JOHN SHUFELDT, MD, JD, MBA, FACEP
Over the years, I have worked with a variety of providers who exhibited significantly disparate skill levels in their ability to manage patient flow. Practicing good medicine is a given; some have been amazingly intelligent providers who make House look like a PG1 psychiatry resident from a non-accredited medical school. Their only downside was that they were pathetically slow, or communicated at the level of a mollusk.

Effective and efficient providers share the ability to communicate, to work efficiently in a team environment, and to multitask—all while rapidly identifying and solving the problems of large and varying acuity patient loads.

Such efficiency is highly respected, yet rarely taught, and can actually improve the care you administer and, thus, help minimize your liability exposure. Greater physician efficiency leads to improved patient satisfaction; better patient flow (patients/hour) diminishes wait times.

Improved efficiency also cuts down on wasted time (and its energy-draining properties), allowing more time to focus on seriously ill patients and reducing the risk of medical errors. Finally, enhanced efficiency goes hand-in-glove with improved teamwork and increased employee satisfaction. This, in turn, leads to lower turnover and an overall more positive workplace. Enhanced efficiency can be attained by focusing on three specific strategy categories: physical, cognitive, and patient disposition.

 
Physical Strategies
Carry the appropriate gear. You don’t need to be outfitted like a SWAT team member, but you should have the “obvious” gear close at hand: stethoscope, pen, trauma shears, and eye protection. You can also use your shears or stethoscope end as a reflex hammer. In addition, keep in mind three key words before each patient encounter:

  • Document. If you are using an EMR, bring the computer tablet into the room with you, as you would a paper chart, for efficient reference and This also makes the patient believe that you have their data close at hand.
  • Complete the record while talking to the patient and explaining the treatment plan. In other words, multitask. Listen while writing or typing.
  • Ask the patient if they have any additional questions before you exit.

Use technology effectively. We all know how frustrating it is to hear a patient say, “I don’t what they said or what they put me on.” Don’t make a patient’s primary physician suf- fer the same fate. Have electronic, modifiable discharge summaries and follow-up instructions on hand to send home with the patient.

PDAs allow point-of-care searching for interactions, drug doses, and procedures. Newer models may include a digital camera suitable for medical photography. Resist the temptation to abuse such technology, however; recently, a fifth-year surgical resident at the Mayo Clinic used his PDA to snap a picture of a patient’s penis with the phrase “HOT ROD” tattooed on it, then sent the pictures to his friends. He is now available to cover urgent care shifts, if you need some help. In-house laboratory investigations can also streamline your time with the patient. Having the results of urinalysis, CBC, and other tests on the chart prior to entering the exam room will allow you to make a one-stop disposition.

Choreograph your movements. Think of the water-ballet scene in Caddyshack; choreograph group tasks, and plan your route through the center. If standing orders are used, first review diagnostic imaging, then evaluate lab results, then see the patient.

Similarly, learn to multitask and minimize the time you spend waiting on various processes. While the laceration you just anesthetized is being irrigated, see a patient and dis- charge the one waiting after medications were given.

Focus. Communicate to all members of the urgent care team situations in which you “allow” interruptions. Personal cell phone calls while in the nursing station or exam room  are unprofessional. Treat even acceptable interruptions as red flags—warning signs that your clinical reasoning is in peril of distraction or derailment. “It fell through the cracks” is kind of like “My neighbor’s dog told me to kill the people” as a defense in a malpractice suit.

Recognize biological limitations. Consider the impact of proper hydration and nutrition in maintaining your optimum performance. I eat Balance Bars throughout the day as op- posed to breaking for meals; this way, at least I have some “balance” in my life.

Similarly, plan breaks. Brief windows of time to attend to basic needs may help you recharge and refocus. Do so responsibly, however; I had one former clinician who went out- side to hit golf balls between patients not a career enhancing move!

Cognitive Strategies
Visualize your timeline. See, in your mind, the current group of patients moving in concert through the process. Frontload ancillary services when necessary. Empower triage and other teammates to initiate treatment. Off-load your clerical and administrative tasks when  appropriate Consider the patient’s plan. Recognize and seek to under- stand the patient’s (and the family’s) agendas. There may be overlapping motives of fear, pain, and basic needs.

When I am getting nowhere with my history, I occasionally ask, “What would you like to accomplish during today’s visit?”

Coordinate tasks chronologically. Time your patients so that rate-limiting activities like wound irrigation, anesthetizing a wound, packing a nose, draining an abscess, obtaining cultures, etc., occur during what would otherwise be waiting times.

Be cognizant of “business hours.” Keep in mind availability of consultation services, diagnostic services (e.g., ultra- sound) and other healthcare professionals at various hours of the day and night.
Maintain your index of suspicion. Beware the high-risk misses: pulmonary embolism, acute coronary syndrome, missed or retained foreign body, occult fracture, lung mass, appendicitis, stroke, subarachnoid bleed, meningitis, is chemic bowel, and acute-angle closure glaucoma. I sometimes have to remind myself that just because someone comes to an urgent care does not mean that they are not hiding something insidious.

Maintain flow. If all patients are stable, initiate simple cases before engaging more complex ones. For example, dilate the eye for the retina you need to visualize, anesthetize the laceration you plan to close, then initiate your assessment of the 92-year-old patient complaining of feeling “weak and dizzy” for the past decade.

Disposition  Strategies
Set the stage at the initial encounter. Prepare patients for your planned disposition (e.g., “This is what will happen if the tests are negative and you are well enough to go home…”). Recognize the inevitable disposition early on; an elderly patient who cannot walk and lives alone requires transfer and admission to an inpatient unit. Initiate this process as soon as you recognize the need.

Strive to make a decision regarding disposition within the first 30 minutes. This starts with recognizing the limitations of the urgent care setting; we provide episodic acute and semi- acute care to our patients. Enable a diagnostic strategy that provides you with the information you need (i.e., only the critical information) to make a timely decision. Beware of asking a patient a question if you do not want to deal with the answer.

Prepare for consultations. When communicating with a consultant, within the first minute provide:

  • the bottom line (i.e., level of acuity: “I have a sick pa- tient who has a PE”)
  • a short patient profile (“38-year-old obese smoker on BCP with dyspnea”)
  • your clinical impression (“their d-dimer is positive, I think they have a PE”)
  • what the patient now requires (“I am going to send them to you for a spiral CT”).

Be flexible. Your ability to deal with nuance changes with the patient volume. Remember, patients pay our salaries. Treat them like they are handing you money, because they are.

Limitations
These elements of performance have not been subjected to quantitative research. Rather, these clinical pearls represent more than 20 years of “experience-based medicine.” One of the benefits of experience is gaining awareness of when and where you can safely “cut” corners to gain efficiency with- out increasing error.
At the end of the day, efficient care combined with excel- lent communication and customer service are the hallmarks of a successful and profitable urgent care center

Strategies on Responding to Variable Patient Acuity and Flow

John Shufeldt, MD, JD, MBA, FACEP

Chief Executive Officer at MeMD, LLC, Mentor and Author at Outliers Publishing, Principal at Shufeldt Consulting, Founding Partner of Shufeldt Law Firm
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