Slow is smooth, Smooth is fast

Speed and efficiency for doctors and AHPs starting out in ED.

Lots of people are worried about their speed in EM.  This is the time it takes to see a patient.  In the bad old days (maybe in some places still) junior doctor’s productivity is measured, and commented upon, with prizes for faster doctors (terrible idea) or euphemistic ‘extra support’ available for those who are ‘slow’.  Junior doctors are also generally a relatively high achieving bunch, they want to be seen to be ‘good’ this generates some anxiety, and nearly every doctor I have supervised have said they are worried that they are ‘too slow’.  Speed is important (I explain why in another post) and it’s right to want to be able to be efficient when you need to be, but how do you do it in EM?  How do you do it in EM when you are just starting out?  Especially when the entire system is in free-fall?

First off you shouldn’t expect to be fast, or try particularly hard to be quick.  You should be working on efficiency here, and that’s different.  So instead of being fast try to avoid behaviours that are going to get you tied in knots.  This is sometimes counter intuitive!

The best piece of advice I can give is to spend more time with the patient. In the age of electronic patient records, summary care records, and electronic discharge summaries it is really really easy to get sucked into reading about a patient’s past medical history to ‘prepare’ yourself to see them. This is rarely helpful, remember you’ve got a patient in front of you with a ‘thing’ the ‘thing’ may or may not be related to what you’ve read about, and you’ll likely have to go back and read stuff again if its relevant after you’ve seen the patient. There are exceptions to this, patients with care plans, and patients who have RECENTLY been discharged from hospital, but generally speaking after checking the ambulance sheet, triage note, and obs, just go see the patient!

The thing the patient can tell you is why they are here.  That is the most important bit of the history.  That is the bit to nail down and invest some time in.  The second most important part of the history is social history and functional status, as this is going to tell you if you can send them home, or not.  Don’t spend ages getting a PMH or DH from the patient, it’s hard for them to remember in many cases, and it will be inaccurate, you can do PMH from the Summary Care Record, or even the Drug history.  Spending the time to see if your patient can walk is time better spent than them trying to remember if they had their appendix out in 1978 or 87.   So see if your patient can stand and walk.

If after taking a history, ordering the obvious tests and writing your notes you do not know what to do go and ask. 

Do not:

  • Wait for the bloods THEN ask
  • Decide to do some bloods, or another test because you aren’t sure, THEN ask

These are behaviours that can get you tied into knots.  It’s ok to ask Middle Grades/SPRs and Consultants for advice.  They’ve got more experience about what is the likely trajectory of your patient, and it is what they are paid to do!

I think some people think that asking at this stage is akin to failure, but finessing your plan at this stage allows you to discuss the decision making that needs to occur after and around the tests that may or may not be needed.  This is valuable educational time, and will make you more efficient in the long run.  Our unit has a large cohort of F2 doctors making up a slim majority of our SHOs.  Now generally speaking in F2 you’ve not had that much exposure to decision making of the density or complexity that happens in ED (on the wards it’s often deferred to more senior docs).  Its ok that that bit (‘the plan’ part) of seeing patients is the bit that you need the most support for.

Deciding if someone needs hospital admission is something that can usually be ascertained from the history, and sometimes some examination findings.  Blood tests in general don’t help with many specific presentations, though there are a myriad of exceptions (like an amylase in pancreatitis, or those lovely high sensitivity troponins).  This means that once you’ve seen your patient, and examined them you should have a pretty good idea of which direction things are going in, and if at that point you aren’t sure it is ok to ask.

Chasing is another low yield behaviour for admitted patients waiting for beds.  Technically in most departments once someone is referred to another specialty most of the work of that chasing and case synthesis falls to the admitting team, but I see a lot of people chasing all of the extant investigations.  This rarely changes the patient’s trajectory, and consumes a lot of your brain power, as you are forced to maintain a long list of every patient you’ve seen.  The trick is working out what YOU need to chase and what can be left for the clerking doctor.  The thing here is that if blood tests aren’t going to help you decide what to do, then you don’t really need to do them.  Especially if the person in front of you looks well, and there is nothing in your differential diagnosis that blood tests will help you decide.  What blood tests do sometimes do is give you a 2-3 hour window in which to observe a patient ‘while they wait for the bloods’ and you can see if the symptom that’s bothering them (or you) goes away. 

I remember quite vividly as an F1 dealing with surgical referrals always, ALWAYS being happier seeing an ED referral than a GP referral because I had less work to do.  Even if the clerking bit of the ED notes was comically perfunctory usually all the ‘work’ (the Bloods, the cannula, the antibiotics) had usually been done, I just had to finesse the ongoing management.  The GP referrals (by their very nature) meant I had to start from ‘scratch’.

