Quick Tips with Dr. Marc Milano

By Marc Milano, MD, FACEP78463787_15

Topic: Patient Satisfaction

As a physician in the ED you are in continual struggle to provide the finest care but deliver an expected level of efficiency. The clock is always ticking in the emergency department and every second you spend, or fail to spend, with the patient is counted toward their impression of you and your performance on the survey.

Patient satisfaction relies on many factors. Clear communication, compassion, and good medical practice form the cornerstones of success. Below are some helpful tricks to bend the perception of time, increase efficiency and give the patients what they want most – a physician’s attention.

Thin Slicing: One way of increasing patient satisfaction is by decreasing room-to-physician times.  A technique that can shorten the time to “first contact” is the thin slicing technique. Simply put, an introduction, followed by a brief, focused history and exam with the promise to return later allows you to see several patients in rapid succession. This way the next patient isn’t waiting for you to complete an extensive evaluation on the previous one. This works especially well if you have several patients to see at the beginning of your shift.

The Pit Stop: When seeing “new” patients, especially given the geography of a large ED, try to quickly stop by and catch up with “old” patients in the same area.  Simple, focused questions like, “How is your pain?” or “Are you doing OK, drinking the contrast for your CT?” will keep the interaction brief.  This saves time and can really score big in terms of patient satisfaction.  It lets patients know that you are on top of things and also gives you a chance to discover any issues or problems early on.

These are just a couple of examples of how simple techniques can have a significant effect on the patient experience–and maybe even make your shift go more quickly and smoothly!

Marc A. Milano, MD, FACEP, is chief of the department of emergency medicine at Bayshore Community Hospital in Holmdel, N.J.  He serves as physician head coach of the Patient Satisfaction Coaching Program at Emergency Medical Associates, an emergency medicine practice headquartered in Parsippany, N.J. Dr. Milano received his undergraduate degree from Rutgers University, his medical degree from St. George’s University in Grenada, and completed his emergency medicine residency at Newark Beth Israel Medical Center.

The Value of Emergency Medical Associates

By Shilpa Amin, MD, FACEP EMA_Eonly

When Emergency Medical Associates (EMA) is integrated into a hospital system, we ensure the highest standards of service on many different levels. EMA was founded in 1977 and has grown into a practice that’s taking the lead in various areas, including practice models, patient satisfaction, EMRs and using medical scribes. As a partner of the company, I’m proud that we’ve been named to Modern Healthcare’s Best Places to Work in Healthcare list for three years. In fact, EMA is the highest-ranking medical management company on the current list.

So how did we come so far? Below are my thoughts on how we accomplish the high goals set by the partnership.

Democratic Partnership: EMA is a rare practice in that it’s truly a physician-led and owned practice. Our physicians govern the company and set the goals yearly for the practice. All our partners have a voice and vote in the company. Our 97 percent retention rate speaks to how we create a culture where physicians can grow and find satisfaction throughout their EM careers. We have initiatives in place to help develop young leaders. We provide many opportunities for our partners to contribute to the company, whether it is a director of an ED, by joining a committee or even becoming a board member and helping run the business side of company. We are closely linked with the New Jersey chapter of the American College of Healthcare Executives (ACHENJ) and one of our corporate directors will assume the role of president of the chapter this spring.

Pioneering EMR and Scribes: EMA created a boutique electronic medical record, EDIMS, which stands for Emergency Department Information Management System. This program was created for and by practicing emergency medicine physicians, who worked along with a team of both IT and risk management contributors. This technology has allowed us to track and trend the patient data that we have collected over the years to develop research projects. Our practice also was among the first to use scribes in the ED.  Our comprehensive scribe training program enables scribes to work closely with providers to ensure timely reporting of labs and radiology reports and ensure efficient chart completion. Our scribes are an integral part of our team and help decrease length of stay in the emergency department.
Client Account Managers (CAMs): Each EMA site is assigned a client account manager to help with day-to-day operations in the ED. Our CAMs are former nursing or ED administrators who have a wealth of knowledge about increasing productivity and efficiency in the ED. They serve as key liaisons between our practice and the hospital.

Operational Metrics: At times it seems like we analyze everything! We have an amazing practice management team at our corporate headquarters that evaluates data and practices to find new ways to improve ED operations. We measure a variety of outcomes; including door-to-provider time, door-to-discharge time, and admission-order–to-floor time, just to name a few. We consistently review these metrics during our monthly business meetings to discuss ways to improve these times.

Observation Units: EMA works closely with hospital administration to improve patient throughput and patient satisfaction. At one site, the team noticed that patients were waiting in the ED for chest pain observation, abdominal pain radiologic and consultant evaluations and TIA neurological testing. Often, these patients occupied beds that could’ve been used for patients waiting to be seen in the ED waiting room. The medical director approached the hospital’s administration about creating an observation unit that would function as an extension of the ED. Our physicians would continue to care for these patients and would work closely with the medical staff to ensure proper testing and evaluation was conducted for the patients. Once evaluated, patients would be discharged or admitted from the observation unit. The hospital’s administration consented, and this observation unit continues to be one that other EDs use as a model.

Community Outreach: Our physicians consider themselves a part of the hospital, and by extension, a part of the community that the hospital serves.  Our clinicians contribute to hospital boards, committees and lectures. They participate in various hospital functions, such as fundraising events, galas and golf outings. Our physicians often speak to local and national news media. Many of our physicians take part in medical missions, most recently traveling to Haiti and Mexico. And, our partners participate in educational forums with local EMS, teaching EMTs about various disease processes and how to improve pre-hospital care.

