What is ONE change that significantly increased your ED's throughput?

[JMC2010]

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Hi Guys,
I find myself taking on more and more responsibility at my shop for ED throughput because I like to solve problems and we have a big one. We currently see around 60K and increasing. I'm reading up on ED throughput as I recognize there is a lot to learn. Currently our LOS is abysmal (~6 hours). I think this is primarily because of a greatly expanded ED without an increase in staffing (we're working on this). We are also opening a CDU in the next few months. These changes will help but even before the ED expansion we had efficiency problems. Our hospitalist group is actually pretty speedy but we do have issues with getting nurses upstairs to take 'report'.

I recognize there are a myriad of factors I'm just wondering if anyone has made a change and then said "Damn that worked well!" If so, I'd love to hear about them!

A couple of major problems I have identified that are easy fixes:

1. Chest pain protocols ordered by triage don't include CXR...patient gets to bed, doc then orders CXR. Boom 45 minutes lost by the time the doc thinks about the CXR again.

2. Problems with females coming back without urine preg POCTs! Such a stupid problem. I'm thinking of assigning a single tech with the responsibility of making sure that no patient reaches a room without a urine done. That way there is someone to be held accountable.

Any thoughts?

 

[gman33]

2. Problems with females coming back without urine preg POCTs! Such a stupid problem. I'm thinking of assigning a single tech with the responsibility of making sure that no patient reaches a room without a urine done. That way there is someone to be held accountable.

Any thoughts?

Do they give a urine in triage or just on the way to the room?
I hate going to see these patients before I know preg vs. non-preg.
Having a patient sitting in a room for an hour without knowing preg status is just crazy.
Happens everyday where I work.

 

[RustedFox]

The one thing that has helped the most?

Adequate staffing.

There used to be a big push to have as few people fill as many roles as possible because it was viewed as reducing 'redundancy'. Big mistake. We ended up making our own telephone calls to answering services and 'waiting on hold' for 20 minutes at a click just to say "Have Dr.Internist call me back; I have an admission for him."

Pathetic.

Look, administration... I'm a doctor. Keep me at the beside and keep me doing the job that I trained to do. If you want throughput (and thus, volume) to go up... then you're going to have to hire more support staff. Period.

 

[Greenbbs]

in all honesty, the three things that improved our thruput are:

1. Appropriate physician staffing ratios paired with adequate nursing. We see 120k patients a year. During our peak times, we have 11 providers (8 attendings and 3 MLP's) staffing the ED (we've got just over 50 physical rooms, but an alphabet soup, etc). Nobody really waits, and we're usually picking up patients pretty quick. there's usually several teams of nurses roving the alphabet soup land to draw labs

2. A doc in triage. We can weed out ~half the stuff from the back. all the lacs/bronchitis/otitis/sprains/useless stuff never makes it to the acute sides. I worked in triage the other day and dispo'd 50 in 12 hours, paired with a midlevel, we can really cut the volume down. This helps us get our door to doc's to ~22 mins for Q4, and our LWOT/LWBS went from almost 8-10% before we had doc triage to *maybe* 1 patient daily.

3. A powerful ED in the hospital with a director that convinced them to board patients in non-traditional locations. Once they bought in, we can really move things.

 

[RustedFox]

I hate to say it, but the more and more that I think about it.... my times and dispos have everything to do with available resources and little to nothing to do with my ability to ‘see them fast'.

 

[Janders]

Repeat after me:
"ED throughput is a hospital-wide issue"
"ED throughput is a hospital-wide issue"

This is your mantra.

The entire HOSPITAL has to help with this. Certainly you can take some control in your ED. However, a TON of the variables are out of your control. You need a fast and efficient lab, including blood draws, transport, and actual test TAT. Same with radiology. You need a system for admissions where it is fast, and easy. No reason to hold a patient for 2 hours waiting to talk to the hospitalist, find transport, find a clean room. If you are so busy you are boarding you are in deep trouble, and need the hospital to work on opening new locations, etc etc.

Some numbers I ran once showed that admin was unhappy because it was taking about 180 minutes for a chest pain patient to make it from arrival to transported upstairs. I broke it down---> it took MEAN 75 minutes from bed request to transport upstairs, and MEAN 75 minutes from troponin order to troponin result (which had to be back before an admission could be booked). So that is 150 minutes taken away already. Meaning that we were receiving, triaging, taking history and examining the patients within 30 minutes, and still failing at getting them up in 3 hours.

This is really easy to draw on a pie chart. Now who has room to improve? The ED tech/Uco/RN/MD team thats done in 30 minutes, or lab / transport / bed booking which is taking 150 minutes?

Anyway, to me the best approach is to make hospital-wide powerful allies who see this as a key issue, then break it in to pieces where teams can work on individual areas of improvement (like making bed booking rapid, or making transport efficient, or speeding lab, or quickening the triage system).

whew. Now that I am done ranting:
The best thing I have done for ED throughput was changing from a MANDATORY 3 hour oral prep for CT scan to a occasionally optional usually 1 hour prep. This single change cut 30-35 minutes of the MEDIAN ED visit for ALL COMERS (not just people getting scanned). That is a massive change.

 

[JMC2010]

Thanks for the replies. A couple of months ago we finally made the switch from PO contrast for every scan to just for those folks with a BMI under 25ish. Huge difference.

 

[deuist]

Lots of good information up above. Some other things:

1. Parallel triage. The patient signs in and goes straight to a bed with nothing more than a chief complaint. The nurse performs initial intake and vitals at the bedside. The doc can see the patient during the same time period. The result is that the waiting room is cleared out faster and the door-to-doc time goes down.

2. Point-of-care testing. My current hospital's lab will not let us do urine drips and pregnancy tests at the bedside. Instead of taking 2 minutes to figure out why the patient has dysuria, the patient now waits 40 minutes for the same result. If you get an iStat that performs troponins, you could do the same for your chest pain patients.

3. Observation units run by the ED staff. Sign out and transfer happens much quicker when you know the people who are accepting your patient.

4. Getting radiology on board with putting a patient's contrast-enhanced CT scan in queue without waiting for the creatinine to come back.

 

[Bostonredsox]

I think one important thing for your throughput is a good working relationship with your admitting hospitalists. When i take and admission from an Ed doc I trust, I give bridge orders to the floor and see them on the floor. I don't come to the Ed and waste time seeing and examining them in the Ed, rather I treat them like a direct admit from a clinic. But if the Ed doc is someone who routinely calls for pts who are far sicker and more unstable then the way they were portrayed over the phone, red flags go up with that provider and I come to evaluate on Ed before dispoing to a floor. Now here that doesn't save a ton of time because the nurses are so slow at sbar to the floor nurse that I can often spend 30 min with them without ever seeing the nurse come to the room. But if your shop has good nursing and transport, alleviating the need for the hospitalist to see your pt in the Ed can definitely improve admission times.

