Archives for March 25, 2006

ACEP News “30 minute rule” rant

There’s an excellent rant in this Month’s ACEP News (members only section, unfortunately). I’m going to edit it a bit, and I hope you enjoy it as much as I did.

March 2006 By David f. Baehren, MD

….. Whoever thought up the "30-minute guarantee" unknowingly sent what little joy there was in triage to the same black hole that consumes manners, common sense, and lost socks.

Now every nurse manager in the universe is under the gun from the CEO to "do something about waiting times–or else." The "or else" implies either unemployment or the institution of their local version of the 30-minute guarantee.  Patients could be guaranteed free movie tickets, free gasoline, or 10% off a colonoscopy if the doctor fails to meet the 30-minute goal

Of course, everyone knows that patients wait because the doctor is not working fast enough. The solution is to give the doctor more patients to see simultaneously. ….

For a thousand years, I will maintain that patients are relatively happy in their blissful ignorance in the lobby. Move them back to the patient care area where they can be ignored in person, and they really start to get annoyed.

Their ringside seat also makes them instant experts on what the nurses and doctors should be doing with their time. Apparently, talking to consultants on the telephone and reviewing a chart while seated are not acceptable activities. God help you if you eat a handful of nuts to prevent starvation while your lunch from 2 days before grows mold in the refrigerator in the break room.

…Any circus juggler will tell you that there are a finite number of balls that can be put in the air simultaneously. Three are easy; things get hairy with more than 10. Problems and mistakes happen when someone tosses in an anvil (patient with acute coronary syndrome and ventricular arrhythmias), and all the other balls drop to the ground. A few roll under the Pyxis.

Everyone has a threshold where productivity falls as the number of active patients goes up. I think mine is 8.6, give or take a tenth. I could make you a graph, but that kind of thing makes my brain hurt (as my third grader likes to say).  I’ve tried to communicate this thought. Possibly you could do better.

What sense does it make to pile more nonacute patients into the treatment area when the physician says (in a pleasant and reasoned manner) that it will slow him or her down? Putting these patients there may make the triage nurse feel better, improve the "door-to-doctor" time, and keep the CEO off the nurse manager’s back, but it doesn’t help the patient.

And it doesn’t help the doctor. But this antiquated idea is not often spoken of these days. Emergency patient flow is complicated. Few understand it, and those who don’t will continue to try to "improve" it by driving you to distraction unless there is reasoned discussion with someone who makes a lot more money than the poor triage nurse.

They had a discussion like this about bloodletting once.

Dr. Baehren is the author of "Roads to Hilton Head Island" and practices emergency medicine in Toledo, Ohio.

Well said!