Regional and National Chapter Involvement: All EMA physicians belong to ACEP, SAEM, AAEM or ACOEP . One of our partners, Michael Gerardi, MD, is the president-elect of ACEP. Our President and CEO, Ray Iannaccone, MD, was the Chairman of Democratic Group of ACEP. We truly understand the importance of these chapters and associations and their efforts to improve emergency medicine as a specialty. Our partners are involved in many committees and sit on various boards of these national groups.

Hospitalist Programs: Often times when the hospital administrators approach EMA to run the ED, we are tapped to provide additional services. Such was the development of our hospitalist and house physician program. EMA provides hospitalist services at six hospitals. The team approach of having the same company run the ED and hospitalist program has allowed for smoother transitions during admission and decreased length of stay in the ED.

After nearly 40 years in emergency medicine, our practice fully understands how an ED functions in relation to the rest of the hospital and the department’s importance within the community. Our physicians are committed to building long-standing relationships with each hospital and the communities that they serve. We have set the bar very high and expect only the best medical care from our team.

Shilpa Amin-Shah, MD, FACEP, is a full-time attending emergency physician at Saint Barnabas Medical Center in Livingston, N.J. Dr. Amin is also the Director of the Physician Recruiting Team with Emergency Medical Associates, Parsippany, N.J. She received a bachelor’s degree from Rosemont College in Rosemont, Pa., and her medical degree from SUNY Downstate, Brooklyn, N.Y. She completed the Jacobi/Montefiore Emergency Medicine Residency Program at Albert Einstein College of Medicine and served as chief resident. She enjoys spending her free time cooking, traveling and trying new cuisines with her husband and two young children.

The Perks of Being an Urgent Care Physician

By Kurt Perry, MDIMG_3548

A short while ago, when I was working full-time in the emergency department of our local hospital, we would get those days when it seemed we just could not keep up with the flow of patients. In between evaluating a chest pain patient for a possible heart attack or a patient struggling to catch her breath, a chart would pop up in the queue for someone with a scratchy throat and cough or a rash that had been present for months. A collective sigh would go out with thoughts of: “Why is this an emergency?” or “Can’t people see that we’re busy caring for those whose lives are in danger?” Yes, we understand that you also don’t feel well, but can’t your primary care doctor take care of this problem?

Well, unfortunately the answer often is “no.” Either the patient has no private physician, or no insurance, or has called her primary care physician’s office and has been told that the doctor is booked and can’t see her until next week. All of which leads her to go to the place of last resort; the safety net of the American healthcare system, the place where no one is turned away, where everyone will be seen eventually, the emergency department.

Likewise, primary care physicians are increasingly busy caring for the chronic health problems of an aging population and have difficulty squeezing in even someone with a minor emergency. And with the Affordable Care Act (“Obamacare”) now in effect, the demand for primary care physicians is expected to increase dramatically as the previously uninsured receive coverage. And so it appears that a niche is developing in the healthcare industry to provide a place for the treatment of minor emergencies — the urgent care center. One need only look around at the number of these facilities starting up to see that there’s a demand for this type of service. And who better to staff these centers than emergency physicians?

The Advantages of a Career in Urgent Care

Unlike working in the emergency department where shifts vary day by day, working in an urgent care center allows for scheduling stability. Whether you are preparing for a family or for retirement, a career in urgent care can provide the stability your lifestyle requires.

While working as emergency physician, doctors are faced with new challenges every day. They work with patients of varying ages and ailments. Their need for change is constantly fulfilled. Urgent care can provide that same variety. From infants to teens to adults to seniors, working as an urgent care physician allows doctors to see a broad range of patients and treat a broad range of ailments from the common cold, broken bones and lacerations to performing physicals and administering vaccinations.

With urgent care centers gaining popularity, the need for physicians to staff the centers is increasing too. Steady hours, variety and more time to spend with patients make working as an urgent care physician a perfect choice for any physician. Keeping up on suturing skills, treating patients in a less stressful environment and developing a stronger bond with patients are just a few of the reasons emergency physicians enjoy working in the urgent care sector, and in our practice, Emergency Medical Associates, a portion of our partners take shifts at local urgent care centers. Some will decide to stay.

I loved working in the emergency department; it’s where I honed my practice and gained the knowledge and experience that shapes my practice today. But now as a full-time urgent care physician, I am equally challenged and fulfilled – but with better hours!

Kurt Perry, MD, joined Emergency Medical Associates in 1997. He is board-certified in emergency medicine and a 2013 New Jersey Monthly “Top Doctor.”  He completed his residency at Monmouth Medical Center, Long Branch, N.J.

Simple Tips for Staying Healthy in the Emergency Department

By Megan McGrane, PA picture for blog

We all know the basics of staying healthy while working, such as good hand washing and appropriate safety precautions. But sometimes while focusing on taking care of others, we forget to take care of ourselves. Here are a few super simple tips to staying healthy while working in the emergency department.

Don’t Forget to Eat

It can be difficult during a busy shift in the emergency department to find time to fit in a full meal. Often times we are so busy that we don’t have the chance to eat until we are ravenous and reaching for anything we see. Grabbing a quick snack out of the vending machine may be easy, but coming to work prepared with healthy options can help prevent the ravenous munchies and keep you on track and energized.
Healthy snacks, such as raw nuts or trail mix, an apple or banana with nut butter (like peanut butter or almond butter), or a quick snack like “roll ups” made of cold cuts, lettuce and cheese, can give you energy and keep you feeling full through your shift. These easy snacks also will help you avoid empty calories from candy and treats that will give you a sugar rush but leave you crashing later in the day.


Sometimes even mild dehydration can leave us feeling fatigued. Staying hydrated can play an important role in helping you feel energized on the job. Try “swapping out” your coffee or soda periodically; when you feel yourself reaching for a caffeinated drink, try downing a cool glass of water instead and watch as your energy bounces back.

