browndog Posted January 15, 2011 Share Posted January 15, 2011 Recently saw a thread on SDN that addressed this issue. I wanted to get the PA take on this topic. What tips can you folks share regarding improving efficiency as a PA/NP in the ED (both fast track and core)? Link to comment Share on other sites More sharing options...
Moderator ventana Posted January 15, 2011 Moderator Share Posted January 15, 2011 get all providers to STOP writing the narcotics to clean house quick - get the frequent flyers out of the ER also, see the patient, document the HPI and ROS - order most tests you can imagine that you can justify (not just ordering tests) - go see another patient - give it an hour or two and circle back to patient and hopfully work up is all done and you can have a broad differential in talking to the patient, take notes so you can docutment well, spend time to examine the patient - (I HATE PA's that never touch a patient and then bill a comprehensive exam) don't do this for pain management - go back and check q 5 min don't do this with unstable patients unless you have great nurses do this when you start to get behind and need to catch up to see more patients (never good to have an chest pain sitting waiting to be seen) talk to management to hire more providers Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted January 15, 2011 Moderator Share Posted January 15, 2011 document during any slow times so if you are just waiting on 1 test you can dispo the pt when it shows up, not have to start writing the whole chart then. Link to comment Share on other sites More sharing options...
browndog Posted January 16, 2011 Author Share Posted January 16, 2011 Thanks for the tips. I know it depends upon the shift, but how many patients in a 12 hour shift is a reasonable number for fast track? How about the core ED? Link to comment Share on other sites More sharing options...
browndog Posted January 16, 2011 Author Share Posted January 16, 2011 I know it depends upon acuity and a million things......just looking for a general measuring stick. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted January 16, 2011 Moderator Share Posted January 16, 2011 fast track 4-6/hr, days with lots of procedures a bit slower. mostly colds/back pain/dental pain 6/ hr is very doable. main side 2-3/hr Link to comment Share on other sites More sharing options...
Moderator ventana Posted January 16, 2011 Moderator Share Posted January 16, 2011 in a 12 I would see about 30 average - we did a lot of suturing..... sometimes as high as 40 but that was a tough day..... Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted January 16, 2011 Moderator Share Posted January 16, 2011 in a 12 I would see about 30 average - we did a lot of suturing..... sometimes as high as 40 but that was a tough day..... sounds about right. I see 25 or so in most 10 hr shifts with a record of 56 in 12.5 hrs working with a slacker doc...who saw 8 pts total in 12.5 hrs taking charts from the same rack.... Link to comment Share on other sites More sharing options...
jaygator76 Posted January 19, 2011 Share Posted January 19, 2011 our PAs avg 30 in a twelve hour shift. not a true fast track though. Link to comment Share on other sites More sharing options...
mytopeka Posted January 21, 2011 Share Posted January 21, 2011 We see mixed fast track (all the fast track plus some middle of the road stuff). In an 8 hour shift we see 15-20. Our charting system is IBEX which is our rate limiting factor. (The charge nurse is the TRUE rate limiting factor, but blaming IBEX won't turn the entire nursing shift against me.) Link to comment Share on other sites More sharing options...
Emerson Posted January 21, 2011 Share Posted January 21, 2011 I average 2-3 patients per hour, but I also work acute/critical care which makes a difference. Efficiency in the ED: 1) Don't order unnecessary tests. If you are going to treat a patient for his URI with a Z-Pak, unless they are toxic appearing a CBC will seldom change your treatment 2) Macros! My group uses PICIS and I have macros built out for the top 20 complaints. 3 clicks and I have full PE/ROS and medical decision making done. Of course each patient is different, so I usually make a few quick changes 3) Chart in the patients room. We have computers in all our rooms and I complete my history, pe/ros, mdm and order set in the room. 4) Order items bedside. For example, If I don't clinically suspect an ankle fracture but the radiograph is pending I will often order a cast show/afo and crutches to be placed at bedside. The second I see the radiograph the patient is ready to go or I simply change the order if I see other acute pathology Link to comment Share on other sites More sharing options...
browndog Posted January 21, 2011 Author Share Posted January 21, 2011 Great tips folks. Thanks. Link to comment Share on other sites More sharing options...
jaygator76 Posted January 28, 2011 Share Posted January 28, 2011 We see mixed fast track (all the fast track plus some middle of the road stuff). In an 8 hour shift we see 15-20. Our charting system is IBEX which is our rate limiting factor. (The charge nurse is the TRUE rate limiting factor, but blaming IBEX won't turn the entire nursing shift against me.) do we work in same ER? :) Link to comment Share on other sites More sharing options...
jwells78 Posted January 29, 2011 Share Posted January 29, 2011 Charting is a huge issue at my per diem job. They just switched from T-system to Meditech EMR.... O....M....G I can hear the bean counters gleefully patting eachother on the back, but it has made a monstrosity out of charting in the ED. The docs are still clinging for dear life to dictation and some are using the Dragon system. I am hoping that there will be some importable macros as described above as the pull-down approach for each component is so time consuming. Not trying to hijack the thread, just kind of re-opened the wound. It's easy to just put the charts aside and save the pile til the end of the shift- but I am easily spending 2-3 hours after shifts over there to complete my charts on this new system. BRUTAL. Anyone else using Meditech? Link to comment Share on other sites More sharing options...
