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Fast and Efficient Practice: The Emergency Department Clinician on the Emergency Department Autobahn
 

Fast and Efficient Practice: The Emergency Department Clinician on the Emergency Department Autobahn

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Patient safety and satisfaction are the focus ...

Patient safety and satisfaction are the focus
within any emergency department. To streamline
navigation on the ED autobahn, i.e., flow, and
thus accomplish these goals most efficiently
can be accomplished by the consideration of
several factors and the application of several
key techniques.

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    Fast and Efficient Practice: The Emergency Department Clinician on the Emergency Department Autobahn Fast and Efficient Practice: The Emergency Department Clinician on the Emergency Department Autobahn Document Transcript

    • WHITE PAPER Fast and Efficient Practice: The Emergency Department Clinician on the Emergency Department Autobahn BY: Kirk B. Jensen, MD, MBA, FACEP Content What Matters Most in Your ED? The ED Physician Roles Flow in the ED Taking a Higher Look at the ED Clinician and Clinical Work Readings to Change Your Practice To-Do’s
    • CONTENTS
    • FAST AND EFFICIENT PRACTICE: THE EMERGENCY DEPARTMENT CLINICIAN ON THE EMERGENCY DEPARTMENT AUTOBAHN Introduction................................................................................................................................................. 2 What Matters Most in Your Emergency Department?.................................................................................. 3 Flow and the Emergency Department.......................................................................................................... 4 Start Strong.................................................................................................................................................. 4 Organize the ED to Work Effectively With You and For You....................................................................... 4 Improve Documentation.............................................................................................................................. 5 Play Well with Others ................................................................................................................................. 6 Finish Strong................................................................................................................................................ 6 Taking a Higher Look at the ED Clinician and Clinical Work..................................................................... 6 Recommended Reading................................................................................................................................ 8 To Dos......................................................................................................................................................... 9 About the Author...................................................................................................................................... 10 References................................................................................................................................................. 11 Contact..................................................................................................................................................... 14
    • INTRODUCTION Patient safety and satisfaction are the focus within any emergency department. To streamline navigation on the ED autobahn, i.e., flow, and thus accomplish these goals most efficiently can be accomplished by the consideration of several factors and the application of several key techniques. 2 |
    • FAST AND EFFICIENT PRACTICE: THE EMERGENCY DEPARTMENT CLINICIAN ON THE EMERGENCY DEPARTMENT AUTOBAHN What Matters Most in Your Emergency Department? Most people would say it is taking care of your patients; and this is true. But let us look a bit deeper. While a fast, efficient, and effective emergency department means greater patient safety and greater patient satisfaction, you have to take care of your team and you have to take care of yourself. Finding the place where all three come together is the sweet spot that we strive for. That is why it is critical to optimize flow – important for your patients, your team and yourself. 