Take a Walk

Taking a 20-minute walk outside is one of the best things you can do for your health, either before or after a shift. Getting sunshine and fresh air also is one of the best ways to help regulate your circadian rhythm when shifting between day and night. A brief walk can help ease stress, improve circulation and boost immunity. Easy, right?

Consider a Multivitamin

As medical professionals, we find vitamins and supplementation can be quite a hot button issue. Experts agree that if you are eating a balanced diet and are in generally good health, a multivitamin is unnecessary. However, when we really get honest with ourselves, how many of us sit down for “three square meals” filled with fresh fruit, veggies and lean protein during our shift work? Consider taking a high-quality multivitamin each day that includes vitamin D. During shiftwork, especially in the winter months, we may not get quality sunshine or eat the freshest high nutrient food as we do in warmer months.  A multivitamin can help fill in those nutritional gaps and keep us up and running.

Practice Stress Reduction Techniques

The emergency department can be a stressful place. Learning a few simple stress reduction techniques like deep breathing or even meditation can have an amazing impact on your health. Meditation can help you lower stress, lower blood pressure and sleep better. The simple technique of stepping aside or going to an empty room and taking 10 quiet, slow, deep breaths can help you reset your mindset in a moment while on the job. This simple act can improve your mental clarity while lowering your stress level.

In the emergency department, our focus is always on our patients. Their health is our primary concern. We skip eating, exercising and hydrating to provide them with exceptional care. Remembering to take care of ourselves first will help ensure a longer career of taking care of patients.

Megan McGrane is a full-time physician assistant at Saint Barnabas Medical Center in Livingston, N.J. She received a bachelor’s degree and a master’s degree in exercise physiology from the University of Pittsburgh and holds a second master’s degree from University of Medicine and Dentistry of New Jersey, Piscataway, N.J. She is a member of the American Academy of Physician Assistants.

7 Tips for Residents When Evaluating an Emergency Medicine Practice

By Shilpa Amin, MD, FACEP

Blue CheckmarksFall is here, and recruiting season is in full effect for graduating and, in some cases, junior residents. As you start your search for the perfect job in emergency medicine, keep in mind that one-third of you are likely to change jobs after your first year of practicing. That’s perfectly fine, because in most locations there are more jobs than there are available EM doctors.

As the director of our physician recruiting team, I have met hundreds of residents, and it seems that most of you have the same concerns. Just in time for ACEP’s Scientific Assembly, I’ve created the following questions and tips to help ensure that your interviews go smoothly, and, if you’re presented with an offer or two, that you compare the offers equally.

  1. LOCATION, LOCATION, LOCATION! Where do you want to be? If you can’t find a full-time job in the exact ED you want to be in, try working at two or three hospitals in that region until a full-time position opens. This will enable you to work in different practice settings and help you determine your true fit. Maybe you thought you really wanted to be in the busy trauma center because that’s what you’re used to from your residency training, but after working in a community hospital, you may find more professional satisfaction in that environment.
  2. YOUR PRACTICE: What type of practice setting do you want? There are several different types, from hospital employee to democratic group to independent contractor. You should evaluate each practice type from a personal and financial standpoint. You really need to understand this aspect clearly as it may frame the rest of your career.
  3. CAREER: What are your aspirations? Do you want to work in an environment that promotes advancement in your career or do you want to be able to just complete your shifts and go home? It’s a personal choice and you don’t have to make the decision right now. You need to know what your options are. If you are in interested in an administrative career, you should ask about these types of opportunities when you go on your interview. Additionally, ask about the opportunity for mentorship.
  4. SCHEDULE and VACATION: Be sure to ask what the required hours per year are to be considered full time. Ask if there’s a part-time option or track. Ask how the hours per year really work: Are you required to complete a certain number of hours per month? How does vacation work? Is there online web-based scheduling? Find out if because you’re the new kid on the block, that you’ll be working a disproportionate number of nights, weekends and holidays. You should ask to see a copy of the schedule when you go on your interview.
  5. QUALITY OF SHIFT: What tools are available to help you when you are working? Will associate practitioners work alongside you to help close that complicated laceration so you can keep the ED moving? Does the ED have scribes and an EMR? Can you complete your charts from home? Do you have access to support staff who can help you attain your medical license and get you on staff at the hospital?
  6. SALARY AND BENEFITS: You need to review this in detail. How is your pay determined? Is it a flat hourly or based on some measure of productivity? How is professional liability insurance provided? Is the tail included? Ask about retirement and 401(k) accounts. Is there a financial advisor available to talk to if you have questions?
  7. TEAMWORK: As an ED physician you are used to leading a team of residents, nurses, PAs, techs, etc. Your team when you are an attending physician is very important. When you go on your interviews, make time for a shadow shift. Take time to talk to the other physicians, APs and nurses. Note how they work together when a critically ill patient is in the ED. You want to be comfortable signing out a patient and feel confident that they’ll receive the same meticulous care you would have provided. Ask about the ED relationship with the hospital attending staff. What specialties are represented? Are they responsive to the ED?

Meet Dr. Amin Shah and other contributors to this blog at Booth 1333 at the 2013 ACEP Scientific Assembly in Seattle!

Shilpa Amin-Shah, MD, FACEP, is a full-time attending emergency physician at Saint Barnabas Medical Center in Livingston, N.J. Dr. Amin is also the Director of the Physician Recruiting Team with Emergency Medical Associates, Parsippany, N.J. She received a bachelor’s degree from Rosemont College in Rosemont, Pa., and her medical degree from SUNY Downstate, Brooklyn, N.Y. She completed the Jacobi/Montefiore Emergency Medicine Residency Program at Albert Einstein College of Medicine and served as chief resident. She enjoys spending her free time cooking, traveling and trying new cuisines with her husband and two young children.

