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