Things that we all can do to manage a busy Emergency Department

Emergency Medicine is a relatively new speciality in India, though there are many one and two year programs that have been around since early 1990s. Medical Council of India recognised EM as an individual speciality only in 2009. Currently there are about 48 MD positions to cater a population of more than 1.25 billion i.e we are producing 48 Emergency Physicians annually on an average to serve the whole country! 

The number of seats are increasing gradually but not on par with our exponential population growth. One problem that we are going to come across certainly in near future is “Overcrowding” which is already a major issue in countries where EM got recognition in the last century. There are many factors that are going to contribute to the problem of ED overcrowding like very few existing Emergency Departments, those which exist are often misused and abused by the other specialities, increasing population etc. There is no doubt that overcrowding affects our performance, increases stress levels and decreases efficiency. Lets look at some ways that might help us in improving the flow through a busy ED:

1) Appropriate Risk Stratification

Risk stratification is something that we do everyday. This can save a lot of out time and can lead to a quick discharges. Many of the deadly diagnosis can be risk stratified only with a good “history and physical”, without requiring any labs. Everyone who walks in with a chest pain does not need a troponin and every abdominal pain does not need a sonogram. If a patient looks stable but needs an investigation that is not really going to change your management in the ED, DO NOT DO IT NOW but do that as an outpatient work up. Don’t make them occupy a bed in the ED unnecessarily. This might look like a trivial thing but it is not. I have witnessed physicians securing airways kneeling down and doing intubations on the floor because ED beds were occupied by young low risk patients waiting for their second sometimes third troponin or sometime by stable outpatients who came to the ED to get their routine blood transfusion! Stay away from this practice. Order those tests that will help you in disposing a patient either to a room/ICU/home. Use clinical decision rules to back up and justify what you are doing. Do not order c-ANCAs/p-ANCAs from the ED. ED is not the place to work up a PUO and vasculitis. 

Always ask yourself before sending a lab test, what are you going to do if the results turns out to be positive/negative?
Do not compromise the care for sicker ones by filling beds with the stable patients who are waiting for an inpatient bed allotment. Not fair..

2) Communicate well - Communicate well - Communicate well

No matter how busy you are, establish a rapport with every patients. You deal with human beings. Try to look at them as people rather than as "bed number 5 with mesenteric ischemia." Explain them what to expect, give them rough time lines, handouts to read about their illness. 

Something that I started doing quite late in my training is making multiple short visits to every patient. This give them a feeling of being looked after well and also strengthened your relationship that has many advantages in the long run like less likely to get sued in case there is a bad outcome or they might mention your name as a "star physician" in the feedback form. This visit can be as short short as 15 seconds where you just make sure that they are doing fine and ask them if they need anything. Also encourage your nurses to do this. You will soon realise that nothing gives more satisfaction than a genuine word of appreciation.

The analogy that I like to use here is (though it is not very precise), think of yourself as an experienced steward/attendant in a restaurant. Your job is to make sure that quality of food is maintained and it gets delivered on time. 

3) Keep the consultations/referrals smooth

Now I have covered this bit in the recent past. A couple of additional points that I would like to make here are:

• Involve your specialty colleagues early if you have a good sense of what is happening. For instance, don’t wait for the white cell count for appendicitis before you call a surgical consult. If you think it is appendicitis, get them to see the patient ASAP. White cell count is an overrated crappy lab. You cannot rule out appendicitis/sepsis with a normal white cell count. 
• When the ED is packed, speak to the attending/consultants directly because they are the ones who are going to make a decision. Do not linger around with a resident who has joined the service last week. Click here to read more on how to ask for a consult.

4) Stay in touch with everyone

EM is demanding and it can get tougher when you have 25 patients and you are the only registrar/consultant on the floor with four other residents. In my opinion, nurses can play a big role here whether its reassuring a patient, or mobilising patients to the ICU. Nurses are extremely under-utilised in India. At this point of time, Nurse Practitioners and Physician Assistants are almost non-existing in India, that puts all the responsibilities on physicians. Empower the nursing staff. Get rid of your ego as a physician and start work together with the nurses. Know their names and address them by using their name.

Nurses work with you, they don’t work under you.

5) Monitor the flow and plan things ahead

Make sure you know why each and every patient is there in the ED, who is waiting for the consultant, who is waiting for labs and who is waiting to get discharged. Now I do understand this is not always possible, so consider using your smartphone, a whiteboard or a computer to do this. I am a bit old-fashioned here, so I have always used a pen and a sheet of paper for this purpose and it works pretty well for me. Find out what suits you and make that a habit. Don't try to do everything but delegate tasks to the residents and follow up on them. 

Regarding procedures, when the ED is busy, do only those procedures in the ED that are required to be done right away and those that will make a difference. If there is no pressing indication for a central venous access, it is okay to give vasopressors through a peripheral IV for a few hours. CVC can be placed in the ICU. 

