As patient volumes increase and health care resources become ever more stretched, it is now more important than ever that we as emergency physicians learn to practice with a high degree of efficiency without sacrificing the quality of our care. After reviewing the literature, speaking with a large number of physicians and reflecting, here are what I believe to be the best ways to improve your on shift efficiency:
Leave every patient’s room with a plan for their disposition.
Of course, you won’t always know each patient’s final disposition after the initial assessment, BUT, you need to have a plan. Leave each room knowing not only what tests you are going to order but also what the patient’s disposition is going to be based on the results of those tests. If you don’t know what to do after your history and physical, spend more time with the patient until you are comfortable you have a reasonable plan in place. Communicate your plan to the patient, so they know what to expect and have the opportunity to raise concerns immediately. Generally, putting in more time up front will improve your efficiency for the shift as a whole. Conversely, if you have all the data you need and your plan is fully formulated, there is no need to spend more time so move onto the next step.
Don’t defer decisions that can be made now.
If a decision can be made immediately, take the time up front to make that decision when the case is fresh in your mind. Particularly with difficult and complex cases, we tend to push off decision making and hope things will become more clear later in the shift. When you have all the information you need, deferring decisions will only leave you scratching your head again later and wasting time trying to remember the case.
Don’t order tests that won’t change management.
Holdover tests are labs or imaging that we order to avoid or delay decisions that add little or no value to your decision making process.
- Uric acid levels (can be low, normal or high in gout)
- 2nd troponin in a patient who you know needs admission
- D-Dimer in a patient you are going to CTPE regardless of the result
When faced with tough calls, sit down and take the time you need to make a decision or figure out what other information you need and how you can get it. If your treatment and disposition will be the same regardless of the outcome of a test then don’t order that test.
Whenever feasible order tests concurrently, not in sequence.
“If the trop is normal then I will order a Dimer” Don’t do that. Order them both at the start or not at all. Ordering in sequence rarely adds value and delays dispositions.
Minimize touch points.
Don’t go into a patient’s room more times than you have to.
- If you are planning to order a Dimer, then tell your patient up front. “I will see you again after your labs are back unless your D-Dimer is positive and then I will see you after a CT scan.” There is no need to pop by and tell them they have a positive D Dimer. Decrease touch points and see another patient.
- Order a road test and PO trial before you come to talk to the patient about their disposition.
- Focus on point #1.
Communicate the plan to nursing. Entering orders into the EMR is not enough.
This will help your orders get done in a timely fashion and keeps everyone on the same page.
When a disposition can be made, do it now, do not delay.
Shortening your list will decrease your cognitive load and allow you to keep moving fast. Plus it frees up a bed to keep the department flowing.
When working at night, see a few patients in the same area at once.
Instead of walking across the ER to see the next patient on the list it’s ok to see the patient who is 2nd in line andt right in front of you. First, clear this with the other night doctor(s) early in your shift to make sure everyone is ok with it (and hopefully doing the same).
SIT in the room with patients but STAND at the work desk.
Sitting, particularly during your initial assessment shows the patient that you care, you are listening and you are taking the time when it matters. At the work desk standing will keep you moving and prevent procrastination before signing up for the next patient.
Don’t cherry pick.
Scrolling through the list, reading triage notes and trying to avoid seeing what appears to be an unpleasant case will slow you down big time. Avoiding seeing the next patient will inevitably lead to procrastinating between cases while you wait for someone else to sign up for a presumably unpleasant case.
Here’s a little secret: triage notes are not very good at predicting which cases will be challenging. I am regularly surprised by how pleasant, fast and satisfying certain cases are that appeared to be disasters from the triage note. Don’t dilly dally, do your part and sign up for the next case on the list without over-thinking.
If you want to see good volumes, use the first 2-3 hours of your shift to fly. This is not the time for a coffee or a chat. Do that later. You should see about half your patients in the first 2-3 hours of a 7 hour shift. Later in the shift you will take handover and be distracted by reassessments (although they will be fast and easy if you follow #1). Try to sprint at the start in order to see good volume and finish on time.
Don’t worry about it too much.
As ER doctors we tend to be highly competitive and self-critical. At the end of the day, it’s better to do an excellent job with 8 patients than provide mediocre care to 12. We can all work on our efficiency but also recognize we each are programmed to move at a particular speed. Some faster and some slower. At the end of the day you will see many more patients and contribute more to the healthcare system in the long run if you can enjoy your shifts, avoid burn-out and work in the emergency department late into your career. So be kind to yourself, don’t stress too much about your numbers, take good care of your patients and enjoy your work.
For more ideas on how to improve your efficiency without sacrificing quality of care check out these resources:
- 14 Tips to Improve Clinical Efficiency in Emergency Medicine - Page 3 of 4
- EM Mindset: Pearls from Efficient Emergency Physicians; Why They Still Love Coming to Work - emDOCs.net - Emergency Medicine Education
- Physician Efficiency in the ED – Are you seeing enough patients?
- Flow Hacks for the Emergency Physician
- Improving physician flow and efficiency in the emergency department
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