When does pph become dangerous?

[Backpack234]

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At some facilities, I’ve noticed that even if you’re averaging 2-3 per hour, for short bursts you’ll still see >6/hr. This seems unsafe to me, but I’ve been told it isn’t.

Where’s the breaking point? When does pph become dangerous?

 

[TooMuchResearch]

Do you mean seeing and dispo-ing 6 pph? I commonly see 5-6 patients in the first hour of a busy shift, but they're not all getting discharged or admitted within the hour. Maybe if it was all fast track stuff but then you're still trying to impose urgent care level efficiency on low acuity ED patients, which seems unlikely.

 

[Backpack234]

yeah. Not actually dispoing because they’re higher acuity. Essentially coming into a shift and the board is full of unassigned patients that have been there for an hour. You’re now seeing at least 6 (Usually more) plus overall management of the ed for usually 2 hours before your partner arrives.

 

[EctopicFetus]

Meh. Seeing them and ordering the right stuff isn’t that hard. Documenting takes time so my scribe helps me there. Follow up of results and closing the loop are the time sinks.
6 in an hour for a short burst isn’t a big deal imo.

 

[jw3600]

6 for an hour or two isn’t that bad. 6/hour for a full shift is so ridiculously unsafe that it should be considered criminal.

 

[TooMuchResearch]

Oh, yeah that's to be expected. I'd rather jump in and start 6 patients in the first hour than have them trickle in 1-2 at a time.

yeah. Not actually dispoing because they’re higher acuity. Essentially coming into a shift and the board is full of unassigned patients that have been there for an hour. You’re now seeing at least 6 (Usually more) plus overall management of the ed for usually 2 hours before your partner arrives.

 

[Zebra Hunter]

Hell, I sometimes do 8-10/hr in short bursts without feeling like this is unsafe. All depends on patient acuity and whether you have a scribe. 6pts/hr for 2 hours should really be no big deal for the average EM doc as long as these aren’t critical patients.

 

[ShockIndex]

6-8 waiting to be seen when you walk in the door is actually desirable unless they are epistaxis and pelvics .

After that, just over 2 pph of reasonable acuity is about right. At the end of an 8 hour shift you will have 2.2-2.5 pph that way.

 

[TheSingularity]

Totally depends on the set up of the shop.

In highly efficient places where I'm not bogged down with bull**** I can go above 3pph sustained and feel ok.

In toxic **** holes it's hard to get above 2.

Sent from my Pixel 3 using SDN mobile

 

[Backpack234]

6 isn’t so bad. But that’s the minimum. It’s been as high as 12 before. If it’s low acuity, no problem. But a fib meth user and nurses can’t get iv access, airway requiring bipap or intubation, stroke alerts and mi as 3 of those 6 feels like I’m being stretched a little thin.

But could be I’m wrong and this is the standard.

 

[GeneralVeers]

I usually pick up 10-12 in my first 2 hours. Any simple procedures I punt to my PA/NP. By hour 3 the next doc comes in and takes the next bolus, while I clean up my original people. Then it's simpler cases at a slow pace for the last 5 hours, followed by going home an hour early.

 

[TooMuchResearch]

I've been trying to convince more of my group that waterfall scheduling and having PAs handle mostly just straightforward stuff is the way to go, but I think I need a few more retirements to happen before we can convince the majority.

I usually pick up 10-12 in my first 2 hours. Any simple procedures I punt to my PA/NP. By hour 3 the next doc comes in and takes the next bolus, while I clean up my original people. Then it's simpler cases at a slow pace for the last 5 hours, followed by going home an hour early.

 

[Cinclus]

I saw about 10 patients in my first two hours yesterday, and then things slowed down significantly when I had to follow up on their stuff and dispo all of 'em. Like someone said above, its easy to see a bunch and order the right stuff, but then there's getting the dispo, which can involve getting a lot of other people to cooperate with you.

 

[emergentmd]

pph or pph in burst says little about safety.

When we didn't have midlevels, I have seen 15 the 1st hour and didn't have much of an issue. Family pack of 3 with sore throat = 10 min to discharge, 3 with coughs, 4 with lab workups, 5 with xrays.

I have walked into inefficient messes where a competent nurse to be found and 4 the first hour makes me want to leave.

