"Medical efficiency" in EM

[SERENITY NOW]

Surge season is hitting us hard, and I've been trying to be more efficient with our limited bed space.  Here is my goal:  dial back as much unnecessary workups as possible, and optimize / expedite the "unavoidable workups".  I've been brainstorming about common scenarios and come up with quite a few.  I'm thinking this could be a beneficial forum exercise as well where we could likely learn from each other....  so please share additions if you have time.   

 

"Situations commonly worked up that could likely be deferred"...

-with flu season, everyone has chest pain with their viral illness.  Many order blood work like troponin which equals an automatic 2-3 hour discharge length of stay (dLOS).  My thoughts are this; EKG and CXR are quick and easy, and if you can explain away sepsis, ACS, PE, CHF / myocarditis clinically, that is enough for me to dc.  Infectious chest pain patients went from dLOS of 2-3 hours to out of dept in 30-40ish minutes.  Is this your practice pattern?  Are you doing blood work on all of these?  Or no workup including no ekg / cxr?

-"Patient sent in from primary doctor for BP 200/110, but he is completely asymptomatic" with no s/s to suggest end organ damage... he needs NO workup at all.  Lots of literature to support you on this.  Check out acep policy on asymptomatic htn.  Discharge length of stay win 2.5 hours --> 15 minutes.   

-first trimester pregnant vaginal bleeding with prior US establishing IUP and known Rh positive who are well appearing.  Most of these get labs and US every time they come in but why?!  How does that change ED management?  I'm thinking FHT and dc to OB.  What is all of your practice here?  dLOS 3.5 hours --> 20 minutes

-epigastric pain in healthy patient with nontender abdomen, no risk for acs, can often completely forgo workup and give rx PPIs with PCP / GI follow up.  dLOS 3.5 hours --> 20 minutes 

-vast majority of pediatrics haha....

-what would you add to the list?

 

"situations with unavoidable longer LOS / workup, but we can still at least expedite it or optimize it"

-see cam berg's ADPs / accelerated diagnostic pathways

-vague nonspecific neuro complaints.  What often happens is workup piece by piece starting with CT head, maybe other imaging later, lots of labs, consults for recommendations, reevals ,etc.  Now we just go straight to CTA head neck from beginning, document why we don't think active stroke or other emergent ddx, dispo in 1/2 the time.  

-young healthy patient, or recently normal creat documented, then no need to wait the 1-2 hours for your creatinine to result, just send them to the CT scanner right away.  Very low risk for contrast induced nephropathy. 

-CHF pathways can be really helpful.  Majority of time its med noncompliance volume overload... give IV lasix immediately, order whole workup, tell nursing staff right away to road test by hour 2 and report back should be ready for dispo.  Know admission criteria for this well so that hospitalist doesn't jerk us around.

-cyclic vomiters (and similarly, migrainers)- most important thing is hit it hard up front - big cocktail with multiple liters of dextrose infused saline, reglan benadryl bentyl haldol capsacin (if marijuana on board)  etc.  repeat PRN orders are preloaded so your interruptions are lessened.  

-others?

 

If everyone shares some of their favorite hacks for increasing efficiency, we could learn some great stuff from each other and I think it would be really helpful.  Please share! 

 

(*mandatory disclaimer especially for new grads: this is informal idea sharing and not 'standard of care'.  Realize that these are simplified discussions excluding a lot of implied information. please don't substitute standard textbook / medical learning. Reference your textbooks, uptodate, colleagues and doctors before implementing anything like these into your practice pattern. )

[NC30]

Thanks for this, this is super helpful! Unfortunately I don't have the experience to add anything. Interested in keeping up with this post.

[EMEDPA]

Agree with all of above. RE: creatinines for CT: we have an istat in the dept for bedside Cr, mostly for CVA workups to expedite the cta head/neck.

[Guest ERCat]

Great post.  I have been thinking about this a lot myself lately. Some of the stuff we do in the ER we know damn well is fluff but we keep doing it.

For chest pain with URIs? I often don’t order any labs at all if the history suggests a viral URI and the patient is young and healthy, and looks well (ie doesn’t look like they have myocarditis... LOL) Usually just a chest x-ray, and sometimes an EKG for these patients (and a flu swab) but otherwise not a lot.

For asymptomatic hypertension, you’re completely right but I cannot get away from ordering my EKG, BMP, and urinalysis. Nothing I ever find changes management. I feel like it’s more reassuring for the patient if anything. If their own doctor sends them in for management and I didn’t do jack it doesn’t instill a lot of confidence for the patient. Often times I check this stuff, it’s back in an hour, and by that time the BP is back to normal without any meds given. Then they just get to follow up with their PCP.

First trimester bleeding with a known IUP? Yeah, I am always getting an ultrasound on that to assess fetal viability. If the patient does eventually miscarry even though there’s nothing that could have been done, it’s easy to criticize the PA who just checked FHTs and kicked them out. OB stuff is high risk territory and we are dealing with two lives and not one (sorry, one life if you’re in New York now apparently) so it’s not worth the risk in my opinion.

Epigastric pain - I always do check labs like LFTs, pregnancy test, and lipase...if the patient is truly NOT tender, the story is reassuring, and there’s no history of worrisome symptoms like fevers or emesis then I might not image them either.

I completely agree with hitting the cyclic vomiters hard off the bat. I usually slam them with two liters of fluids, Reglan, Benadryl and a GI cocktail right off the bat. Plus capsaicin cream on the belly for the cannabis users.

I do the same thing with migraines and back pain - why screw around? Migraines get fluids, Toradol, Benadryl, Reglan and dexamethasone early on and if that doesn’t work, Tylenol and IM Haldol (but usually it does work). Back pain patients usually get Toradol and Robaxin and a lidocaine patch! Usually feel better fast.

Sometimes  when I have a patient that may need multiple imaging studies, I don’t have a problem calling the radiologist to do a brief look over the images to tell me if  anything is abnormal. So even if their formal report doesn’t come back for a CT scan of the abdomen for another half hour, I can already be ordering the ultrasound if the radiologist didn’t find an etiology for the patient’s belly pain on that CT (for example).