ED Efficiency

WTF 8 Minutes

This is a first draft (2024-12-26). If there’s anything you’d change, add or delete, I can add. This is based on things I’ve read & conversations with people in our department. Happy to add more.

Efficiency in the Emergency Department is about maximizing impact by preserving your energy, managing limited resources, and streamlining workflows—so you can provide better patient care and have a smoother shift.

1. Efficiency Principles

  • What is Efficiency in the ED?: Efficiency means completing simple tasks quickly and approaching complex tasks with the thoughtfulness they require. ^Ab It is not multi-tasking but prioritizing what needs to be done first versus at other times versus delegated versus not done.
  • There are three limited resources on each shift: time, space and mental energy. Learn to manage each efficiently.
  • Two Key Decisions for Every Patient: Disposition (always required) and diagnosis (optional but often helpful). [^Ab]
  • Prioritization Over Multitasking: You can’t really do two things at the same time. You can only switch between tasks. Switching comes at a mental cost. Prioritize wisely.
  • Medical Knowledge First: Build foundational knowledge; efficiency comes with competence. Create a way to integrate on-shift reading to enhance knowledge and efficiency over time. Knowing what to do helps you make dispositions, which in turn can save you time, space and mental energy.
  • Track Performance: Reflect on shifts and track metrics like patient volume or charts completed. Common metrics against which Emergency Physicians are measured include:
    • wRVU’s: which is derived from the complexity of patients seen. This is based on what you document.
    • Patients per Hour: this may or may not be adjusted for acuity and complexity. So it may pay to get some of those quick-in-and-out patients seen. It also doesn’t incorporate signed out patients for whom you assumed care.
    • Length of Stay (LOS): in the ED. ED boarding adversely affects this for admitted patients and is beyond our control. However, getting discharged patients in-and-out can help lower this number.
    • Disposition Time:  how long does it take for you to decide where the patient will go from the ER. This is closely related to LOS, but measured slightly differently.
    • Admission Rate: is a controversial one. Groups try to incentivize over admitting, however if you have complex patients you need to admit them. Don’t discharge patients who shouldn’t go home.
    • Bounceback rate: how many of your patients come back in 48 to 72 hours.
    • Documentation Completion Rate: usually within 24 hours.
    • Procedure Volume: number and complexity of procedures.
    • Press Ganey (Patient Satisfaction) Scores: are surveys sent out to a sample of discharged patients. They are asked about
      • Courtesy of the doctor
      • Degree to which the doctor took the time to listen to you
      • Doctor’s concern to keep you informed about your treatment
      • Doctor’s concern for your comfort while treating you
      • Doctor included you in your treatment decisions

2. Managing Time

  • Prioritize High-Value Tasks: Focus on decision-making, facilitating dispositions, and communication.
  • Delegate When Possible: Use staff and students to offload non-critical tasks. Ask your staff for help: have the clerk check on a lab delay or a tech put on a splint. Learn staff names and ask for help when needed.
  • Batch Tasks: Group tasks like documenting multiple patients or making follow-up calls at the same time to save mental energy.
  • Optimize Patient Interactions: Sitting during interactions can build rapport without significantly adding time.

3. Managing Space

  • Utilize “Vertical” Space: See patients in chairs (where they are vertical) when bed space is limited (patients are horizontal in beds). Put chairs in hallways or unused pods.
  • Move admitted patients to holding areas when safe to do so. This could be Pod C or a hallway bed. Those who require close monitoring should remain close-by.
  • Finish all discharges as soon as possible. Instead of seeing a new patient, discharge the one who is waiting. This makes room for new patients.

4. Managing Mental Energy

  • Frontload Your Efforts: See 2-4 patients per hour early in the shift when you’re sharpest. Slow down to 1-2 in the second half. Tie up patients in the last 30-60 minutes.
  • Recognize Stress Levels: We are most productive in the goldilocks sweet spot, not too little and not too much stress.
The Yerkes-Dodson Law shows the relationship between level of stress and performance. There’s a Goldilocks level of stress which leads to the best performance. You can be too stressed and not stressed enough.
  • Stay Active in Low Volume: Avoid getting complacent during slow periods. If there are no new patients to see, don’t just sit there. Go check on all the old ones. There’s always something to be done to move things along.
  • Recognize when You’re Distressed. If overwhelmed, focus on reducing your load: discharge patients, complete charts, or enlist help. Decompressing your workload can restore focus and energy.
  • Strategic Self-Care: Hydrate, snack, and take breaks to maintain focus.
  • Avoid Mid-Shift System Fights: Save big-picture frustrations for post-shift reflection. Take care of the patient in the moment the best you can, then email your administrators afterward.
  • Make decisions early. If you don’t know what to do right now, you probably won’t get a flash of insight later, but you’ll definitely be more tired. So figure it out now. Do the thinking up front.

5. Effective Communication

  • Let your nurses know what you’re thinking. They can help you move care forward by reminding you when a CT is back or troubleshoot when things aren’t moving. They are your eyes and ears. Appreciate and use that extra help.
  • Speak Competently to Consultants: Prepare concise, focused questions. Structured models like Kessler’s 5Cs can help streamline conversations. [^Kessler-5C] Before calling the ophthalmologist, have the visual acuity and slit lamp exam done. Know what orthopedic options are available for a given fracture (look it up on http://www.orthobullets.com or http://www.wheelessonline.com). They’ll appreciate you made the effort, you’ll look smarter and you’ll become smarter.
  • Script Responses to Patient Concerns: Address concerns about testing with empathy and clarity. For example, “”I feel we can give you safe care without that MRI. Less testing is cheaper, safer, and gets you home faster, but let’s talk about why you want that test. What are you worried about?” Most often people don’t want tests, they want to know they don’t have a scary diagnosis.
  • Set Disposition Expectations Early: Discuss likely dispositions with patients upfront. Let them know they’ll likely go home so they can arrange a ride or come to terms with the disappointment of not being admitted. Or if they’re being admitted, better to know early they’ll need to find someone to feed their cat.

