2-Hour Length of Stay ED, Would You Like Some Fries with That?

In the ED community there is a new marketing tool—30 minute or no-wait Emergency Department.





The implication is that a provider (physician, PA, or NP) will greet you a la WalMart and begin the relationship immediately. There are billboards, internet advertising, etc. that proclaim that your care will be improved because it will be faster.

On the upside, if properly conducted where the patient is fully evaluated there should be significant PRC or Press-Gainey score improvements.

I would prefer to see the metrics based on both speed, quality, and outcome.

Welcome to  the 2 hour LOS ED.

The provider will either discharge, admit, or carefully discuss with the patient and family the “battle plan” for disposition at the 2 hour mark.

1. Discharge prior than 2 hours
2. Admit prior than 2 hours
3. Discussion with patient
   a. Outline the time frame
   b. Discuss need for more tests (i.e. CT abdomen)
   c. Waiting for consultant
   d. Providing more treatment to avoid admission (i.e. fluids, 2nd set of Troponin levels, etc)

This would be the “ED Value Plan” that encompasses speed, efficiency, communication, and quality. (9 out of 10 members in my family would choose this plan).

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”.

2 Hour Length of Stay in the ED - Would You Like Some Fries with That?

In the ED community there is a new marketing tool—30 minute or less no-wait ED service.

The implication is a provider (physician, PA, or NP) will greet you- a la the Wal-Mart greeter- to begin the service relationship. There are billboards, internet advertising, etc. that proclaim your care will be improved because it will be faster.

If properly conducted where the patient is fully evaluated, there should be significant PRC or Press-Ganey score improvements.

I would prefer to see the metrics based on speed, quality, and outcome.

This would be the “ED Value Plan” that encompasses speed, efficiency, communication, and quality. (9 out of 10 members in my family would choose this plan).

The provider will discharge, admit, or carefully discuss with the patient and family the “Battle Plan” for disposition at the 2 hour mark.
1. Discharge prior than 2 hours
2. Admit prior than 2 hours
3. Discussion with patient.
         a. Outline the timeframe
         b. Discuss need for more tests (CT abdomen)
         c. Waiting for consultant
         d. Providing more treatment to avoid admission (i.e. fluids, 2nd set of              troponin levels