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
Originally Published 22 June 2007

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
- 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
- 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
Originally Published 22 June 2007
"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.
ReplyDeleteSet 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