SHIFT MAGIC
Learning how to navigate a shift efficiently and effectively is the magic of emergency medicine residency. There are a variety of approaches, but my own personal practice and what I expected of junior residents as the Academic Chief is detailed below. Much of this is specific to our NMCP ER and its demographics, but this is also where you will spend most of your EM time.
Learning how to navigate a shift efficiently and effectively is the magic of emergency medicine residency.
Volume. Our shifts are scheduled for eight hours, but expect AT LEAST one hour extra of turnover and admin. As an EM intern, once you figure out our system and become more efficient, you should see approximately eight patients per shift, especially as you near the end of your EM rotation or approach the end of your intern year. As an intern, you should focus on the quality of patients and learning how to work up the most commonly encountered chief complaints. Later you can focus on quantity. As an EM2, during the first half of the year, you should see around ten to twelve patients per shift, again, focusing on the quality of the patients and solidifying your EM knowledge base. Constantly seek out the sick patients requiring a higher level of thinking and care. By the last half of your second year, you should start pushing your volume to beyond twelve and attempt to see nearly fifteen patients. This will prepare you for the initial beat down that third year brings. At this time, you are also allowed to start proctoring medical students during your shifts, which helps you explore your system in preparation for the next year.
Constantly seek out the sick patients requiring a higher level of thinking and care.
As an EM3, you go from a happy, low responsibility second year, where you were focusing only on your personal learning, to suddenly managing the department, proctoring interns and medical students, and vastly increasing your volume beginning July 1. This is a massive and difficult transition for some, but the better you prepare for that moment, the easier the transition. As an EM3, in our department, you regularly see between twenty and thirty patients in an eight hour shift, and sometimes more. During this time, efficiency is crucial. So the sooner you figure out your processes and flow, the better. As a fourth year, nothing really changes from third year, you are just much better and faster at seeing patients, and what previously seemed like an overwhelming shift will seem easy.
Turnover. Transition points have been established as the most dangerous periods of patient care. Learning the art of the turnover is necessary to becoming a competent resident and capable physician. Turning over and receiving turnovers require skill. A few salient points:
- The culture of turnover varies widely depending on the facility, but I encourage you to turnover patients and to receive turnovers willingly. Some institutions and individuals don’t want any turnovers, but want the departing provider to disposition all of their patients. This is harmful for a few reasons. It will fuel burnout when providers needlessly stay for hours after each shift waiting for labs/imaging/consultants to make a final disposition. It also discourages departing providers from picking up new patients near the end of a shift. This creates unnecessary length of stays, harms patients, and often provides a huge bolus of new, sometimes sick patients for the arriving providers. But refusing turnovers also hurts you. Your colleagues will be less willing to receive your turnovers, requiring you to stay late repeatedly, and lead to your own burnout. Again, I encourage you to receive turnovers willingly and to turnover your own patients willingly – with a few caveats.
- If I am nearing the end of a shift and evaluate a patient that I know will require a lengthy workup and eventual turnover, I frequently am more conservative and order more labs/tests than my usual practice to ensure that nothing is missed and that the oncoming provider is comfortable with the workup. EM physicians differ significantly on their risk aversion and thoroughness of workups, so I adopt the practice patterns of my more conservative colleagues in this case. Then they are not required to completely trust my gestalt when discharging a patient with a somewhat risky complaint.
- If there are loose ends that can be tidied quickly, then absolutely stay beyond your shift to help disposition, but try not to make staying late a habit. Also, if the ER is really busy and the arriving physician is getting crushed, help by staying behind temporarily to disposition patients and establish a tidy turnover.
- The best turnovers have a specific plan and only need one or two tests to make a final decision – a delta troponin, a CT thorax for PE, i.e. “dispo per CT.” Often, you can prepare the discharge paperwork, print the outpatient prescriptions, and counsel the patient on the turnover and the plan. At that point, the oncoming physician needs only to follow up on that last test and say one last goodbye to the patient before pressing the discharge button. In some cases, since you know your patients best, you should also call the consulting physician to give a heads up if admission is anticipated. This will save much grief for your successors and allow them to focus on their own new patients in the busy ER.
- In our NMCP ER, we follow a turnover format – resuscitation room usage, incoming patients, floor issues, equipment issues, consultant issues, sedation capability, and then we “run the board.” When you run the board, use a system – SBAR, I-PASS, or something similar – to discuss each patient. When receiving turnovers, take notes as needed. I found that quickly typing pertinent information in the comments section of our EMR was efficient. Then when turnover was complete, I would jot a quick note for each patient.
