Closing the Deal

How does one efficiently, safely, and compassionately make the disposition on a patient in a busy ED?

Sometimes the choices involved are complex, and for any given patient, there is always more than one tactic. In the end, the best approach will always consider the unique characteristics and circumstances of the patient & family in question.

Get in the habit of asking yourself whether you have been able to:

1. Provide quality care. (Even if “you and your staff’’ are the only ones to appreciate true quality.  It is good to remember that even when the patient/family doesn’t get it, your staff does.) 
2. Deliver a reasonable diagnosis or problem identification in layman’s terms.
3. Provide decent discharge instructions. My bias is an electronic document with highlighted advice with very time specific advice.
4. Show the patient team the x-ray. (This move is a subset of a number of actions that serve to “involve” the patient/family in the diagnostic decision process. Other actions of the same type may include a more detailed discussion of lab or consultants findings).
5. Set reasonable expectations on the timing and course of illness. (From this, the patient/family should be able to discern if things are going as expected;  or, if not going as expected, recognize that they need to return and/or execute your safeguard follow-up instructions (see #6)
6. “CALL OR COME BACK” ANY TIME IF NO IMPROVEMENT OR WORSENING OF ANY CONDITIONS. (see #5)
7. Explain why this disposition is best for them, given the present information.  Clearly state why they need to be admitted, to be transferred, to be sent home, or to see a specialist for more testing, treatments and evaluation. This is a good time to mention any known risks to this disposition approach, state them clearly, and state alternative disposition options.
8. Try to identify the type of patient you are dealing with.  You might have seen, during your discussions, the principle means through which the patient processes information. Is this visually? (e.g. show the x-ray, lab tests, Wikipedia), and/or through hearing? (I hear what you are saying), and/or with a strong emotional dimension? (I feel your concern/ pain).
9. Try to discern, finally, whether you have met the patient/family needs, especially whether you have succeeded in establishing their trust in your evaluation and plan.

These steps work most of the time. However, like diagnosis and treatment, effective disposition is an art form that has to be developed over time. It helps to be mindful of the psychological processes that are present.  While for you  it is a closing (you are closing the deal, after all; usually while attending to multiple other patients whose deals you would similarly like to close), for the patient, this moment may very well be a beginning.  Your recognition of the patient’s viewpoint and needs are best communicated when you give evidence of your interest in their outcome, follow-up, and other further care. 

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”.

The Value of a Nurse Practitioner, Physician Assistant or Physician in Triage - Is placing a provider in triage cost effective?

The experience I’ve had in a 65,000 visit ED has been mostly positive.

1. Door to provider is 35 minutes of less on average
2. Room to provider is 15 minutes or less
3. AWOLS are 2% or less even when total volume rises to 200 pts/day
4. When the volume climbs above 200 pts/day--corresponding to admissions of about (60/day)--the benefits of physician triage are less consistent.  Why?  Complications arise; these result from a variety of factors augmented by the increased load, and include: an increased number of patients being held in the ED, overcrowding-stimulated variances in patient mode of entry, and--most importantly--a relative decrease in available nursing and ancillary staff.

Role of triage provider:

1. Initiate testing with rapid diagnosis and disposition in mind.  The goal to keep in mind:  enable the interior ED provider to make a 1 pass visit for a final admit or discharge disposition.
2. Be alert for high risk, subtly ill, patients (Level 3) Standard nursing triage classification has some shortcomings here. Moreover, in times of higher triage volume, periodically scan the waiting room and the queue for such patients that might be later in line, or overlooked.
3. See minor cases and discharge without tying up beds. (e.g.  med refills, toothaches) (Level 1)
4. Try to distribute patients with an “eye on flow.” If possible and practical, to all areas evenly (Level 2, 3).
5. When possible visit patients that bypassed triage(brought by rescue or walk-in) if free and sufficiently staffed. Especially in times when “the back” is swamped, but triage is not, the triage provider may see these patients, initiating care and diagnostic testing.  If the provider is able to safely leave triage, go to the back, and see these new un-triaged patients, the care process can be accelerated dramatically.
6. Preorder on patients that came by rescue or were sent directly back without triage that the other provider has not seen.
7. Initiate minimal treatments like Zofran, ASA, and Tylenol on patients that will be entering the ED for further care (Level 2,3)

Is it cost effective?

We think so. Indeed, we have found that our treated volume has increased 10-20% using the same staffing model plus physician triage.

Difficulties to anticipate:

• It’s not for everyone. That is, such a plan is not for every emergency department, and likewise not for every provider, either.  It is advantageous to experiment first, before committing resources, to work out “bugs” and get a feel for how this will work in your particular ED, and with your individual physicians.
• A provider with rapid multitasking skills is needed.
• Shoot for an upper level of pre-order accuracy…say  95%.  This can be determined by the number of tests/treatments were added on a given patient inside the ED.  If none are ever added (100% accuracy) then a case can be made for over-ordering in triage.  If too many are additionally added all the time –increasing patient stay--(say an additional 50%) then more care and diagnostics need to be started in triage. 

