86. Mastering Workflow and Overwhelm

Specific strategies to improve workflow and manage overwhelm during an emergency department shift.

Guest Bio: Landon Mueller, MD is an emergency physician and fellowship trained sports medicine specialist who gave the best talk I’ve ever seen on managing workflow in the emergency department. Now

 

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We Discuss: 

There are 3 phases of an ED visit:  assessment by the clinician, interventions/work-up, and disposition.  Of these, “Dispo is king”.

• Assessment and work-up are by far the most resource-intensive phases. Disposition is the least.
• From a departmental standpoint, when you disposition a patient you are freeing up resources. You are clearing up the physical space (emptying a bed, etc) and also the mental space (making a diagnosis, charting, putting in orders, etc).
• Despite recognizing this, when feeling task-saturated it is common for clinicians to want to delay a discharge in order to prevent the influx of more patients.  
• We have to remember that “dispo is king” is taking into account the entire department, not just one patient. So often the best thing for the totality of department flow is to delay the actual discharge of one patient in order to complete tasks on other patients that will move their dispo forward.

There always seems to be an abundance of things that need to get done during an ED shift. What is the hierarchy of tasks? 

• Think of the hierarchy as if it were a food pyramid, with the most important tasks on the bottom.
  • 1st layer:  stabilizing and managing critical patients 
  • 2nd layer:  patient deposition (this includes finishing your chart so you can close the loop on that encounter, freeing up mental space to focus on new patients)
  • 3rd layer:  assess new patients (and get their workup going)
  • 4th layer:  rate-limiting steps (ie. complete procedures)
• Tips for checking lab/x-ray results:
  • Landon checks labs piecemeal as they come back, doing this when he’s sitting at the computer completing other tasks.
  • If he’s going to be discharging a patient, he waits until everything is back before checking labs.
• Prioritize tasks so they move the patient towards disposition.

What is the best strategy for blocking out time to free yourself up when your body or skill is the rate-limiting step?

• Batch your tasks together.
• Communicate your rate-limiting steps with the other parties involved. For example, if your patient needs a pelvic exam, ask the nurse to get the patient ready and schedule the time that you’ll meet him/her in the room to do it.

One of the master skills of an emergency clinician is being adept at parallel processing.  What advice is there to help those who prefer linear processing to not only become an effective parallel processor, but also to thrive in that situation?

• Both linear and parallel processing skills are critical in the ED environment.
  • Resuscitations and individual patient encounters are linear processes.
  • Parallel processing comes into play when you are managing multiple patients who are in different phases of their ED encounter (ie. assessment, workup, disposition), and you have to seamlessly transition between those different phases.
• The literature shows that we best improve at seeing multiple patients simultaneously during our intern year of training.  
• You get better at parallel processing by 1) doing it and 2) working on ancillary skills such as having a hierarchy of tasks and identifying/communicating rate-limiting steps.

Swarming is an efficiency multiplier and should be prioritized in the hierarchy of tasks.

• Swarming is parallel processing for the individual patient. 
• It involves getting all parties at the bedside to discuss the patient at once. Examples are being present when EMS delivers a patient to hear their report. Or having the trauma team, EM team, nurses and EMS all at the bedside on patient arrival. 
• While it might not be feasible to “swarm” for every patient, we should try to make it a priority.

ED clinicians are often praised for being great at multitasking. But what we’re really doing is task-switching.

• Multitasking by definition means you’re doing 2 (or more) discrete tasks at the same time.
• Task-switching refers to the quick switch of attention from one task to another. These interruptions are ubiquitous in the emergency department and disrupt workflow.
• What techniques can we use to mitigate the negative effects of task-switching?
  • The literature shows that we get interrupted 7-19 times per hour, or on average every 6 minutes. And after interruption, we don’t go back to the original task 62% of the time.
  • Task-switching is part of the ED job and it’s not going to change. 
  • What we can do is to defer our interruptions more than we do.
    • One study found that we only defer interruptions 3% of the time.
    • Unless we’re being interrupted for a critical action, when possible we should finish our primary task before shifting our focus to a secondary one. This way we can give both tasks our full attention.

Batching tasks is a critical skill to managing multiple tasks.

• Batching tasks that you do at your computer and taking care of as many of those tasks as you can while you’re there (ie. charting, entering orders, calling consultants).
• Also batch patient care tasks which you do away from your computer (ie. assessing new patients, giving verbal discharge instructions, doing procedures).
• The goal is to limit the number of transitions between your computer and patient care tasks. This makes you more efficient and saves energy.

Strategies for keeping organized and efficient:  the “external hard drive” and “running the board”.

• Having a strategy to keep track of your tasks can keep you organized. Landon calls it his external hard drive.
  • Whether you use sheets of paper, a notebook, the tracking board, or your scribe, having a place to document what needs to get done with checkboxes after completion can be helpful.
• It’s also beneficial to “run the board”.
  • This is a quick review of what needs to happen for each patient, where they are in their course, and making a disposition plan. Landon does this every time he returns to his computer (approximately every 20 minutes).
  • When you run the board, you’re putting together your hierarchy — the framework which helps you decipher what is the most efficient thing to do to find dispositions for your patients.
  • A 2018 study found that physicians who ran the board were overall more efficient and saw more patients per hour.