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I have completed bits of my EM training from India. Currently I am boarded with credentials from Christian Medical College, Vellore and also from the prestigious Royal College of Emergency Medicine, UK.  I am currently working in London as an A&E doctor, trying to appreciate the differences in the practise and culture of Emergency Medicine across different healthcare systems. I have always been an avid FOAMed supporter because FOAMed played an indispensable role during the days of my initial training. Through this blog, I aspire to disseminate knowledge and stay up to date with the EM literature. 

Monday, December 28, 2015

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

4 comments:

  1. Great going Dr Lakshay, keep it up

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  2. Very nice article. One question I have is that how do we manage the so called VIP patents who are stable but come to in ED' especially in India ?

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  3. Thanks for reading. This is kind of a tough question. Let me try to answer this.

    1) First thing, make sure that they are actually stable and do not have an atypical presentation. This is a bad place get fooled with the prejudice that they are stable. Nobody is going to take excuses if you screw up here.
    2) As always, be nice.
    3) Be direct: If you think they do not need any sort of emergency care, convey this to them politely with reasoning and briefly explain how things work in the ED (they might not be aware of this). They are usually busy people and trust me they also don't want to be in the ED. What I have seen is, regardless of bed status in the hospital, they get a bed within 30 minutes. You can also tell them why do you think ED is not good place for them (things like overcrowding, sickest will be treated first in the ED, possible delay in care of relatively stable patients).

    Some might refuse to give history unless you call the plastic surgeon or the cardiologist. Explain them in a sentence why history taking is important and why you are asking these questions. Many would agree after that.
    Some would like to examined only by their physician.. thats fine..just let the physician know that Mr. XYZ is here..but again make sure you are not missing anything life threatening.

    This is just based on my limited experience in EM. Do you have any other thoughts on this?

    Thanks once again!
    Lakshay

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