Time Management in the ED: Is there such a thing?

In All Posts, Education & Quality Improvement by Rob WoodsLeave a Comment

Being efficient with your time during an ED shift is an important skill to develop. Not only will this help you (and your staff) keep up with the demands of a busy emergency department, but as a learner this will also provide you with the opportunity to see more cases and have more time for teaching and feedback. This blog post will outline some tips and tricks for managing your time effectively throughout your EM rotation.

Before the Shift:

Efficiency starts with being prepared. Before starting your EM rotation, take the time to read through your orientation package (if one is provided). This often contains useful information regarding the logistics of your rotation and expectations of you as a learner. Also ensure that your IT accounts are set up and working properly; arrive early for your first shift and make sure your login works.

You can also take this opportunity before your first shift to walk around the department. Some sites have formal orientations while others don’t. If your site doesn’t have a formal orientation, ask a clerk who’s worked there before to show you around, or find a resident or staff member who can quickly give you a tour (nurses are often great resources!). Take this opportunity to figure out where the bathroom is and where to put your things. This is also a great time to ask where important equipment is stored (e.g. the suture cart, the ultrasound machine, paper-based resources such as prescription pads and order sheets). As a learner, helping out your staff by being prepared with the right equipment and paperwork shows that you’re engaged and can help make your staff’s life easier. This also frees up more time for them to teach you, instead of spending it tracking things down.

Additionally, make sure you bring your own food for an ER shift! You definitely don’t want to leave the department to grab food and end up missing an interesting resuscitation or trauma. Finally, knowing how to process orders is also important; ask where to place routine orders vs. how to place an urgent order. Knowing all of this information prior to starting will help you focus on caring for patients while on shift.

During the Shift:

When starting a shift, the first thing you need to figure out is how your supervisor likes to run their shift. When you first meet them, establish clear expectations. Do they want you to review each case with them before ordering labs, or are they okay with you getting started on some investigations? Do they want you to see more than one patient at a time? Should you proceed with simple treatments and private exams or do they want to know about them first? What order do you pick up patients in; i.e. are you in a particular area (acute care, rapid assessment, subacute, psych) at a particular time? Once you have established these expectations you will be better able to align your work with your attending physician and the type of shift you are working. Often, doctors will pick up the majority of new patients at the start of a shift, when they (hopefully) have a pretty clean slate and lots of time to work up complex patients. As a result, it’s important to clarify with them when and how they want to review cases early in the shift. Mid-shift, try to pick up lower acuity patients and procedures. Even if a case seems simple, check with your preceptor which patients you can pick up near the end of shift. There are few things more frustrating than picking up a complex patient with 30 minutes to go in the shift; this has big implications for handover and often forces your attending to stay late!

No matter how well you manage your time, there will still be moments when your attending is busy and you are in limbo; make use of this time! Review your case again in your head, practice a sample one liner, think about what investigations you would order, and commit to a plan for the patient. This provides you with the cognitive experience of managing this patient. If the staff picks a different plan, this is a prime learning opportunity for you to figure out how you should tweak your own plan in the future.

This is also your chance to reassess your patients. Did their pain get better? Have results come back? Has your differential diagnosis narrowed? Make sure you document these reassessments, including the time of reassessment. It often takes approximately 1 hour for blood work, urinalysis, and X-ray results to be reported. It’s inefficient to keep refreshing your screen to see if a result is back, especially when you’re waiting on a urinalysis only to find out the patient hasn’t even peed yet! Anytime you order a urine, make sure it is actually collected. Sometimes patients need something to drink or an in and out catheter. As for labs and imaging, if they are not being completed, find out what the hold-up is. Sometimes radiology is backed up with imaging studies or high acuity patients (e.g. traumas, strokes). It is also important to decide when you should ask your attending to reassess a patient. Tell your attending about your reassessment either when all of the results are back or a significant result is back. That way you are not wasting their time with multiple reassessments containing incomplete information.

Finally, if a patient is ready for discharge, reassess them again and determine if there are any further tests, scripts, or referrals required before they leave. Try to prepare these forms yourself as much as possible in order to maximize efficiency and save your staff time. Also check in with their nurses and see if they have any thoughts or concerns about the patient. Use their experience to guide you; they will have a good sense of how things are run in the department. 

After the Shift

The end of a shift is when your evaluation and feedback will occur. Most (if not all) EM rotations make use of daily evaluation forms, since you are often working with many different preceptors throughout your rotation. Try to fill out your daily evaluation form throughout the shift with information such as: the patients you saw, the procedures you did, the interpretive skills you worked on, and any mid-shift feedback you were provided. Filling it out as you go will save your attending physician time at the end of a shift, and leave more time for feedback! When it finally comes time for your end of shift evaluation, you can bring up any feedback you were given and offer a reflection on how you adjusted your behaviour for subsequent cases. This shows that you’re interested in improving and are ‘coachable’ – a key trait that residency programs are looking for.

Final Thoughts

Hopefully the tips and tricks outlined in this post will help you to manage your time more effectively throughout your EM rotation, and will mean more patient encounters for both you and your preceptor. As a result, your staff will be in a better position to stay on top of the patient load coming into the ED, and they will also have more time to teach you and provide you feedback. Win-win for everyone!

This post was copyedited and posted by Megan Chu.

Reviewing with the Staff

Managing time is a constant life goal that many of us struggle with even years into being staff. Especially when you\'re transitioning (into clerkship, residency or even into practice) it is extra challenging because of the added pressures of how things work in your particular ED. It is also essential to work/life balance. If you\'re always stuck at work 2-3 hrs after your shift it really increases your cognitive drain. To set yourself up for success, break your shifts into thirds.

First third, set expectations with your staff, let them know your learning objectives then see as many patients as possible, keep track of learning points as you go, ask for feedback after each patient, and pick 1-2 things you\'ll adjust for the next patients.

Next third, get your shift goal or EPA done (be sure to integrate the feedback you received before). Then reassess your patients and at the end of this block make sure you eat something. Get feedback on your adjustments and try and wrap up any remaining questions or learning objectives. If you have not had a chance to chat/see/do this is the time to remind your staff. This is also a good time for any just-in-time resource review you may need to do for your remaining patients.

In the last third, ask before you pick up patients (your staff will likely steer you towards \"one-touch\" patients), try and disposition your ongoing patients and make sure you do your evaluation early in this block so it\'s not something you\'re both stuck waiting around for. Then you can both get out on time and enjoy life outside of the ER!

Alim Nagji
Alim Nagji is an ER staff at Joseph Brant Hospital (JBH); St. Joseph Healthcare Hamilton. He is the Director of Emergency Medicine Clerkship for McMaster University and the Director of Simulation Learning and the Clinical Teaching Unit for JBH. He has interests in medical education, simulation and global health. Send him your favourite meme on twitter @alimnagji

Rob Woods

Program Director at University of Saskatchewan
Rob is an emergency physician and STARS Transport Doc located in Saskatoon, Saskatchewan. He founded the Royal College emergency medicine residency program at the University of Saskatchewan (USask) and currently serves as Program Director. He has also recently founded the Clinician Educator Diploma AFC program at USask.

Julia Heighton

Julia Heighton is a second year medical student at the University of Calgary with an interest in emergency medicine and FOAMed. When she’s not busy with school, she spends the majority of her free time playing intramural volleyball and hiking in the Rockies.