85 percent of their time waiting. We do not want to cut down on the 15 percent of our time spent with patients; we want to improve and streamline our processes. We want to be fast at fast things and slow at slow things. Fast and efficient is not about racing through everything. We can only go as fast as the slowest processes in the ED. TRIAGE PLACEMENT TRIAGE AND REGISTRATION MD IN THE ED CALL FOR BED OR DISCHARGE TEST AND TREAT EXIT ED DISPOSITION DECISION TO EXIT THE ED ROOM UTILIZATION There are opportunities to improve flow and throughput throughout the life cycle of an emergency department visit: The three most important drivers of human behavior are love, money and fear. There are days you show up for work because you love it and wouldn’t want to be anywhere else. There are days you show up because you don’t want to let your team down. And there are days you just want to earn your paycheck. Being a good emergency physician means you need to think through why you’re doing this and what it’s all about for you. There are three major dimensions to what an Emergency Department physician does: Doctoring, Deciding and Documenting. Patients spend 15 percent of their time receiving direct patient care and • Leverage your clinical talent. Clinical talent should be roving intellects engaged in value-added activities at all times. • Hire right (or repent at leisure) • Optimize the physician, mid-level and nursing mix and consider the use of scribes. • Find the right clinical support mix for the team. • Tailor the clinical hours and staff to the facility and to patient flow. • Have your A-team on the floor at all times. The role of the clinical staff is to make diagnostic and treatment decisions and to manage the team and patient flow. Anything else is a non value-added activity. To truly understand this, try this exercise in your ED: take a 3 by 5 note card and write down in five-minute intervals what you are actually doing for a whole day or clinical shift (or only for one hour!) See how much of your time is actually spent on valueadded activities, how much of what you did could and |3
    • “We are what we repeatedly do. Excellence is not an act, but a habit.” ~ Aristotle should be done by a physician and only a physician (substitute “mid-level practitioner” or “nurse” as the situation requires), and how much of what you do or did should or could have been offloaded to someone else in your system or on your team, or perhaps, should not have been done at all. Flow and the Emergency Department • Start strong • Organize the ED to work effectively with you and for you • Improve documentation • Play well with others • Finish strong Start Strong The first part of starting strong is getting prepared before you start. Take a few moments to get organized and mentally prepared. Bring your meals with you. Get there early. Work hard early in your shift; it sets the tone for the rest of your day. Let’s say your goal is 4 | to see 20 patients in a 10 hour shift at an average of two-plus patients an hour. Many times you can get five to ten patients started within the first hour. The less “batch and queue” you have, the better off service delivery is for everybody. Organize the ED to Work Effectively With You and For You You are the captain of your ship. Position yourself near a place where the patients and their charts enter the emergency department. This is called situational awareness. Good situational awareness means you will know when patients are coming in to the ED, when family members are arriving, and who needs what kind of treatment. Putting yourself where you can keep your eyes on the entire emergency department is powerful and effective. Evaluate patients as the charts are “put into the rack.” Find the flow that works for you. Put your hands and eyes on the charts or carry a patient log. It allows you
    • FAST AND EFFICIENT PRACTICE: THE EMERGENCY DEPARTMENT CLINICIAN ON THE EMERGENCY DEPARTMENT AUTOBAHN to organize your day and have the information you need when you need it. Develop good relationships with your attending physicians and call them early. Make the unit clerk your best friend. Get the family members involved early. A good unit clerk (unit coordinator) knows exactly what is going on in the ED at all times. They can keep you and your ED humming. They can remind you of the chest X ray you wanted, the surgical consultant that you need, the hours when Dr. Smith is in the hospital or outside the hospital. The unit clerk and the charge nurse are far and away your most important allies when it comes to keeping the ER running smoothly and effectively. They play a critical role in the relationship. They can be a valuable source of information. They will certainly play a role in your disposition plans. Sign out safely and effectively. Personally sign out to your patients when you go offshift. Let them know that you are leaving and you are handing over the patient’s care to your partner. It’s the right thing to do – it’s good for you, your patients, Recognize what you can do by and for yourself. Don’t batch charts. Seeing patients one at a time is seldom the most effective approach. On the other hand, batching five or six charts isn’t either. It’s