 

[jw3600]

6 isn’t so bad. But that’s the minimum. It’s been as high as 12 before. If it’s low acuity, no problem. But a fib meth user and nurses can’t get iv access, airway requiring bipap or intubation, stroke alerts and mi as 3 of those 6 feels like I’m being stretched a little thin.

But could be I’m wrong and this is the standard.

6/hour for a shift? Or 6 IN AN HOUR? You post is too vague about an important distinction.

 

[migm]

My shop has been 30 over 8 hrs, I usually stay about 30-45 m to get everything done. It feels uncomfortable. I usually see 5-9 in the first hour.

 

[ShockIndex]

My shop has been 30 over 8 hrs, I usually stay about 30-45 m to get everything done. It feels uncomfortable. I usually see 5-9 in the first hour.

3.75 pph would make me feel uncomfortable in a shop with moderate acuity (~10-20% admit; 5% CC) even if I had great support and excellent nurses. That is the pace that I typically see in an UC.

 

[migm]

3.75 pph would make me feel uncomfortable in a shop with moderate acuity (~10-20% admit; 5% CC) even if I had great support and excellent nurses. That is the pace that I typically see in an UC.

About 25% admit, probably 7-8% CC. It's profitable but uncomfortable. I review my charts a lot

 

[Backpack234]

6/hour for a shift? Or 6 IN AN HOUR? You post is too vague about an important distinction.

6 in an hour. Didn't mean for a misunderstanding. I mean get to work and see at least 6 charts on the rack which you're responsible for. End up seeing them all in about an hour, but that's the minimum.

Also, 6 in an hour near the end of your shift. The mid-day lull occurs and 6 people sign into the waiting room at once, 6 admitted patients move upstairs and they all come back at once.

And to add, these are all level 3 or higher acuity patients.

 

[ShockIndex]

About 25% admit, probably 7-8% CC. It's profitable but uncomfortable. I review my charts a lot

Yeah, the only way that I could sustain that pace and acuity without degrading performance would be to chart at the end of a shift. What you are doing would make me uncomfortable too. Like others in the thread, I can flex up to 6 or 7 pph, but that is only sustainable for me if there are periods of 1-2 pph. What you’re doing is hardcore.

 

[thegenius]

About 25% admit, probably 7-8% CC. It's profitable but uncomfortable. I review my charts a lot

About 10% more than the national average.

There is no way we could admit 25% of our patients without significant pushback by the hospitalists. They already pushback now and we are at ~15%. it's one of the 2-3 most frustrating parts of my work.

 

[TooMuchResearch]

Figure out how to manage your dispos a little more creatively at the end if you're going to be expected to see anyone that makes it in at the end...

6 in an hour. Didn't mean for a misunderstanding. I mean get to work and see at least 6 charts on the rack which you're responsible for. End up seeing them all in about an hour, but that's the minimum.

Also, 6 in an hour near the end of your shift. The mid-day lull occurs and 6 people sign into the waiting room at once, 6 admitted patients move upstairs and they all come back at once.

And to add, these are all level 3 or higher acuity patients.

 

[EctopicFetus]

It’s also dangerous if you are a pseudo em doc. Aka a non em trained doc.

 

[migm]

About 10% more than the national average.

There is no way we could admit 25% of our patients without significant pushback by the hospitalists. They already pushback now and we are at ~15%. it's one of the 2-3 most frustrating parts of my work.

i don't know what to say other than the obvious which is maybe our population is different. We are pretty quick on the discharge when possible. I do not often (it is the exception) get pushback from hospitalists

 

[psychapp121]

I usually pick up 10-12 in my first 2 hours. Any simple procedures I punt to my PA/NP. By hour 3 the next doc comes in and takes the next bolus, while I clean up my original people. Then it's simpler cases at a slow pace for the last 5 hours, followed by going home an hour early.

how can one go home early if their assigned to a particular shift?

 

[TooMuchResearch]

how can one go home early if their assigned to a particular shift?

Finish their patients up and have overlapping coverage. If the docs are RVU incentivized, the oncoming doc likely won't have an issue with the outgoing doc leaving early. Or work at a place with enough documentation/wrap up time included and get things done before this time is up.

 

[deleted547339]

how can one go home early if their assigned to a particular shift?

If there is overlap. We will routinely send a doc home at one of my sites. We have a 6P-2a shift and a 10p-6a shift. If it’s not bad, the overnight doc will often tell the 6P doc to stop picking up new patients around 11.