So in general – spend more time with the patient, and less time with electronic records.  Ask earlier for help with plans.  This will make things smoother, and that will make you faster in the long run.  Your notes (and I cannot stress this enough) do not need to be perfect, you are not writing a letter to your Gran, you don’t need to keep a handover sheet, all that information should be in the clinical record.  Spending time writing a little handover sheet or keeping a book is wasted time.

Inter-speciality referral fights are still a thing, and can bog down any doctor.  Don’t ever try to deal with these on your own.  Come find a SPR or Consultant who will be able to cut through whatever issue is holding things up.  Referral criteria and automatic referral pathways really help here (we’ve got lots of them where I work).  Many hospital specialties say they don’t like them, but a number of things happen if you pick up the phone to speak to a specialist when you don’t need to that can slow down the care for that patient and make a department overcrowded.

  • Asking for another specialty to review prior to them coming to the ward.  This comes in two flavours:
    1. The safety check, asking for an ICU r/v or an anaesthetic r/v prior to transfer,
    2. The check it’s not the other specialities ‘problem’ before they come to the ward
  • Both of these things can happen on a ward, and if you thought they needed ICU you’d probably have called them yourself.  If you aren’t sure if your patient needs ICU or an anaesthetic review ask an ED senior, they’ll know
  • Asking for test Y or treatment X prior to going to the ward
    • This helps the speciality, and sometimes the patient, but does mean they stay in the department longer, and sometimes when they ask you to order the test you can get into a tangle with a radiologist.  Usually it’s best to ask them to order the test they want.  If radiology are ready while the patient is in ED, brilliant.  If not they can have it on the ward.  Doing the test in ED takes up valuable nursing and portering time, and that time might be better used doing something else.
  • Asking for a review from speciality X before test Y can be done
    • If this is the agreed pathway then the accepting specialty can do all of that on their ward. 
  • Refusing a referral, this needs to be brought to the attention of the SPR or the consultant, because it’s against the rules in most institutions.
  • Accepting the referral, but saying they’ll see the patient in the ED because ‘they might’ discharge the patient.  This snarls up space in the ED unnecessarily, I know for example that over 90% of our referrals are admitted, so seeing the patient in the ED rarely results in a discharge.    
  • This does depend a little bit on your local set up, sometimes some orthopedic patients, and surgical patients can go home with further specialist follow up or reassurance

It’s also important to note that inter-speciality disagreements always involve two very stressed people trying to manage an unmanageable workload. If you are going to call another speciality, at least for the first few times I would recommend talking to an ED senior first. They might know of local pathways or procedures for the situation you have found yourself in.

Ongoing care and handovers

If you are seeing a patient towards the end of your shift and know they are going to need to be handed over, it’s worth putting a bit of effort into your plan and documentation to make it easier for the person receiving it. 

Ideally; you need to handover a patient like this:

 I have seen them, I am waiting for X if X is Y do Z if X is T do B

Don’t handover a patient if you’ve seen them but don’t have a plan.  Find a SPR or a consultant and you can make a plan to handover.  Don’t ever handover a patient with the plan of ‘discuss with senior’ because what that means is that the person you are handing over to has to go and see the patient AGAIN and then discuss with the senior.

It is better to hand over 5 tidy patients than 6 partially seen patients with no plan.

It is best to handover up the chain of seniority.  I am unable to convince all my colleagues of this (though more and more are coming round to my way of thinking).

The patient no-one wants to see

They sit there on the board like a dam, maybe there are language difficulties, maybe it’s a regular attender, maybe it’s a problem no one particularly ‘likes’ to see.  Maybe you can see from the triage note it’s an intractable problem that you cannot solve. 

Most of the time these are simpler problems than you think. 

Language barriers are less of a problem than they used to be, and a short call with a telephone interpreter service can yield loads of useful information.  Also sometimes the problem is simple enough for that not to be required.

If you pick up that patient, I guarantee that within seconds the board will look better as the dam will have been broken, your behaviour here makes everyone faster.  You see you can be sneaky here as well.  You can go and see the patient, then after you’ve done your notes go and ask for help.  Every registrar and consultant is going to be happy you’ve taken the plunge and done the hard bit, and no one is going to question the need for help!   One of my colleagues calls this patient the ‘domino patient’.


Try to be efficient rather than fast.  Don’t rush, just don’t do things you don’t need to do.

Ask for help. The best time to ask for help is after you’ve seen the patient and written your notes.

Your history should be focused on understanding why they are in the ED, and what has happened to them.  You don’t need to do a clerking (please don’t do a clerking!).

Chase things that matter, nothing else.

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