 

[Cynic]

We had the biggest improvement when we went to a faxed report sheet for the nurses to send to the floor. The ED nurse faxes a sheet with all the patient's info on it. This serves as report. They would call the floor and notify whoever picked up that the report was faxed and the patient was on their way up in 15 min. The patients came up when they were admitted.

It used to be a huge game at our shop when the ED RN would go to call report to get the patient upstairs and never actually get through to the receiving RN or their charge nurse. A lot of times the floor nurse would be overwhelmed/busy so they employed stall tactics ...bed's dirty, they can't talk now they're in a room, we're in report, blah blah blah. Sometimes the ED charge nurse would go upstairs to find the bed was clean or other nurses were just chillin' while the ED was busting at the seams...it was especially worse the closer it got to shift change.

 

[JMC2010]

We had the biggest improvement when we went to a faxed report sheet for the nurses to send to the floor. The ED nurse faxes a sheet with all the patient's info on it. This serves as report. They would call the floor and notify whoever picked up that the report was faxed and the patient was on their way up in 15 min. The patients came up when they were admitted.

It used to be a huge game at our shop when the ED RN would go to call report to get the patient upstairs and never actually get through to the receiving RN or their charge nurse. A lot of times the floor nurse would be overwhelmed/busy so they employed stall tactics ...bed's dirty, they can't talk now they're in a room, we're in report, blah blah blah. Sometimes the ED charge nurse would go upstairs to find the bed was clean or other nurses were just chillin' while the ED was busting at the seams...it was especially worse the closer it got to shift change.

I like the idea of faxing a report. This is clearly a big problem at our shop and I think this is a nice solution that I hadn't heard before. Thanks!

 

[Cynic]

No problem. I was part of a lean six sigma group to improve ED throughput and this came up on our radar as something we could address. One caveat is that the ED RN's had mobile phones so the floor nurse could get a direct line if they had any questions about the patient. Nurses do a great job of handing off patients and anything you do to expedite that has to have to be at least as good if not better than what they already do. The report sheet offered a nice 1 page fill in the blank and checkbox system that improved and standardized RN to RN report, making it an easier sell to the floor nurses.

There was obviously some resistance from the floor's angle, but when you stress that
1. The ED doesn't get to choose when it's patients come in, why do you get to?
2. We're improving hand-off with this report
3. We're increasing throughput by freeing up beds at peak hours (ie 3PM/7PM/11PM) faster
4. It improves patient satisfaction: the bulk of these patients who were waiting to go to the floor were sitting in an uncomfortable cart in a noisy ED without a TV. At least upstairs they got blankets, a real bed, and a TV...

We had already implemented ways to track our different times during the process, so once we trialed faxed report and compared the old way vs faxed report, the LOS was so glaringly different (esp around 7AM/3PM/7PM/11PM) it was nearly impossible for them to go back.

 

[Venko]

Cynic - Thats an awesome intervention! We sometimes have a similar problem and if it begins to become more consistent this may be an interesting solution to try for us.

Regarding biggest advance in throughput…I believe having admitting privileges has made the biggest impact in my experience of moving patients through an ED. We have a closed unit except for surgical, neurological, and psychiatric consultations. When we admit patients, if there is a dispute, the ED attending has the final say. There are time expectations for consultation which are upheld by the hospital administrative committees.

 

[deleted109597]

Regarding biggest advance in throughput…I believe having admitting privileges has made the biggest impact in my experience of moving patients through an ED. We have a closed unit except for surgical, neurological, and psychiatric consultations. When we admit patients, if there is a dispute, the ED attending has the final say. There are time expectations for consultation which are upheld by the hospital administrative committees.

Totally jelly. Your department has a huge amount of respect. When we have these discussions at meetings, the admitting docs (mixture of hospitalists, private docs in the community, and the family residency) all dig up old horror stories of how terrible the ED docs used to be, and we get shot down.

 

[Venko]

Ninja,

If you ever do get the chance to have full admitting privileges, the other departments will continually try and take it back. We keep data on patients who go to the ICU within 24 hours of admission, RRTs and codes within 24 hours of admission etc and continually prove in meetings where other depts want to take this privilege back that we are succeeding in doing an excellent job. It squashes the issue each time.

Good luck in the process, I wasn't involved in setting this situation up to offer any advice. I recognize how fortunate I am to have this setup though!

Cheers,
venk

 

[Tiger26]

Ninja,

If you ever do get the chance to have full admitting privileges, the other departments will continually try and take it back. We keep data on patients who go to the ICU within 24 hours of admission, RRTs and codes within 24 hours of admission etc and continually prove in meetings where other depts want to take this privilege back that we are succeeding in doing an excellent job. It squashes the issue each time.

Good luck in the process, I wasn't involved in setting this situation up to offer any advice. I recognize how fortunate I am to have this setup though!

Cheers,
venk

From first hand knowledge, I agree with Venko--amazing how much the patient flow improves with full admitting privileges. Other than the surgical services and neuro (who has tremendous ownership of their patients), the medicine services don't evaluate patients in the ED, which allows for quick dispos and transport

 

[JMC2010]

Ha, admitting privileges seems like a pipe dream at my old school shop. Certainly would make a huge difference.

The more I'm looking at this the more I wonder how best to institute a lot of the changes. We are a busy place, most of our nurses work hard. We have decent nursing leadership.

The problem is that throughput is critical for safety and financially and professionally for the ED group, but there is no such incentive for the nurses. What do they care if we see 1 more patient an hour, it's just more work for them. Generally i'm very easy going and never get upset with my nurses. I feel that's the right way to do it for the most part but maybe some of these un-resulted urine pregs would start getting done if I wasn't such a softy. Or maybe I should call our nursing director every time a chest pain comes back without an xray? I just don't know. Ideally the ED functions as a team and we have universal goals but certainly the ED group has a stronger incentive to move faster.

 

[Arcan57]

Ha, admitting privileges seems like a pipe dream at my old school shop. Certainly would make a huge difference.

The more I'm looking at this the more I wonder how best to institute a lot of the changes. We are a busy place, most of our nurses work hard. We have decent nursing leadership.

The problem is that throughput is critical for safety and financially and professionally for the ED group, but there is no such incentive for the nurses. What do they care if we see 1 more patient an hour, it's just more work for them. Generally i'm very easy going and never get upset with my nurses. I feel that's the right way to do it for the most part but maybe some of these un-resulted urine pregs would start getting done if I wasn't such a softy. Or maybe I should call our nursing director every time a chest pain comes back without an xray? I just don't know. Ideally the ED functions as a team and we have universal goals but certainly the ED group has a stronger incentive to move faster.

Having not worked at your shop these may not be applicable/feasible, but there some statements that stood out for me.

1)The problem is that throughput is critical for safety and financially and professionally for the ED group, but there is no such incentive for the nurses.

Throughput is a CMS reportable core measure this year. The hospital has to care about it, by default. Which leads to the nursing leadership as addressed in:

2) We have decent nursing leadership.

