Arcan57

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Spinning off Pinipig's thread regarding an ultrafast colleague there were suggestions about how to improve your LOS (defined here as doc-to-dispo to eliminate some of the system factors outside of your control). Like any other measure of quality in EM, focusing on improving LOS in a vacuum leads to an overall decline in quality of care.

1. Don't work up people that aren't sick. This is the biggest time saver in the ED. It takes a 4 hr belly pain work-up and turns it into 20 minutes. A two and half hour peds fever work-up becomes 10 minutes of physical exam and explaining to parents conditions for which to return to the ED. This is also the most dangerous method to employ cavalierly since if something bad happens it's impossible to prove the labs wouldn't have been helpful because they were never drawn.

2. Work for (or work to implement) a system that has a culture of the admitting physician accepting responsibility for the patient on phone call from the ED. You'll never be able to replicate 40-50 min doc-to-dispo times if you have to wait for everything to come back prior to admission. This can be easily abused (see all the "ED sux" sentiment among medicine residents who work in those systems) but it's stunningly efficient to be able to look at a patient, see they need admission, make a phone call, and forget about the patient.

3. Prioritize disposition. If the metric you're aiming for is doc-to-dispo, it makes no sense to pick up bunches of new patients when you have existing patients that need to leave. This is one of the tips that has very few downsides (unless your dispo process is inordinately labor intensive such as prolonged log-in times with short time-outs on your EMR). It eliminates batching, improves flow, gives you more time when you're only thinking about one patient, etc. And for most patients, seeing you resets their clock somewhat so they're actually happier to be waiting in the room a little longer as long as once they see you things move along.
 

WilcoWorld

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Prioritize disposition
This is so key it needs a chain.

I saw an analysis once that showed you save something like 20 minutes in LOS per patient by discharging old before picking up new. It may be hard to believe, but when you look at the process aspects, it becomes crystal clear.
 
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Arcan57

Arcan57

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This is so key it needs a chain.

I saw an analysis once that showed you save something like 20 minutes in LOS per patient by discharging old before picking up new. It may be hard to believe, but when you look at the process aspects, it becomes crystal clear.
And I worry that it gets lost due to admin's obsessive focus on door-to-doc times. So docs prioritize eval'ing patients despite the fact that the system clogs up and grinds to a halt without dispositions.