Closing the Deal

How does one efficiently, safely, and compassionately make the disposition on a patient in a busy ED?

Sometimes the choices involved are complex, and for any given patient, there is always more than one tactic. In the end, the best approach will always consider the unique characteristics and circumstances of the patient & family in question.

Get in the habit of asking yourself whether you have been able to:

1. Provide quality care. (Even if “you and your staff’’ are the only ones to appreciate true quality.  It is good to remember that even when the patient/family doesn’t get it, your staff does.) 
2. Deliver a reasonable diagnosis or problem identification in layman’s terms.
3. Provide decent discharge instructions. My bias is an electronic document with highlighted advice with very time specific advice.
4. Show the patient team the x-ray. (This move is a subset of a number of actions that serve to “involve” the patient/family in the diagnostic decision process. Other actions of the same type may include a more detailed discussion of lab or consultants findings).
5. Set reasonable expectations on the timing and course of illness. (From this, the patient/family should be able to discern if things are going as expected;  or, if not going as expected, recognize that they need to return and/or execute your safeguard follow-up instructions (see #6)
6. “CALL OR COME BACK” ANY TIME IF NO IMPROVEMENT OR WORSENING OF ANY CONDITIONS. (see #5)
7. Explain why this disposition is best for them, given the present information.  Clearly state why they need to be admitted, to be transferred, to be sent home, or to see a specialist for more testing, treatments and evaluation. This is a good time to mention any known risks to this disposition approach, state them clearly, and state alternative disposition options.
8. Try to identify the type of patient you are dealing with.  You might have seen, during your discussions, the principle means through which the patient processes information. Is this visually? (e.g. show the x-ray, lab tests, Wikipedia), and/or through hearing? (I hear what you are saying), and/or with a strong emotional dimension? (I feel your concern/ pain).
9. Try to discern, finally, whether you have met the patient/family needs, especially whether you have succeeded in establishing their trust in your evaluation and plan.

These steps work most of the time. However, like diagnosis and treatment, effective disposition is an art form that has to be developed over time. It helps to be mindful of the psychological processes that are present.  While for you  it is a closing (you are closing the deal, after all; usually while attending to multiple other patients whose deals you would similarly like to close), for the patient, this moment may very well be a beginning.  Your recognition of the patient’s viewpoint and needs are best communicated when you give evidence of your interest in their outcome, follow-up, and other further care. 

The 5-Minute Focused History and Physical Exam

Speediness has become a necessary virtue in EDs and urgent care settings, where providers, without exception, are expected to provide accurate, efficient, cost-effective care quickly.  While it may often feel that such expectations are not realistic, it is still nevertheless true that perceptions of promptness and efficiency are major factors in determining patient satisfaction.

Therefore, achieving a balance between speed, quality of care, safety, and efficiency, requires that each provider refine and polish a personal approach that facilitates rapid, complete, assessment in a minimum amount of time, using whatever tools are at hand.  In most cases--even in complex presentations--this can be accomplished in 5 minutes, or less, and is facilitated when using an EHR with the capacity to present information succinctly.

TIMELINE:

MINUTE 1:  45 seconds- review pertinent data; 15 seconds- establish common ground, put patient at ease.

MINUTE 2:  30-60 seconds- Allow the patient to speak. Listen.

MINUTE 3:  15-30 seconds - Discover the patient’s motivation (reason) for the visit. You will have already gotten the main clues, but make sure you also understand the driving forces behind the decision to come to the ED… Did the family drag them in? Are they worried about a stroke? Etc.

MINUTE 4:  30- 60 seconds - Ask very specific chief complaint driven high risk questions to identify the seriousness of the problem

MINUTE 5:  30- 60 seconds - Perform a goal directed physical while simultaneously restating the patient’s story. This reaffirms confidence in you as the provider, gives an opportunity to correct any overlooked concerns, and gets the key physical elements examined.

If you have an electronic order entry system at the bedside, you may be concurrently clicking off initial orders while gathering information during minutes 4 and 5. 

This system is very effective.  It allows you to keep with the patient flow and concentrate on treatment plans and dispositions (creating space for the next encounter. Additionally Patients immediately perceive that you are concerned about them, engaged, and “on their team” concerning their medical issues.

The next blog will be on how to “close the deal”.