If you have decent nursing leadership, they need to be pushing down the actions that move the metrics. Frequently, the nursing director is a useful mammal but is undermined by one or more charge nurses that see the admin part of their job solely as protecting their nursing staff. No army functions well without good sergeants, and no ED moves the metrics without continual support from its charge nurses.

3) Or maybe I should call our nursing director every time a chest pain comes back without an xray?
This statement worries me. Lack of physician involvement in the work-up is going to add significant time to length of stay due to missed orders/add-ons, etc. Especially if the group's practice is to eval a patient after tests have come back. Eval after shotgunned tests can make the provider look like an absolute stud in terms of pph, but hoses LOS, door-to-provider, and to some extent patient sat. Well-thought out standing delegated orders can improve LOS, but it doesn't substitute for early provider eval in terms of throughput.

 

[JMC2010]

3) Or maybe I should call our nursing director every time a chest pain comes back without an xray?
This statement worries me. Lack of physician involvement in the work-up is going to add significant time to length of stay due to missed orders/add-ons, etc. Especially if the group's practice is to eval a patient after tests have come back. Eval after shotgunned tests can make the provider look like an absolute stud in terms of pph, but hoses LOS, door-to-provider, and to some extent patient sat. Well-thought out standing delegated orders can improve LOS, but it doesn't substitute for early provider eval in terms of throughput.[/quote]

I think I gave the wrong impression with a poor example. We see patients pretty quickly as soon as they make it into the ED. However, our wait times are pretty horrendous so a better example would be when a 25 year old female with lower abd pain who has sat in the waiting room for 3 hours comes back without a POCT urine preg. Then everything stalls waiting for something that should have been done hours ago.

 

[Arcan57]

3) Or maybe I should call our nursing director every time a chest pain comes back without an xray?
This statement worries me. Lack of physician involvement in the work-up is going to add significant time to length of stay due to missed orders/add-ons, etc. Especially if the group's practice is to eval a patient after tests have come back. Eval after shotgunned tests can make the provider look like an absolute stud in terms of pph, but hoses LOS, door-to-provider, and to some extent patient sat. Well-thought out standing delegated orders can improve LOS, but it doesn't substitute for early provider eval in terms of throughput.

I think I gave the wrong impression with a poor example. We see patients pretty quickly as soon as they make it into the ED. However, our wait times are pretty horrendous so a better example would be when a 25 year old female with lower abd pain who has sat in the waiting room for 3 hours comes back without a POCT urine preg. Then everything stalls waiting for something that should have been done hours ago.[/quote]

I understand. Our compliance with standing delegated orders at triage is spotty at best and my last shift featured multiple patients with clear-cut presentations that came back 2-4 hrs into their stay with nothing ordered. It sucked.

 

[Tiger26]

I think I gave the wrong impression with a poor example. We see patients pretty quickly as soon as they make it into the ED. However, our wait times are pretty horrendous so a better example would be when a 25 year old female with lower abd pain who has sat in the waiting room for 3 hours comes back without a POCT urine preg. Then everything stalls waiting for something that should have been done hours ago.

I understand. Our compliance with standing delegated orders at triage is spotty at best and my last shift featured multiple patients with clear-cut presentations that came back 2-4 hrs into their stay with nothing ordered. It sucked.[/quote]

We started urine serum qualitative HCGs when we realized they were only a few dollars more because waiting on the urine proved to be far too variable

 

[Arcan57]

We started urine serum qualitative HCGs when we realized they were only a few dollars more because waiting on the urine proved to be far too variable

I order serum HCGs routinely for the same reason. The problem I routinely run into is the incontinent LOL with AMS that has a completely negative except the nurse waits 3-4 hrs before making an attempt at obtaining urine.

 

[JMC2010]

Interesting, I wonder how much we charge for our serum HCGs...our techs/triage nurses are champs at getting blood but urine is much more spotty. I would have assumed it was a significant amount but if it's not that different that could be a neat fix.

 

[dotcb]

In my ED, serum HCG charge is $275, urine pregnancy charge is $81. Costs are about $30 and $10 each.

 

[deleted109597]

Make them do the urine test with blood then.
http://academiclifeinem.com/trick-of-the-trade-urine-pregnancy-test-without-urine/

 

[docB]

Wow! It's interesting how something that works wonders one place causes huge problems in another. We have fought tooth and nail against being given admitting privileges. In our environment if we were given the priveledges the internists wouldn't see the patient for 24 hours and we would be liable for them throughout that time. As it is our bylaws say that in a dispute about the need for admission between the EP and the admitting doctor the admitting doctor must come and see the patient and discharge them themselves within 2 hours. For us that's better than being the only doctor on the case for the first day.

The thing that made the biggest difference in our setting was having the nurses protocol the patients with standing orders (labs, EKGs, X-rays, etc.). That really sped things up. Sometimes when it was really busy the workups were back by the time the patient was placed in a bed. Utilization was probably not great but admin didn't seem to care about that at that point for some reason. We lost that protocols when the EMR came around because they didn't comply with CPOE but oh well.

 

[Venko]

Wow! It's interesting how something that works wonders one place causes huge problems in another. We have fought tooth and nail against being given admitting privileges. In our environment if we were given the priveledges the internists wouldn't see the patient for 24 hours and we would be liable for them throughout that time. As it is our bylaws say that in a dispute about the need for admission between the EP and the admitting doctor the admitting doctor must come and see the patient and discharge them themselves within 2 hours. For us that's better than being the only doctor on the case for the first day.

The thing that made the biggest difference in our setting was having the nurses protocol the patients with standing orders (labs, EKGs, X-rays, etc.). That really sped things up. Sometimes when it was really busy the workups were back by the time the patient was placed in a bed. Utilization was probably not great but admin didn't seem to care about that at that point for some reason. We lost that protocols when the EMR came around because they didn't comply with CPOE but oh well.

We have admitting privileges in the sense that we can put a patient in a room on any service essentially we want but they are required to write the admit orders and see the patient when they arrive there.

This is different than us putting in admit orders for them and no one seeing the patient for a day.

Maybe that helps clarify the difference?

 

[Bostonredsox]

We have admitting privileges in the sense that we can put a patient in a room on any service essentially we want but they are required to write the admit orders and see the patient when they arrive there.

This is different than us putting in admit orders for them and no one seeing the patient for a day.

Maybe that helps clarify the difference?

My problem with this is I get calls for bunches of admits at once, when the Ed docs change shift, so I get 6 admits at once at 7pm. They tried the method of letting the Ed docs write admit orders to the floor without communicating anything to us other than "I am admitting pt x to tele". But with 7 at once, and each pt requiring me to see them, take a history and put in all there cpoe orders, even at a speedy 20min a pop it's 2-3 hours before I see them all. And the 76 y/o sent to the floor with simple PNA, who in reality had a lactate of 8 that wasn't checked, is now descending into shock on the floor with a floor nurse with an IQ of 8. So for he same reason you guys don't want to admit and be liable for them till they are seen by the internist, I don't want them admitted to the floor under my name, whereby they become my responsibility immediately, until I have seen them.
So I am very much against the Ed having admitting privileges, atleast not to my service. The only person that should be able to admit to my service is me, after I have seen the pt. trust no one with your license.