Patient acceptance:

“Mikey likes it.” That is, when the process and procedures are explained to patients and families by the staff, they are generally very accepting

Conclusion:

When your administration asks you to see every patient in 30 minutes or less, this is the easiest first step. Of course, it does not solve all problems. To fully control LOS is entirely another animal altogether.  With physician triage, therefore, you make some significant and noteworthy progress, but it may only take a small bite out of your overall LOS statistics.

What Will the Future EDs & Urgent Cares Look Like? --- The Remote Controlled Practice

The Big Bang Theory

The future of medicine is in a state of flux due to politics, economics, demographics, provider shortages, and consumer activism. The paradigm will need to shift to accommodate the seemingly endless demand on the healthcare industry. Expectations (realistic or not) of quality, efficient care will drive the shifting process.

I expect to see a new process similar to the one below:

1. The basic face-to-face to provider will be a “physician extender.”
2. This extender will be supervised by a “physician advisor.”
3. The physician advisor will be on location in high volume, high acuity facility.
4. The physician advisor will interact with the extender from this remote location via electronic devices for multiple urgent care practices simultaneously. On the “Big Bang Theory” television show Sheldon created a portable extension of himself through technology. Perhaps physicians will find a way to be in two places at once…
5. Consultants will be available through Skype, telemedicine, Ipad’s facetime and other such technology. Through this technology physicians can interactive with both the patient and the physician extender. A “Flow Facilitator” will be watching all the data streams and communicate with the local provider determining what to do next to achieve maximal efficiency.
6.  Artificial intelligence from EHR to take symptom complexes and PMH to assess risk of that particular patient's visit (maybe 15 years away.)
7. EHR becoming user friendly rather than onerous.
8. Patients carrying their entire medical history on their personal device.

Consumer demand will dictate a flow of patients into the system. The majority will rely on classic medical care; however, a large segment of the population will adopt an anti-technology “Luddite” approach in response to the all the available technology. They will resort to massive increases in alternative medicines.

Regardless of the quality of the care in this remote model, the “Human Touch” will always be needed to inspire confidence in the patient.

Electronic Health Records and Voice Recognition Technology

The Electronic Health Record has imposed a new set of standards on the provider. These standards can include multiple clicks , typing, and “cut and paste”. This leads to potential decreased productivity, overtime (which is rarely compensated), and potential mistakes for the technologically impaired (myself included).

There is one “quick solution” that can, proponents say, “ease your pain.” Will it, really? The call to invest in voice recognition technology, become proficient at it, and reap the promised rewards is hard to ignore.  However, it is important to make sure your Electronic Health Record (EHR) can easily support these dictated notes without a lot of unnecessary steps.

The triple combination of a provider, voice recognition technology, and scribe (another blog topic: medical assistant/scribe or “data jockey support”) can lead to increased productivity that will hopefully offset your costs. You may, as a consequence, spend more time with your patients and provide more efficient care.

The Role of the Provider in Triage

The proposed addition of a physician’s assistant or nurse practitioner at triage adds a new wrinkle in the fabric of patient processing. The political and administrative motivation to do so is usually an external demand to achieve “door to provider” times of less than 30 minutes. If claimed by a hospital, usually in the form of “see the doctor within 15 min or less,” it is a powerful advertising tool.

The clinical benefits of adding a high-level provider at triage include immediate reliable assessment, pre-ordering of tests, and direct, speedy, discharge of minor problems.  The upside to these is the potential to create often needed space in the ED and/or waiting room. The downside is that these results provide no guarantee that average patient LOS will be any shorter than if triage were performed by a qualified nurse or other non-physician staff.

Q&A

Q: What kind of provider is necessary out in triage? 

A:  At minimum, triage requires a highly skilled physician’s assistant or nurse practitioner, with extensive experience, who understands the clinical needs and operational characteristics of the particular ED in question. Since an associated goal is to also improve the patient experience and ultimately his/her satisfaction, the personality characteristics of the triage provider are essential. Optimal personalities do not “grow on trees,” yet even if uncommon, one would look for those who exhibit a “gentle touch,” a welcoming, understanding manner, and an ability to skillfully handle the stresses of triage.

Q: Can a physician do this job?

A: Yes, but it is expensive and some, perhaps most, physicians are better suited to encounter (conscious) patients after other staff has done the initial meet, greet, & initiate functions.

Q: How much of a work-up is needed from triage?

