How Do I Know If I Go Too Slow? Improving Efficiency for Residents, Part 2

Originally Published: Common Sense, March/April 2016

Author: Gregory K. Wanner, DO PA-C
Senior Emergency Medicine Resident, Thomas Jefferson University

Author: Andrew W. Phillips, MD Med
Critical Care Fellow, Stanford University, Division of Critical Care
Staff Emergency Physician, The Permanente Group

In “Improving Efficiency for Residents, Part 1” (Common Sense, Mar/Apr 2016), we discussed patients per hour (pt/hr), factors influencing efficiency, and the value of efficiency. In this article we will share advice on how to safely improve efficiency.

Recap of Part 1
Our review showed that PGY-1 residents average between 0.73 and 1.06 pt/hr, PGY-2 residents range from 0.85 to 1.33 pt/hr, and senior residents see between 1.05 and 1.41 pt/hr.1 These numbers may seem a little low, but they are averages across several studies that include different shift lengths and practice environments. Some of the factors that influence efficiency are shift length (longer shifts appear to reduce productivity) and distractions (emergency physicians are interrupted every 5.8 minutes and are required to unexpectedly switch tasks every 8.7 minutes).2,3

Speed versus Efficiency
Learning to be efficient is more important than learning to be fast, and there is a difference. The number of patients seen per hour, while important, does not tell the whole story. Avoiding discussions with patients, minimal documentation, and hurrying through procedures are not appropriate ways to increase patients per hour. Efficiency, however, makes use of all available resources to help move patients through the ED without cutting corners. It takes practice — lots of practice. As residents, we can all improve our efficiency.

Improving Personal Efficiency
Being productive and improving efficiency in the ED can be difficult. There are, however, several ways for residents to improve clinical efficiency.

• Start your shift by seeing as many patients as possible in the first couple of hours, while you are fresh and have few distractions. One author recommends having “two speeds in the ED: on and off” with the suggestion to avoid “slow mode” even when volume is low.[4]

• Use low volume periods to catch up on documentation or begin writing discharge paperwork. The objective should always be to “keep your plate clean” by preparing discharges or calling for admission as soon as a firm disposition decision is made. Keeping the ED clear when volumes are low will help to buffer the inevitable patient surge later. 

• Discover and focus on why the patient is here early in the encounter.[5] This may sound obvious, but we’ve all had patients who, after a full workup, ask during the discharge conversation, “Well, aren’t you going to look for X? That’s why I’m here.” Focusing on the true reason for the visit rather than just the chief complaint makes for a more efficient evaluation. In the same vein, ask about work notes up front — that may be the entire reason for the ED visit. 

• Identify the slowest step in a patient’s workup, such as the obvious imaging study or consultation. Beginning that step early can decrease a patient’s time in the ED.[6]

• Everything in parallel: be sure to do something else for the patient while your rate-limiting step is happening. Running in parallel doesn’t have to be with the same patient, either. See if your headache patient is feeling better on your way to see your new patient. Schedule bathroom trips on your way to see a patient. Make the most of your physical movements.[7]

• Communicating plans or changes in plans to nurses can help streamline the patient’s course through the ED and decrease interruptions. Try to order all necessary labs up front, but if additional labs are needed be sure to inform the nurse.[4]

• Delegate responsibilities. Having a nurse, technician, or medical student set up for a pelvic exam or irrigate a wound can safe precious minutes.[6]

• Finally — and there is no reference for this other than advice from a wise attending — make a personal checklist of things you ask all patients before discharge (G.M. Garmel, MD, personal communication, July 1, 2012). Rather than waiting until just prior to discharge, ask those questions at the end of your initial encounter. This will prevent interruptions that keep the patient from leaving when you have already mentally moved on to the rest of your patient list. For example:

• Work excuse? 
• Ride? 
• Pharmacy? (Re-sending electronic prescriptions and calling the “old” pharmacy to cancel is painful.) 
• Does the Medicaid patient need a prescription for OTC analgesics? 

 

Improving System Efficiency
Although residents may be able to improve their own efficiency, there are often systems-based issues that can slow us down. After all, ED crowding is a “complex, multifaceted” problem.[8] Flow issues, boarding admitted patients, and computer problems can all slow down an ED. For additional information, a good review of ED crowding and flow solutions appeared in Annals of Emergency Medicine a few years ago.[8] While much of that is beyond the scope of this article, some systems issues can be improved by residents. One study evaluated the changes in efficiency and teaching after modifications were made in the resident staffing model. By changing the supervisory structure and making a senior resident and intern team responsible for a geographic region of the ED, residents saw more patients per hour (an increase from 1.24 to 1.56 pt/hr), and residents also felt teaching improved.9 This suggests that quality teaching doesn't have to be sacrificed for the sake of efficiency — an important point since education is the main goal of residency training.

Take Away
Increasing efficiency as a resident is a progressive process — don’t rush it and don’t cut corners. Little by little you will notice your efficiency improving. Try incorporating our suggestions into your practice, and ask your attendings for their thoughts on efficiency as well. By the end of residency you will be amazed at how far you’ll go, and how quickly you will get there.

Acknowledgments: We would like to thank the many attendings who have offered valuable advice for improving efficiency over the past several years. Several of those recommendations are incorporated into this article.

References

1. Wanner GK, Phillips AW. How Do I Know if I Go Too Slow? Improving Efficiency for Residents, Part 1. Common Sense: American Academy of Emergency Medicine. March/April 2016: 33-34.

2. Jeanmonod R, Jeanmonod D, Ngiam R. Resident productivity: does shift length matter? Am J Emerg Med. 2008;26(7):789-91. PMID: 18774044

3. Chisholm CD, Collison EK, Nelson DR, Cordell WH. Emergency department workplace interruptions: are emergency physicians "interrupt-driven" and "multitasking"? Acad Emerg Med. 2000;7(11):1239-43. PMID: 11073472

4. Klauer KM. 14 Tips to Improve Clinical Efficiency in Emergency Medicine. ACEPNow. July 2015. Available at: http://www.acepnow.com/article/14-tips-to-improve-clinical-efficiency-in-emergency-medicine/?singlepage=1

5. Sadosty A, Kruse B, Vadeboncoeur T. Five simple steps to improve an emergency physician's efficiency. The American Journal of Emergency Medicine. 2008 Nov;26(9):1056–7.

6. Shafe, Michael. Fast and efficient practice: the Emergency Department Autobahn. ACEP Annual Scientific Assembly. 2007. Seattle, Washington. Available from: http://www.acep.org/uploadedFiles/ACEP/Practice_Resources/issues_by_category/crowding/SA_crowding_syllabi/TU136.pdf. Accessed April 8, 2016.

7. Mahadevan SV, Garmel GM. An introduction to clinical emergency medicine. 2012.

8. Hoot NR, Aronsky D. Systematic review of emergency department crowding: causes, effects, and solutions. Ann Emerg Med. 2008;52(2):126-36.

9. Nable JV, Greenwood JC, Abraham MK, Bond MC, Winters ME. Implementation of a team-based physician staffing model at an academic emergency department. West J Emerg Med. 2014;15(6):682-6.