Tracking Patients in the Waiting Room

[Janders]

As an SDG, what have you done to mitigate WR workups and/or make the process more efficient? From a CMG place, there is virtually no effort on the part of our leadership to make things more palatable.

I don’t know if there are really tricks. Things that seem to help—
(1) A Culture that aggressive, triage-based workup is not just OK, its GOOD for patients, it promotes safety, and improves flow. Unleashing the triage RN to order basic labs and EKGs and plain films based on chief complaints, via a med-exec approved protocol. People will tell you getting a troponin on someone in the WR who isn’t wearing a cardiac monitor is bad; however grabbing that positive troponin out of the WR at the 60 minute mark instead of the 4hr mark when they got in a real room is GOOD. You need to sell this entire process.
(2) You need lab (phlebo) and radiology (grab all things from the WR) leadership to support your WR efforts. Staffing a separate ED tech to do blood draws, EKGs, etc is also an option. In this discussion w/ leadership, you can note the relative cheap cost of this staff, and the cost benefit of poaching those LWBS. These staff members will make the hospital money, while improving care and satisfaction scores.
(3) Having good relations w/ your triage RN staff and secure text chat will make this even better. They can warn you of things they think need to happen that they don’t have approval to order (Head CT, DVT US). You can run out and meet the patient in the triage bay for 60s and confirm/order. etc.
(4) Patients don’t like having their HPI done in the WR; Patients DO like it when the busy ER doctor comes to “help speed things along” and “make sure they are doing ok”. Make your staff look good, working in bad situations.

The real issue is when you start getting all these results back, and the patient cannot be discharged home based on them… they need IV meds and nursing interventions. Hard to get all of THAT going routinely in the WR…

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[HemorrhagicShock]

I just do veternary medicine on these patients. If you cannot provide me with a reasonable history, I will simply treat you as if you were a demented nursing home patient dropped off at our door.

Basic exam. Make sure nothing hurts when I push on it. Look for any obvious signs of trauma. If anyone claims they fell, scan their head/neck. CBC, Chem, UA, EKG. DC if all normal. If they look reasonably well / stably chronically unwell, I honestly don't even care what their chief complaint is. Reassure the muggle that "your tests look good and we're going to send you home now. Call your doctor tomorrow."

This is exactly what I do, except I'm horrible and add a troponin to that order set, and perhaps a few other things depending on whatever PMH happens to be in the EMR.

The most hilarious part to me is when the rare medical student who rotates with us will pick up a patient like this. My absolute favorite thing to teach them about EM-specific history taking is "they lied to you medical school, the answer is a lot of times NOT in the history, and open-ended questions are trash." The wide-eyed stares that they give me keep me going!!

 

[Interpolfanclub]

I just had a very similar discussion with our director. What admin/CMG ghouls don't understand is that these patients are anything but straightforward.

"What medications do you take?"
Oh my, oh God, oh dear. Let me see (ruffles thru 10+ pieces of paper, makes 2 phone calls, tries unsuccessfully to log on to CVS on their phone, etc).

"Why are you here?"
Well they said that I might be having an emergency.
"Who are *they*?"
The people I called. I think it was a nurse.
"What number/office/service?"
Oh, I don't remember. Ask my sister. Here, let's call her.

That's the real timesink for me.

This is how I know we all have the same job, no one understands this except us. I die inside when someone takes their phone out. Because they inevitably need their glasses which they don't have, and then there is a password, and the wifi doesn't work, and then they need to call someone, and then their phone rings and and and and. I just cut them off and tell them I can find it "in the computer."

I ALWAYS scan the chart before going in to see a patient, especially an elderly patient because frequently there are phone records or texts from the family that help with the history. "I'm here because my labs are bad" is a notorious cc requiring detective work.

 

[HemorrhagicShock]

I ALWAYS scan the chart before going in to see a patient, especially an elderly patient because frequently there are phone records or texts from the family that help with the history. "I'm here because my labs are bad" is a notorious cc requiring detective work.

Almost always there's a reasonably dictated discharge summary within the last two months for these types of patients since they're always in and out of the hospital. That document is worth its weight in gold, and far far far more helpful than anything 99% of these patients can offer regarding their own history.

