Having an effective guideline to follow will help you prevent decision-making fatigue and breathe easier
Imagine the following scenario: You walk out of your trauma bay after a 90-minute resuscitation and find three charts in the rack to be seen. You still have to do an LP on Mr. Jones, and a pelvic exam on Ms. Smith who have both been in your department for the last four hours. Don’t forget that you have five patients who need to be dispo-ed. The medical student wants to staff a patient with you, and that’ll take another 20 minutes. You’re hungry, tired, and haven’t seen a bathroom in eight hours.
Certainly, that scenario is familiar to most EM physicians, and if you work in a busy ED, it may be your typical shift. How do you decide what to do first? How will you get through all of these tasks?
This feeling of being overwhelmed and losing of control of your shift is the result of decision overload, and is a problem with which most EM physicians contend . Decision overload results from working in a complex environment where innumerable decisions must be made quickly and with limited information. The result is lowered productivity, increased stress, and potentially burnout.
Fortunately, EM physicians are not unique in dealing with decision overload. Business leaders and academics have come to recognize that decision fatigue is a near-universal problem in our modern lives and have devised strategies to help manage the chaos [2,3].
One common solution to decision overload offered by these thinkers is to apply a simple set of rules to manage the overwhelming number of decisions that must be made in complex environments. For instance, In “Simple Rules: How to Thrive in a Complex World,” authors Donald Sull and Kathleen M. Eisenhardt use examples as varied as Napoleon’s troop movements and Tina Fey’s comedy writing to demonstrate how complexity and chaos are often best managed with the use of a simple set of rules .
This process can be easily applied to the shift management in the ED setting. Creating a seemingly simple rule set for managing the chaos of your ED will decrease the number of decisions you need to make on shift, and help to organize your team. Instead of reacting in the moment, you will have a process already in place to decide what to address first.
For example, consider completing your ED tasks in the following order:
- Stabilize critical patients
- Do procedures
- See new patients and start their workup
- Re-evaluate and disposition patients
- Finish any incomplete charting
When a new task arises of higher importance than the task you are currently working on, you would switch to the task of higher importance and then work your way back down the list.
Applying this process to our initial case study, after first stabilizing your resus patient, you would do the LP and the pelvic exam, then hit the chart rack and staff the med student patient, and finally get to all of those dispos.
That sense of overwhelm when deciding what task to take on next and how to prioritize all of the tasks ahead of you lessens, and you can get on to the process of moving the department forward. Importantly, the cognitive energy spent in deciding what needs to be done can now be used on more important tasks such as time at the bedside, diagnosis, and teaching students and residents.
Of course, the task list above may need to be tailored to your particular ED environment, but by using a simple rule set on your next shift, you should experience greater efficiency and fewer moments of being overwhelmed.
- Chisholm C, Weaver C, Whenmouth L, Giles B. A task analysis of emergency physician activities in academic and community settings. Ann Emerg Med. 2011 Aug;58(2):117-22. PMID: 21276642. http://www.ncbi.nlm.nih.gov/pubmed/21276642
- Ferriss, T. The Choice-Minimal Lifestyle: 6 Formulas for More Output and Less Overwhelm. The Four Hour Work Week Website. http://fourhourworkweek.com/2008/02/06/the-choice-minimal-lifestyle-6-formulas-for-more-output-and-less-overwhelm/. Published 2008. Accessed June 1, 2015.
- Sull, D, Eisenhart, K. Simple Rules: How to Thrive in a Complex World. New York, NY: Houghton Mifflin Harcourt Publishing Company. 2015.
If I followed the recommended rules- unfortunately, while repairing a laceration I’d miss recognition of a new patient with a critical life threat that hasn’t been detected yet and I’d be stuck for hours after my shift completing charts.. not sure of a great solution, but having a framework is very helpful. Personally, I follow the following path:
1. Stabilize critical patients
2. See new patients and initiate work-up
3. Disposition patients ready for dispo
— then the order is more fluid and situationally dependent
4. Procedures: delegate if possible (ie. APP, students, etc.)
6. Complete charting (increase priority if >3-5 charts behind)
Thank you for the article and insights!