60-90 before your shift. If you do, order stuff and pass it off to the next doc. No one is going to complain if you order a bunch of labs on belly pain, peek in to make sure they are stable, and pass it on to the next doc that you ordered stuff and haven't examined them.
6. Learn to Type fast, if not get dragon or a scribe.
7. You know your disposition on 95% of the pts after talking to them. Order labs and get them out or admitted. No need to solve all of their problems.

Do all of this and you will rarely stay back. I would say in a month, I would stay back more than an hour once and that must have been a high volume shift. Usually I am out the door when the new guy comes in. Everyone is always shocked when I leave right on time, while other docs are staying back 2 hrs to chart. I have worked at busy sites, no scribes, no dragon. See 2.5-3 pph (no fast track) and leave right on time. Yes, that means seeing 24 pts in an 8hr shift and leaving right at 8 hrs.

 

[deleted547339]

I'm not sure if you are agreeing with me or mocking me.

Our jobs involve us being uncomfortable. That doesn't absolve you of doing what's right for the patient. Stepping out of your comfort zone is part of working in the ED whether you are a physician or a nurse.

But throwing your hands up and saying "I'm uncomfortable! Not doing this!" without trying or learning and pawning it off to someone else is pretty weak sauce in my book, especially when the patient needs an intervention.

I am 100% agreeing with you.
Me: Hey RN X, please do this safe and life saving intervention
RN X: that makes me uncomfortable and isn’t in the scope of practice
Me: I’m pretty sure it is, I do it all the time. It will be fine.
RN X: uhhhh....talk to the charge.

Email: you have poor nursing communication skills.

Thankfully, the nurses in my ER are too green to push back on much, my ICU nurses on the other hand.

 

[AlmostAnMD]

Me: Hey RN X, please do this safe and life saving intervention
RN X: that makes me uncomfortable and isn’t in the scope of practice
Me: I’m pretty sure it is, I do it all the time. It will be fine.
RN X: uhhhh....talk to the charge.

Email: you have poor nursing communication skills.

I thought I posted this before I realized it wasn't me

I don't have much else to add

 

[Psai]

I am 100% agreeing with you.
Me: Hey RN X, please do this safe and life saving intervention
RN X: that makes me uncomfortable and isn’t in the scope of practice
Me: I’m pretty sure it is, I do it all the time. It will be fine.
RN X: uhhhh....talk to the charge.

Email: you have poor nursing communication skills.

Thankfully, the nurses in my ER are too green to push back on much, my ICU nurses on the other hand.

Smh

 

[thegenius]

I don't think EMTALA should be dumped. You will see a crap ton of patient dumping by hospitals if we get rid of EMTALA. Your volume will also drop, and you will make less money.

We would get along just fine. I doubt any other country has something like EMTALA and people aren't dying left and right, or waiting 2 days to get an xray.

Now lower volumes would reduce my pay, and that would suck.

However overall, the fact that every ER doctor wants to say "just leave the ER now you are not sick" for about 1 out of every 5 patients that walk into the ER suggests that there is massive abuse of the ER.

Or, don't call it an ER, call it "Instant Care Room", and staff it with pediatricians and internal medicine docs that are there for us to turf the totally non sick shiit to.

Or allow us to charge people money or else they don't get anything. "Ma'am, you have a UTI. This is not an emergency. If you want antibiotics, please pay this ER $100. Then we will give you a prescription."

 

[deleted836128]

Great post. Here are some ways I try to be more efficient:

1) I thin slice. Sometimes when I am slammed with having to see six patients at once, I quickly stop by the door and say, “Just wanted to get a quick history so I can order some tests and speed up the process for you. Then I will be back later to talk more and get a good exam.” I get a quick run down of the case and do my crazy “Have you had feverschestpainproblemsbreathingcough?” sort of thing. I quickly add in orders and move onto the next. Then I go back in and get a more thorough H and P later. Usually I find that I got the jist of the case the first time and don’t even need to order anything else.

2) I front load at the beginning of my shift... taking six to seven or so in the first hour. I will take a few here and there until the halfway point of my shift when I pick up another bolus of patients.

3) I do tend to document at least the HPI, ROS, and PE briefly, along with my first sentence of my MDM, before seeing the next patient. Firstly it’s a way of rethinking the case through in my mind. I find that if I don’t do this I am more likely to forget to order something. It’s also much more efficient to just knock the chart mostly out of the way from the get go rather than struggling to remember things later on. When the patient is ready for dispo, I import all the labs and imaging. This is another check point in place to make sure I didn’t miss anything. Then I order the discharge, and finish the bottom of the chart (diagnosis, discharge or admit time, patient education, follow up). Later all I have to do is the MDM.