Tips for Getting to the Heart of Each Patient’s Complaint

By Marc Milano, MD, FACEPblog

We are at the front line of medicine. In fact, in many of our hospitals, the majority of admissions come through the emergency department. And in some cases, up to 90 percent of patients who are admitted begin their care in the emergency department. This gives us an opportunity to have a huge impact on the trajectory of their care. But it also lets us set the tone for the rest of their experience of that care.

Hospital Care Quality Information from the Consumer Perspective (the Hospital Consumer Assessment of Healthcare Providers and Systems or HCAHPS) scores are publicly reported, and they are being progressively linked to hospital reimbursement. For these reasons, it is imperative that we begin to shape the patient’s perception of care from the very beginning of the episode.

The following tips are focused on getting to the heart of each patient’s complaint quickly and tactfully. Using these strategies, you will be able to rapidly assess the patient’s concerns so that you can begin to address them early on.

The (Sometimes) Hidden Agenda

I remember hearing a wise and experienced nurse manager once say, “Patients in the ED have come here because they have just had enough.” It is our job to determine exactly what it is they have had enough of. Sometimes it is obvious, like the pain of a kidney stone. Often, however, the answer is more subtle. Maybe they have had enough of their daily headaches or back pain. And it’s always possible that they’ve had enough stress from work or life, or maybe enough of being ignored by friends or family.

If you ask open questions and behave in a non-judgmental way, patients are more likely to open up and let you know their real concerns. A good way of approaching this is to ask, “I know you have had this problem for quite a while. What was new or different about it that caused you to come in today?” Let patients know that the more information they provide, the better chance you will be able to provide the best care. This is an effective way to improve a patient’s experience, which will translate into favorable scores and comments on the surveys–which will translate into a good day for the CEO and a long career for you

The “Inner” Voice

The following list is a guide to not letting your “inner voice” come out. We all want to ask these questions but nothing good can come from them, so here is the “Don’t ask why” list:

  • Don’t ask why they haven’t seen their PMD about this problem already
  • Don’t ask why they came back to the ED for the same problem…again
  • Don’t ask why this couldn’t have waited until tomorrow. or next week, or…
  • Don’t ask why they didn’t take the Tylenol at home
  • Don’t ask why they did something inappropriate or reckless to cause this problem.

Again, we are all thinking about these questions, but we can use more tactful ways to get answers to them.

It is our responsibility to the patient, the hospital and the healthcare system to provide a healing environment and create a therapeutic relationship. Kindness, understanding and addressing the hidden agenda are key elements in achieving those goals.

Marc A. Milano, MD, FACEP, is chief of the department of emergency medicine at Bayshore Community Hospital in Holmdel, N.J.  He serves as physician head coach of the Patient Satisfaction Coaching Program at Emergency Medical Associates, an emergency medicine practice headquartered in Parsippany, N.J. Dr. Milano received his undergraduate degree from Rutgers University, his medical degree from St. George’s University in Grenada, and completed his emergency medicine residency at Newark Beth Israel Medical Center.

Residents Retreat

By Michael Silverman, MD, FACEPEMA, Save the Date Postcard 2013, UPDATED(m)

As a seasoned physician, I take great responsibility and pride in shaping the careers and professional lives of residents. There is a world outside the hospital and emergency department walls – a world of enrichment that is vital to the success of residents. Academic conferences are one of the best ways residents can retreat from the hospital yet continue to enhance their careers.

The 11th Annual Advanced Emergency and Acute Care Medicine Conference held September 17-20 in Atlantic City, N.J., is the perfect opportunity to learn and network with other physicians. The following are my top five reasons that residents should attend this conference.

1. Great Educational Content and Nationally Recognized Speakers. Very few regional conferences bring to the table the name recognition of these nationally renowned speakers, who bring educational content comparable to that of a national-level conference. The broad range of emergency medicine subject matter and cutting-edge information is like having the Olympics of Grand Rounds speakers over a three-day period.

Speakers from the American College of Emergency Physicians (ACEP) board of directors include:

  • Andrew Sama, MD, FACEP, President of ACEP
  • Michael Gerardi, MD, FAAP, FACEP, Vice President of ACEP

Nationally renowned research experts and lecturers at the conference include:

  • Fredrick M. Abrahamian, DO, FACEP, FIDSA from UCLA
  • Christopher Amato, MD, FAAP, FACEP, Director, Pediatric Emergency Medicine Fellowship Morristown Medical Center, Morristown, NJ
  • Richard Cantor, MD, FAAP, FACEP, Professor, Emergency Medicine and Pediatrics, SUNY Upstate Medical University, Syracuse, NY
  • Douglas L. McGee, DO, FACEP, Einstein Medical Center, Philadelphia: Chief Academic Office, Einstein Healthcare Network
  • Frank Peacock, MD, FACEP, Associate Chair and Research Director, Baylor College of Medicine, Houston, TX
  • Charles V. Pollack, Jr., MA, MD, FACEP, FAAEM, FAHA, FCPP, University of Pennsylvania Health System
  • Alfred Sacchetti, Jr., MD, FACEP, Chief, Emergency Services, Our Lady of Lourdes Medical Center, Camden, NJ
  • Richard Shih, MD, FACEP, Director, EM Residency Program, Morristown Medical Center, Morristown, NJ

2. Procedural and Airway Skills: Leaders in the field will review and demonstrate advanced techniques in airway management, dental blocks and ultrasound-guided central line placement. This allows residents to meet experts and learn procedures and techniques that may be taught differently than at their residencies. Learning hands-on from a variety of academic experts is a great way to expand your skill-set for those challenging patients.

3. Job Opportunities: Part of a career in medicine is the job search. This conference allows residents to meet staff and leaders in the field of emergency medicine and possibly be introduced to practice opportunities. Meeting physicians from different local groups is an opportunity to start or expand their job search.

