Changes at DSH:

We are looking at working with the hospital in improving patient flow, streamlining patient care and stopping the LWBS. The hospital has asked that we stop all triage level 4/5s from entering the ED during the busiest hours of the day. This plan is based on the idea that the physicians are working together with each other and the midlevels to treat patients as smoothly and quickly as possible. This will entail some changes in how we do things. The most basic changes are: 1. 4/5s may be seen and treated by the midlevel without direct assessment by the ED physician. We are doing this at other facilities, and this is now in place at DSH. There are, however, four reasons to see a 4/5 prior to discharge. They are patient, nurse or midlevel request and physician interest in the case. As a physician, you will have the opportunity to review any chart that comes up for discharge (red house) and sign off or notify the midlevel that you want to see the patient prior to discharge. We do not expect 100% or 0% direct evaluation of the patients. The second midlevel shift will be spent entirely out in the triage area. Your primary responsibility is to see, treat and discharge the 4/5s from the triage area. This will be rather basic now, but the new ED will have a better area for evaluation and treatment. The new shift will be from 12 to 10. There will be a nurse from 11 to 11 in the area to help you. We also hope, time permitting, for you to evaluate and write orders on the triage 2/3s. The minimum requirement for LWBS to be changed to an elopement is a H & P on the chart. If the ED is full and the waiting room over run, then the History can be as simple as cough and the Physical can be as simple as VSS, Febrile. Then write orders with the last one being move patient to monitored bed ASAP. Then sign off the chart and transfer the patient care to the physician who will be going home latest. We expect all the physicians to go out to the waiting room. UHS is expecting it. With the new ED there may be less demand to do so, but for now this is not a request. We are going to try to be less concrete about who works with which midlevel. This will break the rule of no Doc can have two midlevels. Great idea, does not work. . We will also break the rule of one midlevel, one doc. With one midlevel always in triage, many times that midlevel gives their doctor everything coming into the ED. This does not work. The main idea is that simple cases should go to the leaving doctor and complex cases should go to the later doctor. This concept should work on all shifts. If the midlevel is seeing a patient at 11PM that is going to need a CT scan and blood, they should consult the D5, not the D4This stops sign outs and transfers and lets you go home on time. There is a gap in midlevel coverage from 5 to 7. The D2 is responsible for the CARD room primarily at that time. If the CARD room is busy, the other physician can help out. The midlevel in triage cant cover both areas. We will change the D4 shift to a nine hour shift. The night guys are not getting their early bolus of patients at the start of their shift. The new hours will be from 3:01 to 12:01. This will leave a gap in physician coverage to one physician from 3:00 to 3:01. If the ED is busy, we expect the D4 physician to stay later. FYI The D4 is described as a shift that is not overnight but ends after midnight. The differential for the D3 is much less than the D4. (Yes there is a D3 shift!)

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So the plan: The physicians will still be assigned the front and CARD room as before, but with the new midlevel shift things will have to be more flexible. New Shifts Midlevels DD 8-5 DM 12-10 DN 7-5 Physicians D1 7-3 D2 11:30-9 D4 3:01-12:01 D5 9-7 The D1 works with the DD from 8 to 1 exclusively. After 1PM the DD works under the rule Easy case, early Doc. Complex case, late Doc (ECED/CCLD) The DM starts at noon and should only be seeing 4/5s that should go to the Early Doc. Any level 2/3s seen by the DM prior to 3 PM should go to the late Doc no matter where that patient is placed in the ED. At 3PM and 9 PM the referral would shift for the new physician. D2 should see all complex cases until 3PM, and then shift to covering the CARD room and all 4/5s in triage. With the DN at 7PM they should only see the 4/5s that are ready to be discharged. The D4 should see all complex cases from 3 to 9, then move to the CARD room and see the last of the 4/5s from triage and work with the DN midlevel. The DN at 9PM will work under the ECED/CCLD rule, working with the D4 and the D5. The D5 will work with the DM and the DN.

This is work in progress and may change during construction and with the new ED.