I also use to meditate during my shifts - seriously. I would take five minutes to sit in a dark room and do a guided meditation. It made a world of difference. I could walk back into my shift feeling completely centered, no longer frazzled. I need to do that more often.

 

[GeneralVeers]

Or allow us to charge people money or else they don't get anything. "Ma'am, you have a UTI. This is not an emergency. If you want antibiotics, please pay this ER $100. Then we will give you a prescription."

We are actually allowed to do this under EMTALA. Once we've established that there is no emergency medical issue, we are not obligated to do any further treatment or evaluation. It is hospitals that drive us to treat everyone. The CEOs are bonused on patient satisfaction, and even these non-paying urgent care patients get surveys. Additionally these patients for some reason have every right to send a complaint letter even though they have no intention of paying for their services. Complaint letters are the quickest way an EP has to losing a job.

 

[hundreddaysoff]

For working at a "magnet" hospital, I find the nursing administration and their policies to be reprehensible, and overall, slow down my workflow. While a good nurse is invaluable, so many of them are so, so bad.

FWIW, I have found nursing policies and personalities overall to be better in community shops vs "magnet" academic places. There is less drama and ego and more of a feeling that we're all on the same team. I chalk it up to a combination of more inexperienced RNs + can attract more micromanaging personalities that will take the ego gratification they need in exchange for less pay.

 

[namethatsmell]

FWIW, I have found nursing policies and personalities overall to be better in community shops vs "magnet" academic places. There is less drama and ego and more of a feeling that we're all on the same team. I chalk it up to a combination of more inexperienced RNs + can attract more micromanaging personalities that will take the ego gratification they need in exchange for less pay.

I've found "cuz rules" is equal opportunity.

 

[thegenius]

So lemme ask a question as I would like to be more efficient in the ED. How do you guys approach a patient like the following:

EMR says: Doe, Jane 47 yr COUGH 88 155/95 16 97% 99.0 1:21
(the last number is how long they have been waiting)

I'll usually look in the EMR for 20 seconds just to get an idea if they come all the time, every now and then, maybe quickly scan a Discharge Summary if one exists to see what their medical problems are. (In all honestly, I usually don't though as I would rather just see the patient.)


So I go into the room,
"Hi I'm Dr. Jerry Garcia, what is your name?"
"Jane Doe"
"Nice to meet you Jane. How can I help you?"
"Well, I've been coughing for about a week, can't really shake it, and my sinuses hurt"



Now....the above takes 20-30 seconds. By that time I've seen the patient sitting on the gurney. Pt is in absolutely no distress. Not coughing. Looks great. I know right now the patient doesn't need to be here, and this is best taken care of by an outpatient doctor. We all know that this patient does not have a medical emergency.

Now, this is like choose your own adventure LOL. Do you
1) immediately proceed to a very targeted PE. Listen to the lungs. Maybe look in the back of the throat. What else is there to do?
2) ask several more questions about history....is your cough productive, fevers, do you smoke, is it worse at night, blah blah....and ask questions about GERD, asthma, PND, etc.


I almost always do #2, and I wonder since there isn't much in #2 that is going to change my mgmt, maybe it's just a waste of time. I might ask if they smoke though, but does it really matter?


So you choose #1, and the lungs are:
1) clear...at that point they likely have bronchitis. Or maybe a URI, or PND. Whatever. It doesn't matter. You just want them to leave. Do you ask "what can I do to help you?" Or just say "you want some antibiotics?" Or just say "I'll prescribe you some meds like prednisone, azithromycin, and albuterol" and just walk out, or even give more like tylenol w/ codeine, phenergan with codeine, or just write them like 5 prescriptions just to get them out?

2) you hear very mild wheezing. so bronchitis with wheezing, maybe mild bronchospasm. Do you want them to get a neb in the hospital? Depending on the time of day, 1 neb will take about 1 hour of time...by the time you go back in to re-evaluate them.


I'm trying to propose a scenario whereby somebody has a complaint and it doesn't matter at all what you do. You can order all the labs and CXR's that you want, you can order 0 thru 5 different treatments or not write any Rx or write a bunch. There will not be a bad outcome, statistically speaking, with this patient.

In this case there isn't a lot of information you could uncover that would make you think the pt has an emergency:
- whether the cough for 3 days, 3 wks, or 3 months
- what treatments they have already tried
- presence of phlegm or color or it
- the list goes on and on



For some reason I choose options that lead me to talk alot, get more information from the patient, and really try to determine if the cough is bronchitic, GERD, asthma, URI, PNA, or whatever else. And I think it's largely a waste of time.

 

[deleted836128]

I do the same thing, TheGenius, and I bet admin wishes I wouldn’t! I usually ask a fairly complete ROS for everyone. The worried well get the “Feverschillsbreathingproblems? Vomiting? Peeing and pooping OK?” But the older people or sick people - I tend to do a lot of digging because it often takes a few minutes to get important details out of them. I really like a complete chart so I will ask about treatments attempted, past history of similar issues, what color the sputum is, how many times they vomited, etc. It usually just doesn’t change outcomes but I can’t get away from it!!!

