II. Definitions

  1. Exceptional Care (AHRQ)
    1. Doing the right thing, at the right time, for the right person and having the best quality result

III. Approach: Patient Expectations

  1. Short waiting time (or an accurate estimate of the waiting time)
    1. Perceived wait time (rather than actual wait time) predicts patient satisfaction
    2. Wait times seem longer when they are unknown, unoccupied or perceived as unfair (lower acuity)
      1. Even the most mild complaint is deemed worthy of prompt medical attention by the ED patient
      2. Keep patients informed of delays (e.g. frequent rounding)
      3. Television, Wi-Fi, reading material, and computers can help patients pass the time
      4. Pre-process waits (frustrating to patients) can be reduced by initiating some orders by triage nurse
  2. Constant communication
    1. Patients value introductions, updating during each phase of care, and diagnostic testing explanations
    2. Providers connect with patients, ensure an accurate history, advise and reassure, and effectively disposition
  3. High quality treatment
    1. Patients value high quality medical care, effective management and coordinated follow-up
    2. Patients may have unrealistic expectations about leaving with a diagnosis or access to consultants
    3. Evidence-based medicine explained clearly in patient-centered terms sets realistic expectations
      1. What can reasonably be accomplished at the emergency visit (e.g. exclusion of life threatening causes)
      2. What remains for continued outpatient evaluation and management
  4. Prompt pain control
    1. Patients value when providers achnowledge, address and reevaluate pain
    2. Small measures (warm blankets, ice packs, heating pads, repositioning) should start in the waiting room
  5. Empathy (from a competent, skillful provider that the patient trusts)
    1. Good listening to the patient's concerns
    2. Understanding of the patient history
    3. Caring about the patient's condition and well being
    4. Informative about the patient's condition with anticipatory guidance about what to expect
  6. Maintenance of privacy
    1. Waiting area
      1. Can be divided into smaller pods
      2. Patients may be alerted of their turn with pagers, messaging (instead of calling name aloud)
    2. Care area
      1. Keep conversations about other patients private, and limit non-patient related conversations to staff areas
      2. Secure workstations when unattended (HIPAA)
      3. Ensure patient privacy during sensitive history and exams (including privacy from the patient's family)

IV. Techniques

  1. See new patients as quickly as possible
    1. Door to Doctor Time: <30 minutes goal (Most important emergency department time)
    2. When a room is available, promptly assign to the next patient
      1. Triage is only needed if multiple patients are waiting
      2. Perform in-room registration
      3. Avoid holding beds for the potential of future Ambulance arrivals if possible
    3. Consider fast track process for more simple, self-limited conditions (e.g. Laceration, URI)
    4. Ashoo in Herbert (2015) EM:Rap 15(10): 5-6
  2. Make a good first impression
    1. Greet patient with smile and introduce self and title and acknowledge accompanying family and friends
    2. Sit down at eye level with the patient, in an un-rushed manner
    3. Maintain eye contact
    4. When pressed for time, obtain enough of a brief evaluation to base initial tests and treatment
    5. Avoid interrupting patient for the first minute (allow them to express their chief complaint)
      1. Establishes rapport, and patient will often reveal their true reason for the visit if given the chance
    6. Record the initial contact time
    7. Apologize for delays
    8. Set expectations for evaluation including estimated total duration of encounter
  3. Identify a patient's needs from the outset (salesperson approach)
    1. Key role of the emergency provider is to help patients and their families deal with uncertainty
    2. Critical to understand the patient's concerns and the true reason for the visit
    3. Needs of the ED patient fit in one of three categories (the products we are selling)
      1. Diagnosis needed
        1. Patient is concerned about a cluster of symptoms and signs (e.g. Chest Pain, Abdominal Pain)
        2. Offer reassurance for those discharged after emergency evaluation
      2. Advice needed
        1. Failed home management for a known diagnosis
        2. Examples: Asthma Exacerbation, Gastroenteritis, febrile illness
        3. Offer home management options for those discharged after emergency evaluation
      3. Education needed
        1. Patient presents with misconceptions
          1. Symptoms and diagnosis
          2. Appropriate management (e.g. Opiate Abuse)
        2. Educate the patient about their diagnosis and best practice in management
    4. References
      1. Swadron, Nordt and Jaben in Herbert (2014) EM:Rap 14(9):13-4
  4. Careful examination
    1. History is often more helpful than examination
    2. However, a careful examination adds little extra time than a cursory one and instills greater confidence for the patient
  5. Treat pain
    1. Address at initial encounter and readdress on rounding
    2. Outside of specific patient care plans and department policies, strive for significant improvement in pain from presentation
      1. Drug dependant behavior can be addressed after presenting pain has been addressed
  6. Frequent rounding
    1. Minimum interval: 1 hour (every 20-30 minutes is ideal)
    2. Review results
    3. Review symptoms including pain
    4. Discuss currently pending results, plan and expected time to next evaluation
    5. Erasable white board with treatment team, plan, times can serve as an excellent communication tool
  7. Express caring
    1. Expression of empathy and caring is central to good medical care and patient satisfaction
  8. Handoffs (transfer of care)
    1. See SIGNOUT Mnemonic
    2. Introduce the oncoming provider and help to establish the patients confidence and trust in that provider
    3. Review the pending evaluation and the overall plan
  9. Discharge
    1. Among the most important phases of care in ensuring better outcomes and fewer unexpected returns
      1. Among the most frequently cited process where communication breaks down
    2. Review your findings and recommendations, and establish an agreed upon plan with the patient and their family
    3. Ask about their questions and concerns
    4. Ask what would make it difficult for them to carry out the management plan
    5. Provide clear discharge paperwork appropriate for literacy and primary language without overwhelming
  10. Follow-up
    1. Provider to patient phone call or email increases patient satisfaction
    2. Patel (2013) Ann Emerg Med 61(6): 631-7 [PubMed]

