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
- No overtime
- No down-coding
- Limit liability
- 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.
The Theory of Compartmentalization
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.
a. Stable patients
i. Give appropriate treatment, if needed
ii. Get your extenders to perform all procedures (if available)
b. Unstable patients
i. Have a game plan already in place for diagnosis (reinventing the wheel takes time and inspiration)
1. Prearranged treatment protocols
a. ACS/STEMI
b. Sepsis
c. DKA
d. GI bleeding
e. Hypertension - Results are parameters for nursing to adjust medications without asking or forcing the provider to “hover”
ii. Notify your consultants early - get help
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.)
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!
b. Recheck them during the encounter and prior to disposition
a. Need CT results
b. Need biomarkers
c. Who is the potential admitting provider?
d. What consultants do I need to call and when? Now? After what test?
e. Who do I need to reassess in 10 minutes or after tests?
a. Admit
b. D/C
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.
a. Review the x-ray and lab data
i. Have all the labs, x-rays, urinalysis been
ordered and sent?
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.
In conclusion put each patient on a pathway to disposition through compartmentalization of all the various tasks.