 

[GatorCHOMPions]

Academics here. Commonly come on and see 10 patients the first two hours during busy shifts. We easily do 3 pph during the peak 12 hours of the day and like 2 pph the other 12 hours. Definitely don’t feel like I do adequate teaching if I’m seeing more than 2.2 pph but that’s just the way it is.

Curious what others in academics are experiencing?

 

[deleted547339]

It all depends on the level of illness, rapidity of testing, quality of staff, EMR, difficulty in admitting, etc. I’ve seen 2pph and felt crushed and 4pph and felt fine. I’ve done 6pph, that was just balls to the wall. It’s all site specific.

I LOVE when I can walk in and see 8-12 in my first 1-2 hours. It makes the day go faster. I despise coming in and only having 1-4 in the first 1-2 hours because of boarding or whatever. The natural flow of an 8 hour shift is about 3 turns of 6-8 patients.

If your triage nurse is good, it helps a lot. We have a FSED where you can see 3pph on your own plus staff mid level patients and it’s not bad. All your ankle sprains already have x-ray reads back before you see them. All your sore throats have rapid strep and flu back before you see them. They don’t let women pass go until you have a UPT. Abdominal CTs are back within about 60 minutes from ordering. May lead to overtestinf, but they know not to order d-dimers, etc. Contrast this with the mother ship where you have can’t get a scan for 8 hours because you don’t have a negative pregnancy test in spite of the fact that you’ve seen them walk to the bathroom three times.

 

[deleted547339]

Academics here. Commonly come on and see 10 patients the first two hours during busy shifts. We easily do 3 pph during the peak 12 hours of the day and like 2 pph the other 12 hours. Definitely don’t feel like I do adequate teaching if I’m seeing more than 2.2 pph but that’s just the way it is.

Curious what others in academics are experiencing?

At our primary site, we do right around 2-2.2 an hour. It’s all staffing resident patients and the faculty shifts are offset by an hour. Outside of interns early in the year, we rarely see patients on our own excluding physician in triage shifts. Pretty cush gig.

 

[ShockIndex]

Academics here. Commonly come on and see 10 patients the first two hours during busy shifts. We easily do 3 pph during the peak 12 hours of the day and like 2 pph the other 12 hours. Definitely don’t feel like I do adequate teaching if I’m seeing more than 2.2 pph but that’s just the way it is.

Curious what others in academics are experiencing?

Roughly 2.5-3 pph. I also have my senior resident cherry pick good student cases for me to solo staff with MS3s and AIs. Meaning, they can bounce questions off the residents and get help with procedures, but the residents don’t have to see it or write the note.

 

[thegenius]

It all depends on the level of illness, rapidity of testing, quality of staff, EMR, difficulty in admitting, etc. I’ve seen 2pph and felt crushed and 4pph and felt fine. I’ve done 6pph, that was just balls to the wall. It’s all site specific.

I could do 6 pph, in my dreams. I dream about that sometimes:
- a consult never says no to me
- a hospitalist never says no to me
- the hospital admin will back up my decisions to summarily discharge people after an appropriate 60 sec MSE and will ignore pt complaints
- labs come back in 30-60 mins
- imaging comes back in 30-60 mins
- I only do REAL emergency procedures, not these bull**** central lines because someone's BP is slowly drifting down 3-5 points/hr that should be done upstairs
- have awesome scribes
- have awesome nurses

I also dream about being on an island without a food shortage, and young women who all want me and can't get pregnant.

It's fun to fantasize

 

[TooMuchResearch]

I order a lot of qualitative serum HCGs.

It all depends on the level of illness, rapidity of testing, quality of staff, EMR, difficulty in admitting, etc. I’ve seen 2pph and felt crushed and 4pph and felt fine. I’ve done 6pph, that was just balls to the wall. It’s all site specific.

I LOVE when I can walk in and see 8-12 in my first 1-2 hours. It makes the day go faster. I despise coming in and only having 1-4 in the first 1-2 hours because of boarding or whatever. The natural flow of an 8 hour shift is about 3 turns of 6-8 patients.