like the “pig going through the proverbial python.” Batching loads up and temporarily overloads your system and your processes. Figure out what the optimal blend is for you and your department. Usually it’s two or three charts or patients at a time. Avoid serial workups. Sit down. and your team. Patients think that you spend twice as much time with them when you sit down. It’s easy on your knees, it’s easy on your back, it puts you at eye level with your patients, and it doubles the amount of time they think you have been spending with them. No counting down. Ask the key questions right up front – don’t wait until the end of your patient encounter. Engage family members as well. Improve Documentation There will be days you show up in the ER and are counting down from the first hour. It happens. But we are professionals, and professionals perform even when they don’t feel like it. “I just don’t understand why an emergency department physician would go to all that trouble to do the work and not take the few extra minutes to get paid for it.” ~ Mel Gotlieb |5
    • Documentation is important. It may not be the most mentally rewarding thing you do but it can be the most financially rewarding thing that you do. Write succinctly and legibly. Bad writing can lead to inadequate records and even medical errors. Hire a scribe. Once you’ve used a scribe, you will probably never want to go back to your previous ways of delivering patient care. Other ways of improving your documentation include utilizing templates for routine charting work, using dictation for important to make their lives easier and/or better. Then actually listen and adjust your behavior accordingly. To knock it completely out of the park, spend 2-4 hours working in triage. You only have to do this once at the hospital you are working in and it will last you the rest of your career. You are “the doc who worked triage,” the doc who “understands what it’s really like.” Spend 4-8 hours actually working as a nurse. It will significantly change your point of view as to how your ER actually works – and it really sets you up with the nursing staff. Finish Strong parts of the history and physical exam, and organizing discharge instructions. Play Well with Others It is critically important to your work and performance to work effectively with your nursing staff. Learn their names. Know their individual and team practice patterns. Invite them in as part of your team, learn how they work, understand their hopes and fears – these are all vital to your success and effectiveness. If you really want to be the emergency department physician of the year, ask your nurses what you can do 6 | Know your best practices for end of shift management. This means you probably shouldn’t batch charts. Be careful with handoffs. You do not want to stop seeing patients four hours before the end of your shift, and at the same time, you want to hand off as few patients as possible. Treat your colleagues the way you would like to be treated. Negotiate pain medicine needs yourself. Do not expect the nurse to do it. Check for allergies. When you are seeing patients who have a medical background, ask them, “What do you think is wrong? What do you want me to check for? What treatments do you need or want or expect?” Address service complaints immediately and on the spot. It’s easier, quicker and better for everyone in the long run.
    • The “Swiss Cheese” Model Hazzards Other holes due to latent conditions Successive layers of defenses Taking a Higher Look at the ED Clinician and Clinical Work Ask yourself: are you really superman or superwoman? Or can you aim for just being somebody with the “right stuff.” Somebody who can take on the mission and carry it through with equanimity, decisiveness, grace and humor? Take care of yourself. Taking care of yourself is vitally important. If you don’t, who else is going to do it? Know your stress tolerance levels. Know your behaviors. When you know how you behave under stress and stressful situations you understand how to better mitigate the effects of stress – on yourself and on your relationships. Remember the importance of the other things in your life. Eat, sleep, exercise, and nurture your relationships. Learn to juggle well. Know what drives you, whether it’s love, money, fear or something else. Learn the importance of the little things that make you operationally effective and the importance of the big things like taking care of yourself and taking care of your team, as well as taking care of your patients. Learn not to think too much. As Henry Ford once said, “Thinking is the hardest work there is, which is the probable reason why so few people engage in it.” Your goal as an emergency physician or an emergency clinician in training was to actually get to the point where you did not have to think too much. Lucian Leape, in his article “Error in Medicine,” points out that the more expert you are, the less you really have to think. It’s more about pattern recognition. When you really have to think, it’s intense and time-consuming. What we consider thinking is often just selecting the appropriate diagnostic and treatment pattern from our memory, then making sure that the selected pattern is successfully executed and that it works as planned. Multitasking makes you stupid. A study at Carnegie Mellon University found that doing several things at once reduces the brain power a person can devote to each task. Sometimes we don’t |7