Moderator True Anomaly Posted February 1, 2011 Moderator Share Posted February 1, 2011 I have only one word to help improve ED efficiency- SCRIBES. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted February 1, 2011 Moderator Share Posted February 1, 2011 Are your scribes free? We have to schedule ours 2 weeks in advance,can't cancel them if it's slow and they make 25% of our hourly rate....needless tosay i don't use one..although all the docs and the slower pa's do now... Link to comment Share on other sites More sharing options...
cobramarty Posted February 1, 2011 Share Posted February 1, 2011 We have been using T-system which is very fast as I chart at the bedside all of my hx. and are soon going to Welsoft. We will see. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted February 2, 2011 Moderator Share Posted February 2, 2011 I love t-system...unfortunately we are going to epic as it's cheaper.... Link to comment Share on other sites More sharing options...
medic25 Posted February 2, 2011 Share Posted February 2, 2011 I love t-system...unfortunately we are going to epic as it's cheaper.... I'll be interested to hear what you think about Epic; we are going to be going with the same thing. Link to comment Share on other sites More sharing options...
Moderator True Anomaly Posted February 2, 2011 Moderator Share Posted February 2, 2011 We don't use scribes. During my last rotation during PA school in a busy trauma ER, they relied upon them, but I don't know if they came out of the doc's salary. I was just blown away with how much faster the doc could move when charting wasn't an issue. Of course, I was made to chart on my own patients :) Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted February 2, 2011 Moderator Share Posted February 2, 2011 Two of the plces i work use scribes. At 1 the clinician pays 100% of their salary , at the other the hospital pays 1/2. If they were free i would probably use them for our busier shifts. Link to comment Share on other sites More sharing options...
RetNavyPAC Posted February 23, 2011 Share Posted February 23, 2011 You guys who are seeing butt-tons of patients - what documentation system do you use? I'm in awe. Seriously. Our clinic system uses Epic ASAP in our EDs (and the Ambulatory module for UC). We average about 2.5-3 pph in the Urgent Care and 1.5-2.0 in the Main ED. This tracks just below what the docs see (allowing for individual variations in skill, comfort and initiative). Our top EP averages 2.4 pph. RVUs are another kettle of fish entirely. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted February 23, 2011 Moderator Share Posted February 23, 2011 You guys who are seeing butt-tons of patients - what documentation system do you use? I'm in awe. Seriously. . at the job where I am fastest we are 100% on paper charts still. another place is paper + dictation( a bit slower), another is 100% emr(slowest). I broke my speed record in Haiti 2 weeks ago; 100 pts in 6 hrs. charting like this: c/c h/a x months exam: nl tx: tylenol Link to comment Share on other sites More sharing options...
rcdavis Posted February 24, 2011 Share Posted February 24, 2011 You guys who are seeing butt-tons of patients - what documentation system do you use? I'm in awe. Seriously. Our clinic system uses Epic ASAP in our EDs (and the Ambulatory module for UC). We average about 2.5-3 pph in the Urgent Care and 1.5-2.0 in the Main ED. This tracks just below what the docs see (allowing for individual variations in skill, comfort and initiative). Our top EP averages 2.4 pph. RVUs are another kettle of fish entirely. Oh common, bring on the RVU discussion! Seriously, I have been in many EDs and have seen multiple systems (from the old days of notes like eric's above.. which were great, and would allow one doc in a moderate (30-50kpt/ yr) to be single covered ...seeing about 40-80 in a shift!). to the MedHost and A-4 systems .. template and EMR by dictation.. which slows you down to your 2.5-3 pph. Hands down, fastest is a paper system. but virtually all paper charts - even tee-syst- get down coded for lack of CMS requiremnts.. and the corporate trade off is that they will make more money recovering "up"codes (by not losing the rvu to downcoders) to offset the decreased pph the paperwork / emr causes. There is no advantage to staying and charting later either... this is time that you do not get paid for ... UNLESS you are RVU based.. either fully or partially... it is then in your interest to chart as much as you can later (providing that you have a system wherein you can rmember enough individual details to do the chart 10 hrs after you've seen them).. and then the extra patients that you see more tha offset the 2 hours extra you stay to do the charting.. I have come to the conclusion, that, with an EMR, the BEST you will get in a standard non - influenza epidemc day-- in which case the numbers double is 3.5-4.5ppd in UC/FT, aqnd 2-2.8 pph in maniside.Remember ASEP states that an residency trained EP should be able see 2.4pph, all comers.. so that is the standard. Most PAs in major see 2-2.5, depending on acuity, primrily because they do slightly more work-ups than the EPs. Tee-sheet and paper charts can add a full 1-2 pph in uc/ft, and 1pph in major... I agree with eric: scribes are great; if you can get a couple to work with you constantly so they learn your style and language... great gig for EMS/ Paramedics. One of my friends uses them and pays out of his pockets.. says that (as he gets $hr guarentee PLUS portion of RVU genertaed.. the indreased RVU he generates/ hr more than pays for the scribes.) I have been expert witness in a couple PA cases, and I can tell you, paper charting is almost universally are terrible for documentation and defending your thinking. Template directed and free style dictation are the best.. comparing similar providers. The other thing I have noted is that ED efficiency is rarely just charting, or physician entered orders.. is more process: keeping the patients vertcal as much as possible, getting things done in parellel rather than serially.. and getting the f'ing patients out of the ED into their room!, driven than paperwork driven. sounds like you are right in the middle of national averages. I would suggest looking at the process more than the chart. good luck v/r davis Link to comment Share on other sites More sharing options...
Recommended Posts
Archived
This topic is now archived and is closed to further replies.