Increase the number of patients you treat in a day: Examine your habits, learn to delegate
As administrators demand an increase in turnaround of patients, ED physicians should examine their clinical practice for ways to improve patient flow
Treating patients quickly is difficult in today's health care environment, but ED physicians must rise to the challenge. "I'm finding it harder to move a patient now than I did 20 years ago, not because of lab or x-ray turnaround times, but because patients are older, sicker, and more diverse," says Richard Cates, MD, MS, vice chairman of the ED at Fairfax Hospital in Falls Church, VA. "Today's ED physicians need to consider patient flow a number one priority."
Slow physicians may be sleep-deprived, inexperienced, or substance-abusing, but the most common problem is an inability to set priorities, says Dighton Packard, MD, FACEP, medical director of the ED at Baylor Medical Center in Dallas. "Fast physicians are constantly performing a mental triage process in a situation that is constantly changing," he notes. "The order in which you do things has a major impact on flow."
Workups in the ED have become longer and more scientific, notes Cates. "ED physicians are now expected to do CAT scans, sonograms, and venograms," he says. "In the long run, this may be saving patients time and improving care, but in the short run, fewer patients are moved through."
Moving patients quickly requires an overall emphasis on efficiency. "Physician organizational skills and teamwork are not taught in medical school," emphasizes Joseph Phillips, MD, FACEP, medical director of emergency medicine at Methodist Hospitals in Indianapolis, IN. "We have to find ways to work efficiently in a collaborative environment."
Physicians face pressure from administrators who want faster turnaround times, even if the problems lie elsewhere. "The fastest physician in the world can be brought to a standstill if there are enough gridlocks in the system," says Cates. "There are many roadblocks to moving the patient through in an efficient manner, but you need to overcome them."
Examine your ED for obstacles to moving patients. "How easy is it to get a call out to another physician, get a phone call, or get a patient to x-ray?" asks Packard. "All of these things can have a major impact on flow, but so can an individual physician. Patient flow affects all aspects of operations, so physicians need to be dedicated to improving it."
Habits are hard to change
Some physicians are resistant to moving patients quickly, reasoning that quick care isn't quality care. "Some doctors feel if they see more than 2.5 patients an hour, it's bad quality, while others routinely see three patients an hour with good quality care," says Packard. "You need to convince the slower physicians that they can practice quality medicine at a faster pace."
It's difficult for ED managers to improve a slow physician's pace, but it's necessary. "You can work with physicians to make them more efficient, but it's not easy," says Packard. "The number of patients you are capable of processing and pushing through, how much time you need off your feet sitting down, and how much time it takes you to produce the chart, are all very individual."
Start by informing physicians they are slow, Packard advises. "Tell the physician, `Your peers are seeing 2.8 patients every hour and you're only seeing two,'" he says. "If the physician realizes a colleague who they respect is able to move more patients, they may start to acknowledge room for improvement."
The next step is to observe the physician. "It's not enough to tell them they're slow, you need to proctor them. Follow them around, find out where they are being inefficient and point it out to them," Packard recommends. "You can also have them work with you or a faster doc to see how you do it."
In some cases, physicians may be unwilling to move faster. "If some physicians are told to move three patients an hour, they may say it's just too much work," says Packard. "Not every physician wants to work that hard, and they might feel they have to pace themselves to get through a shift. Age is another factor-maybe we can't see as many patients at 60 as we did at 30."
Learn to delegate
Physicians need to delegate in order to move patients, says Packard. "You should delegate certain orders to nurses by protocol or policy," he says. "You can't do that with subtle things, but if a guy was playing basketball and twisted an ankle and heard a pop, that is obviously going to need an x-ray, so why not order that from triage?" (See related story on the nursing role in patient flow, page 52.)
Some physicians want to do everything themselves, Packard says. "If you're going to move patients through quickly, you can't be doing all the bandaging and splinting yourself," he says. "Train your nursing staff as to how you want it done, and check it afterward, but you don't need to do it all yourself."
Another option is to hire a support person to assist with appropriate tasks. "If you can consistently see more patients per hour, maybe it's worth it to pay for your own technician," Packard suggests.
Time-consuming documentation prevents doctors from moving patients, so look for ways to delegate it, Packard says. "It doesn't matter if it's a hand or electronic chart, either way, to do a good chart takes time, and there is no way around it," he notes. doctors hire scribes for $30,000 to take down the history and physical, and they never have to write again."
