The thoughts and opinions of a 35 year board certified emergency medicine physician blogging about everyday life, the role technology has played in the emergency department business, and the art of practicing medicine. The times have changed: Health-care IT, EHRs and Meaningful Use!
Do you carry a heavy work load in the emergency department? Do you feel overwhelmed? Do you find yourself asking: What should I do first? What should I do next? Would this be easier with an Electronic Health Record?
It’s important to have a battle plan to achieve maximum ED effectiveness.
The EHR has helped me achieve ED efficiency. I’ve worked full time as an ED physician since 1978 with 150,000 clinical visits, 6-7% mid-level support and 11-12 RVU’s per hour.
My Personal Efficiency Goals are:
2.3 - 2.5 patients/ hour
Contact patient within 30 minutes of arrival
Discharge within 120 minutes
Make Admission decision within 120 minutes
To achieve these goals, I follow a theory of compartmentalization.
1.Approach each patient with all the data that is available from triage, old records, rescue, and patient personal profiles. The two to three minutes you spend to do so will save a great deal of time and focus your evaluation.
2.Walk in the room with the EKG and the old EKG
3.Determine why the patient is there.
4.Make a game plan with the patient, nurse, and family within time frame (avoid unsolicited visits from family members to desk)
5.Order tests and treat patient in a parallel paradigm. Most treatments can be completed while tests are being performed.
i.Give appropriate treatment, if needed
ii.Get your extenders to perform all procedures (if available)
i.Have a game plan already in place for diagnosis (reinventing the wheel takes time and inspiration)
1.Prearranged treatment protocols
e.Hypertension - Results are parameters for nursing toadjust medications without asking or forcing theprovider to “hover”
ii.Notify your consultants early - get help
6.Know the risk factors and red flags for standard chief complaints
iii.Treating Hypotension - can always give O2 and fluids while trying ascertain the cause. Assume sepsis, if normal cardiac and no blood loss (GI bleed, ectopic, AAA etc.)
7.Analyze the Vital Signs
a.Your Electronic Health Record should list them and then remind you when you identified them in your History and PE
a.Abnormal vital signs need explanation!
8.Identify the items that will make the disposition - What is the rate-limiting step? ASSIGN A COMPARTMENT FOR EACH PT
b.Recheck them during the encounter and prior to disposition
a.Need CT results
c.Who is the potential admitting provider?
d.What consultants do I need to call and when? Now? After what test?
9.You can usually tell in 1-3 minutes
e.Who do I need to reassess in 10 minutes or after tests?
c.10% no idea, no clue, run preliminary screening tests and then plan on re-evaluation. You may have to start over, do not spin your wheels. Order a sedimentation rate.
10.Make a decision of how many active patients you can manage at given time. Maximum is 8-10.
11.When you reach that level, make some decisions.
a.Review the x-ray and lab data
i.Have all the labs, x-rays, urinalysis been ordered and sent?
ii.Your tracking board should inform you of when tests are complete, the status of blood work (4 of 6 complete), and if x-rays have been performed and are ready for evaluation.
iii.PACs should have an icon with a preliminary reading.
iv.Critical value notification should be on the tracking board.
b.Call the admitting physicians
c.D/C the patients. A standardized prescription writer
and discharge instructions are needed
d.Reassess all other patients.
e.Start seeing new patients.
12.Should I see and new patient or make a disposition? Always err on the side of creating space. Your PRC scores will increase.
In conclusion put each patient on a pathway to disposition through compartmentalization of all the various tasks.