 

[Venko]

My problem with this is I get calls for bunches of admits at once, when the Ed docs change shift, so I get 6 admits at once at 7pm. They tried the method of letting the Ed docs write admit orders to the floor without communicating anything to us other than "I am admitting pt x to tele". But with 7 at once, and each pt requiring me to see them, take a history and put in all there cpoe orders, even at a speedy 20min a pop it's 2-3 hours before I see them all. And the 76 y/o sent to the floor with simple PNA, who in reality had a lactate of 8 that wasn't checked, is now descending into shock on the floor with a floor nurse with an IQ of 8. So for he same reason you guys don't want to admit and be liable for them till they are seen by the internist, I don't want them admitted to the floor under my name, whereby they become my responsibility immediately, until I have seen them.
So I am very much against the Ed having admitting privileges, atleast not to my service. The only person that should be able to admit to my service is me, after I have seen the pt. trust no one with your license.

I can understand the pressures of having so many people arrive so quickly. It happens to us everyday where 20 to 30 people show up in the waiting room in an hour. They are people who no one has seen, and believe they may be dying or suffering from a different emergency. The hospital will need to ask themselves…is it better that these people sit waiting to be seen while others board in the ED for an inpatient physician to do an admission when they have already been evaluated by an attending, or is it better to take the chances with them being on a floor waiting to be seen, while those who have not been evaluated AT ALL are seen?

It's a question for hospital leadership, because you're right, at the physician level, no one wants to be the one with unseen patients on their service…EM, IM, no one. Its like hot potato 🙂

Now, as for the lactate etc, you're right, a mistake or oversight made will linger in your memory forever…it happens to everyone in every specialty. In reality, if you track the number of times a disposition changing or critical management changing oversight happens, it is likely to be lower than you expect…we track it…ours was around 1 in 250 admissions. When these happen, we have picked up the situation and included it automatically into our peer-review system so it can be studied and patterns can be addressed.

Now, how can you trouble shoot numerous admissions in a short period of time? Its probably something similar to what we do when we get six or 10 new patients roomed in our pods…you look throughout the complaints, and vitals…pick an order to see people. Pop into the pneumonia patients room and say, I would like to get some things going for you and I'll be back to finish a more complete history shortly…get their antibiotics, fluids, diet, and nursing orders in, check their allergies and move on to the next patient. This should take about five minutes per patient and an additional five minutes to travel between patients…so about an hour before everyone has been seen briefly and critical orders are in place. Then make a second sweep and pick up the stuff you missed.

I know its nice when you can go straight through things like family hx and social hx all in one shot, but in those moments when you get seven or ten new patients you can't do that. You have to think and work differently to get through those times. Trust me it happens to everyone. Surgeons in my shop do it better than anyone. They have census lists that approach 100 patients and many need operative or critical care interventions and they still manage to balance it all expertly. You may have other people who have mastered the situation in your shop and will want to consult with them. However, to say because you cannot do your entire thirty minute intake process per patient patients should board in the ED, is likely unacceptable to the person who is in the waiting room with their small bowel obstruction and is waiting for NG decompression etc.

Again, because no one wants to take responsibility of this it becomes a hospital administration level problem.

Also, the nursing staff on the floor should be able to alert you that the guy with pneumonia is looking worse and you should divert to them sooner. If they cannot identify that…thats a training and motivation problem that administration should support you in changing.

 

[Bostonredsox]

I can understand the pressures of having so many people arrive so quickly. It happens to us everyday where 20 to 30 people show up in the waiting room in an hour. They are people who no one has seen and believe they may be dying or suffering from other emergency. The hospital will need to ask themselves…is it better that these people sit waiting to be seen while others board in the ED for an inpatient physician to do an admission when they have already been evaluated by an attending or is it better to take the chances with them being on a floor waiting to be seen while those who have not been evaluated at all are seen? Its a question for hospital leadership because you're right at the physician level no one wants to be the one with unseen patients on their service…EM, IM, no one. Its like hot potato 🙂

Now, as for the lactate etc, you're right a mistake or oversight made will linger in your memory forever…it happens to everyone. In reality if you track the number of times a disposition changing or critical management changing oversight happens it is likely to be lower than you expect…we track it…ours was around 1 in 250 admissions. When these happen, we have picked up the situation and included it automatically into our peer-review system so it can be tracked and patterns can be addressed.

Now, how can you trouble shoot numerous admissions in a short period of time? Its probably something similar to what we do when we get six or 10 new patients roomed in our pods…you look throughout eh complaints, and vitals…pick an order to see people. Pop into the pneumonia patients room and say, I would like to get some things going for you and I'll be back to finish a more complete history shortly…get their antibiotics, fluids, diet, and nursing orders in, check their allergies and move on to the next patient. This should take about five minutes per patient and an additional five minutes to travel between patients…so about an hour before everyone has been seen briefly and critical orders are in place. Then make a second sweep and pick up the stuff you missed.

I know its nice when you can go straight through things like family hx and social hx all in one shot but in those moments when you get seven or ten new patients you can't do that. You have to think and work differently to get through those times. Trust me it happens to everyone. Surgeons in my shop do it better than anyone. They have census lists that approach 100 patients and many need operative or critical care interventions and they still manage to balance it all expertly. You may have other people who have mastered the situation and will want to consult with them. However, to say because you cannot do your entire thirty minute intake process per patient is likely unacceptable to the person who is in the waiting room with their small bowel obstruction and is waiting for NG decompression etc.

Again, because no one wants to take responsibility of this it becomes a hospital administration level problem.

Also, the nursing staff on the floor should be able to alert you that the guy with pneumonia is looking worse and you should divert to them sooner. If they cannot identify that…thats a training and motivation problem that administration should support you in changing.

You can't just go pt to pt at my shop doing a few orders and critical questions, you have to finish that pt, or you never will. Because at my shop, at the end of that quick hour round on 7 admits you speak of, you've received 3 more admissions and 10 floor calls and someone in the MICU needs to be intubated. There is only one of me at night for anything and everything on the floor plus what you send up.

The surgeons see 70 pts because they write pathetic 2 line notes which would not pass for a level one note. VSS, belly soft, will follow. You write something like that as a hospitalist and bill a 233 and cms will be coming for there money. We don't have that luxury.

And your tracking of Ed misses is great, sure as **** doesn't happen at my shop. When I pick up the dead leg that needs urgent surgery that was sold to me as a dvt I get "why did you delay this pt leaving the Ed"? Not thanks for catching the dead leg. There is no Ed peer review here. They are too in dire need of Ed docs to fire anyone for screwing up so there's no backlash.