If your triage nurse is good, it helps a lot. We have a FSED where you can see 3pph on your own plus staff mid level patients and it’s not bad. All your ankle sprains already have x-ray reads back before you see them. All your sore throats have rapid strep and flu back before you see them. They don’t let women pass go until you have a UPT. Abdominal CTs are back within about 60 minutes from ordering. May lead to overtestinf, but they know not to order d-dimers, etc. Contrast this with the mother ship where you have can’t get a scan for 8 hours because you don’t have a negative pregnancy test in spite of the fact that you’ve seen them walk to the bathroom three times.

 

[deleted547339]

I could do 6 pph, in my dreams. I dream about that sometimes:
- a consult never says no to me
- a hospitalist never says no to me
- the hospital admin will back up my decisions to summarily discharge people after an appropriate 60 sec MSE and will ignore pt complaints
- labs come back in 30-60 mins
- imaging comes back in 30-60 mins
- I only do REAL emergency procedures, not these bull**** central lines because someone's BP is slowly drifting down 3-5 points/hr that should be done upstairs
- have awesome scribes
- have awesome nurses

I also dream about being on an island without a food and good shortage, and young women who all want me and can't get pregnant.

It's fun to fantasize

Again, that was balls to the wall unsafe. This isn’t me thumping my chest saying I’m great. I’ve been at a solo coverage shop where I’ve seen 36 in 6 hours. It was balls to the wall and I wouldn’t do it again.

As above, it’s all site specific.

 

[Got Em]

If you see 8-12 in the first 2 hours and then 2 per hour after this, when do you guys usually chart if you don't have a scribe? We have attendings here that do most of their charting after the shift if they see patients this way.

 

[ShockIndex]

If you see 8-12 in the first 2 hours and then 2 per hour after this, when do you guys usually chart if you don't have a scribe? We have attendings here that do most of their charting after the shift if they see patients this way.

I charted during my shift and had virtually all of my charts completed at the time of dispo. As a personal rule, I completed my notes during the shift and signed them after a quick proof read after the shift.

We used Epic with Dragon voice recognition support. I could knockout most notes using dictation and templates in under 2 minutes. I average 2.5-3 pph in most busy days regardless if I was at the academic shop or a community affiliate.

 

[TheSingularity]

Are all these folks pushing these rates RVU driven? If you're not paid on RVUs there's no reason to go above 2pph.

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[emergentmd]

If you see 8-12 in the first 2 hours and then 2 per hour after this, when do you guys usually chart if you don't have a scribe? We have attendings here that do most of their charting after the shift if they see patients this way.

In an 8 hr shift that is about 3pph. Kindda tough but if you get good at charting, you can do it. if not, then you just stay late or see 1.5 pph after your bolus.

3pph with charting is typically my limit to leaving right on time but I have learn to do a chart in about 2 minutes.

 

[Groove]

If you see 8-12 in the first 2 hours and then 2 per hour after this, when do you guys usually chart if you don't have a scribe? We have attendings here that do most of their charting after the shift if they see patients this way.

I chart in real time. Even if I pick up several patients in the first couple of hours which is not uncommon, I almost always chart as soon as I put in orders. Sometimes, I will see 2-3 patients, put in orders for all 3 and chart on all 3 but I rarely exceed that number before starting the chart. I don't use scribes anymore but we have dragon dictate. If I'm seeing more than 1 person without sitting down at a workstation, I will dictate the HPI as soon as I walk out the door, on the way to the next room in my dragon mobile app and say "next paragraph" and then do the same on the next patient. Sometimes, I'll even dictate in front of the patient (Transfers are a great example, when I've got all the paperwork laid out in front of me. ) When I sit down, the dragon text box will have all 3 HPIs and I just cut and paste each one to the corresponding chart. I don't necessarily use dragon on every chart, maybe 50%. I exercise brevity with simple charts and simple chief complaints. I see some guys dictating or typing elaborate paragraphs for the dumbest ESI 4s and 5s, even 3s and it's such a waste of time and makes no difference in the end.

Admitted pt's get their notes finished within 30 mins after I've admitted them. Most of the time, I'm finishing it as soon as I get off the phone with the hospitalist. In my checkout tab on Cerner, every note is green (completed) as soon as they drop into that page. Hence, 100% of my notes are completed by the end of my shift and I can't remember the last time I spent any amount of time documenting after a shift or documenting from home. IMO, that's the way to do it. I'll be glad to start charting after a shift when someone starts paying me to chart. Until then, I don't chart off the clock. Some of my colleagues pick up way too many patients and have half finished charts at the end of their shift and are spending 2-3 hours charting from home after work. That's ridiculous. They might make $15/hr more than I do at the end of the month but they are spending 28-30 more hours "working" than me and aren't getting compensated for it. I'm sure it makes the CMG happy but it's a rookie mistake IMO.

