It’s 1am. My 12-hour shift ended an hour ago but I’m still in the hospital working on my incomplete charts. I’m exhausted and my brain is fried. I desperately want to go home and get a good night of sleep before returning for my shift tomorrow. However, leaving now means I will have to come back early tomorrow to finish my documentation before the start of my next shift. I take a deep breath and power through until the last chart is finally complete.
The early stages of burnout
I had only been out of residency for a few years but I was already starting to feel the effects of burnout. I found that I was beginning to feel cranky and agitated all the time. I would get depressed at the thought of having to go back to work. I would routinely spend an hour or more after each shift, or occasionally on my days off, completing my charts. I knew that this extra time spent on documentation was contributing to feelings of burnout that I was experiencing. “If I’m feeling like this after working for just a few years, how could I possibly sustain this for the next few decades?” I’d routinely ask myself. Realizing that this was absolutely not sustainable I committed to figuring out strategies that would allow me to leave my shifts on time with my charts completed.
Some things are out of your control
There are numerous factors affecting the throughput of patients in the emergency department but it is important to realize that many of these factors are out of your control. These include things like department space, staffing, sick calls, lab processing time, delays for imaging studies, etc. Todd Beel, MD, FACEP, notes that “fifty percent of efficiency is a systems issue.”1 While there’s always the option of joining the administrative team to effect change on an operations level, most of us would be best served to focus on the things that are within our immediate control.
Focus on the things you can control
I try to adopt this as a life philosophy but it certainly applies to the work environment. After accepting the fact that there will always be systemic issues related to department flow that I won’t be able to change I decided to figure out what I could do to improve my own efficiency and allow me to leave my shifts on time. Here are some of the things that I have found to be helpful in my own practice.
- Adopt a “pre-shifting” strategy – When I did my internal medicine rotation in medical school I was introduced to the concept of pre-rounding. This involves checking the newest test results, reading the most recent progress notes, and assessing your patients before rounding with your team. This allows you to be as prepared as possible for your presentation and help to streamline the rounding process. The better prepared you were, the smoother the rounds would go.
I refer to “pre-shifting” as the period of time just prior to the start of my shift that similarly allows me to mentally prepare for the work day. I allow around 15-20 minutes for this process. I use this time to grab some coffee and a snack, review the final results and studies from my previous shift, do follow-up calls with patients, clear my inbox, and take care of other tasks that I would otherwise try to squeeze in during the course of my shift.
Before adopting this strategy I noticed that the start of my shifts often followed a similar pattern. I would walk in several minutes before my scheduled shift and would immediately be pulled in multiple directions: the outgoing doc looking to sign out, the ED tech asking to get some EKGs signed, the charge RN notifying me of the cardiac arrest that is 5 minutes out, etc. The hunger pangs would start to kick in about 2 hours into my shift and make me deeply regret not arriving early enough to grab a bite before the shift began. Meanwhile, I’m ruminating about a patient I had seen the day prior and trying to figure out when I can find a few minutes to make a follow-up call.
As a medical student I was advised by one of my attendings to start each shift with “a full stomach and an empty bladder.” I think this is great advice but I would expand it and recommend that each shift should also begin with a clean mental slate. Minimizing the number of tasks that you need to complete and the number of times that you task-switch during your shift will allow you to better focus on the patients in front of you. Pre-shifting helps you accomplish this and ultimately leads to more efficient charting, quicker dispositions, and ultimately more effective use of your time.
- Minimize distractions and interruptions – Easier said than done, I know. A study by Chisholm et al2 found that physicians working in an emergency department were interrupted a mean of 31 times in 180 minutes. While it is impossible to eliminate all distractions and interruptions while on your shift there are steps you can take to minimize them. Do you typically do your charting in a workroom and find yourself getting sucked into work gossip? Find a more secluded place to escape to focus on your charting. Getting frequent calls from nurses to find out what the plan is for your patients? Speak with your nurses at the beginning of each patient encounter to discuss the plan up front. Pay attention to the most common distractions that you encounter on a typical shift and figure out ways to minimize or eliminate them.
