The Anatomy of a Super ER – Part One

ER outsideMuch like British naval vessels once considered noon the start of their day,  7 am is the start of the day in the Paterson ER (150,000 visits per year). During the next 24 hours an average of 415 patients will seek care (Monday and Tuesday always being the busiest). They will be cared for by 17 emergency physicians, 4 nurse practicioners, and 45 nurses supported by three dozen scribes, techs, transporters and registration personnel.

white space

7 clockBut for now only about 30 patients are in the department. It is a busy time of transition. The night shift physicians and most of the nurses have been here since 7pm.  When they came in nine zones were humming along at full power. Now they are turning over only four areas to the day shift.

white space

Before the new team can begin caring for patients the off-going  Team must sign out. Physician to physician. Clinical nurse to clinical nurse. Charge nurse  (See Inset) to charge nurse. All patients in the emergency department proper are “owned” by someone. This ownership (responsibility) forms the basis of the complex systems that provide medical care.

white space

Private-ED-Rooms-SJRMC“Ownership” in the Paterson ER is geographical. This very large ER (88 beds with 15-20 additional spaces for overflow) is broken down into nine zones (excluding the Resuscitation bays and Psych area). Each zone is staffed by a set team of one physician and two nurses for 8-10 beds. They are supplemented with a scribe for the doctor, trainees (residents, medical students) and pull from a pool of transporters, registrars and techs.

white space

CHARGE NURSE – The senior nurse responsible for the immediate operations of the department. Typically all personnel (excluding physicians) work directly for the charge nurse during their shift. The charge nurse generally has the most comprehensive situational awareness from moment to moment and handles  100+ communications per hour. They are traffic controllers, problem solvers, coaches, fixers…. all-knowing and all-important.

white space

Because of this scale areas have specialties. Zones 1-3 (Main ER) care for adults, are open 24 hours a day and receive the most critical patients. Zones 8 and 9 are pediatric and also never close. Zone 4 (also known as Supertrack) is a hybrid unit taking care of ambulatory patients with low to moderate intensity complaints. Zones 5 and 6 make up the SrED (Senior ED) and specializes in the care of those 65 and older. Finally Zone 7 is an area in transition currently taking care of the excess demand the other units can’t handle.

white space

ED blueprintAt 7 am with only four zones open (3 in Main ER and one in Peds along with the Psych and Trauma areas), the department can comfortably handle the roughly 8 patients an hour that are arriving. Beginning at 9 am that rate will sharply increase until 20 patients are presenting for care per hour. As demand increases more zones with more beds will come on-line.

white space

EMERGENCY PHYSICIAN – A physician who practices exclusively in emergency departments after receiving specialized training during their residency (after medical school). Generally certified by the American Board of Emergency Medicine or American Osteopathic Board of Emergency Medicine. PatersonER has one such training program that graduates six physicians per year. While residents they are closely supervised by emergency physicians as they learn the art and science of the emergent evaluation of the acutely ill patient.

white space

The pattern will be much the same for each of those 415 patients. 1)Come in, 2) get triaged (sorted), 3) go into a treatment area (bed), 4) be seen by the doctor and nurse, 5) receive ordered tests and treatments, 6) receive a disposition and 7) leave. Some patients will require this faster, others slower.

white space

Some will require very intensive care and others just an xray or a prescription. Frequently those who are dying will be saved. Sometimes though a patient will die. All will be touched by multiple people and their care will require the close cooperation of multiple departments and systems during their stay. Compassion amongst organized chaos will be the order of the day

white space

trackingTechnology plays a big role in modern healthcare but particularly in a SuperER. Without electronic medical record system (EMR) that integrates bed management, medication/test ordering, charting, and disposition planning there is no way this complex system could function. Though paper certainly exists in the ER more and more information is transmitted electronically. It is not unusual for physicians to have 4-5 different program running in order to access their patients’ current information, previous history, lab results, and digital images of radiology tests (CTs, ultraounds, etc).

white space

ultrasoundBEDSIDE ULTRASONOGRAPHY – Since the 1980s emergency physicians have been making use of bedside ultrasound machines to expedite the care of patients and improve care. Commonly they are used for the evaluation of abdominal pain, complications of pregnancy, and rapid diagnosis of the critically ill (FAST exam – see image). This great, non-invasive technology is also being used to make certain high risk procedures safer including the placement of central venous catheters.

white space

Next week Anatomy of a SuperER – Part Two will highlight some of the important innovations at PatersonER including Pivot Triage, the SuperTrack, and our astounding evolution of the emergency care of geriatric patients. We will also get in depth into the care of some of the most critical patients including those with major trauma and life threatening heart and brain emergencies. Stay tuned!

white space white space

Written by:

white space

David Adinaro MD, FACEP

white space

professional david adinaroDr. Adinaro is the president of NJ-ACEP for 2013-14 and is the Chief of the Adult Emergency Medicine at St. Joseph’s Regional Medical Center in Paterson, NJ. He is also the current editor of the “Year of Confusion…Year of Opportunity: 20 Things Changing Emergency Medicine” blog. Dr. Adinaro can be reached via  @PatersonER .

white space white space

This publication represents the personal opinion of the author and does not reflect NJ-ACEP or his employer.


