Tuesday, September 15, 2015



Guest Blog (DRK) with Oversight (RB)

As an emergency medicine resident in the (very) late 1970’s I serendipitously happened to create one of the earliest renditions of an ED tracking board. Resources being scant, I went to the local office supply, to buy a very large erasable white board, which took up an entire wall.  On it were placed strips of colored tape in vertical columns for patient names, chief-complaint, stage of care, pending issues, and anticipated disposition; each room or care-space in the department had its own horizontal row.

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.


         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.
 *For those of who like to research such things from an academic/theoretical viewpoint, consider the article by Berg Computer Supported Cooperative Work 8: 373–401, 1999 Kluwer Academic Publishers. Accumulating and Coordinating: Occasions for Information Technologies in Medical Work. This pivotal work is not-uncommonly referenced by another seminal thinker Bob Wears (e.g. The Chart is Dead—Long Live the Chart Annals of Emergency Medicine Volume 52 No 4- October 2008 p. 390….and many more).

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