And trusting the floor nurses to pick up the decompensating pt....ha. Just hand your license over now. You are correct. Most all of these issues are administrative level problems, but the jury doesn't give a **** about that, when they die on the floor, it will be on my head make no mistake about it. I see them first. Even if it's just a 5 min eval, review of labs, and "the look test"

 

[Venko]

You can't just go pt to pt at my shop doing a few orders and critical questions, you have to finish that pt, or you never will. Because at my shop, at the end of that quick hour round on 7 admits you speak of, you've received 3 more admissions and 10 floor calls and someone in the MICU needs to be intubated. There is only one of me at night for anything and everything on the floor plus what you send up.

The surgeons see 70 pts because they write pathetic 2 line notes which would not pass for a level one note. VSS, belly soft, will follow. You write something like that as a hospitalist and bill a 233 and cms will be coming for there money. We don't have that luxury.

And your tracking of Ed misses is great, sure as **** doesn't happen at my shop. When I pick up the dead leg that needs urgent surgery that was sold to me as a dvt I get "why did you delay this pt leaving the Ed"? Not thanks for catching the dead leg. There is no Ed peer review here. They are too in dire need of Ed docs to fire anyone for screwing up so there's no backlash.

And trusting the floor nurses to pick up the decompensating pt....ha. Just hand your license over now. You are correct. Most all of these issues are administrative level problems, but the jury doesn't give a **** about that, when they die on the floor, it will be on my head make no mistake about it. I see them first. Even if it's just a 5 min eval, review of labs, and "the look test"

Your frustration jumps off the page. Doesn't sound like patients should come to the hospital when you're not around. Its surprising the place even functions when you go home? The community is just SOL I guess then?

Sorry for the sarcasm but if you read your post it sounds very egotistical. I know you've had good pickups in your career. The people around you have done the same. You are not the gift to the world of medicine you think you are, none of us are. I have picked up amazing things and saved lives but I have missed things and trusted my colleagues to catch them. I know that I don't work on an island trying to stave off attorneys at every turn, I work as a team to care for patients.

I have felt this same way when I was in a county hospital, when I was in private community hospitals, in extremely large centers like the one I'm in now. Be humble, look to make things better instead of assuming you have it all figured out now. Otherwise, you will live with this current state forever.

As for the surgeons…the surgeons in my hospital produce very comprehensive consult notes and deliver care that in general is better than anyone else in the hospital in my humble opinion. Please do not tarnish them by your generalizations, because they work too hard to deserve it.

By the way, I'm confident that everyday you work you make mistakes. Despite your best efforts to prevent them and your sense of impending doom because there are attorneys circling you, let me just ease your curiosity…you make mistakes everyday. Calm down and try and make the system better instead of accepting the status quo where any patient who doesn't get seen by you over a period of continuous 30-45 minutes will die of severe sepsis or walk out with an amputation. Furthermore, if you are getting ten patients per hour for the entire night…I would be very very surprised. That means your ED is getting at least 20 patients per hour for 24 hours…Im not sure if there is an ED that is getting 480 patients a day…maybe there is but its very few thats for sure.

Start working in reality instead of your perspectives which are clearly off

 

[Birdstrike]

Wow! It's interesting how something that works wonders one place causes huge problems in another. We have fought tooth and nail against being given admitting privileges. In our environment if we were given the priveledges the internists wouldn't see the patient for 24 hours and we would be liable for them throughout that time. As it is our bylaws say that in a dispute about the need for admission between the EP and the admitting doctor the admitting doctor must come and see the patient and discharge them themselves within 2 hours. For us that's better than being the only doctor on the case for the first day.

Agree. That's a privilege I never wanted. Any time the subject came up, we reviewed risk management cases where ED doc writes admit orders, and the patient goes to some dark corner of the floor somewhere to rot, with no admitting doc anywhere to be found. The ball can be dropped due to any number of fumbles including: shift change, miscommunication, incompetence, passive aggressive refusal to work, or simply being overwhelmed by never ending admissions. End result: A severely bad outcome occurs and the only MD name on the chart is the EM doc who signed his name to admit orders then let the patient out of his orbit. I also would rather sacrifice a little throughput efficiency, to at least have the piece of mind that the only patients I am responsible for, are the one's within earshot.

 

[Birdstrike]

You can't just go pt to pt at my shop doing a few orders and critical questions, you have to finish that pt, or you never will. Because at my shop, at the end of that quick hour round on 7 admits you speak of, you've received 3 more admissions and 10 floor calls and someone in the MICU needs to be intubated. There is only one of me at night for anything and everything on the floor plus what you send up.

The surgeons see 70 pts because they write pathetic 2 line notes which would not pass for a level one note. VSS, belly soft, will follow. You write something like that as a hospitalist and bill a 233 and cms will be coming for there money. We don't have that luxury.

And your tracking of Ed misses is great, sure as **** doesn't happen at my shop. When I pick up the dead leg that needs urgent surgery that was sold to me as a dvt I get "why did you delay this pt leaving the Ed"? Not thanks for catching the dead leg. There is no Ed peer review here. They are too in dire need of Ed docs to fire anyone for screwing up so there's no backlash.

And trusting the floor nurses to pick up the decompensating pt....ha. Just hand your license over now. You are correct. Most all of these issues are administrative level problems, but the jury doesn't give a **** about that, when they die on the floor, it will be on my head make no mistake about it. I see them first. Even if it's just a 5 min eval, review of labs, and "the look test"

Are you a resident, or is the place you work at just a little bit of a sh-t show?

 

[Janders]

Its really simple, when you step back and look at it:

Is it safer to leave patients unseen in the waiting room, or send patients who HAVE been seen up to the floor, where the floor staff is overwhelmed and might not get to do a full H&P for 2-3 hours? This is assuming you've fully saturated you ED with hallway stretchers and the like.

When the overnight doc tells me he is overwhelmed and can't handle another admission, but every bed and hallway is full in my ER and there are 10 in the waiting room, and EMS calls with a code 5 minutes out... I'm sorry but the admitted patients are coming up! I've seen them, they have a set of labs, a provisional dx... etc.

If it is so busy upstairs that the admitting doctor is overwhelmed and can't handle the volume, the correct answer is to have MORE admitting doctors, or a PA helping... NOT to hold patients in ED beds longer and leave untreated patients in the waiting room longer.

 

[dotcb]

From the hospital financial perspective, patients should go to their floor bed when it becomes available, as keeping them in the ED leads to ambulance diversion and lost income. This just need to be worked out between the EM group and inpatient services. It's a hospital flow issue, which is not an EM issue, but a hospital issue. Cases need to be reviewed, feedback given. At my center, we write provisional floor orders, which last 1 hour, and then the patient is the admitting physician's responsibility.

It doesn't bother me too much when the inpatient team attempts to retrospective quarterback on my first crack impression of a patient.

 

[Bostonredsox]

Your frustration jumps off the page. Doesn't sound like patients should come to the hospital when you're not around. Its surprising the place even functions when you go home? The community is just SOL I guess then?

