Waiting to Be Seen: Where EM Policy Meets Practice is a new EM Cases blog series, authored by Dr. Howard Ovens, a veteran Emergency Department Director, whose main purpose is to share ideas and generate discussion on the role that public policy and administrative practices play in creating the conditions that help front line emergency providers achieve better patient outcomes.
Last month in introducing part one of our guest blog on quality assurance I told a story about a missed opportunity with follow-up care. This month I’d like to share a story with a happier ending. Recently, a patient presented at our emergency department (ED) with a non-specific fever. After discharge the patient’s blood cultures were reported positive, but attempts to reach this person over the ensuing 36 hours at the contact numbers provided were unsuccessful. An enterprising colleague googled the patient and found contact information online that eventually led to a call to the patient in a hotel room in another city, but when reached the patient was ill and confused...
This is Waiting to Be Seen 9 on EM Cases - Improving Follow up From the ED, Quality Assurance Part 1. We all face the challenge of how to manage final reports that arrive after the patient has been admitted or discharged, but some EDs are more organized and diligent than others in systematically addressing their obligations in this area. In this two-part guest blog, Dr. Lucas Chartier, an emergency physician in Toronto, will discuss best practices in departmental organization in part one and the obligations of the individual physician in part two. No ED will ever be perfect, but there are some positive lessons to share and we likely all can do better in reducing risks related to test result follow-up.
Succeeding with the dirty task of hand hygiene promotion How many psychiatrists does it take to change a light bulb? The punch line to that old joke is, of course, “One—but the light bulb has to want to change.” But just as it’s tough to get patients to modify their behaviour (quit bad habits, take up good ones, comply with their meds, etc.), it’s also difficult for ED leaders to get their staff to alter their practices for the better. One example I find many EDs struggle with is improving hand hygiene. Despite what research has shown, some staff may believe they wash their hands plenty, thank you very much. Others may accept the evidence but struggle to remember to comply with hand hygiene guidelines, or competing priorities in a busy shift may get in the way of even the best of intentions. Access to a sink or supplies may be a problem when we provide care in hallways or waiting rooms; on the other hand, we may encounter patients stealing and drinking unsecured hand sanitizer. (Practice tip: If a patient becomes more intoxicated or less responsive after arrival in the ED, they may have consumed sanitizer.) In this month’s guest post, Dr. Mike Wansbrough, a colleague of mine at Mount Sinai Hospital in Toronto, Ontario, talks about his journey as our department’s “hand hygiene champion” (which means I was smart enough to delegate this thankless task to someone else—thanks, Mike!). Mike is a creative guy, so when he faced frustrations in trying to change the “light bulbs” that are my medical staff, he thought an online movie in this era of YouTube sensations might help. A link to the short film is provided below; the content has been researched and vetted by infection control experts and is only four minutes long. You are welcome to use it if it helps with your own hand hygiene efforts. I plan to make it mandatory viewing for our staff. Do you have other tips, suggestions, or resources on this issue to share? Please share them in our comments section so we can all learn from each other!
Triage as a system of managing patient flow in the emergency department seems to be under attack. For instance, Dr. Shawn Whatley, a colleague of mine in Ontario, recently published the book No More Lethal Waits, which criticizes the current approach to triage and has received a fair bit of media attention. The first step Dr. Whatley proposes to improve ED access is to “revamp triage” and “close the waiting room.” Also, in 2015, Dr. Rick Bukata, a well-known American emergency physician and educator, wrote an article titled: “Has triage become an intrusive waste of time?” Dr. Bukata’s question was rhetorical; his answer was a firm “yes.” Are these ED physicians right? Is triage obsolete? I will explore the parts I think they have right and where they and others go wrong in this blog.
A New York Times article titled “How Measurement Fails Doctors and Teachers” went viral on social media in January and caused a lot of chatter in medical circles. Its author, a professor of medicine at the University of California, gave voice to a wide sense of frustration, and while I understand that feeling and think it’s justified, I don’t agree with labelling measurement as the culprit. As I expressed in my first WTBS blog post, “Why Recording Time to Initial Assessment is Worthwhile,” I believe my job as an administrator is to make the job of my staff easier, and measurements can help us maintain standards of care and understand where gaps in the system may exist—when such data are collected and used appropriately. In this guest blog, Dr. Lucas Chartier, an emergency physician in Toronto with a background in quality improvement, expands on the subject of how we’ve gone off course in our zeal for measurement and helps us try to find the path back to our intended goals.
In Emergency Physician Speed How Fast is Fast Enough – Part I, Dr. David Petrie addressed the issue of physician productivity (patients per hour, or PPH), the many factors that influence how quickly emergency physicians can process patients, and some of the tradeoffs between speed and quality. He also discussed the processing rate of the entire ED and introduced the concepts of surge capacity and the effect of crowding on safety if the ED can’t keep up. In this follow-up blog, Dr. Petrie expands on the departmental aspects of throughput and safety, and calls on policy-makers to recognize the need to include surge capacity in planning efforts. He also makes some powerful arguments about the related issues of so-called 'inappropriate visits' and the changing role of the ED. In this post - Emergency Physician Speed Part 2 - Solutions to Physician Productivity , he also brilliantly dismantles some common myths about ED visits — and drivers of costs.
Racing legend Mario Andretti famously said, “If everything seems under control, you’re just not going fast enough.” He was talking about cars, but to many beleaguered emergency physicians trying to keep up with the patient queue, emergency medicine often seems this way. This guest blog on emergency physician productivity began as a question to our national association, the Canadian Association of Emergency Physicians (CAEP): Are there any national standards with respect to emergency physician productivity, i.e., expected number of patients assessed per hour? The question was referred to the CAEP Public Affairs Committee and triggered a lively email discussion among our members....
I view the emergency department as a safe refuge, a modern-day secular sanctuary. We are the one health-care service that never turns anyone away; we provide shelter to the homeless on cold winter nights, safety for battered women, and food for the hungry. I have always felt this “sanctuary” role was part of the core mission of the ED, one with a great potential for improving lives, or at least providing comfort.
Funding and freeing the future of learning that is FOAMed Longtime followers of EM Cases will have noticed a progressively prominent display on its website of the logo and inclusion of the name of the Schwartz/Reisman Emergency Medicine Institute — or SREMI —over the past two years. Some of you may have wondered what an Emergency Medicine Institute is, and what this one has to do with EM Cases. It's about funding FOAMed. What is SREMI? SREMI was established in November 2013 by a founding gift from our patrons, Gerald Schwartz and Heather Reisman. It is a partnership of Mount Sinai Hospital (now part of the Sinai Health System) and North York General Hospital in Toronto. Our vision is to advance the discipline of emergency medicine through the development of new knowledge — research and translating that knowledge into practice — as well as advocating for system improvement through better public policy. The partnership brought together two hospitals that already knew each other well and collaborated extensively; Mount Sinai brought strength in research and education including simulation, North York added its national reputation in continuing medical education. Dr. Anton Helman, the founder of EM Cases, [...]
As both an emergency director and a practising emergency physician, I believe it is the job of administrators to make the challenges of front line staff easier, not vice-versa. Clinicians are too busy taking care of patients to perform purely administrative chores. But one task that I would ask all emergency doctors to adopt is the step of recording the time of Physician Initial Assessment, or PIA times. The time from arrival until they first see a physician is what most patients consider their ED wait time, and it is an important metric to report. Yes, it means one more small box to fill out in your charting, but it can be of huge benefit to doctors. Allow me to explain why....