It's all about pacing yourself and resisting the urge to pick up more patients than you can physically document on in real time (or manage for that matter). Resisting the urge to put your name on every patient that has been sitting there without a physician signing up for them and feeling a sense of pressure to pick them all up at once. That just gets you behind, overwhelms you and worsens ED metrics because chances are if you had waited 5 or 10 more minutes, the next doc would have caught up and put their name on them and gotten to them sooner. By using my system above, I never get behind and never feel any anxiety about getting behind. It keeps me relaxed, cool and calm throughout my shift and I like that.

 

[Groove]

At some facilities, I’ve noticed that even if you’re averaging 2-3 per hour, for short bursts you’ll still see >6/hr. This seems unsafe to me, but I’ve been told it isn’t.

Where’s the breaking point? When does pph become dangerous?

I don't necessarily think bursts of high PPH is unsafe as long as the pts are low acuity. I can chew through bursts of patients, especially during flu season and can discharge many from the waiting room. Personally though, in a high acuity, high admission rate, high volume ER, I find that anything over 2.5pph (average) is difficult to sustain long term without cutting corners. Obviously, there's exceptions to that like the above example. All docs I've worked with that average over 2.5pph during a month cut corners and start missing stuff. One of our docs who routinely sees 30+ pt's a shift (9hrs) sent out a shoulder dislocation other night and interpreted the XR as normal. The pt checked into an ER across town and got it reduced then called our ER the next a.m. and gave our 6am doc an earful. I pulled the XR up, that humeral head was nowhere near the glenoid. It's much easier to miss stuff when you're going warp speed at a reckless pace. (I'm not pointing fingers, as I've missed stuff too but merely making a point.)

 

[deleted547339]

Are all these folks pushing these rates RVU driven? If you're not paid on RVUs there's no reason to go above 2pph.

Sent from my Pixel 3 using SDN mobile

If you’re solo coverage, RVUs don’t matter. You’ve got to see them now or later, might as well be now in case they’re sick, and they’re happier that way.

I chart while on shift. If I don’t have a scribe, I’ll usually go see 2-5, then sit down for a few minutes and put in orders and chart. Thankfully, my hospital system tends to keep the same patients, so most people have PMH, PSH and SH that I can import - or they are healthy if I’m at the FSED and there’s nothing to remember but “3D nonproductive cough” or “ankle sprain, fall from standing.” So anyways, I dictate my HPI, have templates ROS and pull in old history and meds (which nurses update). I’ll dictate my MDM, then go on to the next chart. As the shift slows down, I’ll pull in labs/imaging/dispo.

I sign the mid level charts either late in the shift or the next day. They are supposed to do them all contemporaneous so I never get the horror story of 1mo later charts that are mismanaged. Plus, we see all the MLP patients. Only one who persistently was late with charts got fired.

 

[hundreddaysoff]

I could do 6 pph, in my dreams. I dream about that sometimes:
- a consult never says no to me
- a hospitalist never says no to me
- the hospital admin will back up my decisions to summarily discharge people after an appropriate 60 sec MSE and will ignore pt complaints
- labs come back in 30-60 mins
- imaging comes back in 30-60 mins
- I only do REAL emergency procedures, not these bull**** central lines because someone's BP is slowly drifting down 3-5 points/hr that should be done upstairs
- have awesome scribes
- have awesome nurses

I also dream about being on an island without a food shortage, and young women who all want me and can't get pregnant.

It's fun to fantasize

- all the patients speak English just like Dan Rather
- I get to shock patients with a buzzer every time they say something that is not a direct answer to the question I just asked
- Meditech and especially Scriptrx never crash or freeze and Scriptrx actually saves my preferred scripts correctly
- the parents of the person(s) who invented One-Hour Sepsis never met so my RNs are always available to do exactly what I want
- diabetes and ESRD do not exist
- Press and Ganey never met
- the average person considers AIDET patronizing rather than humanizing
- I get shocked every time I'm about to put in orders on the wrong patient