Efficiency in the Emergency Department

Doing Things Faster Without Sacrificing Quality

2004 ACEP Reference and Resource Guide

As bottom-line and time-management pressures continue to increase at hospitals of all sizes, speed and efficiency are more important than ever in the emergency department.

Long waits in the ED create a range of problems, the first of which is that patient satisfaction suffers. "The number one patient complaint is having to wait too long. And these days especially, we can’t afford patient dissatisfaction," says Todd L. Beel, MD, FACEP, Clinical Instructor, University of Michigan Medical School, Ann Arbor. Beel is also on the faculty of St. Joseph Mercy Hospital and the University of Michigan Emergency Medicine Residency in Ann Arbor.

"Most emergency departments have a threshold for LBE’s (left before exam) of about 1 percent. And it’s estimated that for every LBE there are nine patients who either never came because of the wait or came and saw a long wait and went elsewhere. So long waits could result in an ED losing as much as 10 percent of patient volume," says Beel.

Patient satisfaction isn’t the only thing that suffers when there are long waits. "When a patient calls a doctor on staff and the doctor tells the patient to go to the ED, that’s a referral. And if we don’t handle the referral well, if the patient perceives that he or she had to wait too long, it will have a negative effect on the referring physician’s practice," says Beel. "It’s also difficult to retain good nurses and clerks in the ED when they frequently have to deal with patients and family members who are angry over long waits."

Fifty percent of efficiency is a systems issue, notes Beel. There are five systems in the ED that affect the speed and efficiency of patient flow: nursing and clerical staff, lab and X-ray turnaround, chart flow systems within the department, the speed with which residents and staff answer pages, and the time it takes to get a patient admitted. "The other 50 percent of efficiency depends on the emergency physicians on duty that day and how they utilize and work within these systems," he says.

Strategies for Doing Things Faster

"Studies show that decisiveness is a key issue in managing patient flow. And while those who choose emergency medicine as a specialty do tend to be decisive, it really takes four to five years of experience to fully develop this quality," says Beel. There are, however, many strategies for doing things faster that can be practiced by physicians at all levels of experience. Beel suggests tackling one or two of these strategies every few weeks and gradually incorporating them into your practice.

Among his recommendations:

Stay focused. Be 100 percent focused on work for the time you’re in the emergency department.

Don’t waste free time. If you have any free time, then anticipate things you’ll have to do, such as writing prescriptions and discharge orders.

Anticipate phone calls to staff and residents for consults. You don’t have to wait until all tests are back before setting a plan of action for treatment. The medical director can help gain acceptance for this strategy by building rapport among departments and explaining to medical staff that everyone has an interest in keeping things moving in the ED so that long waits can be avoided.

Admit patients who obviously need to be admitted. Don’t wait for all the test results. Get the admission process started early if you know where the patient needs to be admitted.

Be flexible. Sometimes it’s important to be able to work extra fast to clear the ED. When the department is backed up, it may be necessary to lower the admission threshold and admit patients faster.

Remember that we’re emergency physicians—not internists. When you see a patient with a chronic problem, treat the patient as a referral. Explain that the condition will need to be treated over time and can be better handled by an internist. Reassure the patient that no harm will be done by waiting for the appointment.

If you’re alone, you don’t have to take charts in order. If all patients are stable, a good general rule is to take the more simple cases first, get them started, then go to the more time-consuming work-ups. The total length of time in the ED will be less for everyone than it might have been if you’d taken patients in order.

Delegate as much as possible. Your time is the most valuable time in the department, so be very careful with it. Delegate to the staff as much as is possible and appropriate.

Avoid ordering any unnecessary tests that will delay disposition. An unnecessary test is basically a test that is unlikely to change the outcome. Patients may have expectations about which tests will be performed, but spending a little time explaining things to them can avoid many unnecessary tests.

If you’re ordering a test, then order all the tests you think will be needed. This avoids the time consumed by a sequential work-up. There is some disagreement about just how cost-effective this may be, but it does save time.

Don’t pick up a new stable patient’s chart until your "to do" box is empty. Be sure you have labs, X-rays and dispositions done first. The ED is like a revolving door and in order to get patients in, you have to get other patients out.

If you’re managing more than six to eight patients, put your energy into their dispositions. You can only handle a certain number of patients efficiently. Once you reach that limit, you need to concentrate on moving those cases along.

Periodically review your pending cases to make sure they’re on track. Assume that 10 percent of what you order is going to be missed. Check to be sure things stay on track and keep moving.

Keep the big picture in mind. The staff will be focused on their own patients, but you’re responsible for monitoring flow for the entire department.

Use running sutures or staples on most lacerations over 2 cm. This can save a significant amount of time during a shift.

Keep a log. Carry a memo book in which you write the name, room number, chief complaint and private physician for each patient. This will help you stay organized and save time in looking for the chart when the physician calls.

Take short breaks and get adequate nutrition. Taking good care of yourself will increase your efficiency in the long run.

Efficiency and Quality of Care

"There are effective ways to demonstrate concern for a patient even when you’re trying to do things fast," Beel says. Make eye contact and shake everyone’s hand as you introduce yourself. Apologize for the wait. Sit down, this reassures the patient that you’re really paying attention. Let the patient talk for a minute without interruption—it increases patient satisfaction and you’ll also get information you otherwise might have missed in your usual questioning. Give the patient and the family a reasonable expectation of how much time everything will take. If it will be a while, suggest that family members eat, rest or take a break. Everyone is happier when they know what to expect.

"Increasing speed and efficiency doesn’t really require major changes. Even just the difference between seeing 2 and 2.5 patients per hour by every physician in the department makes a big difference," says Beel. "For example, if two doctors work side by side for an eight-hour shift and each of them is able to work fast enough to see 0.5 more patients per hour, then at the end of that shift there are eight fewer patients waiting to be seen. So small differences can make a big change over time."

Beel acknowledges that doing things faster inevitably raises concerns as to whether quality of care may be sacrificed.

"There will always be those cases that don’t lend themselves to faster ways of doing things. Usually there are about 10 percent of patients each shift whose cases are real conundrums. Those are the tough work-ups — the ones you know may take six or more hours. There will be serial tests, consults, multiple exams. These cases don’t lend themselves to most of the time-saving strategies. But I find that when I’m keeping things caught up in the department and working more efficiently on the other 90 percent, I have more time and more resources to devote to that tough 10 percent," says Beel. "Working faster, and thereby limiting the time the department is over-saturated, actually allows a physician more time for the patient with a difficult or life-threatening problem."

Working faster and more efficiently also adds to an emergency physician’s sense of satisfaction and well-being. "It’s so much nicer to work in a department that’s caught up — patients and staff are happy, and things flow well," says Beel. "Emergency physicians who tend to be more efficient also tend to enjoy their work a lot more. And they’re usually able to leave work at a reasonable time."

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