    • have a choice. Sometimes we have to multitask. But understand the consequences. Teenagers can drive a car, dial a cell phone and IM simultaneously faster than adults can, but they can’t recognize the danger up ahead as well as your mature and savvy brain can (the one focused primarily on driving, situation awareness, and threat recognition, not the teenage brain totally absorbed with a cell phone, talking with passengers, and instant messaging). Learn where, when, and how you can control or limit your need to multitask. Be familiar with James Reason’s operational model for institutional error, or the “Swiss cheese” model for error. (See above) It is seldom one “mistake” or one “slip” that gets you in trouble. It is the summation of a number of small errors that will most often get you into trouble. Avoid interruptions. A study from the University of Illinois found that it takes on average 16 minutes and 33 seconds for a worker interrupted by email to get back to what he or she was doing. Think through the number of interruptions that you experience. Emergency department doctors are interrupted 9.7 times per hour while office physicians are interrupted 4 times per hour. It is amazing that we do as well as we do. In fact, the only reason clinical and operational outcomes aren’t worse is that you are so good at what you do. It helps make up for all of this – the interruptions, the multi-tasking, and the continuous partial attention paid to multiple patients. 8 | Recommended Reading Patrick Croskerry, MD, PhD. has written eloquently on error management, thinking and what we can do in the ER to optimize what we do. I would urge you take the time to review some of these references. Read the book “The Goal” by Eli Goldratt. It’s a novel that delineates the Theory of Constraints. After you read this, you will not walk into an ER without thinking about the theory of constraints. You won’t stand in line, walk into a lecture hall, or wait for a cup of coffee at Starbucks without thinking about the theory of constraints, dependent events, statistical fluctuations and how someone could make this process (and your life) a bit better. Spend an hour reading the article “Error in Medicine” by Lucien Leape. It can positively change your life and your outlook. “The Psychology of Waiting” by David Maister (davidmaister.com) will take you through the eight principles of waiting, what people experience and think while they are waiting and what you can do. A cardiology friend who read it ten years ago went back home to his work and changed his office cardiology practice. He did not add staff, he did not redo the building, he did not rank and yank, hire and fire. He simply changed his processes based on this one article – and his patient satisfaction survey results went from worst to first. This is powerful material. It can be wonderfully effective for you and your Emergency Department.
    • TO DOS  Discuss your practice profile with a couple of trusted colleagues. ASK: – How do you practice? – What works? – What could work better? – What doesn’t work so well? – What’s it like for you or for the team when I am in the ER?  Have your work patterns observed by a trusted colleague or nurse.  Become a student of others. – Observe the people who are good or the people whose practices you admire. – Spend part of a shift tagging along with them. – Always look for ways to get better at what you do (CQI for the individual clinician).  Take a course or two.  Emulate Benjamin Franklin. Ben Franklin worked on one trait a week. Know your weaknesses and work on one every week. Remember, we are emergency clinicians. We can do this. |9