4. Local Networking and Career Opportunities: Beyond providing potential employment opportunities, the conference allows residents the chance to meet, speak and spend time with leaders in emergency medicine. Many of the conference’s lecturers are available during breaks and in the hospitality suite to discuss career options beyond the job search. Local and regional ED directors and career specialists in fields ranging from ultrasound to hyperbaric medicine to toxicology to pediatric EM are at the conference and are great resources to discuss your career path.

5. Physician Wellness: Physician wellness has become a hot topic in resident education. Residents work hard and need to take time out for wellness. What better way to promote wellness than spending time with colleagues in Atlantic City, where you have relaxation, fine food and esprit de corps?

These opinions are the opinions of Dr. Silverman, and may not reflect the opinions of Emergency Medical Associates or of Morristown Medical Center residency program.

Michael Silverman, MD, FACEP, joined Emergency Medical Associates in 1999. Dr. Silverman is a member of EMA’s Board of Directors and the assistant residency director in the Emergency Department at Morristown (N.J.) Medical Center. He is a diplomate of the American Board of Emergency Medicine and is a fellow of the American College of Emergency Physicians. He is a member of the New Jersey Chapter of the American College of Emergency Physicians and is the president of the NJ section of the Delaware Valley AAEM chapter. Dr. Silverman received his medical degree from New York Medical College, Valhalla, N.Y. He completed his residency at the Medical Center of Delaware at Christiana Care, Newark, Del. Dr. Silverman also is board-certified in internal medicine and undersea and hyperbaric medicine



A Numbers Game: Using Mathematical Theories to Better Predict – and Staff for – Fluctuating ED Volume

By Phillip M. Stephens, DHSc, PA-C       Traffic-congestion[1]

Understanding overcrowded emergency departments is an elusive exercise, but an important one. Emergency department managers are coming to understand it is largely a math problem, with concepts like “capacity over demand” appearing in current literature. But the constructs still are not widely implemented. Higher math applied with dynamic rather than static applications is the best utilization of these mathematical models, and we must educate managers about these new paradigms. What are these new ways of analyzing flow?

Analyzing Throughput

A decade-old conceptual model describes analyzing the problem by input, throughput and output methodologies. But even these models lack the arithmetical power to convey the necessary meaning.

The unique formulas of game theory proven by mathematician John von Neumann and applied by professor John Nash , which are used to understand scenarios of conflict and cooperation, are more appropriate, as human behavior, however difficult to measure, must be factored into any equation. Personal interactions, with their substantial effects on ED patient flow, are simply more complex than the literature suggests.

Consider our local emergency department designed for around 200 patients in a 24-hour period. Typically, this number is often exceeded. But even when it is not, wait times are unpredictable. Why?

Understanding Unpredictable Wait Times

With a 40-bed capacity, a 200-patient per day demand requires each bed to be turned over 5 times during a 24-hour period – or every 4.8 hours. That seems like a reasonably achievable goal, but rarely is the department able to function at exactly 100% capacity, and there the problem begins.

Typically, the department is functioning at between 40 and 60 percent of capacity. To simplify the math, let’s assume an average of 50% capacity, meaning half the beds are being used for boarding. Boarding is a national problem best understood as a facility-wide issue, but typically treated as solely an ED problem. It’s a huge mistake to approach boarding departmentally rather than system-wide–but that’s another discussion. Today we are just doing math, not psychology.

At 50% capacity, the department is down to 20 open beds that now must be turned 10 times in a 24-hour period or once every 2.4 hours. The impact of the boarding problem on efficiency is then clear, substantial and pervasive. But again, this is overly simplistic. Managers tend to understand the construct to this point but ignore the even more pervasive influence of variation. Understanding variation requires higher math.

The higher math is not too painful. Where k is the constant of variation and y varies inversely to x by the same factor, we represent this inverse variation by the formula xy=k. Now rarely do emergency departments experience this simplistic algebraic form, as volume cycles are not proportional. But the three points are:

  1. Volume is dynamic
  2. Volume occurs in waves
  3. Volume’s impact is complex.

Volume rises at one period during the 24-hour cycle while asymmetrically falling during another portion. But rather than apply algebraic principles to staffing and planning in dynamic fashion by matching resources to flow, many managers simply plan for the mean. Planning a department based on the mean results in appropriate staffing only half the time. Managers envision a bell curve when planning for the mean when a calculus sine wave provides a more accurate depiction of the reality. If boarding is the pervasive problem, variation is the elusive problem. It’s like hitting a moving target and is a formulaic fact we must teach administrators. Managers see numbers and pretend the numbers mean something in a vacuum. But external influences and cycles must also be factored.

Consider our example emergency department once again. In 2011, the average arrival rate per hour was 8.54 patients, equaling around 204 patients each 24-hour period. However, the variation was quite broad. The lowest hourly arrival rate was over a narrow period of time between 3 a.m. and 6 a.m. with an average of 3 patients per hour. The highest arrival rate was longer and sustained. Between 9 a.m. and 6 p.m. the arrival rate was 11 patients per hour. That’s broad variation. Staffing to address a volume of 8 patients an hour is insufficient when capacity over demand modeling indicates that expecting no fewer than 12 patients an hour is required for optimum system performance.
Imagine an ED that sees an average of 8 patients an hour and staffs for 8.3. There already is little wiggle room when 0.3 more arrive than staffing permits, and 0.3 adds up. And when 11 patients arrive in an hour and the situation is compounded by a problem such as boarding that has already diminished capacity, patient volume cascades into the lobby.

But this discussion has focused on only two long-standing variables – boarding and variation. There are many newer concepts we must teach administrators who help manage departments and incorporate them into our thinking and analysis of department efficiency. The new paradigm is a comprehensive view of the multitude of variables that disturb flow.