ER 2030: The Future of Emergency Medicine?

SJRMC CRITICAL CARE BUILDING ”If only I had a crystal ball…”

I don’t. So I had our residents participate in an exercise where they brainstormed on what the ED of the future will require. I thought as they are part of the future of medicine they would have some great ideas. How right I was!

white space

I gave them as background the following:

  • That currently EDs account for about 4% of HealthCare costs
  • Control upwards of 15-25% of expenditures (admissions)
  • Patients managed at home will become increasingly complex
  • Expectations are that more acute/chronic treatment will be outside of in-patient hospital units

I then gave them a specific patient in the year 2030:

  • 64 year-old recently retired physician (me in 17 years)
  • Complaining of fever, chills and abdominal pain with a history of diabetes and hypertension
  • Most medical records not at this institution

I then asked then to describe the necessary changes, improvements, technologies, that would be needed to care efficiently for 250,000 patients a year (our current volume 150,000)  and provide proper, coordinated care for the above patient. I asked them to consider the following:

  • Emphasis on coordinated care
  • Integration of technologies
  • Information management
  • Patient flow

technologyTECHNOLOGY

Being a group firmly planted in Generation Y they were very comfortable and specific on the need in terms of technology. They wanted healthcare technology to be as universal, easy to operate and intuitively obvious as what the make use of on a daily basis now.

A number of their suggestions were focused on electronic medical records and the need for them to be more portable, multimedia, and interactive.  Aside from the obvious need for a universal medical record they also suggested:

  • Incorporation of photos especially of wounds for comparison
  • Fingerprint ID
  • Personalized electronic discharge instructions (to phone/email, etc)
  • Personalized charting software
  • Improved dictation systems
  • System integration (one screen for all records – ED, past hospitalizations, Radiology, Lab, PMPs)

Their other technology improvements were focused on very specific patients issues:

  • I-Cloud Microblood Chip (implanted blood analyzer)
  • Affordable Pad-based ultrasounds
  • Advanced, non-radioactive cardiac imaging
  • Video-Chat for prehospital calls and communicating with other physicians
  • At-home telemetry
  • Universal health care provider communications (eliminate answering services)
  • Virtual Translation services
  • Wireless EKG
  • Jetpacks for patient transport (my favorite!)

health care system

SYSTEMS

To be clear systems are not all about computers but rather the structures humans create to accomplish specific tasks. Health Care systems are by nature complex, dynamic and tightly coupled (See posts on High Reliability ED). For many physicians in training this is not a well understood concept. Residents, to be honest, spend most of their time mastering the medical parts of health care and do not generally look at the systems they work in. However, our residents did a great job suggesting needed additions to our current systems to improve the efficiency and coordination of care.

  • Expanded use of observation units
  • Telephone triage (prior to arrival)
  • On-site access to primary care (directly from triage)
  • In-house pharmacies in EDs
  • Shuttle systems for getting patients from ED directly to primary care sites
  • Kiosks for patient entered medical data (chief complaint, meds, allergies, review of systems)
  • Multidisciplinary facilities (coupling primary and specialty care closer to EDs)
  • Personnel Optimization
    • Increased specialization of different roles of health care providers
    • More systematic assignment of personnel to meet flow demands
  • Improved safety checks prior to discharge to reduce bounce-backs

case23_fig1CULTURE

Finally, the residents brainstormed on what other changes in the culture of both Medicine and being a Patient. Almost universally the group agreed that patient accountability (the flip side of the medical coin) was the number one concern. Their desire was for patients to feel more ownership and responsibility in their own care.  This seemed to be in response to the increased expectations placed on physicians in improving the value of care.

Other areas they sought improvement included:

  • Better integration between community/schools and the health care system
  • Palliative Care  teams available in the ED
  • Improved communication between Private physicians and the ED (both directions)
  • “Super Gyms” – integration between wellness facilities and hospitals
    • to improve life-style modifications.
  • Informative health videos in ER waiting rooms
  • Outpatient pain management referred directly from ED

This exercise was hugely entertaining and enjoyable for all who participated. If you would like to share your views please feel free to add a comment!

