ED/EQ: When are you going to see Room 8?

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Patient prioritization can be a challenge and a stressor for the doctor and ED nurse.  It is an example of how different mindsets can lead to frustration and a breakdown of a collaborative approach. We show how the principles of emotional intelligence could resolve this situation before it became a proble:

Recently a nurse filed a complaint about a doctor who was expertly managing a very sick patient in an overflowing single-coverage emergency department.  After intubating and placing a central line, correcting the toxidrome with IV bicarbonate and consultation with poison control, this doctor saw several elderly patients with fever, one COPD flare and possible stroke, and discharged a patient with normal X-rays after a FOOSH.  What the doctor did not do was see a patient with frequent visits to that emergency department with chronic pain, despite several requests from the ED nurse to do so.  The RN pleaded with the family to stay, but they left angrily without being seen.

Here is our team members’ point/counterpoint.


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Nurse: I know the family well and have a good rapport with them.  Reviewing the results of the diagnostic studies that I ordered at triage would have reassured the family.  If the patient had some important findings, he would have waited for the next doc.  If the patient did not, he could have been discharged.  The encounter would have resulted in a paid visit and avoided a patient complaint.  I tried explaining this all to you and you dismissed me.

Doctor: I was swamped and there were patients who were critically ill.  I saw the sickest patients first as I am supposed to do.  We were so busy I only had a few minutes to spend with each patient, and I know that family to be difficult.  I would have seen them instead of the patient with the FOOSH, but I knew that the visit would not be brief because of their demanding nature. The new doc was arriving in an hour, and I thought it reasonable for them to wait.  I took great care of all those sick patients and all you can do is complain that I didn’t see someone who didn’t need medical care at all!

Ouch.  This was a total breakdown of team culture and communication, and sadly a common one. Let’s find the common ground, the point of divergence and how our teammates find the path to resolution.


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Common ground:  Both the MD and RN want patients to be seen and discharged expediently.

Divergence:  Prioritization of patients.  Everyone agrees the sick are seen first, but the RN wants patients to be seen in order and the doc wants to see the quick ones. The reasoning is solid for both the doc and the nurse—seeing patients in order is a standard, and yet turning over rooms when the ED is busy is also reasonable.

Path to resolution:  Open a dialogue and outline your thought processes without abbreviations because this is not the time to take shortcuts in communication. When the nurse approaches you about Room 8, stop what you are doing, give him your full attention and say, “We are both tired and at the end of a long day, and we want the same thing—open beds.  I was going to head to Room 7 and see the woman with the FOOSH because she can be discharged quickly.  Would you like me to see Room 8 instead?  To be honest, I don’t think I can manage it without your help.

The beauty of this approach is that you avoid a conflict because it is now the nurse’s choice. He can help you to see Room 8 or let you go to the FOOSH in Room 7.  You have offered a path for him to achieve his goal.  What if he refuses?  Point out that you are really trying to work with them around this issue, and ask what alternate suggestions he may have.


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If he agrees, make a plan together.  Ask him to precede you into the room with an apology for the wait and inform the family that he has pulled you from another task so that the two of you can work together to answer their questions.  This is a great time for the nurse to “hang crepe”—a term that describes the foretelling of bad news—and explain to the patient that if his questions can’t be answered by you there is a new doctor coming in 45 minutes that will take over.

Ask the nurse what he knows already.  Does the patient want a note for work?  Reassurance?  Narcotics?  If the nurse doesn’t know, he can hypothesize.  “I told the doctor that you might have been worried this was a kidney stone.”  Putting the reason for the visit in concrete terms lets you conclude the visit in a reassuring way.

Enter the room with an apology.  Start with what you have been told by the RN so the patient can confirm that all parties are on the same page.  If the conversation if difficult, you can redirect it by having printed test results and reviewing them with the family and patient.  Highlight the “diabetes screening test, test for anemia, liver and kidney tests” and show them a printed copy of X-rays taken —even a single view is appreciated.  This not only accurately informs the patient of what was done, but demonstrates the number of valuable tests that were performed.

It may not be possible to make the family happy.  But now you have changed the direction and the content of the conversation.  Openly seek confirmation from the RN on the assessment of the patient condition and/or the plan of care.  Turn the encounter from an ‘us versus them’ conversation to a three-way conversation that shows the family that that their caregivers’ opinions are united.  This is an especially useful tool if the RN knows the family, but is priceless even if they don’t.  It creates a dialogue stream that softens and shapes the family dynamics with you.

If the family is appeased and the interaction is comfortable, signal the RN to return to his other duties as soon as possible.  But if the family is not appeased and an emergency condition is not identified, simply acknowledge the patient’s feelings and focus on the positive.  “I know that it is frustrating to have abdominal pain and not find a cause for it. Oddly, many patients will not agree with you if you continue on, “but it is better that we have not found anything worrisome like cancer.” Instead, try “it is common for us to not find a cause when people have chronic pain, but the good news is that for most people it finally goes away and nothing worrisome is ever found.  I hope that happens soon for you.”

Pie in the sky?  No. In today’s world of busier days and sicker patients, we must consciously develop a culture of outstanding team communication to facilitate the best patient care and customer satisfaction.  The time you spend doing this will be repaid in spades through complaints and negative encounters that you avoid.

Make a conscious decision to work together and have exceptional communication.  State this explicitly at the start of each shift.  When moments of stress and frustration occur, recognize them and acknowledge them.  When friction occurs with a teammate, identify the common ground and how to find the path to resolution together.  This is the heart of emotional intelligence, and it is just as critical to define and develop as all our other ED processes, because when we work as a team we are not only better clinicians, but happier people.

ABOUT THE AUTHOR

Keri Gardner, MD, MPH, FACEP is the Chief Medical Officer and Chair of the Malpractice Claims Committee for NES Health.

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