Sorry for the sarcasm but if you read your post it sounds very egotistical. I know you've had good pickups in your career. The people around you have done the same. You are not the gift to the world of medicine you think you are, none of us are. I have picked up amazing things and saved lives but I have missed things and trusted my colleagues to catch them. I know that I don't work on an island trying to stave off attorneys at every turn, I work as a team to care for patients.

I have felt this same way when I was in a county hospital, when I was in private community hospitals, in extremely large centers like the one I'm in now. Be humble, look to make things better instead of assuming you have it all figured out now. Otherwise, you will live with this current state forever.

As for the surgeons…the surgeons in my hospital produce very comprehensive consult notes and deliver care that in general is better than anyone else in the hospital in my humble opinion. Please do not tarnish them by your generalizations, because they work too hard to deserve it.

By the way, I'm confident that everyday you work you make mistakes. Despite your best efforts to prevent them and your sense of impending doom because there are attorneys circling you, let me just ease your curiosity…you make mistakes everyday. Calm down and try and make the system better instead of accepting the status quo where any patient who doesn't get seen by you over a period of continuous 30-45 minutes will die of severe sepsis or walk out with an amputation. Furthermore, if you are getting ten patients per hour for the entire night…I would be very very surprised. That means your ED is getting at least 20 patients per hour for 24 hours…Im not sure if there is an ED that is getting 480 patients a day…maybe there is but its very few thats for sure.

Start working in reality instead of your perspectives which are clearly off

I don't even know how to respond to this. Literally nothing you have said is true in regards to the meaning of my posts. My "career" is still infantile. No **** I'm no gift of god, I can barely walk and breath at the same time. And you can substitute me for any other hospitalist on staff here, they all feel the same. No our Ed doesn't send us 20 pts an hour, but they bunch admissions up to 6-7-8 at a time and then are dormant for a few hours then bunch more. And they always fall within a 60 minute range of there overlapping shift change. And when there is one provider in house at night covering all the floors, the MICU and all Ed admits, these slams of 8 admissions, often filled with two surgery dumps, get quite taxing, especially when badness is going down on the floors. I know the Ed is Slammed, but atleast you never have to leave your unit. We have to be everywhere and it's taxing at night, but I digress.

Either way, I have no idea wtf you are talking about with me thinking I know everything or that I pick up every miss or never miss anything. Nothing in my posts had anything to do with any of that sort of nonsense. I merely said I am not comfortable allowing admissions from someone else to reach the floor, let alone several in a bunch, without me seeing the pt. if you ****ed up, it's my head. Doesn't mean you did **** up, or that I'll come up with some super diagnosis you missed, it just means I don't trust my license to others and if that pisses you off, well I'm sorry. Obviously this is case by case. If your sending me a 41 year old chest pain with a normal EKG and flat trops whose now pain free to rule out, yeah send him up I'll see on floor. But the selection of who I'm comfortable allowing to be sent up before I see them is my decision, as it's my license on the line if they code when they hit the floor. And believe me they do.

 

[Bostonredsox]

Are you a resident, or is the place you work at just a little bit of a sh-t show?

Both. I'm a third year resident and will be a hospitalist here in 4 months. And yes this place is a sh-t show by all accounts.

 

[Bostonredsox]

Its really simple, when you step back and look at it:

Is it safer to leave patients unseen in the waiting room, or send patients who HAVE been seen up to the floor, where the floor staff is overwhelmed and might not get to do a full H&P for 2-3 hours? This is assuming you've fully saturated you ED with hallway stretchers and the like.

When the overnight doc tells me he is overwhelmed and can't handle another admission, but every bed and hallway is full in my ER and there are 10 in the waiting room, and EMS calls with a code 5 minutes out... I'm sorry but the admitted patients are coming up! I've seen them, they have a set of labs, a provisional dx... etc.

If it is so busy upstairs that the admitting doctor is overwhelmed and can't handle the volume, the correct answer is to have MORE admitting doctors, or a PA helping... NOT to hold patients in ED beds longer and leave untreated patients in the waiting room longer.

Completely agree with your last paragraph. 100%. But administration doesn't seem to give a ****.

 

[bougiecric]

I don't even know how to respond to this. Literally nothing you have said is true in regards to the meaning of my posts. My "career" is still infantile. No **** I'm no gift of god, I can barely walk and breath at the same time. And you can substitute me for any other hospitalist on staff here, they all feel the same. No our Ed doesn't send us 20 pts an hour, but they bunch admissions up to 6-7-8 at a time and then are dormant for a few hours then bunch more. And they always fall within a 60 minute range of there overlapping shift change. And when there is one provider in house at night covering all the floors, the MICU and all Ed admits, these slams of 8 admissions, often filled with two surgery dumps, get quite taxing, especially when badness is going down on the floors. I know the Ed is Slammed, but atleast you never have to leave your unit. We have to be everywhere and it's taxing at night, but I digress.

Either way, I have no idea wtf you are talking about with me thinking I know everything or that I pick up every miss or never miss anything. Nothing in my posts had anything to do with any of that sort of nonsense. I merely said I am not comfortable allowing admissions from someone else to reach the floor, let alone several in a bunch, without me seeing the pt. if you ****** up, it's my head. Doesn't mean you did **** up, or that I'll come up with some super diagnosis you missed, it just means I don't trust my license to others and if that pisses you off, well I'm sorry. Obviously this is case by case. If your sending me a 41 year old chest pain with a normal EKG and flat trops whose now pain free to rule out, yeah send him up I'll see on floor. But the selection of who I'm comfortable allowing to be sent up before I see them is my decision, as it's my license on the line if they code when they hit the floor. And believe me they do.

Dude, take a step back. Humble yourself. This post seethes frustration and is exactly representative of Venko's description above. Don't blindly disregard others' perception of you... many times there is a kernel of truth in there that is important to reflect on. You are too young to be this persistently angry.

 

[Birdstrike]

our Ed doesn't send us 20 pts an hour, but they bunch admissions up to 6-7-8 at a time and then are dormant for a few hours then bunch more. And they always fall within a 60 minute range of there overlapping shift change. And when there is one provider in house at night covering all the floors, the MICU and all Ed admits, these slams of 8 admissions, often filled with two surgery dumps, get quite taxing, especially when badness is going down on the floors. I know the Ed is Slammed, but..

The ED has been getting slammed 24/7 from bogus "go to ER" dumps since before we were all born. You don't think people in the ED get irritated with this, and complain about it?

Constantly.

The ER gets killed and then it gets pushed down stream and the admitting people get killed.

This is high pressure, high acuity, customer satisfaction-driven, profit-driven Medicine of the 21st century.

If you want the ability to control your workflow and be able to deflect dumps and your patient/payor mix, you need to go outpatient.

Being a hospitalist is just the other side of the same coin as EM. The pro's/con's, patients, circadian rhythm disruptions are more similar than different. Basically, they're the same.

You see it as, "Why am I getting killed by the ED? Why am I getting shelled with 6-10 sick patients at a time?"

