Managing the Busy ED

Emergency departments are busy places. Working in the ED environment is unlike most other areas of medicine. Stress levels can be high, maintaining patient flow in the face of access block and exit block can seem futile, and a chaotic environment where you are forced to multi-task and do ‘more with less’ becomes a breeding ground for medical errors that threaten patient safety.

Most doctors learn to survive and thrive in ED the hard way – by trial-and-error – with the philosophy ‘experience is what you get when you need it most’. However, new ED docs needn’t have to reinvent the wheel.

Here are some tips and strategies for managing the turbulent flow of life in a busy emergency department.

Key reference: Campbell SG, Sinclair DE. Strategies for managing a busy emergency department. CJEM. 2004 Jul;6(4):271-6.). PMID:  17382005 (fulltext)

1. Manage risk in a defensible fashion and avoid solving non-emergency problems

• Tailor investigation and management to risk
  Diagnostic certainty is often unrealistic, and needs to be balanced against the cost and risks of investigations and interventions, as well as the patient’s ability to cope with the consequences of a missed diagnosis. Disposition is often more important than diagnosis. Ensure adequate follow-up.
• Avoid investigations that are better done elsewhere
  Can the patient can be safely discharged with further work-up as an outpatient? Exhaustive investigation does not need to take place in the ED, and is often unnecessary and inappropriate.
• Don’t order tests that will not or should not affect patient management
  Avoid opening up a ‘can of worms’ you didn’t want to know about in the first place…
  Ask yourself, “How will this test change this patient’s management or disposition”. No tests are ‘routine’.
• Implement guidelines and clinical decision rules to initiate necessary testing
  Use standing orders for nurse-initiated clinical pathways or to assist Junior Doctors in working independently. They can help maximize patient flow without needless investigation or meddling by superiors. Pathways need to be audited to ensure they are being used appropriately.
  Examples include: pregnancy tests for females with abdominal pain, Ottawa Ankle and Knee Rules for ankle and knee injuries, Hip Fracture protocols, Chest pain and PE protocols, NEXUS and the Canadian C-spine and CT Head rules.

2. Communicate with patients

• Develop a good rapport
  Be professional, be friendly, be interested, shake hands, use people’s names and involve the whole family. This is good manners, helps with the ‘healing process’ and means you’re less likely to get sued. Apologize when appropriate. Make sure you know who the patient is if the cubicle is crowded with family!
• Get interpreters early
  Anticipate the need for interpreters, do what you can without them but don’t waste time.
• Focused exploration of the presenting complaint
  Aim to solve problems, use a focused history to get the information you need to know.
• Make multiple short visits to the patient’s bedside
  This is very important – it helps patient’s take in and accept information, strengthens the patient-doctor relationship and keeps the patient up-to-date with progress.
• Anticipate the outcome and communicate expectations to patients early
  Another crucial point – patients get frustrated with the uncertainty of not knowing what they might have and not knowing when or whether they will be able to go home from the ED. Give the patient a time frame (always slightly over-estimate) for when investigations will occur and when decision nodes will arise, and what the possible outcomes will be. Anticipate these outcomes by lining up other services in advance, e.g. social work, ‘settling in’ services, etc.
• Don’t delay uncomfortable decisions
  If its inevitable, deal with it now!
• Use patient handouts
  It is part of being human that people will forget what you say soon after you say it. Give them something to take home. Also, they can read it while you do other stuff, so they will be primed for your subsequent explanation and advice.
• Politely communicate the concept of “emergency facility”
  Be careful with this one, make sure its appropriate, e.g. patient wants a Saturday night ear syringing session. There’s nothing worse than a critically ill patient returning to the ED saying, “The last doctor said I was wasting the ED’s time”.

3. Communicate with other ED and non-ED staff

• Communicate with nurses
  Tell them what you need done, what your differential diagnosis is, what your ‘plan of attack’ is, and what the expected outcome is (including time frame). Educate when appropriate and practical.
• Communicate with clerical staff
  Ensure that patient labels and notes are organized early and that clerical staff have a proactive approach to organizing admissions. Previous medical information for a patient can be sought before they are seen by a doctor, or even before they have arrived.
• Communicate with orderlies
  Orderlies make the world go round – let them know when they’ll be needed so they can plan ahead and you don’t get held up.
• Communicate with other ED doctors
  Handover appropriately (and document), ensure junior staff are adequately supervised and feel supported.
• Know how to communicate with non-ED staff
  We need to coordinate with a lot of other staff and services, know who they are and build relationships.
  They include: radiographers, technicians, physiotherapy, occupational therapy, liaison psychiatry, social work, drug and alcohol counseling, administration, other hospitals, general practitioners, the ambulance service, the aeromedical retrieval service, as well as other emergency services including the police.

4. Deal with admitting teams in a professional manner

• Get to know the admitting teams
  Things run more smoothly with a bit of oil on the old ED-admitting team relationship cogs.
• Communicate with admitting teams on bed issues
  Don’t let a lack of beds compromise appropriate patient management and disposition (not always easy). Be honest, so that you can call in favours when you really need them.
• Make sure your consultation requests are clear, focused and appropriate
  Again its about building up a bank of goodwill, that can be spent when you need it most.
• Don’t delay referral when consultation is clearly needed
  Although admitting teams may hate this, they can just grin and bear it. If you think the patient has appendicitis, call the surgeons after taking your hand off the abdomen. Get the bed booked early and document time of referral. Any ‘issues’ – speak to a higher power!
• Insist on consult response from physicians who have the authority to make decisions
  This advice is gold – when there is a patient flow log-jam or things aren’t happening fast enough, go straight to the top to get the key decisions made. The patient comes first.

5. Constantly monitor departmental flow

• Use a board or electronic monitoring system
  Keep an eye on this, look to see which patients need re-review and which junior doctors may need senior oversight. Is the case-mix skewed so that one admitting team is getting hammered, which may cause a bottle-neck later on?
• Communicate with the charge nurse
  A no brainer this – the charge nurse runs the show!
• Monitor transfers through the ED
  Only ED should accept patients to ED. Don’t accept patients that can and should be managed elsewhere. Inpatients at other hospitals must have inpatient beds waiting for them before they are transferred.
• Multitask
  While I don’t really believe in “multi-tasking” as we can really only focus on the task at hand, plan ahead so that you can choreograph the various steps in the management of multiple patients. Eat and go to the toilet (not at the same time!) while you’re waiting for test results.
• Have pre-arranged plans and policies for overcrowding
  Lets you ‘ship ’em out’ to the ward corridors from the ED corridors in accordance with policy XYZ when you’re overcrowded, (supposedly) with a minimum of bureaucratic fuss.

Continue on to Part 2 of managing the busy ED.

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 this subject in general.