One of my gripes about working in the ED as a doctor is...the place isn't set up to maximize physician efficiency. Sure, they expect you to see 2.5 patients an hour...but when it takes 20 minutes to log into the various computer programs, trouble shoot the printing process, and then find said printout to sign and place with the chart (if you can find the chart)...there's no way the "goal" of 2.5 patients can be reached.
Let's take last night...
...there were 4 docs there, only 2 computers available for our use. My kindergartner can tell you that 4 docs need 4 computers. As everything is computerized now, I can't even look up lab results, or discharge a patient without using the computer. So, I found myself standing...waiting...for a computer to open. While patients have been in the waiting room for 6 hours or more. Then, when 'productivity' scores are released, it seems we're just...slow. And to compensate for the utter inefficiency of the system...doctors are expected to 'just speed up'. Making an already stressful, high-liability, acute situation...even moreso. There are only so many corners you can cut. So, some of my colleagues will opt to stay hours past their shift, doing charts, and continuing to dispo patients...stuff that they should have done hours prior (which would be both better for the patients we've seen, and for the patients in the waiting room), but couldn't for fear of slowing down...and being the "slowest person in the group." So, the patients (all of them) endure less than optimal medical care.
Why do we let them punk us like that? 10 hours of work should be done in 10 hours. It should not be expected/required that you do 12 hours of work in 10 hours. If the system is so inefficient that only 1.75 patients/hr can be *properly* seen...that's how many we should see. And charting/paperwork shouldn't be saved until the end of the shift. Documentation as you go is more accurate, and provides better communication to consultants and other healthcare team members. Above all, it allows you to keep everyone straight, and demonstrates real-time decision making and outcomes. Not to mention it's a total pain in the ass trying to gather all the pieces of information needed to compose a good note...after the fact.
So, what have I noticed that distinguishes 'efficient' EDs from 'inefficient' ones?
1. Smaller is better. The new trend is to build these 'mega emergency departments.' Where everything is spread out...very pretty...but inefficient. If you have a large ED, you need to break it down into essentially 2 completely different departments. Where one doctor is in one area...period. Not theoretically, but actually. There are EDs where the idea is to have one doc in an area, with a couple/few nurses...and that's where they stay for the entire shift. But in actuality, the doctor's patients are placed all over the place...in various areas...depending on "which nurse is up next to receive a patient." Additionally, the beds fill up in a particular area, depending on the disposition of the patients, their acuity, etc. So, patients will then be placed...anywhere there's room. Seems logical on the surface. But, then you have a doc running around this big ass ED, trying to care for patients from one corner to the other. This is inefficient, and slows down the flow. This ultimately is not good for patients. If the ED were to be divided (physically divided) into 2 discrete entities, this would not happen. Kind of like how Starbucks will frequently put 2 (separate) stores right across the street (or around the corner) from each other. It just works better...not having a huge, inefficient, chaotic, place to conduct business - but rather 2 (or more) completely separate places of business.
2. Each physician needs his/her own work station. As demonstrated above, it is a bad idea to require the usage of computers with not enough work stations. Waiting in line for a computer...isn't conducive to ED flow. And, not just random computers should be available...but rather each doc their very own. That way, you can set up the computer...log in...and not have to worry about getting up for a second...and losing your spot. Additionally, I could argue that this is better for patient privacy.
3. The computer should stay logged on. I'll approximate that I spend 30 minutes a shift logging on to various programs...each of which shut down after a couple of minutes of "idle time". Another joint commissions bright idea, I'm sure. HIPAA, CMS...someone who doesn't understand the practical impact this has on ED flow and subsequent patient care. The computer should be in a place that patients don't have ready access to. Once I log on, I should stay logged on. Perhaps there should be a way to tell the computer how long I'm working, and to log me out at the end of my shift. But logging on every 2 minutes...is not the most efficient option.
4. Speaking of logging on...can I have 1 login name and 1 password? Currently I have like 4 different login names/passwords. So...I end up writing them all down in my pharmacopoeia. I also see people put little stickies on the side of the computer. It has to be 'safer' and 'more protective of patient data' for me to have 1 login/password in my head versus all my info in a book...or on a stickie pasted on the side of the computer!!