Because three hours ago, the ED got shelled with 6-10 sick patients at a time (along with 24-40 undifferentiated non-sick people to sludge through). And guess what, the ER docs are just as irritated as to the who's, what's and why's about why they're getting slammed daily, as you are.

So you can blame them and say, "If only we had better ER doctors, if only we had better surgeons, if only..."

But realistically, the ER will continue to be overwhelmed and therefore everyone downstream will continue to be overwhelmed. That's just the way inpatient medicine is, when you are downstream from EMTALA.

Consider going out patient. You may make a little less money, be little more bored, but may save a lot of frustration.

 

[RustedFox]

Yep.

Had a talk with one of my hospitalists the other day (who is a genuinely good guy and an unreally smart doc). Had to admit to him an ETOH guy who couldn't find anyone to come get him/was getting late/nobody was gonna answer the phone for him/etc. Guy had already been there for 4-5 hours and nursing "managment" is now doppleganging by my desk asking me "What are we going to do with this patient and why haven't you done it already?!"

Okay, admit.

Conversation goes like this:

Hospitalist: "Jeeezus, man. What the hell? This is ridiculous the number of just flat drunks that we're getting. Its not just MY responsibility to dry them out, you know."
RustedFox: "Yeah, man. I know. But guess what: I only bring the ones to you that I can't realistically dry out and send home. For every one that you get, I have to cope with three or four."
Hospitalist: " (....) Never thought of it that way. Wow. How many are you getting?"
RustedFox: "Step into my world, amigo. The only difference between you and me is that you don't have a stopwatch and a pistol pointed at you all the time; with a white-coat-wearing Nurse-Boss coming by twice every 10 minute to remind me to move it."

 

[FLTDOC1]

I am sure you have ALL seen this. Some EM attendings are ultra conservative compared to others. This type of practice has a profound effect on ED flow.

Yes, external issues will effect ED flow but the level of experience, judgement and cojones of the attending EM staff will make or break an ED. Attending #1 -frequent use of consults and advanced imaging ( resident remarks that when seeing any belly pain with him -start drinking for CT) Any vague numbness gets a neuro consult. If the pt has a vagina -call gyn. ect ect ect
Attending #2 - much more conservative use of consults, labs and imaging.
Stats at end of month ( for same # of pts seen) show #1 is ordering 3-4x as many CTs and MRIs as #2, admitting twice as many pts - with no difference in morbidity and mortality. Whose shop moves the pts thru at a faster rate?

 

[Arcan57]

I am sure you have ALL seen this. Some EM attendings are ultra conservative compared to others. This type of practice has a profound effect on ED flow.

Yes, external issues will effect ED flow but the level of experience, judgement and cojones of the attending EM staff will make or break an ED. Attending #1 -frequent use of consults and advanced imaging ( resident remarks that when seeing any belly pain with him -start drinking for CT) Any vague numbness gets a neuro consult. If the pt has a vagina -call gyn. ect ect ect
Attending #2 - much more conservative use of consults, labs and imaging.
Stats at end of month ( for same # of pts seen) show #1 is ordering 3-4x as many CTs and MRIs as #2, admitting twice as many pts - with no difference in morbidity and mortality. Whose shop moves the pts thru at a faster rate?

Of course, but in general that's not an educatable behavior. Doc #1 will eventually gravitate towards a community hospital with a good payor mix and fee for service consultants that are hungry for business. Doc #2 will gravitate towards low payor mix/minimal resource environments where occasional misses are more tolerated.

We are a specialty that venerates gut instinct. Telling a post-residency doc that their gut is wrong (especially the over cautious type) generally just creates additional stress and job dissatisfaction without improvement in throughput.

It's also quite possible that the consult happy doc is buffering their workload to cover for discomfort with volume by introducing soft stops that generate complaint proof excuses for delays in patient flow.

 

[namethatsmell]

I don't know about your shops, but it's not uncommon that patients wait for discharge papers for 20+ minutes at some of my shops. Obviously there's no incentive for the nurse to discharge patients more quickly since it makes the next patient come sooner and makes more work for them...but if nursing leadership pushed this from the top down maybe it would happen.

Not only does it slow down the ED, but it pisses off patients who just want to leave and it opens the door for more things to "come up" with patients who are trying to stay. Badness all around.

 

[Bostonredsox]

The ED has been getting slammed 24/7 from bogus "go to ER" dumps since before we were all born. You don't think people in the ED get irritated with this, and complain about it?

Constantly.

The ER gets killed and then it gets pushed down stream and the admitting people get killed.

This is high pressure, high acuity, customer satisfaction-driven, profit-driven Medicine of the 21st century.

If you want the ability to control your workflow and be able to deflect dumps and your patient/payor mix, you need to go outpatient.

Being a hospitalist is just the other side of the same coin as EM. The pro's/con's, patients, circadian rhythm disruptions are more similar than different. Basically, they're the same.

You see it as, "Why am I getting killed by the ED? Why am I getting shelled with 6-10 sick patients at a time?"

Because three hours ago, the ED got shelled with 6-10 sick patients at a time (along with 24-40 undifferentiated non-sick people to sludge through). And guess what, the ER docs are just as irritated as to the who's, what's and why's about why they're getting slammed daily, as you are.

So you can blame them and say, "If only we had better ER doctors, if only we had better surgeons, if only..."

But realistically, the ER will continue to be overwhelmed and therefore everyone downstream will continue to be overwhelmed. That's just the way inpatient medicine is, when you are downstream from EMTALA.

Consider going out patient. You may make a little less money, be little more bored, but may save a lot of frustration.

Alright alright I concede. You are correct I know the Ed is getting slammed and **** rolls down hill. But I have to say atleast at my shop it is somewhat practitioner dependent. Several Ed docs who I think are great docs keep the workload streamlining, send people home that don't need to be admitted, and admit as they come, not in a batch. Others batch em up, admit everything with a pulse and function like triage nurses. The last few nights it has been two guys who are the latter so I guess I'm somewhat just venting, sorry.

And I love inpatient medicine, detest outpatient. More than likely I am going back to fellowship after these two years are up because hospitalist medicine has become so bastardized it's just a catchall for all patients and a workload dump for consultants who don't want patients on there own service, superimposed on endless social work. Things are much better in the MICU and the medicine is much less adulterated. That is where I have always belonged, just stuck on the floors for the time being.

 

[Venko]

I don't even know how to respond to this. Literally nothing you have said is true in regards to the meaning of my posts. My "career" is still infantile. No **** I'm no gift of god, I can barely walk and breath at the same time. And you can substitute me for any other hospitalist on staff here, they all feel the same. No our Ed doesn't send us 20 pts an hour, but they bunch admissions up to 6-7-8 at a time and then are dormant for a few hours then bunch more. And they always fall within a 60 minute range of there overlapping shift change. And when there is one provider in house at night covering all the floors, the MICU and all Ed admits, these slams of 8 admissions, often filled with two surgery dumps, get quite taxing, especially when badness is going down on the floors. I know the Ed is Slammed, but atleast you never have to leave your unit. We have to be everywhere and it's taxing at night, but I digress.