For example, despite the broad variation of patient arrival, departments rarely feel the broad variation; even when arrival times reach a low of only 3 an hour; patients are still backed up from the previous peak. Why isn’t the variation felt as it seems busy all the time?
Why do things back up when efficiency studies and supporting departments say our departments are at top efficiency, funding and staffing? The answer is found in multidisciplinary research.

Automobile Traffic Research Sheds Some Light

The National Science Foundation funded traffic flow pattern studies. Traffic engineers published the results in New Scientist Magazine . Even in deterministic models, which predicted uniform traffic flow, phantom traffic jams still occurred when a critical threshold was reached, seemingly for no reason.

Automobile drivers making small, preventive-driving corrections (human behavior) resulted in waves of traffic jams not unlike waves seen in water due to small perturbations that amplify themselves. Natural human behavior had been difficult to mathematically factor. The amplification of small behaviors results in a mathematical constant, whether in water, traffic or emergency departments. Perturbation theory has become a mathematical concept all its own. Anything that has flow is affected by small perturbations that amplify through systems. It is why one vehicle suddenly slowing from 55 mph to 50 mph by human reaction causes traffic to stand still 20 miles behind it if the viscosity of vehicles is at a critical threshold.

This also is why game theory models are proving more accurate in predicting ED flow, as they account for human behavior. Perturbations occur in the actual flow, and their causes are complex and human:

  • Incentive structures adjust between hourly versus productivity pay,
  • Individual provider efficiency varies,
  • Staffing motivation fluctuates, and
  • Patient acuity levels change.

Even so, a recent study at our facility revealed that despite the multitude of factors that affect length of stay, volume alone explained nearly one-third of the variation (r2 = 0.28). This does of course mean that ED flow remains largely dependent on the number of patients who arrive seeking care. Nevertheless, we have the potential–and on behalf of our patients and our staff, the duty– to influence the remaining two-thirds of what we can actually control.  We all see the negative impact that small factors can have on patient flow; we must remain determined to detect and correct those that can have a positive impact.

The ironic downside to these new paradigms of analyzing flow is that if we solved all of these analytical problems, there is yet another variable of human nature known as the Pigou-Knight-Downs paradox, which takes effect. Traffic engineers discovered that traffic flow did not in fact  improve when they fixed the apparent mathematical problem by building new bridges designed  to have the capacity to eliminate the backups that were occurring. In short, they demonstrated that increasing the capacity of a bridge to any value less than twice the traffic flow has no ultimate effect on travel time. Why? “If you build it, they will come.” This means the ED that effectively solves many of its flow problems will realize more flow to its department – just as people adjust driving patterns to a newer, bigger bridge to get to work–and throughput times may paradoxically be no better than before.

The overarching point is that we don’t currently measure emergency department efficiency with the needed sophistication.

We also, despite sharing similar problems, do not approach flow with the sophistication of the traffic engineers. We simply measure what is easiest to measure.
By increasing the sophistication of our methodology for understanding flow, and by subsequently educating administrators about these new paradigms, we can instill a new way of thinking about how we manage ED flow. Paradoxes notwithstanding, the effort will be worth it–for our hospitals, for ourselves, and for our patients.

Phillip Stephens, DHSc, PA-C, is the associate practitioner site director for Emergency Medical Associates at Southeastern Regional Medical Center, Lumberton, N.C. He is adjunct faculty at A.T. Still University in Mesa, Ariz., and has practiced as an emergency medicine physician assistant for more than 20 years.

The Business of Saving Lives

By Shilpa Amin, MD, FACEPDoctors discussing a patient's medical chart.

As part of the recruiting team for an emergency medicine practice, I’ve had the opportunity for potential new hires to shadow me during shifts. These physicians come from various residency programs, big and small, urban and rural. After a busy shift, they all say the same thing: “Wow, it was so busy, but it didn’t feel that busy. That’s amazing.” I smile when I hear that.

As an ED physician, I can never be sure what my shift will consist of, but regardless of what the day brings, I know it will run more smoothly because of the tools my practice provides its physicians.

Tool #1 Associate Practitioners (APs): Our PAs and NPs are a direct extension of our care. They work very closely with us and help manage the large patient volume. They are excellent with procedures such as laceration repair and splinting. We count on our APs to help manage the ED flow and disposition. They handle multiple patients at a time and will discuss each case with the patient’s primary medical doctor and call appropriate consults.

Tool #2 Medical Scribes: Our medical scribes, called clinical information managers (CIMs), are priceless. They are essentially “super scribes” and are integral partners in our patient care.  I frequently bring the scribe to the bedside with me so she can document the history and physical in real time. We can then move on to the next patient and increase our efficiency. She will then follow up on labs, radiology and previous testing performed in other hospitals. This allows me to spend more time with my patients. Our scribes undergo intensive training at our corporate headquarters, where they learn not only about medical dictation but also the medico-legal aspects of charting. In one ED where I work, nine out of our 11 scribes are leaving for medical school in July! And they are not the first. Several of our CIMS have returned as residents and a few have actually joined our practice a few years later.

Tool #3 Our Electronic Medical Record: Our practice developed its own electronic medical record, called EDIMS, to increase efficiency in the ED. It is a boutique EMR designed and created by ED physicians. It’s an easy-to-navigate full suite system that includes order entry, lab results, discharge instructions and prescriptions as well as the clinical chart. We are even able to fax the patient’s note from the system to his or her primary care physician.

 Tool #4 Bedside Orders: Often when I initially see a patient I will bring a tablet or computer on wheels (COW) with me so I can place bedside orders. The tablet also is useful because I can show patients their X-rays and lab results.

