Tips for Rock Star Emergency Department Efficiency and Workplace Wellness
Author: Holly Caretta-Weyer, MD (Oregon Health & Science University)
Every resident wants to be the one who, when they walk into the Emergency Department for their shift, everyone says “I am so glad to see you tonight!”. However, there is no real guidebook on how to be that resident. When you ask different stakeholders in the ED what it is that makes those residents rock stars, you get varied responses; however, two things that come up over and over again is how efficient they are and how they manage to keep cool and upbeat throughout the entire shift. So how do you become that resident?
Clear the Deck
Before your shift, make sure that you clear your head of all the outside noise as best you can. Take some time before your shift, even if it’s just five minutes, and mentally prepare for the next 8-12 hours. This may mean meditating, working out, or painting. Find something that helps you focus on the work at hand when you walk in the door.
Set the Tone
Choose your ‘tude, as my mother used to say. This means choosing to be upbeat and positive no matter what rolls through the door. If you are happy to be in the ED and promote teamwork, everyone else will follow suit.
Orient Yourself to Dispositions
This is one of the key ingredients to on-shift efficiency. Make it a goal to have an idea of where the patient is headed or what the decision point will be for their disposition when you walk out of their room. From there, run your list often. For me, this means every time I am in front of the computer. Identify the rate-limiting steps for each patient and any hold-ups in the workup to keep things moving. Once you become the rate-limiting step, do what needs to be done without delaying the patient’s disposition.
And delegate! Emergency Medicine is a team sport – if your attending is up for it, ask them to do some of the scut work such as discharges or calling consults.
Control What You Can Control
Control your personal patient volume. Here is where you say “Yeah right! Have you seen my ED?” I’ll qualify this statement – control the patients you have in front of you. Clearly you can’t bar the door to the ED; however, you can triage the patients and tasks that you have in front of you. For example, if a bunch of patients get roomed, you can mentally triage them to one of three options. First, you can lay eyes on them and determine if they need immediate intervention. Second, you can put in some orders from afar to get their workup rolling. Third, you can go see and disposition them in one go. This way, you use your time most efficiently. Additionally, the ED is a revolving door – in order to get patients in, you have to get patients out. Dispositions will naturally free you up to see more volume.
Touch It Once
Just like email, treat every task in the ED like you want to get to “Inbox Zero.” If you are reading an EKG, finishing a chart, calling a consult, or putting in orders, do whatever you can to complete it ideally in one go. You will get interrupted – it’s how you deal with those interruptions that makes a difference! You can avoid the “I forgot to do/order/complete that” phenomenon by coming back and finishing what you were doing when you were interrupted so that there are no incomplete workups when you are ready to disposition the patient.
Don’t forget that multitasking is a myth! Instead, we practice task switching, which involves addressing interruptions, switching back to what you were doing, closing the loop, and then moving on to the next thing.
Identify Flow Bottlenecks
As you move further along in your training, try to see and own the big picture. Early on, you focus on just your own patients, but when you are out in practice, it is your job to monitor the flow of the entire department. There are ways you can start to work on this now as a resident. Start by running the list with your charge nurse early and often. They will often be able to identify and remedy logjams that you didn’t even know existed. Charge nurses are your strongest ally. Additionally, have an idea of who can move into the hallway or be dispositioned quickly if something catastrophic like a mass casualty incident should occur. Identifying bottlenecks and potential solutions on a daily basis will help your overall flow in the long run.
Hit the Rest Button
At some point during your shift, you will hit a wall. Nothing will get done while you have no energy, are hangry, or need to use the bathroom. Intubating a level 1 trauma while doing the pee dance can be somewhat perilous (for both parties). Take five minutes to get a snack, use the bathroom, breathe deeply, or refill your coffee supply. Taking good care of yourself will improve your efficiency and make you better able to care for your patients in the long run.
Recharge Your Batteries
At the end of each shift, accept your limits and forgive yourself for not being perfect. Give yourself some time to process unexpected or difficult situations or patients at the end of each day. The physiological consequences of a stressful clinical encounter are significant and can last for days – you need to process it before you can move forward. Find someone you can talk to – a friend, spouse, or colleague – to reflect, decompress, and celebrate small wins. After that, do something you love to take care of yourself. For me, it’s working out or going for a long walk or hike. Make sure you love yourself so that you can keep coming back and giving 110% on each subsequent shift.