Either way, I have no idea wtf you are talking about with me thinking I know everything or that I pick up every miss or never miss anything. Nothing in my posts had anything to do with any of that sort of nonsense. I merely said I am not comfortable allowing admissions from someone else to reach the floor, let alone several in a bunch, without me seeing the pt. if you ****** up, it's my head. Doesn't mean you did **** up, or that I'll come up with some super diagnosis you missed, it just means I don't trust my license to others and if that pisses you off, well I'm sorry. Obviously this is case by case. If your sending me a 41 year old chest pain with a normal EKG and flat trops whose now pain free to rule out, yeah send him up I'll see on floor. But the selection of who I'm comfortable allowing to be sent up before I see them is my decision, as it's my license on the line if they code when they hit the floor. And believe me they do.

The feeling comes from the following:

- you were the one who picked up that the pneumonia patient had a high lactate...I think eight in your example because no one checked it. This implies that the ED doc screwed up and you were there to catch their mistake...

- you were the one to identify the missed arterial occlusion causing limb ischemia that the ED docs missed...

- the surgeons write inadequate notes unlike you who must therefore write much more appropriate notes

- the nurses aren't able to help you because...

Regarding the patient volumes...

- I suggest take 30-45 mins an make micro consults and then revisit the seven patients that you hypothetically admitted.
- you then countered that although you had recently (35-45 mins before) received seven admits, you expected to get another bolus of patients before you could continue with the original seven admits.
- this would mean roughly ten or more admissions in one hour.

Did I misquote you?

 

[Bostonredsox]

The feeling comes from the following:

- you were the one who picked up that the pneumonia patient had a high lactate...I think eight in your example because no one checked it. This implies that the ED doc screwed up and you were there to catch their mistake...

- you were the one to identify the missed arterial occlusion causing limb ischemia that the ED docs missed...

- the surgeons write inadequate notes unlike you who must therefore write much more appropriate notes

- the nurses aren't able to help you because...

Regarding the patient volumes...

- I suggest take 30-45 mins an make micro consults and then revisit the seven patients that you hypothetically admitted.
- you then countered that although you had recently (35-45 mins before) received seven admits, you expected to get another bolus of patients before you could continue with the original seven admits.
- this would mean roughly ten or more admissions in one hour.

Did I misquote you?

You extrapolated a Bolus of 7 pts followed by another set in a short timeframe to a 12 hour total, not what I implied, your own logic there. Even if there are no admits for 3 hours your still behind from the 10 you already got. On average, h/p, evaluation, orders and paperwork takes 30-45 min per pt. so 7 admits at once is 3.5 - 4.5 hours of work...,if you get anything else in that timeframe you are still fighting from behind. Make sense? And ten admissions in an hour and a half happens frequently, as I said certain people batch there admissions. Even though they've cleaned out there admits to me all at once and will now not call for 3-4 hours, the floors and MICU will still keep calling so seeing, ordering and documenting all of those admissions in any meaningful timeframe is quite difficult.

A typical night here. Phone call at 715pm. I have 5 admits for you. Phone call from other Ed doc at 830, I have 4 admits for you and hang on, I think the other guy has one more. That's 10 admits 90 minutes into my shift. Even if neither of you call me for 3 hours, I'm still likely to be behind significantly because of all the floor calls and crap, plus if any of those ten admits turns out to be quite sick, which usually 1 maybe 2 are. Add in a rapid response or a code on the floor or in MICU, and it just stockpiles. Then midnight, 2 am rolls around and I get called for 3-4 more. Hopefully will be quiet after that as we average about 14-15 admits per night but I'm already miles behind.

And commenting on a few pickups I've been fortunate to find, which presumably any other admitting doc would have also picked up, gives me a label of who I am?? I compared the surgeons notes to the hospitalists notes, not surgeon x's note to my note. And the feeling of the floor nurses is mutual across most all providers here, at the attending level. What it seems like is I mentioned a few cases in discussion and you've used that to paint a picture of who I am as a doctor. Bit unfair don't ya think?

 

[deleted109597]

We get the same bolus at both ED nursing shift changes, and the amazing moments when all of the upstairs beds are clean at the same time, effectively emptying the department. Every day is a test of low level surge capacity.

 

[Venko]

You extrapolated a Bolus of 7 pts followed by another set in a short timeframe to a 12 hour total, not what I implied, your own logic there. Even if there are no admits for 3 hours your still behind from the 10 you already got. On average, h/p, evaluation, orders and paperwork takes 30-45 min per pt. so 7 admits at once is 3.5 - 4.5 hours of work...,if you get anything else in that timeframe you are still fighting from behind. Make sense? And ten admissions in an hour and a half happens frequently, as I said certain people batch there admissions. Even though they've cleaned out there admits to me all at once and will now not call for 3-4 hours, the floors and MICU will still keep calling so seeing, ordering and documenting all of those admissions in any meaningful timeframe is quite difficult.

A typical night here. Phone call at 715pm. I have 5 admits for you. Phone call from other Ed doc at 830, I have 4 admits for you and hang on, I think the other guy has one more. That's 10 admits 90 minutes into my shift. Even if neither of you call me for 3 hours, I'm still likely to be behind significantly because of all the floor calls and crap, plus if any of those ten admits turns out to be quite sick, which usually 1 maybe 2 are. Add in a rapid response or a code on the floor or in MICU, and it just stockpiles. Then midnight, 2 am rolls around and I get called for 3-4 more. Hopefully will be quiet after that as we average about 14-15 admits per night but I'm already miles behind.

And commenting on a few pickups I've been fortunate to find, which presumably any other admitting doc would have also picked up, gives me a label of who I am?? I compared the surgeons notes to the hospitalists notes, not surgeon x's note to my note. And the feeling of the floor nurses is mutual across most all providers here, at the attending level. What it seems like is I mentioned a few cases in discussion and you've used that to paint a picture of who I am as a doctor. Bit unfair don't ya think?

We only go off what you put out there. Your posts come off as arrogant and bad mouthing of every other service mentioned. If that's not who you are, let it not be what you post.

For example, you could have said...

- I worry there can be important missed findings with patients when the ED gets overwhelmed. Although its unusual, I once found a person who had acute limb ischemia or severe sepsis that was under appreciated.

- surgeons may be able to carry more patients because in my experience they are tend to need less documentation than our hospitalists by the nature of their specialty.

...

Hopefully you understand the tone differences...also, it comes off as though everyone else has a problem and not you when you have not listed one thing you could do better to fix the situation. You have listed the ED physicians part in batching admissions, the nurses part in that no one trusts them to identify sick/not sick, the surgeons inability to document, the EDs missed findings...what did you say was your contribution to the problem?

This is why it comes off like you must be the only perfect cog in this wheel.

I hope this helps you understand why I and possibly others walk away with an impression that you are egotistical / egocentric.

If its not who you are, then act / speak differently.

 

[Bostonredsox]

sorry. i will choose my words more carefully next time.