The more complex the delivery of emergency medical care becomes, the more critical it is that we find ways to become lean, mean EM machines. Recently, I worked a day shift and was in a comfortable pace, but I noted a steadier volume at 7:30 a.m. than usual. I checked with one of the nurses, making certain the patient in room 10 had received his ice and ibuprofen and was on his way to radiology. She responded, “Why are you in a hurry? We aren’t that busy.” My response was, “How efficient we are now will dictate how we will handle our increased volume later.” We can’t always predict how many patients we will see or how they will be distributed during our shift, but we do have control over what we do with those we already have. From my perspective, there should be two speeds in the ED: off and on. Slipping into slow mode during lulls in volume can be a disastrous strategy. Efficiency results in increased productivity, improved patient safety, happier staff, satisfied patients, and preservation of your sanity.

Through interactions with others and my own experiences, I’ve compiled the following list of efficiency principles that you may find useful.

1 Identify the decision and work toward it. Every step must bring you closer to your decision point.

2 High volume will drive your efficiency out of necessity, but low volume can tease you into relaxing too much, making you become inefficient.

3 Establish expectations up front with patients and staff.

4 Advise nursing of your plan. Inputting orders into the electronic medical record (EMR) is not good enough. Communicate your intentions. Don’t delegate communication to a computer.

5 Avoid holding pattern tests. These are ordered (often in complex cases) to defer your disposition decision or decisions to order advanced imaging, but they add little to no value to your decision-making process.

1. Four examples of holding pattern tests:
   • The acute abdominal series (if you need the CT, order the CT)
   • Erythrocyte sedimentation rate and C reactive protein, which are nonspecific inflammatory mediators that rarely change disposition
   • The second troponin when you know the patient needs to be admitted anyway
   • Uric acid (may be high, low, or normal in gout)

Start thin slicing! When busy, use your blink response.¹ EPs often know in 30 to 60 seconds what their patients will need. You can take five to six charts, visit each room from the hallway for 60 seconds, and order what is appropriate. Let patients know you will be back to perform your full evaluation, but you want to make sure they are making progress while waiting for you.