Saturday, August 11, 2012

How to Save Money Running the ER: "Mobilization"

Well, as an former ER doctor and a former, avid ER-user for bouts of hypotension from dysautonomia, my first implementation would be to educate ER doctors about what dysautonomia is.   It is just like it sounds, -dys for "dysfunction", and "autonomia" for the autonomic nervous system (ANS).  Patients get syncope from standing up.  ER Diagnosis?  Orthostatics.   Treatment?  Fluids, 0.9% NS at 70 ml/hr.  Titrate to alleviate orthostatics.

I would also educate ER doctors on a cluster of Invisible Disabilities:  Chiari MalformationMultiple Sclerosis, Interstitial CystitisLyme DiseaseFibromyalgiaLupus, Mastocytosis or Mast Cell DiseaseMultiple Chemical SensitivityIrritable Bowel SyndromeChronic fatigue syndromeCoeliac DiseaseCrohn's Disease, Inflammatory Bowel Disease, Metabolic SyndromeSclerodermaSj√∂gren's syndrome

That being said, here are my real thoughts:  I think the concept of "Triage" is too segregated.  It is time for a more holistic approach that will also save money.  I call it "Mobilization".

So, it is "Triage for Trauma, and Mobilization for Medicine".

First, the doctor needs to be the first person to see the patient.  No more RN doing an evaluation in the Holding Area, and then sending a hypoxic patient back out to the ER waiting room (while the patient is in AFib, brewing with renal failure and a pneumonia).

The doctor needs to be the first one to see the patient, and needs to write orders before (s)he walks away from the patient.  Oxygen, EKG, chest x-ray, blood labs, sputum.  Well.  That only takes 10 min, and let's see....we have mobilized how many people (n = 4; nurse for oxygen, EKG tech; x-ray tech, phlebotomist)...and how many machines (n = 8; ) oxygen tubing, EKG machine, x-ray machine, chem lab, CBC lab, blood gas lab, microbiology lab, bleeding time lab).  12 Forces are being "Mobilized" within the first 10 min.  That is the goal:  Mobilization of efforts within a minimum amount of time.

One can see that the doctor is the grand orchestrator, mobilizing both machines and humans to descend on the patient.  This is quality time, discovery time, assessment layout.  Mobilization of forces is required so that the patient is worked-up and treated at the same time.  No need to segregate everything into separate steps.  (And, the iv can go in through the same venipuncture as the blood draws for labs.)

"Mobilization" works for all patients, but is geared for the Medicine Patient with underlying pathophysiology of the pulmonary, renal, ANS,  or other major system disorder.  It's all about spotlighting the Doctor at the Patient's bedside, folks.

For the Trauma patient, Triage works, just like it does in the Military.  Minor trauma can wait while the full Trauma Team of Surgeons, Anesthesiologists, and other professionals get the Major Trauma Patient to the OR, or if needed, the Team can do procedures in the ER.

And don't forget to alert the ICU, as that patient is sure to need a bed there.

Decrease the waiting times for everything:  the time for the patient to see the doctor, the time for labs and studies to be ordered, the time for labs and studies to be completed, the time for definitive treatment, the time for the first unit of blood to go in, the time for OR personnel to arrive, the time for an OR, the time for an ICU bed.

How is the best way to do this? 
Simply Think Ahead.  

No More Tears: A Physician Turned Patient Inspires Recovery
by Dr. Margaret Aranda
ISBN: 978-1-62205-838-2

Additional Articles by Dr. Margaret Aranda

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