Tool #5 Partnership: I didn’t fully understand the benefits of becoming a partner in the practice until I was at the American College of Emergency Physicians (ACEP) annual meeting and met up with a friend from residency who had worked in three different EDs in less than three years. When I asked him why he kept moving around, he said that the work environment was not as collegial as he expected. He didn’t enjoy going to work. Our practice has created a culture of collaboration. I understand the rarity and feel fortunate that I can ask any of my partners during a shift to review an X-ray or EKG, or jump in and help if I have a critically ill patient.

It’s a blessing to find a job that provides the tools for success. As a physician, I’m in the business of saving lives. It is my goal to make sure the sick injured and worried patients who enter the emergency department leave the hospital healthier and happier than when they arrived.

I feel very fortunate to have the tools I need to succeed.

Shilpa Amin-Shah, MD, FACEP,  is a full-time attending emergency physician at Saint Barnabas Medical Center in Livingston, N.J. Dr. Amin is also the Director of the Physician Recruiting Team with Emergency Medical Associates, Parsippany, N.J. She received a bachelor’s degree from Rosemont College in Rosemont, Pa., and her medical degree from SUNY Downstate, Brooklyn, N.Y. She completed the Jacobi/Montefiore Emergency Medicine Residency Program at Albert Einstein College of Medicine and served as chief resident. She enjoys spending her free time cooking, traveling and trying new cuisines with her husband and two young children.

Medical School Perspective Through the Eyes of a Scribe

By Chaz Sineri    Sineri Charles

Life Before Medical School

I’ll never forget that day.

I was sitting in the ED typing a chart for a 75-year-old nursing home patient with CHF when I got that long-awaited email. It was a medical school acceptance letter! I may have whispered a few swear words before the physician asked me, “What happened? Did the potassium come back hemolyzed again?” I responded, “No, but I was accepted into Medical School!”  I got a smile, a big thumbs up and a “Let’s go see the next patient in 2.” Life in the emergency room never stops.

I became a Clinical Information Manager (CIM, or medical scribe) more than four years ago. I knew before becoming a scribe that medicine was a career that I wanted to pursue, but I wasn’t sure in what capacity.  I figured being front and center with all of the “hustle and bustle” of an emergency department would give me sort of an idea. Fast forward a few years and here I am at West Virginia School of Osteopathic Medicine finishing up second year and getting ready to head to Martinsburg, W. Va., to start rotations.

New Beginnings

Transitioning from an urban city like New York to rural, country-style living was definitely a change, but I think I handled it with class. I live in “The coolest small town in America”: Lewisburg, W. Va. On the first day, I was accepted with open arms, and the whole experience has been terrific.  Native West Virginians have shown me the “ins and outs” of living in a rural community and quickly became awesome—and I expect lifelong-friends. Unlike the typical medical school community, every student in the class works to help the others, and the “cut throat” competition is non-existent.

Once a Scribe, Now a Medical Student

Becoming a scribe prior to medical school has helped me in ways I could never have imagined. First and foremost, I can relate to the stories that my professors tell us. I was very lucky and grateful to work with physicians who took me to the patient’s room with them to witness the patient-physician interaction; that alone was an invaluable experience.

Being trained in writing physician charts is the obvious advantage. Having that tool under your belt heading into med school is definitely a plus. Just recently, I had the privilege of tag teaming with a fellow student to evaluate and treat a patient at a clinic. Under the supervision of a preceptor, we were responsible for obtaining a detailed history and physical. Finally, we presented the case with possible diagnoses and plans for treatment. This was a great experience, as it was something I had watched working in the emergency department day after day. As a scribe I had taken careful notes as to what was ordered (Chest X-rays, EKGs, CTs, labs) for patients with various presentations and applied that to my studies in medical school.

Within the first week of classes I found myself writing “SOAP” notes in clinical skills classes. We were taught about the “Subjective, Objective, Assessment, Plan” criteria for writing about cases. While this was a new experience for most of my fellow classmates, it was old news for me. One of our first activities was to evaluate a standardized patient and collect and write out the history of the present illness (HPI).  Having the background of being a scribe allowed me to enjoy this activity while most of my classmates were as nervous as I was on the first day as a scribe.

At the hospital where I worked, scribes were scheduled in 12.5-hour blocks, spending most of the shift with the same physician. My first shift felt like it lasted a couple of days. At first, I couldn’t imagine being enclosed in an ED for that many hours, completing chart after chart. Looking back, it was great preparation for the 16-hour days that are medical school.

Occasionally, I had the privilege of observing procedures performed by the physician, such as ET intubations, ultrasound-guided central lines and full codes. During various training labs (after perfecting a specified task), I have been asked by professors, “So what did you do before coming to medical school?” I simply smile and say, “I was a medical scribe.”

What to Expect in Medical School

A typical day of medical school starts off waking up at 7 a.m. Sadly, the only “me” time is brushing my teeth, showering and throwing on some clothes. Breakfast is non-existent, any day. I’m lucky if I remember to grab a frappuccino from the fridge as I run out the door. First class is at 8:10 a.m. sharp. Depending on the body system that’s currently being studied, the topics could range from pathology to pharmacology to case studies or immunology or microbiology. Trust me: there is nothing more exciting than learning about the types of diarrhea while you are trying to wake up! As a scribe I always found it interesting how physicians would ask the patient to describe his or her stool to them. They would ask, “Is there mucous? Is there blood, is it mostly liquid? Is there any solid pieces?” Besides being grossed out to say the least, I figured there had to be a reason. Well, weeks of studying about the different mechanisms of diarrhea gives you great insight into what could be the cause, which leads you to the treatment that much more quickly.  Since most people feel bashful talking about their bowel movements, I use the analogy one of my professors taught me.  I simply ask, “Does it have the consistency of apple juice, apple sauce, or apple pie?” Since everyone is familiar with the consistency of these snacks, it makes the experience that much less awkward.