5. And, can we quit changing the passwords every 3-6 months. This is another reason you find passwords on scraps of paper, stickies on the computer, or written in frequently lost pocketbooks.
6. Decrease the scut. Can we hire a clerk, high-school student...anyone, that can load the printer with paper, keep the necessary documents stocked, and print out aftercare instructions and acquire the patient's signature? I do so much scut...it's no wonder patients wait for 6 hours. It takes hours of my day printing pieces of paper, signing them, and placing them with the chart (after finding the chart). When my lab results are available, put them with the chart and notify me. When my radiographs are done, do the same. If an extended period of time has passed, and the data remains incomplete, call the lab, call the xray tech...find out what's going on, and fix it.
7. Have ED techs set up procedures, irrigate wounds, gather equipment, etc. And when rooming a patient, place them in the appropriate space. ENT, eye, Gyn, etc.
8. Have the nurses take less breaks. Man, they are *always* on break. I must say, I'm very jealous. We get no breaks. I can't even urinate or take a sip of water during many of my shifts. They get like a 45 minute 'lunch' and 2, 15 minute breaks. I can only dream!!
9. I need necessary work items in my work area. Can we have needed documents, trash cans, printers...you know, the things we need to work, near our work stations - and not solely across the way in the nurses station? It is a poor use of my time to make multiple trips *per patient* to the island for supplies when those very items could be placed in a spot more convenient for me.
10. The location of my patients matter. Ultimately, the flow of the ED, how many patients are seen, and how quickly they are dispositioned depends on me. And if things are not set up for me...the ED doesn't work well. Ancillary staff and nursing are important...but so am I. That needs to be taken into consideration. It's easy to understand why the nurses need their patients together, so why would it be any different for the physicians?
11. Don't bring patients back from the waiting room until they are ready to be seen. Bringing a patient from the main lobby into a smaller waiting room is a stupid idea...and only serves to frustrate the patient. Just when they think they're going to be seen, it's more waiting. Kinda like being in line at Disneyland, going thru the maze...thinking you're finally at the front of the line...turning the corner only to see a brand new maze. This frustration on the part of the patient only serves to slow us down...and lowers
12. One thing that worked well at one place I worked: have the clerk call the medicine consultant. We, physicians, requested a medicine consult by asking the clerk to obtain one. She wrote the patient's name, chief complaint, and a 1-2 line "reason", that we provided, on the book. When they returned the call, she gave the consultant that info, and they came down. If they had questions, or we had a more acute patient, of course we'd be more aggressive and communicate more directly. But for the routine 'chest pain r/o MI' on a patient that you know didn't have an MI, but you can't send home because 'what if he did?'...this process works well. And most of our admissions are more or less well-appearing, low risk, CYA, bullshit...so, why fake the funk? Why waste time calling medicine and hanging around until they return the call for these patients? It's not like they won't come see the patient. The process is streamlined, and it works very well.
13. Writing holding orders for admission works well.
14. Paperwork. There's absolutely too much paperwork. Documentation, is done for billing, and less so for patient health information communication...which is unfortunate. Much of what we write is irrelevant, but required for payment. Therefore some medically pertinent items are excluded...because there just isn't enough time to do everything. Decrease the number of sheets of paper, and the amount of random bullshit we need to include for payment, and things will move faster.
And finally an ED Wish
I wish I could go out to the waiting room and tell people "Look, tonight is busy...and if you're not very sick, the wait is in excess of 5 hours. We'll see you, but don't ask us 'how much longer?'" It seems appropriate to tell people the honest answer to that frequently asked question ("How much longer, I've been here for 3 hours already?")...but we don't. We say "ummm, weeelllll, it depends on how sick people are....I don't know exactly....yadda, yadda, yadda", when in fact we absolutely know that it won't be in the next 5 hours!! We did this a few times in residency...and the ED waiting room cleared out. Non-urgent people left, and the emergent people got better care. I also heard about UC Davis doing this rapid screening (meeting EMTALA) then sending people out *from triage* if they were non-emergent. The only thing is...the paperwork is a rate-limiting factor, even in a 'rapid' triage system. If that could be stream-lined....the ED would work so much better.
Getting feedback from those of us *actually working in the ED* is the best way to make things better!!