COMPARTMENTALIZING,
PRIORITIZING, ACCUMULATING, AND COORDINATING: A BIT OF HISTORY:
Guest
Blog (DRK) with Oversight (RB)
Why in the world did I do this? Well, it is of note that after
a few years, the hospital became the urban flagship for the University of
Florida EM program. I was an attending. Many would wander into the area to see
this “device,” and my explanation for its presence was as an attempt to make evident
to all what was going on in terms of compartmentalization and strategizing.
Before then, in my experience, that cognitive process remained rather
non-communal, as it was usually kept within the heads of the docs and head
nurses, spoken by mouth, and maybe visible, if at all, only via clipboard
rack. This new board seemed a step
forward, in that other doctors, nurses, and ancillary staff, could all see what
was going on, often at a single glance.*
Communication as well as prioritization (compartmentalization) was
enhanced.
Now those
of you who have grown up in EM and UC medicine since may well find it hard to
visualize a world without tracking boards.
You may also find it hard to imagine a world without cell phones. But in each of those instances, the world was,
indeed, long (long) without these.
Since
those earlier times, when working on developing one of the first EMR programs
for the ED, placing tracking board functions within an electronic system became
a goal. Decades later, even with that
functionality, though, we are still, for the most part struggling. Why? Principally because efficient EM
practice requires individual, personal, compartmentalization, in addition to
whatever may be going on from a global, departmental view.
IMPROVING
EFFICIENCY THROUGH PERSONAL COMPARTMENTALIZATION
The
Merriam-Webster Dictionary defines the verb compartmentalization as three kinds of actions:
: to separate (something) into sections or categories
: to separate (two or more things) from each other
: to put (something) in a place that is
separate from other things.
At its best, and even at its not-so-best, compartmentalization allows one to deal with large quantities of input
at the same time, in a variety of situations, and without getting confused,
agitated, error-prone, or stressed.
A classic example is the single provider Emergency Department
or Urgent Care with 8 or more simultaneous patient encounters. The stressors on
the situation are
1. Time
2. Patient satisfaction
3. Making the proper diagnosis and
treatment plan
4. Interruptions
5. Interactions: staff, family,
phone calls, new information.
6. Interruptions
7. External forces demanding unreasonably rapid
patient flow.
8. Interruptions
9. Finally, the hardest one: following up
on each individual patient to ensure that 1-8 have been handled thoughtfully
and reasonably.
10. And then: finishing the endless
documentation formally known as paperwork.
A mental
compartmentalization technique can be used to divide up the patients in a
prioritized manner that limits potential for confusion. After each patient is
seen (by you), they are put in virtual mental schematic of the department,
noting their location, their problem, the key bits of information needed to
make the final disposition of this patient, and the typical time frame needed to make a disposition for this
complaint. Think tracking board, but written within your own mind.
An example
would be a patient with RLQ pain in room 2. Your disposition will perhaps be
based on the results of the CT scan for appendicitis and you expect completion
in about 2-3 hours. At the same time, you might have a patient with an Acute MI
in room 1. Your anticipated disposition here, is arranging for catheterization and
initiating a treatment protocol. Time frame should be 30 minutes to hour. Now
the patient in room 8 has bronchitis. Disposition in real time with
prescriptions and follow up, might be completed in 30 minutes to hour.
All
this is inescapably overlaid on a fact sometimes noted, but rarely voiced: the best of the “older”
ED docs would have diagnosed with ADHD as children. Had the current version of political/diagnostic
correctness been in place in prior generations; likely they would have been
medicated, and real talents pharmaceutically precluded. That is, an ADHD-like cognitive mind is a
benefit in the ED. Woe to the doc who has to complete one thing before going on to another (we all know them). Attention has to shift, and rapidly, but nevertheless, to be effective, a supervening
mechanism to focus attention is needed.
Compartmentalization, mental compartmentalization, is indeed such a
mechanism.
If you
can compartmentalize your thoughts, and prioritize your actions, you can deal with
the heart attack, check for the CT on the tracking board, and discharge the low
acuity patient, almost simultaneously. The result is a well compartmentalized, well prioritized, tiered tracking board; the highest tier is (mental), within you; the next tier is external (physical) a displayed tracking board. The one (mental) sits inside the other (displayed), but only the displayed version is visible. Your mental board shows the rows and columns for
you to easily access. The ancient Greeks
used to use this type of mnemonic scheme to facilitate memory of huge amounts
of data. They would visualize a large building with many (many) rooms,
cubicles, spaces, and into each would mentally place any item they wished to
remember. To retrieve, they “went” where
they knew it was.
Using this technique can help you to
function efficiently, multitask, and move patients through the department. Notice it requires a bit of balance, and
assumes some conditions that may or may not be present in your facility at all
times. For example if you have three MIs and an incoming rescue unit, your
compartmentalization/prioritization is going to have to achieve a different
level than if you have one rash to see. But it can be very helpful, even under
significant stress, to be maintaining your own internal tracking board. In
fact, even if you hav three MI’s going on, you can probably also handle a rash.
All this
does take practice, and a key to making it work is pre-thinking the steps
needed to make disposition on the case, as early in the encounter as possible (like after
the first 5 words). A partner of ours (name unmentioned) was known for making dispostions at the time the first EMS call came in. If you can train yourself to think [encounter-->disposition], you will be 10 steps ahead of the game. Even if there are three active MI’s,
you will be thinking about which ones are
going when to the cath lab, which are being transferred (perhaps), and also what
to do with the rash. Such direct planning is rarely, if ever, written on actual
tracking boards. Developing, practicing, and “seeing” your own internal tracking board and using the material/actual tracking board as a real-time assistant will
significantly enhance your ability to process patients.
XpressTechnologies
Electonic Health Record with charting, tracking board, prescripton writer, and
follow-up instructions has been time-tested to dramatically improve efficiency.
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