Each class is 50 minutes long. When a professor starts to go on and on about a case they had a decade ago and spill over into our break, you bet there are 150 pairs of eyes staring them down. That 10-minute break between classes is used to get up and get that blood flowing through those veins.

After four hours of knowledge overload, it’s LUNCHTIME. Well not really – class is at 1 p.m. and it’s Clinical Skills. That requires you to be wearing business attire, a white coat, a name tag and a smile.  So lunch is spent changing. No matter how many times I go to the Clinical Education Center, I still get nervous. Well, it’s the uncertainty. You never know what’s going to be behind that door. Just like the Emergency Department!

The professor tells me, “Room Red 2.” I sit in front of the computer next to the door and wait for my doorway instructions to pop up on the screen. Finally, the scenario pops up on the screen:

A 60 year-old male with abdominal pain

Vitals:  Temp 100.3, RR 18, BP 128/81, Pulse Ox: 99% RA.

Evaluate the patient…

I knock on the door, and the voice tells me, “Come in!” I quickly wash my hands and greet the patient with, “So tell me what brings you in today?” (With a gleaming smile of course).” He responds, “Ugh I’ve been up all night with this pain in my stomach.” I quickly ask him, “Can you tell me more about that?” In my head the “ding” goes off, noting to myself I got full points for my opening statements. He responds, “It started to hurt me last night here,” (he points to the lower right quadrant of his abdomen) “after I ate dinner and then I felt nauseous and vomited a few hours later.”  I quickly narrow down my differential to: appendicitis, diverticulitis, a kidney stone.

I continue asking him questions: “Is there anything that makes it worse?” He tells me, “Yeah, my wife. I swear she must have hit every bump on the way here because I felt every one of them.” At this point I’m almost certain I know where this is going. I finish asking the questions and then tell him, “I’m going to do a quick physical exam.” He agrees and I begin, already having noted that he looks uncomfortable, but not terribly sick. I start with his ENT exam, and he doesn’t appear jaundiced or dehydrated. I put my hand on his shoulder and listen carefully to his heart and lungs, which seem normal—and I tell him so. I then listen for bowel sounds and begin to palpate his abdomen.  When I checked for rebound tenderness in the RLQ, he nearly jumps off the table.  I finish my physical exam and wrap up my encounter. The patient asks, “Doc, what do you think it is?” I respond, “Based on the history and my exam, we are going to rule out appendicitis. I am going to order a complete blood count to check for an elevated white blood cell count and a CT of the abdomen with contrast to visualize the appendix.” I wrap up the encounter and tell him to hang tight. “These tests don’t hurt, but they will take a while.”  I leave the room and sit down to write up my “SOAP” note. We are given nine minutes. I imagine when I worked as a scribe in the ED and patients waiting to be seen. I quickly begin to type:

John Doe is a 60-year-old male who presents complaining of a 1-day history of moderately intense, sharp right lower quadrant pain associated with (+) nausea, (+) 1 episode of vomiting, (-) diarrhea. The pain is constant and exacerbated by movement and gets “a little better lying still.” He describes the pain a 8/10 severity. The patient has no appetite and has not eaten since the evening when he vomited. The patient has had several brown stools that are not blood streaked nor tarry in nature. He denies any recent travel, consumption of uncooked or undercooked foods. He reports feeling “a little feverish”, with (+) chills. He reports (-) dysuria, (-) increased frequency, (-) contact with others with similar symptoms.  He denies ever having a similar episode in the past. His medical and surgical histories are unremarkable. He does not smoke, drink or use illicit drugs. He does not take prescription medications, over-the-counter medications, or herbal supplements. The patient is not allergic to any medications, has never been hospitalized and is up to date on all immunizations. He is a married man in a monogamous relationship, who feels safe at home. He works as a paralegal, is a born-again Christian, living in the rural hills of West Virginia.

I continue to type my physical exam, assessment and plan. Done with a minute to spare! I give myself a pat on the back as I walk out of the door. So, I’m free for the rest of the day, right? WRONG! The day has just begun. Remember those classes from this morning?  There are 100 pages of reading to go with that material that needs to be sifted through before tomorrow’s classes. Since medicine is constantly building upon concepts, it’s important to understand the core concepts, or figuring out subsequent information will be a challenge. So off to the library I go to find a corner to nestle myself into and study until I find my forehead on the keyboard.

The Scribe Advantage

There is no doubt that becoming a scribe prior to medical school has had its benefits. The most obvious advantage is being able to answer the question: Is medicine a career I want to pursue? Observing the daily routine of an emergency department as well as typing physicians’ notes, coding etc., gives you unique insight into the joy, stress and fatigue of practicing emergency medicine. The scribe training class taught me the art of typing physicians’ notes, diligently gathering and disseminating diagnostic exams and coding for all of the procedures performed — all invaluable skills that will be used every day in the medical field. My recent medical school class on coding was a “no brainer” after coding thousands of charts as a scribe. Since I had already learned about “Evaluation and Management” (E&M) codes and procedure codes, I was able to easily follow along.

But most important, as a scribe I gained great respect for the physicians and associate practitioners I had the privilege of working with. When a physician asks you to complete a task, you do it to the best of your ability with a smile. And once the physician knows you are a medical student, you can expect to be grilled on the minute details from all of those late nights studying!

Charles Sineri was a Clinical Information Manager for Emergency Medical Associates at Richmond University Medical Center, Staten Island, N.Y. Sineri received his undergraduate degree from Drexel University, Philadelphia, and is a second-year medical student at West Virginia School of Osteopathic Medicine, Lewisburg, W.Va. He plans to pursue a residency in emergency medicine and practice in New York City.


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