 

[thegenius]

I do the same thing, TheGenius, and I bet admin wishes I wouldn’t! I usually ask a fairly complete ROS for everyone. The worried well get the “Feverschillsbreathingproblems? Vomiting? Peeing and pooping OK?” But the older people or sick people - I tend to do a lot of digging because it often takes a few minutes to get important details out of them. I really like a complete chart so I will ask about treatments attempted, past history of similar issues, what color the sputum is, how many times they vomited, etc. It usually just doesn’t change outcomes but I can’t get away from it!!!

I've got a habit that part of me doesn't want to stop, but it takes time. I always (well 9/10) ask the same beginning questions:
- what are your chronic medical problems
- what medicines do you take on a regular basis
- any major surgeries?
- smoke or drink?
ok...so what brings you in today?

Now I can look this stuff up too most of the time. But I have a thing about NOT wanting to look at prior med/surg and previous admissions because it biases you when you see the patient.

I'm very slowly beginning not to ask all those questions, but it's hard not to.

 

[n2b8me]

So lemme ask a question as I would like to be more efficient in the ED. How do you guys approach a patient like the following:
EMR says: Doe, Jane 47 yr COUGH 88 155/95 16 97% 99.0 1:21
(the last number is how long they have been waiting)

80 minute wait for bronchitis! holy crap I'm sorry. That sucks the wait time is so long. I can give you some medicine to help you feel better. I think the efficiency issue is not a problem you can quick fix. Getting to the bottom of why the wait is so long is the bigger issue. I would approach the patient from a service recovery standpoint rather than efficiency... that ship has sailed about an hour ago.

 

[GeneralVeers]

I've got a habit that part of me doesn't want to stop, but it takes time. I always (well 9/10) ask the same beginning questions:
- what are your chronic medical problems
- what medicines do you take on a regular basis
- any major surgeries?
- smoke or drink?
ok...so what brings you in today?

Now I can look this stuff up too most of the time. But I have a thing about NOT wanting to look at prior med/surg and previous admissions because it biases you when you see the patient.

I'm very slowly beginning not to ask all those questions, but it's hard not to.

Wrong approach. Never ask about medicines. It's completely irrelevant, and your nurse should get a list for you. I always look up prior visits. Sure it biases me, but it lets me know if they are a frequent flier, are going to ask for drugs, etc. If they've had a recent admission for the same problem, it considerably shortens my interview if I can say: "I saw you got admitted for the some problem last week, they diagnosed you with COPD and sent you home. What has changed tonight?"

Honestly, interviewing the patient is the least useful part of the medical evaluation process, as only about 10% of what patients say is valuable. For patients who I know I'm sending home immediately based on triage complaint, vitals, age and history, I ask enough questions, and cover enough physical exam points to make the patient think I'm being thorough and that I care. That shouldn't take more than 5 minutes in the room for run-of-the-mill urgent care complaints.

 

[thegenius]

80 minute wait for bronchitis! holy crap I'm sorry. That sucks the wait time is so long. I can give you some medicine to help you feel better. I think the efficiency issue is not a problem you can quick fix. Getting to the bottom of why the wait is so long is the bigger issue. I would approach the patient from a service recovery standpoint rather than efficiency... that ship has sailed about an hour ago.

Yup. They will often wait longer between 2P and 12A too.

 

[thegenius]

Wrong approach. Never ask about medicines. It's completely irrelevant, and your nurse should get a list for you. I always look up prior visits. Sure it biases me, but it lets me know if they are a frequent flier, are going to ask for drugs, etc. If they've had a recent admission for the same problem, it considerably shortens my interview if I can say: "I saw you got admitted for the some problem last week, they diagnosed you with COPD and sent you home. What has changed tonight?"

Honestly, interviewing the patient is the least useful part of the medical evaluation process, as only about 10% of what patients say is valuable. For patients who I know I'm sending home immediately based on triage complaint, vitals, age and history, I ask enough questions, and cover enough physical exam points to make the patient think I'm being thorough and that I care. That shouldn't take more than 5 minutes in the room for run-of-the-mill urgent care complaints.

So do you just give them what they want? Or do you say "I'll prescribe x and y" and then leave?
What if they say "I've already tried x and y and it ain't workin' doc"

 

[deleted547339]

80 minute wait for bronchitis! holy crap I'm sorry. That sucks the wait time is so long. I can give you some medicine to help you feel better. I think the efficiency issue is not a problem you can quick fix. Getting to the bottom of why the wait is so long is the bigger issue. I would approach the patient from a service recovery standpoint rather than efficiency... that ship has sailed about an hour ago.

