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ER Goddess

ER Goddess

Slaves to the Billboards

Simons, Sandra Scott MD

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doi: 10.1097/01.EEM.0000512768.23377.fe
    ED metrics, door-to-doc
    ED metrics, door-to-doc:
    ED metrics, door-to-doc

    ‘Mom, that's a little unreasonable,” piped up my 9-year-old from the backseat as we drove by an ER billboard that prominently displayed an average wait time of four minutes. “That would be stressful, seeing everyone that fast.” Even my kids understand how absurd some of today's time metrics are. “Hospitals probably make more money showing shorter wait times on a billboard because people want to go there because it's faster,” he concluded. Out of the mouths of babes.

    EPs are never more stressed about time than when we're in the ED, where every move is timed, tracked, and reported to the guys in suits to make us move even faster (as if we are sitting around eating bonbons). Each time we meet their time metric for door-to-physician greet, they lower it again.

    I had a rare slow shift recently, and two patients complimented my bedside manner and a third asked me to be her doctor. Sadly, this isn't the norm because I'm usually too rushed to establish rapport. It's very telling that many of the patients who are happiest with me are those who had sutures, I&Ds, or fracture reductions because I actually spend time with them at the bedside as I do the procedure instead of scurrying out to see the next patient.

    Neither patient nor doctor ever wants a patient encounter to be rushed, especially not to keep up with arbitrary time metrics. Patients want to know that when we do have to hurry out of their rooms, it's because someone is sicker than they are, not because we have 10 minutes to see every stubbed toe and splinter. A physician's sense of urgency to recognize and treat the critically ill is a more legitimate reason to hustle than time constraints imposed by businessmen from their offices.

    The crux of emergency medicine is “sick” vs. “not sick,” and an EP's priority is rapidly differentiating the two. We constantly monitor the tracker looking at chief complaint, age, and vitals, risk stratifying who comes first and who can wait. We survey stretchers rolling by, watch patients coming back from triage, and choose our path through the ED to glance in rooms with potentially serious complaints, incessantly screening for distress and making sure we don't have to go immediately to a patient before he decompensates. We understand how pathologic processes can overtake our bodies, and it is our job to race against them.

    Let us do our job.

    We know it's our responsibility to light fires under less experienced team members who may not understand how quickly a patient can deteriorate. We also listen when nurses see something clinically worrisome and light a fire under us. We all went into this to save lives, and when someone is “sick,” we are on it as a team, whether there is a wait time billboard in front of our ED or not. And no matter what the time metric mandates, we know the “not sick” can wait.

    Let Us Do Our Jobs

    Sadly, the most educated people in the department are not always given the autonomy to triage how to best spend their time. Instead, clipboard-wielding pencil-pushers are imposing time constraints on EPs. Some of these time constraints are valid. I embrace the entire health care team sharing my sense of urgency about the critically ill. Time is myocardium, time is brain, and time is testicle. The golden hour of trauma and the golden hour for sepsis are premised on evidenced-based medicine. By all means, hold us to these worthwhile time constraints. We'd hold ourselves to them anyway.

    The 10-minute door-to-doc time constraint, however, is unreasonable. It is mind-blowing that after busting our butts all night, even saving a few lives, and still picking up new patients at 6:50 a.m., docs are told at 7 a.m., “Admin wants to know why wait time is 13 minutes.”

    We're already overachievers and want to keep up and please everyone. Sometimes, no matter how well we staff or prepare, it's just a busy shift, and demanding we see all patients in 10 minutes won't help that. It will only make us so preoccupied with moving on to the next patient that we barely focus on the one in front of us.

    Aside from violating emergency medicine's central tenet of triaging time and attention to the sickest people, the 10-minute door-to-greet metric is a logistical nightmare. Either we're trying to see patients in 10 minutes when they're in triage for 15, or we're seeing patients who have been dumped immediately into an exam room without any assessment for the sake of speed. ED processes are becoming so hasty that often we have done our H&P and rectal and are halfway through orders, and there are still no vital signs on the patient! Seeing patients without vital signs may be faster medicine, but it's not better medicine.

    “Sorry, you weren't immediately seen, but someone almost died here tonight. It took time to bring him back, so everyone else has had to wait” should be an acceptable apology. Unfortunately, we've created the expectation that everyone will be seen in the amount of time indicated on billboards, and now many people will accept nothing less.

    EPs are burning out faster than ever for the sake of billboard times. Sometimes we feel like bad docs because we have to hurry so much. If we rush through someone's care and miss an emergent medical condition and they go home and die, who is liable? We are. The suits who push time metrics aren't in danger of losing their medical license or living with the guilt of mishandling someone's health.

    Why are we EPs allowing nonclinicians to prioritize speed over more important aspects of patient care? It's time for EPs to take back the clock. We have a finite amount of time on each shift, and what we do is too important to let others dictate how we use it.

    We're not there to be at the beck and call of whoever decides to walk into the ED. We're not there for convenience. We're there to help those in crisis. Instead of rushing away from a bedside to meet a time metric, we should be able to stay a few extra minutes to make a difference for someone who truly needs us because that is what we're there to do. Let's get back to spending our time on what matters.

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