6. Efficient Patient Flow

6.1 After Sign-Out

  1. Triage Critical Patients: Stabilize first.
  2. Fill up all your rooms: Request new patients early while you’re at your highest energy. Learn to love the early boluses.
  3. Quickly Meet All New Patients: A brief 2-3 minute early encounter helps establish rapport, set expectations, and prioritize care. Let them know you’ll be back.
  4. Discharge or Update Old Patients: Free up space and move toward disposition. For those who are remaining, share your understanding of the plan and address any of their concerns.
  5. Return for Comprehensive New Patient Exams: Follow a structured workflow.

6.2 Initial Patient Evaluation

  • Stabilize first. Obviously, if a patient requires stabilization, do that first.
  • Avoid Extensive Chart Biopsies. Read the triage note, look at today’s vitals and at most 1 discharge summary and recent ED visits. You can always do more digging later if needed.
  • Go see the patient. Spend more time with the patient than the EHR. Use open-ended questions but guide the discussion in the right direction. Finish the entire exam while you’re there: pelvic, rectal, eye exam, etc.
  • Before you leave the room, talk about disposition. Let patients know the potential disposition before you leave the room so they can prepare themselves (logistically or mentally). “I think there’s a 70% chance you’ll be able to go home.” If they have concerns with that, they can bring that up early.
  • Place all the orders at one time. Order all anticipated tests upfront. If uncertain, consult guidelines or a colleague.

6.3 Trackboard Rounds

  • Do this every 1-2 Hours. It helps you not forget things.
  • Focus on Dispositions: Remove bottlenecks. Determine what’s pending and what can be done to expedite it. Is Ready-To-Move clicked?
  • Update Diagnoses: Clarify working diagnoses and document progress.
  • Monitor Pending Results: Follow up and expedite where possible.
  • To-Do List: Prioritize next steps for each patient and write down everything you need to do. Use paper, or a notepad.exe file (like Scott E does).

6.4 Walking Rounds

  • Be very brief. 1-2 minutes per patient.
  • Are you comfortable? Ask if they are “comfortable” (a key word in patient satisfaction surveys).
  • Sorry about the delay. inform them about any delays (another key feature of patient satisfaction).
  • Review their results. Use Haiku to go through all their results and what is pending.
  • Review planned disposition. Re-emphasize what you think the disposition will be.

7. Teaching and Supervising

7.1 Working with Residents

You may have the opportunity to work with off-service residents or interns.

  • Pre-assess the patient. Check for stability. Look at the triage note, the vitals and talk to the patient for 1-2 minutes to ask why they’re where. This will also help put a disorganized learner’s presentation in context later.
  • Encourage concise and thoughtful presentations that include a prioritized, differential diagnosis, diagnostic & treatment plan and predicted disposition.
  • Check the orders to ensure everything is in place properly. If you need to make changes, let the resident know you’re making changes and why.
  • Run their list with them periodically focusing on disposition, pending tasks (results, consults, procedures), and documentation.

7.2 Working with Students

You’ll also have the ability to work with students. Most students want to feel like they are making a meaningful contribution while also learning something.

  • Pre-assess the patient briefly. Check for stability. Do a quick 2 minute evaluation to help put the student’s presentation in context later.
  • Guide their presentations. Student presentations can range from focused and on-point to undirected and lengthy. This is part of the learning process. One trick to help focus them is to have them start with assessment and plan. Their H&P presented next needs to support what they said in the assessment and plan.
  • Enter orders together. Either have the student pend the orders and sign together, or enter them directly together.
  • See the patient with the student. Summarize the student’s presentation to the patient and ask for clarifications or corrections. Do a full appropriate physical exam.
  • Teach them one takeaway. Call it out as a “teaching point” to make it obvious.
  • Encourage thoughtful documentation by comparing theirs with yours. Have them reflect on what was different.
  • Delegate tasks to the student. Involve them in the meaningful work of the team. This allows them to learn from patients other than their own. One task they can do is update patients on all their results and answer questions. Any questions they can’t answer, they should look up (but also ask you about).

8. Charting and Documentation

  • Efficiency Over Perfection. Chart as you go (“see three, chart three”). They don’t need to be novel length, but should cover the important pertinent items to show you considered and eliminated scary diagnoses.
  • Avoid Copy-Paste Pitfalls. Avoid copy-pasting to ensure your documentation reflects your thought process not someone else’s. Cut-and-pasted text may not meet billing requirements. And it adds to chart bloat. The only two things I copy-and-paste are EMS Notes (because they’re buried in Care Everywhere) and Radiology preliminary impressions (because these have been known to mysteriously and unpredictably change).
  • Use smart phrases and macros appropriately. Smart phrases can save time for repetitive tasks, but be sure you do not document anything that you haven’t done. Read everything in your smart phrases before committing it to the chart.
  • Document Dispositions Early. Time-to-disposition is a common metric used to measure physician productivity.

References

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