110. A Strategy For Mid-Shift Overwhelm. This coaching session helped one doctor conquer the deluge and get home on time

In this real-life coaching session, we walk Dr. Brit Long through building a framework to help navigate being overwhelmed during the middle part of an emergency department shift. Since this session, he has become more efficient, gotten home earlier on a consistent basis, lowered his stress level, felt less burnout, and experienced more joy in his career. 

In this episode, we discuss:

• The fundamental differences between the beginning, midpoint, and end of the shift
• Why mid-shift is so fraught
• What we usually do when feeling overwhelmed
• Why willpower will almost always fail as a sole strategy for keeping up with documentation
• The specific steps for navigating mid-shift overwhelm
• Early detection of overwhelm
• A mid-shift action plan
• How to keep up with documentation
• The real reason timely documentation is important
• Breaking through your comfort zone
• Brit’s plan for triaging tasks 
• Why deferring charts is so seductive and a slippery slope

Guest Bio

Brit Long is an assistant professor of emergency medicine in San Antonio, Texa, and Editor-in-Chief of Clinical Content at emcdocs.net. He is one of the most published authors in the field of emergency medicine. In addition to that, he is a father of two and works in both academic and community settings.

The Article

Mid-shift in an emergency department is a special beast. It’s the point of maximum to-do’s and the highest likelihood of task saturation. This is also where keeping up with documentation starts to slip. Falling behind isn’t a character flaw, it’s the perfect combination of too much on the plate meeting depletion of energy, willpower, and intention. 

What’s the usual answer to this? Heads down and muscle through! But forward momentum by brute force of will is not a long-term strategy for thriving in a career. Eventually, that brute force tank will be empty.

It’s not like you don’t know it’s coming. More often than not, you will have a lot on your plate in the middle innings of a workday. Here’s the 35,000-foot view of what an average day in the ED looks like:

• Beginning of the shift: You’re fresh as a daisy and your only job is patient intake
• Middle of the shift: Energy is starting to wane and you have a combination of patient intake, results interpretation, consultant calls, procedures, disposition, interruptions, and a fleeting dream that it would be so nice to complete a few charts. 
• End of the shift: You’re tired, but your only job is clean up and dispo

One of the reasons mid-shift is so fraught is that there’s too much to do and it’s easy to expend a lot of energy yet feel like you’re not making progress. Having a consistent workable strategy for mid-shift will pay dividends for your entire career. The keys to thriving during this period of a shift are twofold: identifying when it happens and then breaking it down into small, actionable steps. What often happens is a checklist of all the to-do’s. This is great! Even better is having a consistent hierarchy to triage what’s on your plate. 

Let’s get to it.

Step 1: Notice the change

Just like you’ve got to enter the right patient into a decision rule, you’ve got to identify when you’ve reached the point of mid-shift overwhelm. 

I can’t tell you what it feels like, only you know it. But you know it. 

Exercise to get familiar with the feeling: Recall a shift where you experienced overwhelm. What were your thoughts, emotions, and physical sensations? It usually begins with a subtle deviation from your usual state and by the time you notice it, you’re overloaded and spinning your wheels. Can you pick out the first moments when it happens?  Give this moment or feeling a name. Brit Long, calls it “The Kraken” and what comes next is Releasing the Kraken!

Step 2: Begin your mid-shift action plan

The time to get organized isn’t when the Kraken is a raging beast. It’s when you sense it first start to stir. When this happens, it’s time to organize and prioritize. The details of what this looks like will be different for everyone, but there are common elements regardless of who you are or where you work.

You’ll need to put the following tasks in a rank order list: new patient evaluations, dispositions, managing critical or potentially critical patients, results review, team huddle, running the board, calling consults, doing procedures, and documentation. Oh yes, documentation. Did you think that would get swept under the rug when the Kraken is released? No way! It’s easy to keep up on charts during the beginning of your shift, but hard when you’re busy. 

Key point: Timely documentation is a procedure you do for YOU. Keeping up on your charts will help you get out on time and also avoid the pit of despair of looking at a virtual stack of 20 charts at the end of your shift.

Here is an example of an order of operations for mid-shift overwhelm.. 

• Priority 1: Stabilize and manage critical (or potentially critical) patients. This must always be the first priority. The sequence of the rest is where you experiment. 
• Priority 2:  Assess new patients (and get their workup going, put in the orders. If no new patients, move to the next priority. The number of new patients you assess here is going to be impacted by their complexity and how much time it takes. You can set a limit on how many patients or how much time you allot to this before moving on to priority 3.
  • Critical action: Complete an H and P on each patient after the initial encounter. 
• Priority 3: Batch results review to see what’s back and identify actionable items and who can be dispositioned. Place consultant calls but not so many that you’ll be overwhelmed
  • Critical action: Run the board and huddle with the team (or charge nurse) to delegate tasks. 
• Priority 4:  Disposition of patients (admit, discharge, start transfer). They say that dispo is king and you may want to put this elsewhere in your order of operations. Our clients generally focus on 2 to 3 patients during this step.
  • Critical action: Finish your chart upon dispositioning a patient. It will free up mental space, allow you to double-check that you haven’t forgotten something (did you really do a complete neuro exam?), and close the loop on that encounter.  Beware, you’re going to feel pressure to do other things besides complete a chart. 
• Priority 5:  Rate-limiting steps (ie. complete procedures).

Repeatedly re-triage tasks until the Kraken has quieted. That might not happen til the end of the shift and there might be several Krakens in one day.

Variations and caveats: 

• Disposition of patients before seeing new patients. The adage of ‘dispo is king’ may hold sway on your list! Brit’s protocol prioritizes patient intake before disposition, but many docs do just the opposite – after managing critical patients, they review results, run the board, and identify dispos. 
• Where you put procedures. Brit has his rate-limiting steps as the last priority but, if dispo is truly king, then procedures might go somewhere near dispositions because when you finish sewing that lac, alas, the patient is now a discharge candidate. 
• Thin-slicing on newly roomed patients. A quick hello or even ordering from the computer to get things rolling while you attend to other tasks.
• Number of consultant calls put out at once
• How often you reset the list and start back at the beginning
• What to do when a critical patient arrives by EMS. You might be in the room for half an hour or more, now you’ve got even more tasks than you had before going in there. How do you re-enter your sequence? Some will restart at the top, others where they left off, maybe it’s going to the intake step, the dispo step, 
• What to do when you are not in ‘patient intake mode’ and EMS arrives with a new non-critical patient. We know that getting an EMS report in real time is important but it may take you out of your flow. Do you prioritize this or let it slide mid-shift? Do you listen in on the report to get the snapshot and then come back for a full eval later? Maybe this is a top priority for you and you complete the new patient eval on every EMS arrival. It’s up to you.

Break through the pain

Documenting in real-time when the ED is busy is hard to do. For many, the comfort zone is to defer charting til you’re not busy. There’s always later, right? For one chart, that’s OK, but they add up quickly. Something to pay attention to is your inner dialogue when it’s time to close the loom of each patient’s EMR in your workflow. What are you doing instead of charting? What are you telling yourself is more important?

There may very well be a critical task that needs your attention, but many things we think of as critical can wait a moment or two while you complete your note.

Proviso: Documenting an H&P, and especially an MDM, in real time requires you to have a robust template library. If you’re reliant on free texting, this will not work. Here are some of my favorite templates that saved me hundreds of hours.

It may be painful to complete those charts. The comfort zone is to not do it and put the burden on your future self. The pain of doing it right now, however, will set you free.

Credit Phil Stutz “The Tools”