Lol. 80 mins!?! They sometimes wait 12 hours at my shop.

I will often times get the unnecessary CXR and counsel them beforehand. Then I tell them about the CXR and it seems like it’s not up to me.

 

[BJJVP]

For some reason I choose options that lead me to talk alot, get more information from the patient, and really try to determine if the cough is bronchitic, GERD, asthma, URI, PNA, or whatever else. And I think it's largely a waste of time.

I don't think it's a necessarily a waste of time. Pts feel like you cared, spent time with them, were thorough in your evaluation, and you're more likely to get the points you need to code an adequate chart. Also, you are probably more accurate at seeing why the pt came (wants an xray, brother had lung CA, has no PCP, couldn't sleep, etc). This helps with pt complaints and satisfaction. I am one of the faster ones in my department. Numbers-wise, I was also in the faster group in residency. I have noticed that all of the slower guys have the same bad habits. Talking to the pts and spending time in the room is NOT one of them.

Here is a list of things that I have noticed the slow ER doctors do:

1) The do not get in the room quickly. Except for times when I am stuck in a room for a procedure or resuscitation, I almost always know what is going on in the dept or the pod for which I am responsible. I know almost instantly when a pt is being brought back. Some guys think that signing up for the pts in the EMR counts. NO, IT DOESN'T. You still actually have to go into the room and begin your evaluation. I have seen some guys wait 20 minutes after signing up before they go into the room.
(0.25 hr added)

2) They order things in series. In your example, you don't want to order an xray and then decide they need blood work, and then noticed they are tachycardic and maybe have a PE. Decisions should be made upfront, as you walk out of the room. For the most part, if I think someone is sick enough for an xray, then they are prob bad enough for blood work. Sure, there are times when I will order an xray and then add blood work if the xray shows a large infiltrate. But one, those times are rare (usually I ordered the xray just to make someone feel better). Two, I am waiting for that xray like a hawk! I will look for that xray as soon as the pt returns from radiology. I don't just notice an hour later that the xray was abnormal.
(0.5 hr added)

3) Once all diagnostic studies are complete, the slower doctors almost refuse to make a decision. For me, as soon as the CT, blood work, xrays are back, I make a decision. The pt needs to be discharged or admitted. You can't just let them sit there.
(0.5 hr added)

4) They don't know where the hangups in their department are. Urines take forever. Before the pts get strapped down to an IV pole, I make sure they go to the BR. If I see urine sitting on the counter, I ask a nurse to send it to the lab. CBCs usually get done quickly. If I start seeing BMPs and troponin results without a CBC, I know something got lost, clotted off, was hemolyzed, etc. Or sometimes only part of the BMP gets resulted, I know then that something went wrong. I get proactive and ask the lab or the nurse about it. A slow doctor will just keep on waiting until everything is back. They only notice these delays when their shift is almost over.
(0.25hr added)

5) They don't put things on autopilot when they can. For migraine HAs, I order meds, then put the discharge order in. That way, the nurse knows this person needs to go home. Sure, I will come back about 10-15 min after the pt receives the meds and make sure they are better. But this way, scripts are already there, dc papers are printed by the RN and ready to go. Otherwise, what happens is you recheck the pt, then put the orders in, then the RN has to actually realize that a dc order is in, then the papers get printed, then the RN goes to lunch first, then the pt is released. Any number of things can disrupt and delay this process. All of this can add anywhere from 30 min to an 1hr to time in the department. Same goes for back pain. If you walked in with back pain and somehow managed to convince me to order a "shot," then the medication and discharge orders are put in at the same time. If a pt needs a splint or a lac repair, then I put the discharge order in and tell the RN don't release the pt until the PA does the procedure.
(0.25hr added)

The numbers I put above are conservative. Some of those delays can be an hour. If you add it up, that's 1.5 hrs saved by being more efficient, proactive. Talking to the pt too much should be the least of your concerns.

 

[thegenius]

I'm guilty of #2 and #3. Where I work I can't just put a discharge order at the same time as meds. There are nursing protocols (ACK!) that require the patient to leave within 15 minutes of the order being put in, so they get mad at me when that's done. I know I know......I know....it's not something that I'm gonna fight. My leadership needs to fight it.

#3 is hard. There are times where I think I can't admit the patient because I know the hospitalist won't take it, yet I don't want to send them home. Or maybe the patient needs another 6 - 10 hours of treatment. Common examples are gastroenteritis in young people, moderate asthma exacerbations, and weakness in old people. Re: AGE: it's poor form to send them home yacking...and if they fail their PO trial they prob shouldn't go home. Now....in reality.....they can go home because AGE is self limiting and people get better. But it looks bad when they come back 4 hours later because their tummy hurts and they are yacking

I'm working at it...I'm trying....