1. Another Day at Work You show up for your shift at 10:00;

2. Six HoursDisposition ExecutedDisposition DeterminedPhysician ReviewsInvestigations InterpretedInvestigations Carried OutOrder InvestigationsReview HistoryPhysician EvaluationRN Evaluation Into The QueEntry in EDAnatomy of an ED Visit 3. Okay, this works YouDisposition Executed Disposition Determined Physician Reviews Investigations Interpreted Investigations Carried Out Order InvestigationsReview HistoryDisposition Executed Disposition Determined Physician Reviews Investigations Interpreted Investigations Carried Out Order Investigations Review History Physician Evaluation RN Evaluation Into The Que Entry in EDEntry in EDRN Evaluation Into The QuePhysician EvaluationReview HistoryOrder InvestigationsInvestigations Carried OutInvestigations InterpretedPhysician ReviewsDisposition DeterminedDisposition ExecutedImportant Phone CallPhysician Evaluation RN Evaluation Into The Que Entry in EDEntry in EDRN Evaluation Into The QuePhysician EvaluationReview HistoryOrder InvestigationsInvestigations Carried OutInvestigations InterpretedPhysician ReviewsDisposition DeterminedDisposition ExecutedTeaMe 4. Okay, this works And Again YouDisposition Executed Disposition Determined Physician Reviews Investigations Interpreted Investigations Carried Out Order Investigations Review History Physician Evaluation RN Evaluation Into The QueAnd AgainEntry in EDDisposition Executed Disposition Determined Physician Reviews Investigations Interpreted Investigations Carried Out Order Investigations Review HistoryPhysician Evaluation RN Evaluation Into The Que Entry in EDYou Again 5. 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Key Points You cannot manage the flow of patients into the ED. Out of sight is not out of mind. The waiting room is a bad, bad place Emergency Medicine, Critical Care, Anesthesia; all manage Geographic Units as well as Patients. You are responsible to keep it accessible to new patients 7. Since You Cannot Manage the Number of Encounters Manage the Order of Encounters Manage the Trajectory Through the Visit 8. In Every Encounter, There Is A Rate-Limiting Step Find it early Start the process NOW 9. The Order of Encounter Triage Category Category 1 2Active Resuscitation Emergency3 4 5Urgent Semi-Urgent Non-UrgentTime to Encounter Immediate 10 min 30 min 60 min 120 minReality: When The Nurse/Paramedic/Visitor Says You Need To See The Patient In Room Do It. 10. Another Little Caveat Simple Problems are Quick Problems (Triage Level 3, 4 and 5) The chart can be done later A full ED, regardless of acuity, is an inefficient ED Nursing time Phone calls Meals Falls Trips to toilet Where are you going on leave? 11. Key Points You cannot manage the flow of patients into the ED. Out of sight is not out of mind. The waiting room is a bad, bad place Emergency Medicine, Critical Care, Anesthesia; all manage Geographic Units as well as Patients. You are responsible to keep it accessible to new patients The process of ED care does not mirror hospital care. 12. Entry in ED RN Evaluation Physician Evaluation Into The QueManage the TrajectoryOrder Investigations Physician Evaluation Investigations Carried Out Review History Investigations Interpreted Order Investigations Disposition Determined Investigations Carried Out Disposition Executed Investigations Interpreted Physician Reviews Disposition Determined Disposition Executed Identify and carry out the CRITICAL ACTIONS. Do not send time or resources on non-critical actions 13. Entry in ED RN Evaluation Into The QueManage the TrajectoryPhysician EvaluationReview History Order Investigations Investigations Carried Out Investigations Interpreted Physician Reviews Disposition Determined Disposition ExecutedSkip ahead when disposition is known 14. What Works? Start your shift on the run. Pick up three new patients in the first 20 minutes Its about getting things started Rate limiting steps Early determination of disposition Yes, the nurse will ask you to see another patient before you are ready for another one. Where does the teaching come in? 15. Patient #1 A 87 y/o female fever to 39, BP 90, HR 120 Alert, confusedPatient #2 A 27 y/o male from RTA, BP 146, HR 120 Obviously deformed R lower leg, chest and abdominal painPatient #3 A 57 y/o female with 2 days of abdominal pain, vomiting and diarrhea 16. Patient #1 A 87 y/o female fever to 39, BP 90, HR 120 Alert, confusedPatient #2 A 27 y/o male from RTA, BP 146, HR 120 Obviously deformed R lower leg, chest and abdominal pain with seatbelt signPatient #4 A 19 y/o with Patient #3 ankle pain after A 57 y/o a stepping off female with 2 curbdays of abdominal pain, vomiting and diarrhea 17. Patient #1 A 87 y/o female abrupt onset HA, vomiting and slurred speech. Presently rouses to verbal stimulusPatient #2 A 28 y/o female ambulates to room with gradual onset HA, vomiting and photophobia; all typical of prior HAs.Patient #3 A 4 y/o fell at home striking head. 18. Patient #1Patient #2Patient #3Just finished dinnerA 27 y/o male with recurrent Sz presents following a 4 minute generalized Sz. Awake and somnolentA 57 y/o female with chest pain 19. The World is Changing. Change Or Be Left Behind Linear care is not efficient Launch the rate limiting step as soon as possible If you know the ending, dont read the whole book. The sickest patients need the most care. But the least sick patients will prevent you from giving them that care get them out.