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Managing the Everyday Chaos of the Emergency Department

Coleman, Matthew

doi: 10.1097/01.EEM.0000424217.37837.1e

    Distraction and stress are not consequences of a busy shift in the emergency department; they are inevitabilities. And a day without a multitude of interruptions is almost like a day off, as many emergency physicians can attest.

    Thom Mayer, MD, the founder and CEO of BestPractices, the executive vice president of EmCare, and a professor of emergency medicine at George Washington University, has worked his fair share of shifts, and been interrupted more times than he can count. That volatile ED environment prompted him to develop strategies to organize the chaos, a topic he covered in a lecture during the American College of Emergency Physicians Scientific Assembly in October.

    “We are in an environment that intentionally or unintentionally disrupts us all the time,” Dr. Mayer said. “Here is the reality. We pride ourselves on multitasking, but it makes you stupid.”

    Multitasking, Dr. Mayer explained, leads to anchoring, which is a form of convergent thinking. And convergent thinking is the ability to give the correct answer to a question that does not require significant thinking. Multitasking “narrows our peripheral vision to complicated issues” that may require divergent thinking, Dr. Mayer said, the type of thought process employed to generate creative ideas or multiple solutions.

    “Is this how you want your pilot or surgeon working?” Dr. Mayer asked. “If you were a family in the ED, you wouldn't think multitasking is such a good thing.”

    Dr. Mayer suggested taking time to “pause, reflect, and reconsider” to combat multitasking. “The times when you are most stressed, when four nurses approach you with information, this is time when you have to pause, reflect, and reconsider,” he said. “One example is when you are about to write a diagnosis down. Think about this because no one can or will do this for you.”

    EPs should take time to care for themselves in addition to cutting back on multitasking, Dr. Mayer stressed. “Get plenty of sleep [at least six hours a night], exercise, drink water, bring meals and snacks, and enjoy the life you have and the ability to take care of patients,” he said. “Get your game face on and know what to expect.”

    Understanding what you face in the ED during your shift is vital to organizing the chaos, according to Dr. Mayer. “Do you have effective leadership?” he asked. “Is there teamwork, patient flow, and satisfaction? You may have a great team and you show up for a shift, and the chart nurse comes to you and says we are three nurses down, and you can slide back down.”


    How can you deal with this? Figure out which team is on staff, “huddle up, and say this is the team we have, and this is what we are going to work with today.”

    A healthy relationship with the nursing staff is vital, and the “psychological temperament of the ED is more on the EP than the nurse,” Dr. Mayer said. Emergency physicians should “know the nurses' names, practice patterns, and stressors. Express public praise, and ask them, ‘What can I do to make your life easier?’”

    Dr. Mayer also said each emergency physician must know his own tolerance for stress, including what it looks and sounds like when hitting the peak. He suggested asking partners or nurses to be honest about these hot buttons so they can be anticipated and avoided.

    He also advised EPs to be decisive, not count down a shift, create an expectation for the patient that can be expected to be achieved, and do personal signouts. And, of course, always focus on the patient. “Anything that puts you closer to the patient is a good thing,” Dr. Mayer said. “Anything that takes you away from a patient is a bad thing.”

    Comments about this article? Write to EMN at[email protected].

    Copyright © 2012 Wolters Kluwer Health, Inc. All rights reserved.