Tuesday, June 28, 2011

Maximize Your Personal ED Efficiency

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

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.
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

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
b.     Need biomarkers
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?
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.

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.

Wednesday, June 1, 2011

Top Ten Myths about EHR's in the ED

1. Solves endless paper issues
2. Improves work flow
3. Increases provider productivity
4. Generates more income through better documentation
5. Integrates easily with other systems
6.  It's Easier to track patients
7. All Paper and printers will disappear
8. EHRs not specifically designed for the ED, can be used in the ED. They  will provide  adequate physician documentation.
9. Products with a history and track-record are better
10. Tablet-PCs are the only answer.