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Multiple patients in the ed
- 1. Another Day at Work • You show up for your shift at 10:00;
- 2. Six Hours Disposition Executed Disposition Determined Physician Reviews Investigations Interpreted Investigations Carried Out Order Investigations Review History Physician Evaluation RN Evaluation Into The Que Entry in ED Anatomy of an ED Visit
- 3. Okay, this works You Disposition Executed Disposition Determined Physician Reviews Investigations Interpreted Investigations Carried Out Order Investigations Review History Disposition Executed Disposition Determined Physician Reviews Investigations Interpreted Investigations Carried Out Order Investigations Review History Physician Evaluation RN Evaluation •Into The Que Entry in ED Entry in ED RN Evaluation •Into The Que Physician Evaluation Review History Order Investigations Investigations Carried Out Investigations Interpreted Physician Reviews Disposition Determined Disposition Executed “Important” Phone Call Physician Evaluation RN Evaluation •Into The Que Entry in ED Entry in ED RN Evaluation •Into The Que Physician Evaluation Review History Order Investigations Investigations Carried Out Investigations Interpreted Physician Reviews Disposition Determined Disposition Executed Tea Me
- 4. Okay, this works And Again You Disposition Executed Disposition Determined Physician Reviews Investigations Interpreted Investigations Carried Out Order Investigations Review History Physician Evaluation RN Evaluation •Into The Que And Again Entry in ED Disposition Executed Disposition Determined Physician Reviews Investigations Interpreted Investigations Carried Out Order Investigations Review History Physician Evaluation RN Evaluation •Into The Que Entry in ED You Again
- 5. RN Evaluation •Into The RN EvaluationQue •Into The Que Entry in ED Entry in ED Physician Evaluation Physician Evaluation Disposition Determined Disposition Executed Disposition Executed Disposition Determined Disposition Executed Disposition Executed Entry in ED Entry Evaluation RN in ED •Into The Que Entry in ED RN Evaluation •Into The Que Entry in ED Physician Evaluation Evaluation RN •Into The Que Physician Evaluation Entry in ED Entry in ED RN Evaluation •Into The Que Disposition Executed Physician Reviews Disposition Executed Physician Reviews Disposition Determined Disposition Determined Disposition Executed Disposition Executed Disposition Determined Investigations Interpreted Disposition Determined Investigations Interpreted Physician Reviews Physician Reviews Disposition Determined Disposition Determined Physician Reviews Physician Reviews Investigations Carried Out Investigations Carried Out Investigations Interpreted Investigations Interpreted Physician Reviews Physician Reviews Investigations Interpreted Investigations Interpreted Order Investigations Order Investigations Investigations Carried Out Investigations Carried Out Investigations Interpreted Investigations Interpreted Investigations Carried Out Investigations Review HistoryCarried Out Review History Order Investigations Order Investigations Investigations Carried Out Investigations Carried Out Order Investigations Order Investigations Physician Evaluation Physician Evaluation Review History Review History Order Investigations Order Investigations RN Evaluation Review History RN Evaluation •Into The Que Physician Evaluation Physician Evaluation •Into The Que Review History Review History Review History Maybe we need to do this a little differently
- 6. Key Points ① You cannot manage the flow of patients into the ED. ② Out of sight is not out of mind. The waiting room is a bad, bad place ③ Emergency Medicine, Critical Care, Anesthesia; all manage Geographic Units as well as Patients. You are responsible to keep it accessible to new patients
- 7. Since You Cannot Manage the Number of Encounters… • Manage the Order of Encounters • Manage the Trajectory Through the Visit
- 8. In Every Encounter, There Is A Rate-Limiting Step • Find it early • Start the process NOW
- 9. The Order of Encounter • Triage Category Category 1 2 Active Resuscitation Emergency 3 4 5 Urgent Semi-Urgent Non-Urgent Time to Encounter Immediate 10 min 30 min 60 min 120 min Reality: When The Nurse/Paramedic/Visitor Says “You Need To See The Patient In Room…” …Do It.
- 10. Another Little Caveat • Simple Problems are Quick Problems – (Triage Level 3, 4 and 5) • The chart can be done later • A full ED, regardless of acuity, is an inefficient ED – – – – – – Nursing time Phone calls Meals Falls Trips to toilet “Where are you going on leave?”
- 11. Key Points ① You cannot manage the flow of patients into the ED. ② Out of sight is not out of mind. The waiting room is a bad, bad place ③ Emergency Medicine, Critical Care, Anesthesia; all manage Geographic Units as well as Patients. You are responsible to keep it accessible to new patients ④ The process of ED care does not mirror hospital care.
- 12. Entry in ED RN Evaluation Physician Evaluation Into The Que Manage the Trajectory Order Investigations Physician Evaluation Investigations Carried Out Review History Investigations Interpreted Order Investigations Disposition Determined Investigations Carried Out Disposition Executed Investigations Interpreted Physician Reviews Disposition Determined Disposition Executed • Identify and carry out the CRITICAL ACTIONS. • Do not send time or resources on non-critical actions
- 13. Entry in ED RN Evaluation Into The Que Manage the Trajectory Physician Evaluation Review History Order Investigations Investigations Carried Out Investigations Interpreted Physician Reviews Disposition Determined Disposition Executed Skip ahead when disposition is known
- 14. What Works? • Start your shift on the run. – Pick up three new patients in the first 20 minutes – It’s about getting things started • Rate limiting steps • Early determination of disposition • Yes, the nurse will ask you to see another patient before you are ready for another one. • Where does the teaching come in?
- 15. Patient #1 A 87 y/o female fever to 39, BP 90, HR 120 Alert, confused Patient #2 A 27 y/o male from RTA, BP 146, HR 120 Obviously deformed R lower leg, chest and abdominal pain Patient #3 A 57 y/o female with 2 days of abdominal pain, vomiting and diarrhea
- 16. Patient #1 A 87 y/o female fever to 39, BP 90, HR 120 Alert, confused Patient #2 A 27 y/o male from RTA, BP 146, HR 120 Obviously deformed R lower leg, chest and abdominal pain with “seatbelt sign” Patient #4 A 19 y/o with Patient #3 ankle pain after A 57 y/o a stepping off female with 2 curb days of abdominal pain, vomiting and diarrhea
- 17. Patient #1 A 87 y/o female abrupt onset HA, vomiting and slurred speech. Presently rouses to verbal stimulus Patient #2 A 28 y/o female ambulates to room with gradual onset HA, vomiting and photophobia; all typical of prior HAs. Patient #3 A 4 y/o fell at home striking head.
- 18. Patient #1 Patient #2 Patient #3 Just finished dinner A 27 y/o male with recurrent Sz presents following a 4 minute generalized Sz. Awake and somnolent A 57 y/o female with chest pain
- 19. The World is Changing. Change Or Be Left Behind • Linear care is not efficient • Launch the rate limiting step as soon as possible • If you know the ending, don’t read the whole book. • The sickest patients need the most care. But the least sick patients will prevent you from giving them that care – get them out.