V. Management: Service Recovery

  1. See Conflict Resolution (for effective methods including better listening)
  2. Address patient or family dissatisfaction, anger or other negative emotions associated with the visit
    1. Address complaints comprehensively allowing for a rebuilding of trust and loyalty
  3. Helpful opening phrases
    1. "It sounds as if you are very upset. Please help me understand more about your concerns."
    2. "Please help me understand what you are most worried about today"
    3. "What are your goals for today's visit"
  4. Goals for listening
    1. Understand the patient's story and what has lead to their negative emotions
    2. Understand the patient's interests, goals and needs
    3. Identify common interests (e.g. to help the patient feel respected, listened to and safe)
  5. References
    1. Claudius, Behar and Charlton in Herbert (2014) EM:Rap 14(11): 2-3

VI. Evaluation: Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS Survey)

  1. CMS Survey of hospitalized patients
  2. Provider related questions
    1. Treated with respect and courtesy
    2. Carefully listened to
    3. Lay explanations
  3. Medication related questions
    1. Pain control
    2. New medication benefits and risks discussed
  4. Hospital related questions
    1. Rate the hospital (0 to 10)
    2. Recommend hospital to others
  5. Resources
    1. Online HCAHPS results
      1. http://www.hospitalcompare.hhs.gov

VII. Evaluation: Press Ganey Emergency Department Satisfaction Survey

  1. Questions
    1. Wait before seeing provider
    2. Provider courtesy
    3. Provider listened
    4. Provider informed you about treatment
    5. Provider concern for comfort
  2. Interpretation
    1. Each question is reported as a percentage of those rating the provider "Very Good" (top score)

VIII. Prevention: Emergency Department process improvement

  1. Improve ED Throughput
    1. Consider a medical provider in triage to expedite initial evaluation
    2. Identify lab hurdles (inadequate staffing, equipment downtime, longer Running labs)
    3. Identify imaging hurdles (inadequate staffing, backup plan in times of surge)
    4. Prioritize discharge of patients ready to return home (discharge before new patients, procedures)
  2. Reduce hospital admission delays
    1. Consider boarding inpatients in hallways while awaiting a room
      1. http://www.hospitalovercrowding.com
    2. Work with elective surgery secheduling to reduce hospital bed competition with busy ED times
    3. Work with inpatient hospital service to prioritize hospital discharges earlier in the day
    4. Expand hospital services to 6-7 days weekly (e.g. stress testing) to reduce boarding of inpatients
    5. Consider assigning a hospital bed czar to facilitate bed utilization
    6. Ashoo in Herbert (2016) EM:Rap 16(7):5-6
  3. Create a high functioning organization (eliminating variability in quality care)
    1. Patients with the same complaint should have the same care and the same outcomes
    2. Christopher Peabody, MD shares his 3 mantras with the ED teams he works with
      1. We keep our patients safe
        1. Speak up about unsafe conditions, and accept feedback gracefully
      2. We get each other's backs
        1. Work collaboratively with one another (providers, nurses, consultants)
      3. Have the shift of your life
        1. Enjoy and look forward to your work
        2. https://www.ted.com/talks/shawn_achor_the_happy_secret_to_better_work?language=en
    3. References
      1. Lin and Peabody in Herbert (2016) EM:Rap 16(8): 5-6

IX. Resources

  1. Emergency Department Crowding: High Impact Solutions (ACEP)
    1. http://www.acep.org/workarea/DownloadAsset.aspx?id=50026

X. References

  1. Ashoo in Herbert (2015) EM:Rap 15(11): 15-6
  2. Bukata (2013) EM Bootcamp, Approach to the ED Patient
  3. Parker in Herbert (2015) EM:Rap 15(9): 19
  4. Tanski (2014) Crit Dec Emerg Med 28(12): 15-22

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