Patients per hour, turn-over and efficient use of staff

There’s some interesting stuff on how best to use physician time. When I see a patient who’s been waiting 6 hrs I always apologise for the delay and if I order an x-ray I tell them that it shouldn’t be too much longer as the major delay is usually to see me.

The other parts of the system, like triage and x-ray seem to work a lot more “efficiently” than the Dr part. We inevitably get called away to various important situations and the patient has to wait.

What I struggle with is that my time – in many ways the most important rate-limiting factor in patient flow is often used in desperately inefficient ways. Most of this comes from having inadequate nursing or ancillary staff.

Most hospitals (at least in US, Aus and Ireland) have patients admitted pts in ED corridors or cubicles. ED nurses time is then spent looking after admitted patients. Sometimes this is actually 2/3 of the patients in the department. As a result ED nurses are not available to do what ED nurses would like to do – look after ED patients and employ their full range of skills of assessment, interventions and procedures like IV lines and the like.

Instead, given that the nurses are so overwhelmed it falls to the Dr to do a lot of these tasks – everything from bringing patients to the toilet to get urine samples, testing urine, placing cannulas. moving patients to x-ray or even into a room where we can actually examine them.

I could easily double the number of patients seen an hour if:

  • I could tick a box to request investigations as opposed to fill forms or take the blood myself.
  • I could have a scribe or even dictate notes instead of hand writing.
  • patients were in a gown, in a cubicle, ready to be seen when I come to see them.

Unsurprisingly, in an efficiency driven, for profit system like the US – they have already adopted most of these features that enable maximum throughput. They also have many, many more senior EM clinicians as opposed to essentially independently working trainees of varying experience.

This is very much NOT a slight on nursing staff. This is a criticism of short sighted planning that while the long wait in ED might be to see a doctor that’s actually because we have nowhere near enough nursing staff and we make poor use of their skills and training.

We get paid the big bucks to see patients, make decisions and spend time with patients. Anything that detracts from that is poor use of our time on on the floor.

Thoughts?

About Andy Neill

EM Reg/Resident based near Dublin. Former anatomy lecturer, theology student and occasional musician @andyneill | + Andy Neill | Contact

Comments

  1. Great post Andy. This is one of my major problems with working in ED, especially as a locum, when I am one of the most expensive work-units in the hospital, so one would assume that any decent management system willing to pay an executive level expert top dollar would want to get maximum bang for their buck, yet, like you, due to a massive under-supply of ancillary staff (who cost 1/10th what I do to employ), I am walking patients to Xray/rolling them to CT, changing sheets on beds, dipping urines, rummaging through store-rooms because items haven’t been restocked on IV/procedure trolleys, obtaining, drawing up and administering medication to patients, taking bloods and putting them in the path chute, all because it’s quicker than waiting for a nurse or orderly, all the while patients are queuing up in the waiting room, not being seen because I’m doing 3 people’s jobs. And to be clear, like you, I am not having a go at nurses, there just aren’t enough, and I’m definitely not pretentious, I’ll happily make beds for locum rates, but it is a stupidly inefficient way to put me to work, an extreme waste of money and in the end, the patients are the ones suffering.

    People think that surgeons waltz into theatre to patients who are already anaesthetized, prepped and draped because they’re narcissistic or egotistical, however that’s not the case. It’s because that’s the most efficient use of their highly skilled and expensive time. Can you imagine if the Consultant surgeon had to go and get the patient from the ward, get the drugs from the drug room, draw up the anaesthetic then give it, then drape the patient, then have to go and rummage through a storeroom because there’s no scalpel or suture material on the operating trolley, then close up, do the dressing, monitor the patient in recovery and take them back to the ward?! Imagine, they’d be lucky if they got one case a day done. Instead they have efficient systems, plenty of ancillary staff with clear task allocation, and minimal redundancy. I know ED patients are far too heterogeneous to apply this level of uniformity of process, but do we really want to be wasting money and the patients time because no-one thinks there’s a better way?

  2. agree! protocolising based on validated decision rules helps. we also have the same problem where orders don’t get entered because the clerks are also portering the patients! things are way more efficient with good division of skills -sometimes though -- the old addage”if you want something done quick -- do it yourself!” applies

  3. there are lots of times that it’s quicker for me to do it myself -- but it shouldn’t be!

  4. Man, you´re so damn right. I work in Germany in an EM system still in its infancy, I suppose it´s even worse here. Helping a patient out of his clothes= 5 minutes, searching for a free cubicle 5=minutes, bringing discharge papers to patient =5 minutes and so on…
    Why does it work like that? Because nobody complains and because there is absolutely no culture of caring for doctor´s AND nurses needs in our system, no wonder that so many docs go overseas

  5. “When I see a patient who’s been waiting 6 hrs I always apologise for the delay…”
    I apologise for the delay with every patient I see. If they turn around and say “Oh it’s only been 10 minutes doc” then I say I’d prefer if it had been 5……..=patient instantly on your side.

Trackbacks

  1. […] Patients per hour, turn-over and efficient use of staff- Excellent article, the system needs to change, ED nurses and Doctor spend way to much time with admitted inpatients, than actually getting on with job of sorting out the resuscitating emergency department patients. […]

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