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You think you’re seeing as many patients as you possibly can. But maybe there are subtle (and not so subtle) ways you can boost productivity.

directos-squareDear Director,

My chairman tells me I need to see more patients. I’ve been doing this for a long time, and, believe me, I really am working as fast as I can. Now, I’m being told that if I don’t speed up, I could lose my job. Are there any tricks to being faster?

-Not Ready for Pasture

Productivity is a complicated but important issue when it comes to our departmental and your individual success. Ultimately, seeing patients is what drives revenue. Bottom line, in a world of decreasing reimbursements and potentially new payment models, seeing more patients remains one of the driving forces for maintaining our income. In the past, I’ve written about the responsibility that the medical director has to make sure we have an operationally efficient ED, which involves appropriate staffing models, including physicians, MLPs, nurses, techs, and scribes.

Providers always have a couple of docs they dread working with. The difference in monthly productivity metrics between “these slower docs” and average providers is usually just a couple of patients a shift. The perception of our colleagues and nurses between fast and slow usually comes down to how you attack the rack in the beginning of a shift or get through a high-volume surge. There are several techniques you can use to not only increase your productivity and efficiency, but also to ensure that you’re one of the docs people like working with because you can crunch through busy times.

Productivity also can be defined by RVUs/hour. RVUs correlate to billing, are ultimately how we get paid and result from a combination of documentation and medical decision making. I’ve written about this metric in the past as well. For the purposes of this discussion, let’s assume your documentation is fine and you’re seeing your groups “average” mix of patients, so we can focus on literally picking up charts and seeing individual patients.

Understand that your goal is a numbers game

Make sure you understand your productivity goal. To average two patients/hour (pts/hr) means that in your typical 10 hour shift, some days you’ll need to see 21-24 patients instead of your goal of 20. This is to balance the inevitable day when you see 16. If your volume fluctuates from day to day, you may average anywhere between 1.4 and 2.6 pts/hr per shift. In other words, make sure you have an extra gear to speed up and see more patients on the busy days when the patients are available.

At two pts/hr, each patient gets about 30 minutes of time (this includes all of the care, documentation, and phone calls you make on the patients behalf but also every minute you spend going to the bathroom, washing your hands, or taking a break to check email). Patients should get either one or three MD encounters. If only one is necessary, take the extra few minutes to tie everything up. Decide in the room if the patient really needs a test or can you make the dispo?

This subset of patients may include those presenting with back pain, URI symptoms, and ankle or other joint sprains. Patients are usually happier with extra physician time (remember each patient gets 30 minutes that gets spread out over their 2-3 hour length of stay) than a quick evaluation and an x-ray. For patients requiring three encounters, these usually break up into the initial H and P, a status update, and a wrap up.

Pace yourself

To stay on track throughout the shift, it helps to understand how productivity changes throughout the shift. For starters, show up on time and ready to work. The team bus for an NFL game doesn’t arrive a minute before kick off and neither should you. Arriving 5-10 minutes early will let you get your white coat on, signed on to the computer and get the lay of the land so you can prioritize what patients to see. High productivity providers usually see well over half of their patients in the first few hours of their shift. There are usually plenty of patients to see since the person you’re relieving has probably slowed down and you’re fresh, energetic and not distracted by having to review lab data or do reevaluations.

Although it sounds obvious, the first secret to seeing more patients is to pick up the chart, or click on the patient’s name in the EMR, and get into the room. You also need to keep track of your patients. I’ve worked with several docs who told me how busy they were but never had any idea of how many patients they saw in a shift. It was only after keeping a patient list did they realize they weren’t nearly as productive as they had thought.

In your first hour of your shift, you should be able to see 4-6 patients. This allows for 10-15 minutes per patient, more than enough to fully evaluate them and write orders. Your second hour should result in 3-4 more patients. Once you’ve hit 7-10 patients that quickly, take a breath, congratulate yourself since you’re well on pace to hit your daily target, have another sip of coffee, and refocus because now it’s time to go back, review data, and update patients (step 2 of the 3 visit model).

For the next couple of hours, you’ll want to try to average about 2 pts/hr. Since all of those patients from your first two hours should be ready to dispo between hours 2 and 4, by midway through your shift, your board could be looking empty so try to re-bolus with 3-5 patients in the middle hour of your shift. This also should leave plenty of time to dispo them all before the end of your shift, thus making a clean sign out. During the second half of your shift, try to stick to 2 pts/hr until the last hour or two when if coverage and volume allow, you can see 1-2/hr and spend time doing patient wrap ups. As a rule of thumb, in the second half of your shift, pick up at least 1 new patient for every 1-2 dispositions your make.

You should be actively reviewing your patient list on your tracking board every 20 minutes or so and expect to keep at least 7 patients at all times. As an EP, you may need to flex to 10-12 active patients but most people lose efficiency if they manage this many for too long or individually manage more patients than that. Don’t lose sight that your board affects everyone else in the ED. Sometimes it is easier and faster to pick up a patient or two before making the dispo on patients that are ready to go. However if rooms are backed up and there are a number in the waiting room trying to get back, it is important to recognize that sometimes it’s faster to free up a room and get another patient back.