Procedures. Once you decide that a procedure is necessary, whether diagnostic or therapeutic, you should prioritize that procedure on your task list. Many residents procrastinate for whatever reason – fear, inconvenience – and postpone necessary procedures that later become a hassle to perform and even more inconvenient. Rapidly mentally triage your patients, quickly evaluate your new patients, input necessary orders, place your patients into a holding pattern, and then do the procedure. When you are finished, some patients will be ready for a final disposition, and the others will be much closer to a completed workup. Rarely, if ever, should you turnover a procedure to an oncoming colleague. This is generally not appreciated, and it is not what is best for the patient.
Tracking. You must establish your own system for keeping track of your patients – who you have seen, who you need to see, what you need to do, what labs/tests are pending, etc. Some EMRs help more than others. Some of my colleagues collected books of stickers, I would encourage you to avoid this for a few reasons. You don’t want to violate HIPAA by losing your sticker book or leaving it places. Also, if busy, it slows you down. I tried this technique initially, but found that some nurses would bring me stickers and others wouldn’t, or there would be no stickers at bedside, or with critical patients I was too busy with other tasks to remember stickers, or stickers weren’t available because the patient wasn’t yet registered. After walking around the ER constantly looking for stickers, I finally realized that this was an inefficient practice and a waste of time. You can just track your patients through the EMR. If you occasionally need to save a sticker for a good case or a procedure or a resuscitation, then fine, but don’t establish a sticker crutch that ultimately slows you down. Also, run your board occasionally to ensure that you are not forgetting patients, or that patients whose workups are completed are not waiting too long for a disposition, or to ensure that you didn’t forget any part of the workup, or to encourage a patient to urinate – you will always be waiting for urine.
Also, if you are feeling overwhelmed, paralyzed by the volume of patients and pending procedures, then pause. Take a moment to center yourself, then prioritize and execute. Finish one task, then the next, then the next, and gradually dig yourself out of that hole. There were multiple times that I found this technique helpful, especially when I felt task overloaded and didn’t know where to begin.
Prioritize and execute.
Jocko Willink
Finally, minimize redundant note taking. At the beginning of residency, I carried a blank paper with me and occasionally took notes, eventually I abandoned this practice too. Note taking outside of the EMR, except for specific circumstances, slows you down. Exercise your brainpower. Listen to the patient, take your history, then repeat the abbreviated story to the patient to ensure understanding. After practicing this method with thousands of patients, your recollection for minutiae with specific patients is more than sufficient, even hours later. Redundant note taking is a crutch, and a waste of time. Save it for when you won’t remember specific data – a doctor’s name, a clinic, a phone number, etc.
Flow. Physicians flow differently throughout the ER, find what works for you. You can often tell how long you will be in a room by the chief complaint. Read the nursing notes, scan the vitals, check for previous visits or pertinent history before entering the room, this will make you much more efficient in the room. Some physicians see patients linearly – they evaluate a patient, start a workup and their note, then move to the next patient an repeat that pattern. Some physicians bolus their patients – they evaluate two or three before returning to their workstation. This practice his highly dependent upon the patient acuity or specific complaint though. Often, placing a few quick orders on multiple patients to initiate workups is warranted, especially if you are busy. Also, if EMS warns you about an incoming trauma or critical patient, place preliminary orders or discharge patients – time permitting. Some emergency departments initiate nursing orders from triage for common chief complaints. This can helpful, but also frequently requires additional studies after patient evaluation. Experiment with your flow, watch other physicians, find what works for you. And then work it.
Some residents approach graduation and experience significant anxiety, but this can be avoided by mentally practicing independently during the last few years of residency.
Mindset. Finally, as you enter your third and fourth year, imagine that there is no attending physician backup. Evaluate your patients and formulate plans as if you were practicing alone. Then, and only then should you discuss your patients with your attending. They may think differently or have additional concerns, but observing this practice will prepare you for practicing independently after residency. Some residents approach graduation and experience significant anxiety, but this can be avoided by mentally practicing independently during the last few years of residency. Also, every attending practices differently, this is often frustrating for residents. But instead of being frustrated, learn as much as possible from each attending. Then formulate your own practice patterns from those experiences, evaluation of the evidence, and your amalgamation of their practices.