A: As usual it depends on the presentation and context.  If space is an issue, the proper ordering of tests can lead to prompt disposition (admit or discharge) shortly after the treating provider arrives to see the patient (1 stop-shop). This works in even complex patients, if an excellent triage provider orders the appropriate tests and initiates key treatments. Whether one test or multiple tests are needed, the treating provider can often make a final disposition (“close the deal”) if results are back and response to treatment can be assessed at the first physician encounter.

Q: What about flow?

A: A good working relationship between the triage provider, and the charge nurse can significantly benefit patient flow through an ED.  Communication between triage and the unit are key to quickly identifying patients at high risk and making appropriate and efficient bed assignments.  While the standard use of 5-level triage has some value, it is not subtle enough to make distinctions between those in the middle, who are often gray-zoned until results come back. That is, not all 3’s are equal; after the dust settles and tests are back, many middle tier patients can be sent to Fast Track or discharged without even being placed in a bed.

Q: What’s the bottom line?

A: The triage provider needs to be an exceptional, dynamic, individual, one with extensive clinical experience, who can not only multi-task but is also able to function as an ED Flow expert.

RVU’S ‐ Successes, Perils and Pitfalls

RVU Components

The RVU (Relative Value Unit) is becoming an important consideration for ED physicians. Its original intent was to become a standard measuring tool for incentivizing clinicians toward increased productivity.

CMS assigns an RVU value to every CPT code, using 3 components:

1. Work –55% ‐ with five sub‐components:
• Time
• Mental effort and judgement
• Technical skill
• Physical effort
• Stress
2. Practice expense ‐ 42% ‐to account for overhead to run the practice / manage the entity to which the CPT code refers (does not include the EMTALA effect)
3. Professional liability‐ 3% ‐ allotted to “address” the cost of malpractice insurance.  Applied at 3%, even if actual PL costs are 1%, 10%, or 50%.

Rationale for RVU Incentivized Programs

 

The rationale for an RVU incentivized program is to increase the overall efficiency of the provider staff by rewarding efficiency. In theory this tool will stimulate clinicians who are marginally efficient, or less than optimally efficient, to improve by linking rewards to performance.

Again in theory, CMS hopes to decrease its (endangered) costs for services by stimulating efficiency. Physician groups would correspondingly hope to gain profitably by improving patient flow.

In an ideal world, this would be a win‐win situation for both CMS and clinicians.

RVU Implementation Systems

There are essentially two ways to implement an RVU system.

The first uses 100% RVU reimbursement, also known as “eat what you kill.”

The second guarantees a base salary; to that base is added a “piece” of the group’s overall RVU pie; the size of each piece is determined by the individual’s percentage contribution to the total RVU pie. Other factors may be given value in either methodology, so that RVU credits can additionally be offered for positive patient satisfaction scores, meeting attendance, night shift differentials, absence of complaints, participation on committees, etc. RVU credits may be subtracted for such things as above average number of complaints, failure to complete charts in a timely fashion, lateness, or other negatives that impact the group’s image or performance.

RVU Program Pitfalls

The unintended (and therefore problematic) consequences of an RVU program are especially evident in three areas:   

1. Competition between physicians
2. Potential for some to game the system
3. Invisible impact on departmental workflow

Competition occurs when clinicians attempt to sequester certain types of (higher RVU) chief complaints, and maintain control of their progress principally for the benefit of their own bottom line. Such activities may become evident as general attitude changes, cherry‐picking of chief complaints, evading of opportunities to pitch‐in and help when these do not directly impact one’s RVU tally, chart hoarding, and others.

Gaming the system has various forms, including uneven use of practice assets (PAs, NPs, scribes), requisition of choice shifts, buffing critical of care charges, working unpaid hours, and others.

Impact on ED Workflow may be unapparent but significant. When the analytic focus is on just RVUs, they become a somewhat distorted numerical representation of efficiency. Other major factors may be hidden by the dominance of the RVU process. Such hiddenness may be of greater consequence in a big department, where some physicians may perform non‐RVU activities that facilitate and support essential ED functionality.

For example a “fast” ED physician who can clear out the waiting room and the incoming queue by seeing a load of “lower value” RVU patients, opens up the department in key ways that enable the influx of higher RVU value patients. In the final calculation, in this case, the clearing physician is of inestimable value, while it is the other physician who gets the RVU credit, creating an imbalance that does not represent true value.

The Solution

Ultimately, it takes sophisticated analysis and constant adjustment to make such a system work. It will not be a walk in the park. Attention should be paid to the cumulative acquisition of know‐how about RVUs and applying them most appropriately for your particular ED and its physician staff.

The best solution might be a combination of equal shares of:

1.  Base Salary
2. "Eat what you kill" - minus practice expense of PA's,NP's, and scribes
3. Rewards for intangibles
• performance metrics (door-to doctor/door to balloon/LOS etc
• patient satisfaction scores
• complaints and compliments
• meeting attendance/committee participation
• risk management CME's
• quality measures (how to measure?)
• resource utilization and consumption

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