Wednesday, November 17, 2010

You Want Me on That Wall...

I am the gatekeeper; now, apparently, I am the timekeeper as well.

It has become the (marketing) rage to tout "Door to Doc" times in the ER under 30 minutes. Essentially, this means that you are GUARANTEED (Ha! Hahahahaha!) to see a provider in under 30 minutes from the time you walk into the department. I am frankly amazed that this declaration is not immediately followed by "....or your visit is free!". Assuming that the patient is one that actually pays the bill.

Rapid Door to Doc is not a new concept, just one the many stupid bandwagons that Suits (and other disguised boxes of hamsters) utilize when they worship at the Altar of Customer Service. It was being given a trial run along with copious billboard advertising at Utopia Medical Center before I left there 4 years ago. We had a fast-track, but the 30 minute "Door-to-Doc" was a bit of a joke. Under an hour, maybe; but unless you were really sick, had chest pain, were holding a severed extremity in triage or bleeding from your eyeballs in general did you have any hope of being placed in a room in under an hour. Never mind seeing the provider. We did much better on doing EKG's in under 5 minutes since we just did them in triage, although we then had to do a room to room search for a provider to initial it. Shouldn't that count? I thought so. Anyway, while the average ER employee would love to have every patient sitting in front of a doc within 30 minutes of hitting the door, in reality, it isn't practical and merely serves to set us up for failure.

I have been told that our Door-to-Doc times need to be 20 minutes, per Dr. Roboto, our medical director; this is the same individual who lacks adult social skills and has been the cause of 6 docs quitting in the last 1 1/2 years, but doesn't see this as attributable to his lack of leadership qualities. Naturally, the first thing to be looked at is NOT the registration process, but triage. It is not the fault of registration clerks that more idiot questions are added to the registration process on a daily basis; I feel badly that they have to ask really stupid questions such as "do you receive Black Lung benefits" and "if a monkey can climb a greased pole in 10 seconds, how much does a pound of butter weigh?, and "do you like cheese?". I get that these are very important to the kind of treatment patients receive. Really, I do. But registration generally takes at least 10 minutes if patients haven't been to our facility and if Helen is doing the registration. Subtract about 1/2 of that if anyone else is doing the job. To add to the mayhem, on weekends and after 5 PM there is only one registration clerk who must also register out-patients. However, Dr. Roboto now says that triage, not registration needs to be streamlined. The man is a rocket scientist I tell ya.

Naturally there are patients with complicated medical histories that are the exception, but by and large an experienced ER nurse should be able to triage quite rapidly; it takes organization and the ability to multitask. In our ER we are all very experienced; with the possible exception of Southern Cathy and Sherry who like to engage people in conversation about their kids, pets and past lives, most of us are very efficient.

To prove my point that the problem lies with the registration process, for the last week I have noted my triage time, as well as the time triage was completed. This has averaged 5-6 minutes for me; I can do a frequent flier dental paineur or migraineur in less than 4 minutes if they aren't on any other meds. After triage, the patient is registered unless it is someone who needs to go right back to a room; that time gets noted as well as the time the provider actually picks up the chart and enters the patient room.

Keep in mind that we are do not have electronic charting in our ER, and probably won't until the end of the present century, so that is a lot of time notation.

Five to six minutes worth of quality triage time. And if there are no other patients I triage them right in the treatment room and have the secretaries register them whenever. Right back to a room, how great is that?

Dr. Roboto doesn't think it's so great, but that is no surprise to me; anything that is actually, well, nursing is trivial; particularly if it requires any skill or concious thought other than blind order-following. A nursing assessment? Insignificant. Nursing process? Unimportant. Critical care skills? Inconsequential. Any nursing input at all? Trifling, unnecessary, worthless.

Roboto's actions scream contempt for nursing in a big way. No wonder nobody likes him. I think a couple of my co-workers have actually switched shifts so as not to work with him. I doubt his own mother can stand him; can't imagine how he can be married and have kids. But hey, he brings on a lot of his problems himself; who can take a man seriously who uses a pocket protector, never wears scrubs because he thinks they are unprofessional, has a fussy little circum-oral beard (door knockers?), talks to his clavicles, wears glasses attached to a little chain and wears a little teeny kid's backpack (probably filled with Fruit Roll-Ups, juice boxes, and jelly sandwiches with the crusts cut off). Also he lacks a sense of humor, which, to me is the worst offense. I am at my best and most passive aggressive self in his presence.

None of the other docs are committed to this lunacy, which is just as well; why put the extra pressure on people for the sake of another marketing ploy with unrealistic expectations? Sicker patients will always get seen as quickly as possible, most in well under the arbitrary 20 minute time frame.