Managing the Emergency Department

OVERVIEW

The emergency department is a busy, chaotic environment where lives are at risk and:

• the needs of individual patients must be met
• patient flow must be maintained
• adequate supervision of junior staff must be provided
• consultants must be communicated with
• the phone must be answered
• as well as numerous other tasks that must be performed!

KEY STEPS TO MANAGING A BUSY ED

As the emergency consultant or the lead clinical doctor on the floor you need to:

1. manage risk in a defensible fashion and avoid solving non-emergency problems
2. communicate with patients
3. communicate other ED and non-ED staff
4. deal with admitting teams in a professional manner
5. constantly monitor departmental flow
6. manage your time
7. streamline the management of uncomplicated patients
8. be an administrator and a delegator
9. be a space administrator
10. be cognizant of the ED philosophy

MANAGE RISK IN A DEFENSIBLE FASHION AND AVOID SOLVING NON-EMERGENCY PROBLEMS

Tailor investigation and management to risk

• Diagnostic certainty is often unrealistic
• 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
• These 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.

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

• 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”.

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 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.

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.

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.

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?

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.

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…

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.

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 and Links

• Campbell SG, Sinclair DE. Strategies for managing a busy emergency department. CJEM. 2004 Jul;6(4):271-6.). PMID: 17382005 [Free Full Text]