Here are some more tips and strategies for managing the turbulent flow of life in a busy emergency department, continuing on from Part 1.

6. Manage your time

• Use slow times to recharge
  Eat, drink, and tell a few jokes.
• Plan procedures
  Pick times when the right people, the right equipment and the right space is available. Procedures may have to wait until after handover.
• Jump-start your history by reviewing previously gathered information
  Some patients should not be seen without the old notes! Always know what has gone on before you see them – review the referral letter, the ambulance transfer sheet and the nursing notes. But don’t get “anchored” on other people’s assumptions.
• Use the nurses
  No comment…
• Avoid a paperwork backlog
  Some docs like to write as they speak to patients. At least try to write contemporaneously unless the cases are really simple and you’re trying blast through a back-log. Are scribes the way of the future?

7. Streamline the management of uncomplicated patients

• Use “flow directed” triage
  If you’re the boss, choose who sees who (not in the romantic sense). On night-shift, for instance, you will want to see all the sick patients, but you might also want to see a lot of the simple or trivial things so that junior staff don’t waste time on them with detailed review-of-systems and neurological exams. Sometimes seeing patients slightly out of ‘order’ better facilitates patient flow.
• Scan charts and anticipate care needs
  This helps identify high-risk patients and may allow you to order tests before they are seen by a doctor.
• Use algorithms and care maps
  As with implementing guidelines and decision rules, they reduce the need for micro-management by senior staff.

8. Be an administrator and a delegator

• Develop a close working relationship with all ED staff
  ED is a team game, if all the players are reading from the same script everyone is more efficient. A team that enjoys work doesn’t mind if there is more of it (within reason!).
• Insist that patients are ready for you
  The ED doc is often the rate-limiting step in patient flow. Be assertive and insist that vital signs and visual acuity are checked, wound dressings are down or the patient is appropriately positioned before you get there. Its not about power, its about efficiency.
• Be flexible to maximize the use of staff
  Staff should be moved between areas and roles according to need. No point having a ‘fast track’ doctor if there are no ‘fast track’ patients…
• Lead by example
  Perform appropriate duties at the appropriate time. Help out others when you’re less busy – that may involve figuring out how the thermometers work or checking a blood glucose!
• Use resources efficiently
  Don’t do things just because you can. Which patients actually need guards? Who actually needs monitoring? Who actually needs an ultrasound in the ED? Who actually needs occupational therapy review prior to discharge?
• Use nurse-initiated protocols
  Delays can be markedly reduced by nurse-initiated protocols for medications (e.g. analgesia), investigations (e.g. Ottawa Ankle Rules), and referrals (e.g. podiatry, social work, etc.).
• Delegate, delegate, delegate
  Delegate but don’t micro-manage. Set time-orientated objectives, and check with the delegated staff if they are on track. Match the delegated task to the skill-set of the delegee (e.g. don’t leave students to flounder with ‘problem’ patients). If a medical degree is not needed for the task, try to find someone else to do it. If you have a Discharge Coordinator – use them till they bleed! Doctors are bad at clerical duties, delegate tasks to clerical staff wherever possible.
• Inform the hospital administration
  Get admin involved early if patient flow has turned into patient sludge – they have ways and means of making things happen…

9. Be a space administrator

• Utilize other space
  ED docs don’t need to be told about waiting room medicine. What about car-park or drive-through medicine? Know the areas of your ED and their capabilities. Where can procedures and continuous monitoring be performed?
• Don’t let location dictate treatment
  It can be hard not to treat a patient in the resus bay like they’re sick, even if they’re not. And vice versa in ‘fast track’ areas.
• Communicate with the inpatient wards
  DISCHARGE, DISCHARGE, DISCHARGE!
• Develop a policy on waiting room patients
  Waiting room patients can be rotated to an assessment stretcher and should be periodically reassessed.

10. Be cognizant of the ED philosophy

• Remember that some patients should not be “rushed”
  Know when your heuristics may lead you astray.
• Remember who you are
  Emergency doctors have to deal with uncertainty and multiple problems concurrently. We can’t and don’t know everything and we don’t need to. We can’t solve every problem we come across. Our job is to identify when patients are truly sick and to make sure they get the right treatment at the right time.

References

Campbell SG, Sinclair DE. Strategies for managing a busy emergency department. CJEM. 2004 Jul;6(4):271-6. PMID:  17382005 (fulltext)

Thanks to Dr Trevor Jackson for directing me to the above reference and educating me about many aspects of this topic.

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

Emergency departments are busy places. Working in the ED environment is unlike most other areas of medicine. Stress levels can be high, maintaining patient flow in the face of access block and exit block can seem futile, and a chaotic environment where you are forced to multi-task and do ‘more with less’ becomes a breeding ground for medical errors that threaten patient safety.

Most doctors learn to survive and thrive in ED the hard way – by trial-and-error – with the philosophy ‘experience is what you get when you need it most’. However, new ED docs needn’t have to reinvent the wheel.

Here are some tips and strategies for managing the turbulent flow of life in a busy emergency department.

