work flow

Started by jok200
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jok200

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I have been noticing some of my attending are simply way faster than others, although they all have complete evaluations. I finally asked one of them and he seems to simply glance at the sex, age and CC and orders initial labs studies based on that quite often before even seeing the patient. i have seen this done by other docs as well, wondering is this pretty common? He eventually goes and talks with them, but by that time some of the blood work is usually returned.


Also, I have been having trouble finding solid resources for trauma management. Gun shot wounds, stab wounds, when I use tintinalli, I don't get much as far as management, wondering what other people are using. a lot of residnets in my program use roses.

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Definitely – I initiate some testing and treatments based on the triage note.

Not on every patient, and if I'm available - I'll see them first or at least see them walk/roll in. I think the key principles are:

Keep the work-ups as minimal and basic as possible so that you're not overdoing it. Be able to justify each of these orders in the event you're asked about them. (For example - there's no way I'm not going to want a UA and pregnancy test on a young woman with lower abdominal pain, but they may not need blood testing. There's no way I'm not going to want a basic metabolic panel for a patient whose glucose is above 300.)
I don't order any CT or ultrasound imaging without seeing a patient.
Fortunately, I have a good enough relationship with our nurses that if I order something inappropriate, they'll let me know and usually I'll just cancel it. If they think the patient needs something that I didn't order, they'll usually tell me that too.

I do not like for junior residents (years 1 & 2) to order things on patients without seeing them – their judgment about this kind of thing is just not mature yet, the chance of being wrong is too high, and they tend to overdo it.
 
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We've had threads on how to get fast before, but my three keys are these:

1) Order initial studies based solely on triage note. My door to doc times are < 10 minutes because our EMR counts doctor time as when I click on them, not when I actually see them. Door times are when the nurses put them in the computer. On an ambulance patient, I've done the H&P by then. This is what your fast attendings are doing.

2) I shotgun my studies. Occasionally, I order too much and then cancel it after doing the H&P. Most of the time, I deliberately under order a little (especially CTs, D-dimers, and sometimes other imaging studies) and then add them after the H&P. Meanwhile, the blood and urine studies I knew I'd need have already been cooking for 30 minutes.

3) I prioritize dispositions. Not only is it easier for me to manage 3-4 patients at a time, but it's much easier for the nurses, which further increases the speed of care my patients get. Fewer blankets and drinks for them to get.

Part of residency is explaining what you're doing and why. That's good for your learning, but I assure you it will get old by your last year.
 
The White Coat Investor said:
We've had threads on how to get fast before, but my three keys are these:

1) Order initial studies based solely on triage note. My door to doc times are < 10 minutes because our EMR counts doctor time as when I click on them, not when I actually see them. Door times are when the nurses put them in the computer. On an ambulance patient, I've done the H&P by then. This is what your fast attendings are doing.

2) I shotgun my studies. Occasionally, I order too much and then cancel it after doing the H&P. Most of the time, I deliberately under order a little (especially CTs, D-dimers, and sometimes other imaging studies) and then add them after the H&P. Meanwhile, the blood and urine studies I knew I'd need have already been cooking for 30 minutes.

3) I prioritize dispositions. Not only is it easier for me to manage 3-4 patients at a time, but it's much easier for the nurses, which further increases the speed of care my patients get. Fewer blankets and drinks for them to get.

Part of residency is explaining what you're doing and why. That's good for your learning, but I assure you it will get old by your last year.
Click to expand...
Agree 100% This is a large part of how my metrics are so good despite working a large chunk of solo coverage (attending-wise, I always have at least 1 resident).

One other thing I'd recommend is trying to manage the WR, or at least formulate a plan for it. Our d2d time can't really be helped if we're slammed (which onlh happens on the days that end in 'Y') but we focus on room to provider, and LOS once in room. Anything that can be done (urines, xr, dopps, POCT, etc) before actually occupying real estate in the back cuts down big time on these 2 numbers.

Oh, and dispo is king. With time, you'll learn once you walk out of a room if they're going home... even if you don't yet know what's going on with them. This becomes the cornerstone of your strategy.

Cheers!
-d
 
"What they said" (points at Daiphon/WCI).

But really; yeah - there's no way you don't order at least an EKG/CXR if the words "chest" and "pain" come anywhere near the chart. Add in any single cardiac risk factor, and boom: you're committed to your workup. This is just one example of "what just HAS to get done".
 
Agree with the above with some caveats/emphasis:

1) Take care not to order things that you may not want after the H&P, but that could commit you to more work up if they're positive (d-dimer is probably the clearest example of this).

2) Don't order bloodwork in this way if your nurses don't draw "a rainbow" routinely. If you can add on labs without difficulty, than ordering based on CC + VS can save a lot of time. However, one place I worked did not allow us to hold onto blood samples at the bedside, so if you ordered a troponin and then decide to add on coags later, the patient would need to be re-stuck. There are few ways to get your patients and staff upset faster than ordering in a way that promotes multiple needle sticks.
 
I'm an intern at a very resident-run department that pushes us to become quicker with out dispos, and the only labs that I order without seeing the patient at this point in my training is a urinalysis and a urine pregnancy if I think the chief complaint and triage note warrants it. One of the main reasons is because I've been burned a few times early on by the patient who goes "oh.. I just went to the bathroom, it might take me a while to go again." Everything else, including the normal chest pain workup I wait until I see the patient. This seems to be pretty standard with my other co-residents including upper levels. With that being said, a lot of times our nurses go ahead and draw blood and do an initial 12 lead for chest pain patients immediately when the chief complaint and history is pretty clear. Then we at least have it if we want it (which we usually do).
 
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