The Emergency Department is a fast-paced setting – solid clinical knowledge, common-sense and the ability to think quickly is important. Here are some tips:
Key points
- Simultaneous processes are better than sequential
- Think ahead
- Focus on getting information that specifically contributes to making a decision
- Give early treatment that makes the patient get better or feel better
- Address delays to assessment or management promptly
What to do as soon you as you have finished assessing the patient
- Leave final documentation until all your tasks are completed
- Send off all the right labs from the beginning (get advice from senior if in doubt)
- If the specimen is suspect e.g. haemolysed don’t bother sending it hoping it will be OK and having to repeat it later
- Request all the useful imaging studies from the beginning
- Chart IV opiates, analgesia, rapid IV fluid hydration, antibiotics, anti-emetics, bronchodilators and ensure they are given early and adequately
- Ensure nurses are aware of the end point you are trying to achieve and in what time frame e.g. comfortable, able to mobilise without pain or dizziness, tolerating fluids within 90 minutes, less work of breathing etc, blood pressure better, making urine
- Don’t continue supplemental oxygen if it is unnecessary
- Everything works faster in office hours (e.g. labs, imaging, ward consults). Request them long before the close of the day
How to train your thinking
- Consider ahead of time what specific criteria will satisfy you that the patient requires admission or is safe to discharge
- Immediately after seeing the patient consider whether they are a likely admission, likely discharge or equivocal pending results or progress
- Anticipate different possibilities that may alter the initial trajectory you are hoping for and how you will deal with it. Don’t be paralysed into inaction when new developments occur. e.g. patient not responding to treatment, tests return negative
- Be prepared to make treatment more aggressive, amend your investigative strategy
How to multi-task
- After all tests requested and treatment commenced, begin assessing the next patient. Don’t hover around the previous patient, tell the nurses what to look out for and when to call you
- By the time you have completed the same sequence with the previous patient, then go back and review all test results and clinical reassess the progress of your patient. Determine if admission or discharge criteria are met. Let seniors know immediately if something unexpected has occurred.
How to prevent unnecessary delays
Inform a senior immediately if:
- unable to obtain blood/IV access < 10 minutes
- lab results > 60 minutes
- x-ray results > 30 minutes
- inability to obtain consult or imaging request
- lack of co-operation from staff or patients
- any disputes
Anticipate issues / Early discharge planning
e.g.
- Early analgesia before x-ray so that plaster splinting is painless when the fracture is diagnosed
- Pre-write the discharge letter if the patient is likely to be discharged assuming the patient will have negative test results and responds well to treatment
- Pre-write the sick certificate and work-cover certificate
- Pre-write OPD referrals e.g. fracture clinic
- Send off script discharge meds before all results are back
- Consider +/- book the means of transport before treatment as been completed
- Engage allied health assessment early so that plans are well in place e.g. social work, physiotherapy, mental health
- Get elderly patients home before midnight
Biggest time-wasters
- Re-writing your notes
- Documenting before requesting investigations / commencing treatment
- Not initiating appropriate treatment early or not monitoring if it needs to be escalated
- Lacking a clear plan of attack from assessment to potential disposition
- Not regularly checking if test results are back
- Not anticipating the next decision if test results will be negative or consults are unhelpful. Not considering multiple contingencies
- Not having your notes and nursing chart in front of you when presenting/referring patients
Recommended time frames
In order of priority (you can skip steps)
- 10 min – Review results of tests of previous patient and review clinical progress. Quickly move forward to finalise…..
- 5 min – Any further treatment not yet initiated or charted
- 5 min – Referral/Disposition + Referral/Discharge planning/Admission Paperwork
- Start assessment on NEW PATIENT
- 5 min – Chart meaningful treatments immediately e.g. resuscitation, rehydration, pain relief, anti-emesis and communicate clear targeted end-point to nurses e.g until vitals normal, passing urine, mobilising, tolerating fluid
- 15-35min – Perform targeted clinical assessment
- 5 min – Generate likely and important DDx
- 5 min – Chart definitive treatment e.g antibiotics, anticoagulation
- 10 min – Initiate targeted investigation (consider contingency plan NOW if investigations were to be normal or equivocal, what threshold would you accept to discontinue further investigation)
- 10 min – DOCUMENT / Discharge paperwork / Scripts
- GO BACK TO STEP 1
Time from first assessment to disposition generally can be achieved in < 120 minutes unless there are excessive waits for CT imaging
Seek Senior Assistance Immediately if you cannot progress these steps rapidly