Streamlining documentation can have a significant effect on patient flow, Packard says. "As technology improves, we may be able to document and take the history at the same time at the patient's bedside," he says. "As I ask the patient questions, I would be checking boxes and taking notes on a grid graph that later becomes the chart."
The practice would save time, but this could also hurt patient satisfaction. "If the physician is busy writing while talking to the patient, it does take away from some of the personal touch," says Packard.
Whatever it takes, try to keep documentation from disrupting patient flow, suggests James Chamberlain, MD, FAAP, assistant professor of emergency medicine at Children's Hospital in Washington, DC. "Fast ED physicians are in the habit of seeing the patient first [and] documenting later as time is available," he notes. "Use of electronic or template charting systems can be useful to jog the memory for an exam you did an hour ago and are charting now."
Here are some ways to improve how quickly patients are moved:
Plan the workup to shorten length of stay (LOS). "You need to set up systems so the right things are done in right order," says Packard. "If the lab is the number one problem with turnaround in your ED, the sooner you get blood drawn and get it to the lab, the sooner the patient can be moved through," he explains. "So, don't send the patient off to x-ray or wait for the ECG before you get the blood drawn."
Don't waste time on telephone calls. Many physicians spend a significant amount of time on the phone, says Gregory L. Henry, MD, FACEP, chief of the department of emergency medicine at Beyer Memorial Hospital in Ypsilanti, MI, and former president of the American College of Emergency Physicians (ACEP). "Know exactly what you want to accomplish before you get on the phone," he says. "What you don't want is a casual phone conversation for 10 minutes."
When consulting, stick to the facts at issue. "The doctor on the outside wants simplicity," says Henry. "You have a 42-year-old male with suspected myocardial disease and you want to admit him to the unit. That's it. Whether he had chicken pox as a child is not important."
Leave messages when possible. Come to agreements with other departments so you don't have to interrupt them with telephone consults, Henry recommends. "For example, I don't need to speak to the orthopedic surgeon about the fact that I just put a splint on a nondisplaced fracture," he says. "All I want them to do is follow up in the office in two days; so, what I need to do is speak to their answering machine or secretary to let them know that."
Don't allow a wait for lab results to delay seeing other patients. Avoid wasting time waiting for lab results, Packard advises. "You may be more efficient by seeing several patients in a row, just introducing yourself and asking what brings them to the ED, then getting the labs ordered all at once," he says. "After you get the results, then come back and do the more time-consuming parts of the history and physical."
Address problems with lab turnaround time. "The biggest impediments to patient flow are registration, lab, and x-ray," says Chamberlain. "Physicians can see most patients in about three to five minutes, then we twiddle our thumbs waiting for the lab results." QA programs should be in place to improve turnaround times, he says.
Don't take outside calls. An ED physician should never get into a telephone discussion with someone about whether they should come to the ED, says Henry. "You ought to have an answering device that says, `If you need an ambulance call 911,' but you shouldn't have a discussion with someone about whether his father is sick," he says. "That is a time waster and also presents liability risks."
If a physician needs to come see a patient that you want admitted, don't waste time describing the case on the phone. "Why tell them about the patient if they are coming down anyway?" asks Henry. "The best thing to do is have them come down, and then present the case."
Start the admitting process as soon as possible. Getting the admitting process started is an important part of moving a patient through, says Henry. "You don't need to have every single lab and x-ray back to admit a patient to the hospital-you can make that decision clinically in most cases," he notes. "Get the ball rolling so the patient isn't sitting in your department for an extra two hours."
Think ahead with substance abusers. "As soon as an intoxicated patient shows up, start the process of finding a responsible family member to take [the person] home, because that is often a lengthy, time-consuming process," says Henry.
Track patient flow electronically. An electronic tracking system allows you to see at a glance where patients are in the process. "You may not get a report back from the lab, but don't notice until it's an hour late," says Packard. "If you have some kind of tracking system built into the process to warn you when things are taking too long, that can be a great aid."
Learn only what you need to know. Unnecessary details can add time to the process. "If I need to decide whether a patient should go into our chest pain unit, all I need to know from the first ECG is whether they need to have an immediate catheterization or thrombolytics, so that is all I want to know," says Henry.
Be approachable. Make support staff feel comfortable offering help or information. "Doctors should send signals that say, 'approach me,' says Cates. "We have to let down our defenses if we have any, and take all the help we can get, because we can't do it by ourselves."
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