 

[RustedFox]

I don’t know if there are really tricks. Things that seem to help—
(1) A Culture that aggressive, triage-based workup is not just OK, its GOOD for patients, it promotes safety, and improves flow. Unleashing the triage RN to order basic labs and EKGs and plain films based on chief complaints, via a med-exec approved protocol. People will tell you getting a troponin on someone in the WR who isn’t wearing a cardiac monitor is bad; however grabbing that positive troponin out of the WR at the 60 minute mark instead of the 4hr mark when they got in a real room is GOOD. You need to sell this entire process.
(2) You need lab (phlebo) and radiology (grab all things from the WR) leadership to support your WR efforts. Staffing a separate ED tech to do blood draws, EKGs, etc is also an option. In this discussion w/ leadership, you can note the relative cheap cost of this staff, and the cost benefit of poaching those LWBS. These staff members will make the hospital money, while improving care and satisfaction scores.
(3) Having good relations w/ your triage RN staff and secure text chat will make this even better. They can warn you of things they think need to happen that they don’t have approval to order (Head CT, DVT US). You can run out and meet the patient in the triage bay for 60s and confirm/order. etc.
(4) Patients don’t like having their HPI done in the WR; Patients DO like it when the busy ER doctor comes to “help speed things along” and “make sure they are doing ok”. Make your staff look good, working in bad situations.

The real issue is when you start getting all these results back, and the patient cannot be discharged home based on them… they need IV meds and nursing interventions. Hard to get all of THAT going routinely in the WR…

What we really need from Admin isn't strategies to navigate this mess... what we need are more space and staff.

But...

 

[TooMuchResearch]

As an SDG, what have you done to mitigate WR workups and/or make the process more efficient? From a CMG place, there is virtually no effort on the part of our leadership to make things more palatable.

We lost money adding a PIT because the hospital system doesn't care about the ED. We provide substandard (new standard) lobby care. We tell surgeons that an upright abdominal exam in a chair will have to do until the patient is in pre-op unless they want to have the patient lie down on the floor. We order IV antibiotics with no real expectation that they will actually get into the patient.

Seriously, we staffed up and are losing money because of it. I've suggested cutting the inefficient, money draining PIT but haven't found favor in this position.

 

[Dr Mantis Toboggan]

We lost money adding a PIT because the hospital system doesn't care about the ED. We provide substandard (new standard) lobby care. We tell surgeons that an upright abdominal exam in a chair will have to do until the patient is in pre-op unless they want to have the patient lie down on the floor. We order IV antibiotics with no real expectation that they will actually get into the patient.

Seriously, we staffed up and are losing money because of it. I've suggested cutting the inefficient, money draining PIT but haven't found favor in this position.

We didnt add an extra position, rather we go to the WR area, see and examine the patients as they arrive, then place orders that may not be done for hours and dictate a full note. LWOT’s down to almost zero now, AMA’s expectedly climbed.

 

[Janders]

Yeah PIT only supports itself with $$$ if it converts enough LWBS to billable events to cover the cost of PIT with professional fees. You need a busy place with high LWBS to do this (clearly using a PA would drop the break-even point)

 

[Dred Pirate]

The hospital is more interested in RFI'ing staff to see how long they're in the room, where they're at, etc. way more than they want to RFI patients.

Our badges have a chip in them to get in doors, etc. We had a third party company placing RFI readers throughout the hospital to "track assets" such computers, etc. I joked with the guy - are you all gonna track us as wel. With a stern face "The hospital decided not to turn that on"

I went and asked a manager friend of mine and he told me hospital upper mgmt actually decided not to turn the employee tracking on because of fear of a lawsuit- not because they realized it was just wrong and creepy,

 

[RustedFox]

Our badges have a chip in them to get in doors, etc. We had a third party company placing RFI readers throughout the hospital to "track assets" such computers, etc. I joked with the guy - are you all gonna track us as wel. With a stern face "The hospital decided not to turn that on"

I went and asked a manager friend of mine and he told me hospital upper mgmt actually decided not to turn the employee tracking on because of fear of a lawsuit- not because they realized it was just wrong and creepy,

Whoa.

 

[CoolDoc1729]

Our badges have a chip in them to get in doors, etc. We had a third party company placing RFI readers throughout the hospital to "track assets" such computers, etc. I joked with the guy - are you all gonna track us as wel. With a stern face "The hospital decided not to turn that on"

I went and asked a manager friend of mine and he told me hospital upper mgmt actually decided not to turn the employee tracking on because of fear of a lawsuit- not because they realized it was just wrong and creepy,

We have these. A while ago a couple of my colleagues left $1000’s lying around more than once in our “office” and it was stolen by housekeeping. It was a mystery for months. I asked my director, can’t they tell who went into the room besides us from our IDs? (We have to badge in) The mystery was solved immediately and the appropriate person was fired. Good thing security was on their game lol

 

[Dred Pirate]

We have these. A while ago a couple of my colleagues left $1000’s lying around more than once in our “office” and it was stolen by housekeeping. It was a mystery for months. I asked my director, can’t they tell who went into the room besides us from our IDs? (We have to badge in) The mystery was solved immediately and the appropriate person was fired. Good thing security was on their game lol

Trust me, I have no problem tracking who goes in certain secure doors ( work in the pharmacy and the ED so obviously we have to have secure areas) - but I draw the line when they are able to tell when we go to the bathroom, cafeteria, or just get up and leave the unit to take a phone call