- Delegate when possible – There are certain tasks that only you, as the provider, can do. I consider these to be the essential tasks. These include things like charting, placing orders and discussing patients with consultants. The greater the percentage of your shift that you spend on these tasks the more efficient your work will be. This is something that I have struggled with in the past. With the intention of trying to expedite patient care I would often find myself transporting my patients to X-ray, putting in IV’s, etc. While performing these tasks on your own may speed up the throughput for that particular patient, keep in mind that every minute spent on a task that could be done by another staff member translates into another minute that could otherwise have been spent completing your essential tasks.
- Chart more efficiently – Of all the factors that can impact your work efficiency this is the one that will likely be the most impactful for the majority of providers. Whether you love or hate them, electronic medical records (EMRs) are here to stay. While it’s easy to get bogged down in the endless number of checkboxes and compliance regulations that accompany EMRs there are numerous ways to harness the power of these systems to not only make your charting faster but more accurate as well. From utilizing autocorrect dictionaries and building macros to using scribes or voice dictation to speed up your charting, there are numerous tools and strategies you can take advantage of to not only lessen the burden of EMRs but to also actually use them to your advantage.
- Complete charts in real-time – You just finished seeing a patient and would like to sit down to write your HPI while it’s fresh in your memory but you see that there are 10 new patients waiting to be seen. Do you begin charting on the patient you just saw or start seeing new patients and postpone the charting until later?
While everyone needs to determine the workflow that best suites them I’d argue that in most cases you are better off writing the chart as soon as possible after having seen the patient. Have you ever left your charting until the end of your shift and then found yourself mixing up the details of different patients you had seen that day who had presented with the same chief complaint? I would guess that my charts take 50% longer to complete when I leave them until the end of my shift because of this extra time spent trying to recall the details of each case.
By doing your charting in real time, immediately after seeing the patient, not only do you save the time that would later be spent trying to recall the details of the case but you will likely include important details that may have been forgotten completely. Charting as soon as possible after a patient encounter not only results in faster documentation but it also results in the most accurate documentation.
- Batch tasks – Before getting up to go reassess your patient, ask yourself, “what else can I do while I’m walking through the department?” Are there other patients you could reassess as well? Do you need to speak with a nurse about repeat labs that need to be done? Frequent laps around the department may allow you to burn more calories but it certainly doesn’t help with your work efficiency.
- Minimize “multitasking” – As much as we like to pride ourselves on our ability to juggle multiple tasks simultaneously while on shifts, a study by Skaugset et al3 shows us that we often aren’t multitasking after all, but rather task-switching. Cognitive load theory tells us that you have a limited amount of working memory available at any given time and that the less cognition that is required for a given task, the more things you can fit into your working memory. Be conscious of the interruptions in your tasks that take place while on shift and think of ways to minimize them. These strategies may include creating lists of tasks that need to be completed in the future, following checklists when performing procedures, and finding a place to document where interruptions will be less likely.
- Initiate dispos ASAP – As soon as you have seen a new patient you should be immediately thinking about their ultimate disposition and determining the information that you will need to make that disposition. To borrow advice from the efficiency master Stephen Covey, “begin with the end in mind.”4 Order all necessary studies up front. If you know that a consultant will need to be involved, contact them early. If there are pending studies for a patient who you know will need to be admitted to a particular service regardless of the test result, contact your inpatient colleagues to let them know about the admission and the pending studies. The cognitive unloading that occurs with each disposition allows us to more effectively use the limited working memory that we have available at any given moment, allowing us to work more efficiently.
Start working more efficiently
My purpose for writing this post is not to help you find ways to cut corners at work or to sacrifice patient care in order to leave your shift on time. The goal is to provide the excellent patient care and documentation that you normally would but in a way that is as efficient as possible. I challenge you on your next shift to begin implementing some, or all, of these strategies. Which do you find the most helpful? Which strategies of effective working have I left out?
- Chisholm CD, Collison EK, Nelson DR, et al. Emergency department workplace interruptions: are emergency physicians “interrupt-driven” and “multitasking”? Acad Emerg Med. 2000;7:1239-1243. 4. France DJ, Levin S, Hemphill R, et al. Emergency physicians’ beh
- Skaugset, LM et al. Can you multitask? Evidence and limitations of task switching and multitasking in emergency medicine. Ann Emerg Med. 2016 Aug;68(2):189-95. PMID: 26585046
- Covey, Stephen R. The 7 Habits of Highly Effective People: Restoring the Character Ethic. New York: Free Press, 2004. Print.