    • About the Author Kirk B. Jensen, MD, MBA, FACEP, is Chief Medical Officer for BestPractices, Inc., a leading emergency physician staffing and practice management group. He has spent over 20 years in Emergency Medicine management and clinical care and is directly responsible for the coaching, mentoring, and career development of BestPractices’ Medical Directors. Kirk B. Jensen, MD, MBA, FACEP, Dr. Jensen is a faculty member for the Institute for Healthcare Improvement (IHI) and has held numerous leadership positions with IHI focusing on quality improvement, patient satisfaction, and patient flow both within the ED and throughout the hospital. Dr. Jensen also serves as a Medical Director for Studer Group. He was honored by the American College of Emergency Physicians as the 2010-2011 Outstanding Speaker of the Year. Copyright © 2011 BestPractices Inc. All rights reserved. This publication may not be reproduced, stored in a retrieval system, or transmitted in any form or by any means – electronic, mechanical, photocopying, recording, or otherwise – without prior permission of the copyright owner. This White Paper is an informational document. Readers should note that this document does not represent an endorsement by any entity. All page headers and custom graphics are service marks, trademarks, and/or trade dress of BestPractices, Inc. All other trademarks, product names, and company names or logos cited herein are the property of their respective owners. Any comments relating to the material contained in this document may be sent to the BestPractices Marketing Department: Email: info@best-practices.com Mail: BestPractices, Inc. Marketing Director 10306 Eaton Place, Suite 180 Fairfax, VA 22030 10 |
    • REFERENCES | 11
    • • Fitzsimmons J., and M. Fitzsimmons. 2006. Service Management: Operations, Strategy, Information Technology. 5th ed. Boston: McGraw-Hill. • Goldratt, E. 1986. The Goal. Great Barrington: North River Press. • Langley GJ, Nolan KM, Nolan TW. The Foundation of Improvement. Silver Spring, MD: API Publishing, 1992) • Institute for Healthcare Improvement (IHI). Optimizing Patient Flow: Moving Patients Smoothly Through Acute Care Settings. Innovation Series 2003. • “Bursting at the Seams: 2004. Improving Patient Flow to Help America’s Emergency Departments.” Urgent Matters Learning Network Whitepaper. www.gwhealthpolicy.org accessed September 17, 2005. • Building the Clockwork ED: Best Practices for Eliminating Bottlenecks and Delays in the ED. HWorks. An Advisory Board Company. Washington D.C. 2000. • Bazarian J. J., and S. M. Schneider, et al. Do Admitted Patients Held in the Emergency Department Impair Throughput of Treat and Release Patients? Acad Emerg Med. 1996; 3(12): 1113-1118. • Full Capacity Protocol. www.viccellio.com/ overcrowding.htm 12 | • Kelley, M.A. The Hospitalist: A New Medical Specialty. Ann Intern Med. 1999; 130:373-375. • Holland, L., L. Smith, et al. 2005. “Reducing Laboratory Turnaround Time Outliers Can Reduce Emergency Department Patient Length of Stay.” Am J Clin Pathol 125 (5): 672-674. • Husk, G., and D. Waxman. 2004. “Using Data from Hospital Information Systems to Improve Emergency Department Care.” SAEM 11(11): 1237-1244. • Green LV, Soares J, Giglio JF, et al. Using queuing theory to increase the effectiveness of emergency department provider staffing. Academic Emergency Medicine. 2006. Jan;13(1):61-8. • Aiken L, Clarke S, Sloane D. Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction, JAMA, 2002;288(16);19871993. • Lardner R. Effective shift handover: a literature review. Health and Safety Executive. June 1996. Offshore technology report-OTO 96 003. Available at: http://www.npsf.org/download/ Focus2004Vol7No2.pdf. Accessed February 3, 2006 • Wears RL, Perry SJ, et al. Shift changes among emergency physicians: best of times, worst of times. Proceedings of the Human Factors and Ergonomics Society 47th Annual Meeting; October 13-17, 2003; Denver, CO.
    • FAST AND EFFICIENT PRACTICE: THE EMERGENCY DEPARTMENT CLINICIAN ON THE EMERGENCY DEPARTMENT AUTOBAHN • ACEP Patient Safety Task Force. Patient Safety in the Emergency Department. Dallas, TX: American College of Emergency Physicians; 2001. • The Effect of Hospital Occupancy on Emergency Department Length of Stay and Patient Disposition. Acad Emerg Med 2003; 10: 127-133 • Perry S. Transitions in care: studying safety in emergency department signovers. Focus Patient Safety. 2004;7:1-3. Available at: http://www.npsf. org/download/Focus2004Vol7No2.pdf. Accessed February 3, 2006 • Croskerry P. Critical thinking and decisionmaking: avoiding the perils of thin-slicing. Ann Emerg Med. 2006;48:720-722. Abstract • Schull et al. Emergency Department Contributors to Ambulance Diversion: a Quantitative Analysis. Annals of Emergency Medicine 41:4 April 2003; 467-476 • Richardson. The Access Block Effect: Relationship between Delay to Reaching an Inpatient Bed and Inpatient Length of Stay. DB Med J Australia 2002; 177:492 • Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. N Engl J Med. 1991;324:370-376. Abstract • Kachalia A, Gandhi TK, Puopolo AL, et al. Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers. Ann Emerg Med. 2007;49:196-205. Abstract
    • Contact 10306 Eaton Place Suite 180 Fairfax, VA 22030 (800) 910-3796 info@best-practices.com www.best-practices.com