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.

6 Limit interruptions. They are dangerous and inefficient. Chisholm and colleagues noted that emergency physicians are interrupted every six minutes and have a “break in task” (an interruption resulting in the physician dropping what they are doing to tend to a different task) every nine minutes.² It is conceivable, and all too common, for multiple breaks in task to occur in series so that it isn’t reasonable to expect someone to remember their initial, uncompleted task.

7 We’ve all heard the phrase “time is money.” Well, in the ED, money isn’t our currency—time is. We should all be mindful that saving time is important, but creating time is critical to a successful shift. Spend it when it helps you reach a decision point (as recommended in Principle 1) and provides added value. Any other use of time is wasteful. Time spent on these things is valuable:

1. Decision making
2. Communicating with patients to clarify expectations and anticipate questions
3. Communicating your plan to the ED staff—entering orders in the EMR is simply not enough
4. Advising others of what is outstanding during a handoff

8 When the decision has beenreached, execute.

1. The most valuable commodity in the ED is a disposition. When you know, it’s time to go!

9 If the decision will be the same regardless of the results, don’t order the test.

10 Tell people the value they are getting by trading tests for your expertise.

1. Perception is the reality you create; you’re in charge. For example, you could say:
   • “I’ll get you home quicker if we order fewer tests.”
   • “When starting the IV, we’ll attempt to get the blood at the same time.”
   • “We can get you an answer without tests. We’ll save you time.”
   • “Do you think you’ve broken your back? I don’t either. X-rays only show the bones [oversimplification] and won’t help you today. Let’s avoid exposing you to ionizing radiation.”
2. However, if you do less, plan for others to challenge your decision when you aren’t present to defend yourself (ie, preemptive damage control). For example:
   • “My doctor ordered a chest X-ray and treated me with antibiotics for bronchitis.”
   • “Bronchitis doesn’t show up on an X-ray.”
3. If you are excluding a diagnosis without a test, tell patients they don’t have it and why.

11 The weakest diagnostic link is the slowest test you order and can nullify the value of point-of-care testing.

12 Employ patient-centered care and shared decision making. It makes patients and families happy and allows you to guide patients to appropriate decisions and away from unwarranted diagnostics. Here are four examples:

1. Lumbosacral spine X-rays for routine back pain: 1. No red flags. 2. Won’t change their management.
2. Chest X-rays: If you know patients do not have pneumonia clinically, tell them. They want an answer, not necessarily a test. If you have chosen to treat them with antibiotics and they don’t need admission, don’t order the X-ray.
3. CT for renal stone: 1. Previous stones with identical symptoms and no risk for abdominal aortic aneurysm (AAA), then don’t order the CT. 2. Young and healthy without risk of AAA and classic presentation, consider shared decision making and no CT.
4. Knee X-rays: With the exception of significant trauma, knee radiographs are rarely useful, so tell patients that. If you suspect internal derangement, then tell them that time is the best test. Most don’t benefit from imaging, but those without improvement may need an MRI.

13 Plan your shift.

1. Beginning of your shift:
   • Avoid taking more than two to three sign-outs.
2. End of your shift:
   • 90 minutes left: Begin expediting admissions (eg, some testing is incomplete but unlikely to impact disposition, so advise the admitting physician of outstanding items).
   • Make phone calls early (eg, admissions, outpatient follow-ups).
   • One hour left: Attempt to see easy dispositions one or two at a time.
   • Establish your system for chart and patient flow and stick to it.

14 Avoid diagnostic pathophysiology.

1. Consider the Frank-Starling curve. Stroke volume increases with increases in left ventricular end-diastolic volumes. However, there is a point at which more volume results in decompensation and reduced stroke volume. Our efficiency in the emergency department matches this theory. The more patients you acquire and the more tests you order, the more you accomplish until the wheels come off of the bus. Then errors are made, patients wait, diagnostics are not evaluated in a timely manner, etc. Know your point of decompensation.
2. Your brain is like a smart phone: Too many apps running, and your phone becomes slow and has no battery life. Patients and outstanding tasks are open apps in your brain. Open less by ordering less. Shut down apps by dispositioning patients as soon as possible.

References

1. Gladwell M. Blink: The Power of Thinking Without Thinking. New York, NY: Little, Brown and Company; 2005.
2. Chisholm CD, Collison EK, Nelson DR, et al. Emergency department workplace interruptions: are emergency physicians ‘interrupt-driven’ and ‘multitasking’? Acad Emerg Med. 2000;7:1239-1243.