Always remember that ICUs can close their doors once they are fully occupied but it is hard for Emergency Departments to do that.

6) When you are on shift, you are on stage!

I learned this during The Teaching Course 2014 and this is how most of the medicine is learned. We learn by observing our mentors, we incorporate their qualities (good or bad) which are passed on to the next generation. A lot can judged about your mentor based on your behaviour. The way you speak, empathise, listen, express....everything. So it is like when you are on a shift, you are on the stage and residents are watching you, learning from your behaviour. Therefore, be at your best possible behaviour. 

Be ready to do even the seemingly easy tasks like starting a peripheral IV or starting a transfusion or passing a blanket/ a glass of water to the patient or passing a bed pan to a patient. Small efforts like this eventually get appreciated by nurses/housekeeping/patients and this would be useful in the long run. In addition, your residents will watch this and pick up these behaviours knowingly or unknowingly. 

7) Ask for help before care gets compromised

When things really go out of control, get into the “disaster” mode. Ask for dermatology in patient beds, speak to the medical superintendent and get them down in the ED. Do whatever you can to avoid any sort of compromises with the patient care. You can involve the patients, the stable ones who are occupying a bed, request them to occupy a chair. Many of them would be more than happy to do that. 

Things that actually matter the most to patients:

• Empathy/attitude (They don't judge you by the quality of medical care that you provide)
• Timeliness of care
• Technical competence of care providers
• Pain management
• Information dispensation 

Other things that you may try out:

• Physician at Triage: Expedites care and almost one third can be can be rapidly discharged
• Virtual wait rooms: Still in the conceptual stage. For non-urgent patient, paramedics contact the hospital to schedule a visit. The patient gets added to the ED queue without having to be there in person and could wait at home. As the scheduled time approaches, the patient comes to the ED.
• Have a dedicated transport staff
• Have a dedicated person to manage financial issues (major problem in India) and arranging in patient beds.
• Point of care testing

References:

1. Campbell SG, Sinclair DE. Strategies for managing a busy emergency department. CJEM. 2004 Jul;6(4):271-6

Understanding Diabetic Ketoacidosis

This episode talks about diabetic ketoacidosis.
Some key points on how insulin maintains normoglycemia before we end with a couple of clinical take home points.

Diabetic Ketoacidosis

Want to read more on DKA, then checkout:
http://rebelem.com/diabetic-ketoacidosis-dka-myths/
http://lifeinthefastlane.com/ebm-diabetic-ketoacidosis/
http://www.emdocs.net/myths-dka-management/

Is CE technique the best way to do BVM - May be not!!

We all are familiar with the CE technique that is used to deliver BMV. This is what we routinely learn during the ED/ Anesthesia/ critical care rotations and also at the life support courses. Is this the best way to deliver ventilation? May be not!

Another technique that can be used is the "The two thumbs down technique" or "The thumbs up technique" that has potential advantages over the standard CE technique.

You might get a weird look from those who are not familiar with this technique. Let people know what you are doing and why you are doing this OR just show them this video (by Rueben Strayer, emupdates).

                   

Take Home: BMV is always a 2 person procedure (regardless of technique used) - Skilled person holds the mask and anyone else can provide the breaths + Consider the 2 thumbs down technique for BMV instead of the CE clamp.

And Believe it or Not - Learning BMV is more important than mastering Laryngoscopy !!
DO check out this link (if you have not already) - emupdates

What Emergency Physicians Should Know About Informed Consent

Every patient with an intact mental capacity has the right to decide on treatment/procedures that he or she would like undergo. And as Emergency physicians, taking an "informed consent" is something that we do on everyday basis. This is another area where mishaps are likely in a chaotic ED. 

First take home point from this post would be to understand that "even if you perform a procedure that was necessary without any complications, you can still be held liable for not obtaining the consent." Therefore, it is vital to have a clear understanding about "informed consent" to avoid miscommunication and bad outcomes. 

So what does "informed consent" mean?
Informed consent is the process by which the treating health care provider discloses appropriate information to a competent patient so that the patient may make a voluntary choice to accept or refuse treatment (informed refusal). It originates from the legal and ethical right the patient has to direct what happens to their body and from the ethical duty of the physician to involve the patient in her health care. Informed consent may not be applicable only to procedures, but also to other significant management decisions.

Patient should get a clear understanding about the facts and the possible consequences before giving the consent. A good way to do that is, questioning yourself  "if you have disclosed the information clearly enough?" or ask yourself “Have I provided the patient with an understanding of what her or she would want to know?”

With an informed consent, we invite the patients to participate in the process of "shared decision making." Once again, stay away from medical jargon while explaining something to the patients. 

Elements of a full informed consent?

