25 June 2010

Friday Flashback - Advice for Interns 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
TESTING STRATEGY
  • 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
TREAMENT AND WORKUP TIME
  • 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.
CONSULTS & ADMITS
  • 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.
DISCHARGE
  • 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!)
STRATEGY FOR THE OVERWHELMED ED
  • 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.

Originally Published 22 June 2007


1 comment:

Anonymous said...

"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; ..."

This is what nursing wants in all orders. Parameters. Thank you!

-SCRN