22 June 2007

Advice for EM Interns (Part Four)

Moving the Meat -- Part Four

Yesterday, I tried to give some tips on efficiency in the ER using generalities and philosophic concepts. Sometimes it helps to be a little more concrete, both in terms of the chronology and the mechanics of the patient interaction. This is how I try to function, and how I advise our new hires:

BEFORE you see a new patient

  • Make mental rounds on your current service
  • Dispo any patient who is ready before picking up a new patient
  • Skim the chart rack and pre-order obviously needed studies on waiting patients; medicate patients in pain
  • Order rooms set-up in advance for laceration repair or pelvic exam
  • 30 seconds with the old records is worth 10 minutes with the patient
WHILE you see the patient
  • Keep your history “On Track”
  • Document in real time at the bedside
  • Determine the patient’s “agenda” and address it expressly (especially if narcotics are a point of contention)
  • Determine a treatment plan and disposition and TELL THEM before you leave the room
IMMEDIATELY AFTER you see the patient
  • Know your decision tree
  • Determine the rate-limiting step and make it priority #1 in the work-up
  • Order the bed for obvious admissions
  • Tell the nurse what you are going to do
  • Start therapy early – a medicated patient is a cooperative patient
  • Order all tests in parallel and not serial manner
  • Utilize Point of Care Testing when available
  • Utilize evidence-based standards for ordering tests
  • Minimize screening tests
  • Defer necessary but non-urgent work to another setting
  • Staged therapy – write orders for progressive medications based on defined criteria. Involve the nurses in the plan and encourage them to take initiative in managing the therapy.
  • Set triggers – in the orders set a trigger where someone will notify you when a decision point has been reached
  • Delegate: RNs may titrate meds; techs can irrigate, dress, and splint; Physician Assistants can suture.
  • Anticipate obstacles for discharge – road test the patient early, call NH or family to ensure the patient can go back, etc.
  • Minimize unnecessary consults or those without an action plan attached
  • Avoid the “I want to run this by you” conversation – know what you want the person to do before you pick up the phone, and begin the conversation with “The reason I am calling you is that I need you to do X…”
  • Don’t play ping-pong – know who you want to do the admit, and if they balk, ask them to call the other service to negotiate the admission.
  • Make sure the patient’s agenda has been addressed
  • Address the 3 Golden Needs: They feel better; They are reassured; They know the next step.
  • Discharge them yourself if possible (Nurses will love you!)
  • Redirect Office consults to direct admits when possible
  • Lower threshold to admit patients with expected prolonged work-ups or ED therapy
  • Admit earlier; write admit orders immediately to ensure the patient goes up immediately
  • Make a strong sales pitch to hospitalist, intensivist, and specialist colleagues: get the admitted patients to the floor ASAP
  • Look at the schedule and talk to the next-leaving doc to determine whether they need to stay late, or call in an extra body early
My $0.02. Again, this is not all original material (the bit about the 3 Golden Needs I vaguely recall from an ACEP lecture) so I cannot take full credit.


  1. I...I...I love you.

    Minimize unnecessary consults or those without an action plan attached

    Nurse K's pet peeve is this one doc who, at all hours of day and night, will call nearly every patient's primary doctor to "let them know" the patient was here and will be calling for a standard ER follow up [not like an on-the-fence admission where the compromise is early follow-up--EVERY patient with anything beyond a sore throat]. If I mention something like "the patient can call the doc herself", he flips out, meanwhile, the lobby is backing up making for a long night. Another doc will call and let the patient's beloved OB/GYN to let him/her know he's admitting the patient for a broken foot or whatever. WHO. CARES. ADMIT THE PATIENT.

    Minimize screening tests

    One doc, who I think is just being passive-aggressive, orders a urine on everyone over a certain age no matter if they're in for chest pain or knee pain or whatever. "Yes doc, they're not complaining of urinary symptoms, have no history of UTI, and after 45 minutes of getting the patient up, unhooking them from the monitor risking them having a cardiac episode off the monitor and walking them to the bathroom, hooking them back up to the monitor and labeling and sending the urine, it's negative."

    It's those type of things that just grind on you. These are excellent recommendations.

    Also, I recommend adding "only admit to telemetry if the patient needs telemtery." None of this "we need tele because the patient is in chronic a-fib" or "we need tele because they're 88 years old and had heart surgery in 1993" or the "admit to tele" for comfort care patients who just had the big head bleed or whatever.



    I, too love you. Can you come work at our hospital?

    We are a big urban hospital, and often (like the other night) have 35 people in the ED waiting to be seen, and more outside. (Since we implemented a new "fast track" area, many of those outside are seen by PAs in our special exam rooms and are dc'd from there, thank goodness, so the load is lightening.)

    Fortunately, in our ED, many of the RNs are very proactive. Most patients get bloods drawn and a heplock inserted as soon as they make it to the stretcher. The ambulance triage nurse often presents cases quickly to one of the attendings so he or she can order the relevant bloods and tests, and by the time the MD gets to the bedside, they have the test results in hand.

    even though we do this we often have long wait times just because of sheer volume. Feh.

  3. Yes. It doesn't help to keep seeing patients if you never dispo any. We operate in a finite amount of space and it doesn't take long to reach full ER constipation

  4. Man, you get a big virtual (but professional!) smooch for this post! Think my docs would be insulted if I put this up?

    Nah, actually they are almost carbon copies of this list (except the nurses are one step ahead on preparing rooms for pelvics, sutures, etc) : )

  5. I love these posts. Even though I am still a student, it is never too early to start learning efficiency... I think most of these posts could apply to students just was easily. Nice work!

  6. Excellent advice, works for urgent care as well. Remember that the PA probably has 7 patients of her own, so inserting a laceration may bog the ED down as well, but hey, someone has to do it.

  7. true i haven't worked er (or as we call it casualties) for many a year, but i summed it up a lot more simply. 1.patient's complaint/agenda. 2.examination and thereby your diagnosis/agenda. 3.get rid of patient (to street or ward)

  8. I wish some of the interns I've had read this. ^^


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