• Nature of the decision/procedure 
• Reasonable alternatives to the proposed intervention (regardless of there costs)
• The relevant risks, benefits, and uncertainties related to each alternative 
• Assessment of patient understanding 
• Acceptance of the intervention by the patient

Concept of Battery

Battery is legally defined as the intentional infliction of offensive or harmful bodily contact, regardless of whether the person was trying to harm or help. For instance, if a surgeon consented a patient for an operation on the right ear and while the patient was under anesthesia, he discovered the left ear was worse and operated on that ear with a poor outcome. The patient will get the damages not based on malpractice, but on lack of obtaining informed consent.

To prove lack of informed consent, patient must prove that:

• Physician failed to disclose adequate information regarding benefits and risks of proposed treatment, as well as alternative treatment options
• Patient need not prove negligence in the performance of the treatment; liability arises solely from inadequate disclosure (Physician is liable even if treatment was medically appropriate and performed skilfully right to damages arises from unauthorized contact)

What is informed refusal?

Informed refusal is when a patient refuses a recommended treatment/ procedure based upon his understanding of facts and implications of not following the treatment.

Waivers to informed consent:

• If the patient does not have decision-making capacity. Find the proxy, or surrogate decision-maker
• Implied consent in emergency
• When the patient has waived consent
• When a competent patient designates a trusted loved-one to make treatment decisions for him or her

For simple procedures like auscultation, drawing blood, physical examination etc. consent can be skipped (implied consent). We generally do not explain patients about risks, benefits and alternatives for auscultation!

How much information is enough?

There are three ways to look at it:

• Reasonable physician standard: What would a typical physician say about this intervention? This standard allows the physician to determine what information is appropriate to disclose. This standard is generally considered inconsistent as the focus is on the physician rather than on what the patient needs to know. 
• Reasonable patient standard: What would the average patient need to know in order to be an informed participant in the decision? This standard focuses on considering what a typical patient would need to know in order to understand the decision at hand. 
• Subjective standard: What would this particular patient need to know and understand in order to make an informed decision? This standard is the most challenging to incorporate into practice, since it requires tailoring information to each patient.

As a physician, you must disclose all of the information that the patient needs to make a decision, but not so much that it frightens the patient from making a decision that would be of most benefit to him or her. This can sometimes be difficult and this is where you can employ some amount of discretion. I personally go with the "subjective standard" and individualise information as per the needs of each and every the patient. 

Consent Forms:
It is fine to have consent forms signed by the patients before the procedure/major treatment (tPA for stroke), making sure that they are aware of the process and understand it. In the ED, patients are distressed and sometimes they just want things to move quickly. This can be one reason for signing the consent form without going through it in detail. The way these forms are designed is scary. For a minute, if you read it through the patients eyes, it can give you goose bumps for sure. 

This is what a typical consent form says:

I confirm the following:

My physician has explained to me the nature, purpose, and possible consequences of the procedure(s) as well as the risks involved, and the possible complications and/ or alternative methods of treatment. I understand that the explanation I have received is not exhaustive because of unforeseen circumstances that may arise and I have been advised that a more detailed and complete explanation of the preceding matter will be given to me if I so desire. Upon reading the previous statement, I do not desire such further explanations. Furthermore, I acknowledge that I have received no guarantees or assurances as to the results that may be obtained from the performance of this operation or procedure.

When we purchase something (a mobile phone), we all enquire about the warranty/guarantee periods but when a patient submits their body to a physician to carry out a procedure/treatment for their own benefit, there are no assurances because every human body is unique and may respond differently to same treatment. 

These "consent forms" carry little value in the court of law. However they do acknowledge that a discussion took place between the physician and the patient but it is hard to find out what exact bits of the consent form were actually discussed.

  

Risk Management Strategies:

When obtaining an informed consent:

• Have a meaningful, unhurried conversation with patient. 
• Make the patient an active participant in the shared decision-making process.
• Provide supplementary information, such as brochures or videos.
• Disclose the most severe risks and the most common risks.
• Don't forget to mention about the alternatives.
• Obtain signed informed consent form.
• Avoid giving casual answers e.g This surgery is as risky as any other major surgery or I have done dozens of such surgeries. Be a little sensitive.
• Be professional.
• Avoid quoting exact numbers or percentages.
• Most important: Never ask a colleague or junior physician to obtain an informed consent on your behalf. This leads to confusion, chaos and miscommunication. Person doing the procedure (Yes, even the the senior physicians) must take the consent. It is important to make sure that the patient and family have the capacity, are clear on the facts and have their concerns addressed by an experienced physician before getting to YES,.

Informed consent requires disclosure, understanding, capacity and voluntariness. It is not just another signed document. Patients must have an intelligent understanding of their diagnosis, risks/benefits of proposed treatment and alternative options.

References:

1. Appelbaum PS. Assessment of patient’s competence to consent to treatment. New England Journal of Medicine. 2007; 357: 1834-1840. 
2. Moore, Gregory P., et al. "What Emergency Physicians Should Know About Informed Consent: Legal Scenarios, Cases, and Caveats." Academic Emergency Medicine 21.8 (2014): 922-927.