The Basics

Unless you’re the only doc there, you should only be laying claim to 1, or 2 patients if the second is fast, at a time. More than that irritates the nurses since they don’t know when you’ll get into the room and this may prevent your colleagues from providing care to a patient sooner than you would. If you have two patients to see, go directly from room to room, rather than back to your work station to document or order. If you need to get through more than four, consider thin slicing—a brief, couple minute encounter to assess the patient and decide on orders and then go back and do a secondary survey after you’ve gotten through your first set of patients.

When you get into the patient’s room, make sure you keep the patient on point. From a patient sat point of view, it’s important to let patients talk without interruption in the beginning, but sometimes you need to redirect them and for patients who don’t focus on the emergency complaint, consider a phrase such as “Sounds like you have a lot going on, but what is most important to you today?” Who knows, maybe they just want a work note? After the H and P, decide on the plan and spell this out for the patient. This sets the expectations, avoids them thinking the ER has an a la carte menu they can request something off in the middle of their visit, and from there, you can typically anticipate the disposition and decide what the key results you will need back to help you make the dispo and maybe even call for an admission without all the data back.

Length of Stay

Decreasing length of stay may be the secret sauce to optimizing ED efficiency. There are numerous drivers that impact LOS. Front loading your tests, rather than ordering sequentially, and certainly not ordering an excessive amount of testing is a good starting point to reduce LOS. To keep your length of stay on track, have clear end points in mind about when you’ll make the disposition. For example, how much IV fluids and Zofran before reassessment for a gastroenteritis patient and how quickly will you re-dose pain patients such as those with kidney stones, migraines, or sickle cell. Ignoring the data you have isn’t going to make the disposition any easier so act on your key values. Interruptions are the bane of productivity and the greater your patient load, the more likely you (and the nurses) will be interrupted from the task at hand for a patient related issue or concern. A discharged patient typically doesn’t result in your being interrupted, so that’s another reason to focus on reducing LOS.

Conclusion

Productivity goals are here to stay and it’s likely the bar will continue to be raised. By understanding your goals, keeping track of your patients and knowing where you are patient wise as the shift progresses will help you achieve your goals. Focusing on length of stay will also free up time so that you can spend that on new patient care.

Michael Silverman, MD, is a partner at Emergency Medicine Associates and is chairman of emergency medicine at the Virginia Hospital Center.

 

 

6 Tips for increasing emergency department productivity

1 - Plan ahead on diagnostics. If you’re thinking you may need a CT, write an order to start PO contrast (if needed).  Then you’re not waiting for them to drink.

2 - Get urine specimens right away. If you need a urine from the patient, tell them when you’re in the room and emphasize that’s usually the test that takes the longest.  Suggest they go urinate now before they get hooked up to IV, etc.

3 - Do tasks in logical order. Think about how long things take and how best things work chronologically.  For example, you have a patient that needs x-rays, blood work, and breathing treatments, let the nurse know you want the blood drawn before the patient leaves the department for x-ray and then breathing treatments after that.

4 - Utilize staffing resources. On a busy shift if you need something to dispo someone, ask their nurse or a tech and tell them why.  “Can you do orthostatics?  As soon as they’re done, I can send them home.“

5 - Inform your scribe and RN. Notify them of the rate limiting test – test upon which disposition is dependent 

6 - Know your decision rules. Use evidence-based medicine to safely eliminate unnecessary testing, reduce radiation exposure and improve throughput.

  • Ottawa knee/ankle/foot
  • Nexus C/Spine
  • Canadian Head CT rules
  • PECARN pediatric head trauma
  • Modified Centor Criteria for strep throat
  • Wells Criteria and PERC Rule for PE
  • Wells Criteria for DVT
 

Comments   

# D.O.Bruce Maulbetsch 2014-04-25 13:50
This is all well and good. Excellent advice. I'm sure that this works quite well in the "perfect ER". Most ED's do not have scribes. Most suffer from "nurseopenia"an d "techopenia", not to mention "provideropenia ". The understaffing of many ED's I've worked in creates an almost constant stream of the interruptions that you refer to, since you are the only one to come to. And as far as LOS, what's to be done when the lone swamped hospitalist that one needs to speak to for an admission does not answer his 4th page after 2 hours? Or when the Locums intensivist covering the ICU calls and asks you to go "do him a favor" and go over to the unit and drop a line because he doesn't want to get out of his motel bed 2 miles away? Pretty words, but unrealistic, if you ask me.
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# MDPamela Bensen, MD 2014-04-28 23:35
I cannot help but wonder:
1. Has this author ever done single coverage in a rural ED?
2. Has this author ever had a good rating from the patient?
3. Has this author ever been an ED patient?
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