David

 


PALLIATIVE CARE IN THE ED – A WISE CHOICE

Originally posted on NJEmergencyDocs:

njacep large

You have probably heard the term “palliative medicine” a lot lately. At least I hope you have! But what does this type of medicine have to do with the Emergency Department?

Let’s start with some basic questions…How often do you ask yourself :

Question-Mark

  • Why am I doing this tube/line/CPR/futile procedure on the poor person who will not get any benefit, and most likely get worse?”
  • How many patients do you see per week that you do a full work-up and management that you would NOT be surprised if they died within the next 6 months?
  • How often are you coding a patient that has obviously been declining for a while with a chronic/terminal condition such as CHF/COPD/dementia and the family has no conception of what is happening?

If you identify with any of these scenarios then read on…

Just as many serious public health questions have ended…

View original 593 more words


In the ER: Too Much or Too Little Pain Medication?

Originally posted on NJEmergencyDocs:

njacep large

Do we as physicians prescribe too many narcotics?  Specifically do we emergency physicians prescribe more than we should? As with much else in medicine the evidence is complex and at times contradictory.  Some examples of the argument that we are not aggressive enough in the treatment of pain are the following (click on them to access links):

If you have spent any time looking at the news or proposed state legislation the answer would clearly be yes. There is an epidemic of deaths related to prescription drug use and misuse. The problem is stark both in terms of the individual tragedies and sheer numbers.

The CDC has some great graphics that…

View original 567 more words


Exit Only! How to reduce CA-UTIs

” A  finger or tube in every orifice” – Old School emergency medicine motto

white space

exit onlyIn my humble opinion foley catheters are the work of the devil.  Yes I know that in the right circumstances they are important in the care of patients and are a god send to those in acute urinary retention.

white spaceTrust me I know (See The Day I Almost Died…).  But everyone also knows many are placed for reasons that do not obviously benefit the patient. (perhaps up to half of those placed).

white spaceAnd to boot they cause infections.  Nasty multi-drug resistant infections. Close to 2,000 to 9,000 deaths per year are attributed to CAUTI (catheter associated urinary tract infections).

white spaceAnd, of course, there is a financial cost.  Estimates are $400M in 2007 dollars (http://www.cdc.gov/hai/pdfs/hai/scott_costpaper.pdf)

quality-assurance-culture

white spaceThe good news is that there is help out there to help us break our habit!

image

site header

This is a great initiative that is working on the state level to help emergency departments bring change to their systems and culture. ( OnTheCusp).  They give you all the tools you need to implement change and produce real results. We will be focusing on the inappropriate reasons that catheters get placed (particularly in the ER):

  • Incontinence (without additional indication)
  • Diuresis (think non-ICU CHF exacerbations)
  • Frequent, nonessential measurement of UOP
  • Nurse’s concern about patient comfort
  • Diarrhea (without additional indication)
  • Patient’s preference (without additional indication)

SJRMC CRITICAL CARE BUILDING

PatersonER will be participating in this initiative and looking forward to increasing the safety of our patients.  We will rely on the systems we have already developed (See previous posts on Collaborative Leadership in the ED and EDQA).

white spaceBelow is a link to a slide set related to how physician leadership plays a vital role.

David

PS:  Let me know if you will be at MEMC VII this September in Marseille. This is going to be my first trip out there!

white space

Quality Initiatives: Physician Leadership in the Emergency Department


“I Stood My Post” – Reflections on My Career

ed-sign

When I am done I will be able to say:
I stood my post.

white space

My post is in the ER.
Next to my patients and their families.
Next to my colleagues.

white space

I have stood this post through good and bad.
Happy and sad.
On beautiful afternoons when my family is out playing
And at night when they are asleep safe in bed.

white space

I do not always share with them what I see.
Some is too horrible to say out loud.
Some is only funny to those like me.

white space

There are times when I think I will soon be done.
That I will not be able to take one more sad thing.
That I will have given away as much of my soul as I can spare.
That I will no longer toil so close to sadness and tragedy.

white space

But that time is in the future.
For now the pride in my work,
the vitality of my colleagues,
and the difference I make every day is enough.

white space

All that good far outweighs the sad.

white space

So for now you know where to find me:
In the ER.
Next to my patients.
Next to my friends.

white space

Standing my post.

SJRMC CRITICAL CARE BUILDING

Dedicated to my friends and colleagues in our Emergency Department at St. Joseph’s Regional Medical Center in Paterson, NJ.

white space