Key reference: Campbell SG, Sinclair DE. Strategies for managing a busy emergency department. CJEM. 2004 Jul;6(4):271-6.). PMID:  17382005 (fulltext)

1. Manage risk in a defensible fashion and avoid solving non-emergency problems

• Tailor investigation and management to risk
  Diagnostic certainty is often unrealistic, and needs to be balanced against the cost and risks of investigations and interventions, as well as the patient’s ability to cope with the consequences of a missed diagnosis. Disposition is often more important than diagnosis. Ensure adequate follow-up.
• Avoid investigations that are better done elsewhere
  Can the patient can be safely discharged with further work-up as an outpatient? Exhaustive investigation does not need to take place in the ED, and is often unnecessary and inappropriate.
• Don’t order tests that will not or should not affect patient management
  Avoid opening up a ‘can of worms’ you didn’t want to know about in the first place…
  Ask yourself, “How will this test change this patient’s management or disposition”. No tests are ‘routine’.
• Implement guidelines and clinical decision rules to initiate necessary testing
  Use standing orders for nurse-initiated clinical pathways or to assist Junior Doctors in working independently. They can help maximize patient flow without needless investigation or meddling by superiors. Pathways need to be audited to ensure they are being used appropriately.
  Examples include: pregnancy tests for females with abdominal pain, Ottawa Ankle and Knee Rules for ankle and knee injuries, Hip Fracture protocols, Chest pain and PE protocols, NEXUS and the Canadian C-spine and CT Head rules.

2. Communicate with patients

• Develop a good rapport
  Be professional, be friendly, be interested, shake hands, use people’s names and involve the whole family. This is good manners, helps with the ‘healing process’ and means you’re less likely to get sued. Apologize when appropriate. Make sure you know who the patient is if the cubicle is crowded with family!
• Get interpreters early
  Anticipate the need for interpreters, do what you can without them but don’t waste time.
• Focused exploration of the presenting complaint
  Aim to solve problems, use a focused history to get the information you need to know.
• Make multiple short visits to the patient’s bedside
  This is very important – it helps patient’s take in and accept information, strengthens the patient-doctor relationship and keeps the patient up-to-date with progress.
• Anticipate the outcome and communicate expectations to patients early
  Another crucial point – patients get frustrated with the uncertainty of not knowing what they might have and not knowing when or whether they will be able to go home from the ED. Give the patient a time frame (always slightly over-estimate) for when investigations will occur and when decision nodes will arise, and what the possible outcomes will be. Anticipate these outcomes by lining up other services in advance, e.g. social work, ‘settling in’ services, etc.
• Don’t delay uncomfortable decisions
  If its inevitable, deal with it now!
• Use patient handouts
  It is part of being human that people will forget what you say soon after you say it. Give them something to take home. Also, they can read it while you do other stuff, so they will be primed for your subsequent explanation and advice.
• Politely communicate the concept of “emergency facility”
  Be careful with this one, make sure its appropriate, e.g. patient wants a Saturday night ear syringing session. There’s nothing worse than a critically ill patient returning to the ED saying, “The last doctor said I was wasting the ED’s time”.

3. Communicate with other ED and non-ED staff

• Communicate with nurses
  Tell them what you need done, what your differential diagnosis is, what your ‘plan of attack’ is, and what the expected outcome is (including time frame). Educate when appropriate and practical.
• Communicate with clerical staff
  Ensure that patient labels and notes are organized early and that clerical staff have a proactive approach to organizing admissions. Previous medical information for a patient can be sought before they are seen by a doctor, or even before they have arrived.
• Communicate with orderlies
  Orderlies make the world go round – let them know when they’ll be needed so they can plan ahead and you don’t get held up.
• Communicate with other ED doctors
  Handover appropriately (and document), ensure junior staff are adequately supervised and feel supported.
• Know how to communicate with non-ED staff
  We need to coordinate with a lot of other staff and services, know who they are and build relationships.
  They include: radiographers, technicians, physiotherapy, occupational therapy, liaison psychiatry, social work, drug and alcohol counseling, administration, other hospitals, general practitioners, the ambulance service, the aeromedical retrieval service, as well as other emergency services including the police.

4. Deal with admitting teams in a professional manner

• Get to know the admitting teams
  Things run more smoothly with a bit of oil on the old ‘ED-admitting team relationship’ cogs.
• Communicate with admitting teams on bed issues
  Don’t let a lack of beds compromise appropriate patient management and disposition (not always easy). Be honest, so that you can call in favours when you really need them.
• Make sure your consultation requests are clear, focused and appropriate
  Again its about building up a bank of goodwill, that can be spent when you need it most.
• Don’t delay referral when consultation is clearly needed
  Although admitting teams may hate this, they can just grin and bear it. If you think the patient has appendicitis, call the surgeons after taking your hand off the abdomen. Get the bed booked early and document time of referral. Any ‘issues’ – speak to a higher power!
• Insist on consult response from physicians who have the authority to make decisions
  This advice is gold – when there is a patient flow log-jam or things aren’t happening fast enough, go straight to the top to get the key decisions made. The patient comes first.

5. Constantly monitor departmental flow

• Use a board or electronic monitoring system
  Keep an eye on this, look to see which patients need re-review and which junior doctors may need senior oversight. Is the case-mix skewed so that one admitting team is getting hammered, which may cause a bottle-neck later on?
• Communicate with the charge nurse
  A no brainer this – the charge nurse runs the show!
• Monitor transfers through the ED
  Only ED should accept patients to ED. Don’t accept patients that can and should be managed elsewhere. Inpatients at other hospitals must have inpatient beds waiting for them before they are transferred.
• Multitask
  While I don’t really believe in “multi-tasking” as we can really only focus on the task at hand, plan ahead so that you can choreograph the various steps in the management of multiple patients. Eat and go to the toilet (not at the same time!) while you’re waiting for test results.
• Have pre-arranged plans and policies for overcrowding
  Lets you ‘ship ‘em out’ to the ward corridors from the ED corridors in accordance with policy XYZ when you’re overcrowded, (supposedly) with a minimum of bureaucratic fuss.

Continue on to Part 2 of managing the busy ED.

References

Campbell SG, Sinclair DE. Strategies for managing a busy emergency department. CJEM. 2004 Jul;6(4):271-6. PMID:  17382005 (fulltext)

Thanks to Dr Trevor Jackson for directing me to the above reference and educating me about this subject in general.

Life in the Fast Lane Medical Blog - Emergency Medicine education blog