Managing the Busy ED: Part 2

Here are some more tips and strategies for managing the turbulent flow of life in a busy emergency department, continuing on from Part 1.

6. Manage your time

  • Use slow times to recharge
    Eat, drink, and tell a few jokes.
  • Plan procedures
    Pick times when the right people, the right equipment and the right space is available. Procedures may have to wait until after handover.
  • Jump-start your history by reviewing previously gathered information
    Some patients should not be seen without the old notes! Always know what has gone on before you see them – review the referral letter, the ambulance transfer sheet and the nursing notes. But don’t get “anchored” on other people’s assumptions.
  • Use the nurses
    No comment…
  • Avoid a paperwork backlog
    Some docs like to write as they speak to patients. At least try to write contemporaneously unless the cases are really simple and you’re trying blast through a back-log. Are scribes the way of the future?

7. Streamline the management of uncomplicated patients

  • Use “flow directed” triage
    If you’re the boss, choose who sees who (not in the romantic sense). On night-shift, for instance, you will want to see all the sick patients, but you might also want to see a lot of the simple or trivial things so that junior staff don’t waste time on them with detailed review-of-systems and neurological exams. Sometimes seeing patients slightly out of ‘order’ better facilitates patient flow.
  • Scan charts and anticipate care needs
    This helps identify high-risk patients and may allow you to order tests before they are seen by a doctor.
  • Use algorithms and care maps
    As with implementing guidelines and decision rules, they reduce the need for micro-management by senior staff.

8. Be an administrator and a delegator

  • Develop a close working relationship with all ED staff
    ED is a team game, if all the players are reading from the same script everyone is more efficient. A team that enjoys work doesn’t mind if there is more of it (within reason!).
  • Insist that patients are ready for you
    The ED doc is often the rate-limiting step in patient flow. Be assertive and insist that vital signs and visual acuity are checked, wound dressings are down or the patient is appropriately positioned before you get there. Its not about power, its about efficiency.
  • Be flexible to maximize the use of staff
    Staff should be moved between areas and roles according to need. No point having a ‘fast track’ doctor if there are no ‘fast track’ patients…
  • Lead by example
    Perform appropriate duties at the appropriate time. Help out others when you’re less busy – that may involve figuring out how the thermometers work or checking a blood glucose!
  • Use resources efficiently
    Don’t do things just because you can. Which patients actually need guards? Who actually needs monitoring? Who actually needs an ultrasound in the ED? Who actually needs occupational therapy review prior to discharge?
  • Use nurse-initiated protocols
    Delays can be markedly reduced by nurse-initiated protocols for medications (e.g. analgesia), investigations (e.g. Ottawa Ankle Rules), and referrals (e.g. podiatry, social work, etc.).
  • Delegate, delegate, delegate
    Delegate but don’t micro-manage. Set time-orientated objectives, and check with the delegated staff if they are on track. Match the delegated task to the skill-set of the delegee (e.g. don’t leave students to flounder with ‘problem’ patients). If a medical degree is not needed for the task, try to find someone else to do it. If you have a Discharge Coordinator – use them till they bleed! Doctors are bad at clerical duties, delegate tasks to clerical staff wherever possible.
  • Inform the hospital administration
    Get admin involved early if patient flow has turned into patient sludge – they have ways and means of making things happen…

9. Be a space administrator

  • Utilize other space
    ED docs don’t need to be told about waiting room medicine. What about car-park or drive-through medicine? Know the areas of your ED and their capabilities. Where can procedures and continuous monitoring be performed?
  • Don’t let location dictate treatment
    It can be hard not to treat a patient in the resus bay like they’re sick, even if they’re not. And vice versa in ‘fast track’ areas.
  • Communicate with the inpatient wards
    DISCHARGE, DISCHARGE, DISCHARGE!
  • Develop a policy on waiting room patients
    Waiting room patients can be rotated to an assessment stretcher and should be periodically reassessed.

10. Be cognizant of the ED philosophy

  • Remember that some patients should not be “rushed”
    Know when your heuristics may lead you astray.
  • Remember who you are
    Emergency doctors have to deal with uncertainty and multiple problems concurrently. We can’t and don’t know everything and we don’t need to. We can’t solve every problem we come across. Our job is to identify when patients are truly sick and to make sure they get the right treatment at the right time.

References

  • Campbell SG, Sinclair DE. Strategies for managing a busy emergency department. CJEM. 2004 Jul;6(4):271-6. PMID:  17382005 (fulltext)
  • Thanks to Dr Trevor Jackson for directing me to the above reference and educating me about many aspects of this topic.
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Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

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