Tips for managing cluster periods at ERs—Part II

Emergency clinician Kaihla Parker, DVM, recently sat down with NEWStat to talk about why ERs have been so busy during COVID—and how anxious pet owners are contributing to those especially chaotic moments she calls “cluster periods.” For the last decade she’s worked as an emergency room clinician at AAHA-accredited Animal Emergency and Specialty Hospital, a state-of-the-art, 24/7 emergency specialty hospital in Knoxville, Tennessee, and today, she talks about some techniques she and her staff have developed to help manage those cluster periods—or even keep them from happening.*

*This interview has been edited and condensed.

NEWSTat: Remind us of what a cluster period is.

Kaihla Parker: It‘s an overwhelming number of cases that come in all at the same time, more than you could possibly manage efficiently, and so depending on how many doctors you have, that number is going to be different for every practice. 

NEWStat: During these cluster periods communication is obviously going to be very important. What methods of communication have you found are most effective during cluster periods? 

KP: First, you need to have a clear idea of all the patients who are there and what they’re there for.

We have a big whiteboard where we write down all the procedures that need to get done for each patient. And then a check box that gets marked off when that step is completed. It lets the whole team know what needs to happen when, and what’s been done already.

It’s very easy to get caught up in the moment, and you‘re just kind of moving [quickly]. so knowing where your people are and what everybody is doing is really important.

NEWStat: When so many things are happening at once, what do you recommend that DVMs not do? 

KP: I think one of the hardest things to do is managing minor procedures that are going to take you off the floor. For instance, doing a laceration repair on a pet who is stable. It‘s hard to try and time those because when things seem calm you think you‘re OK to do it, and then five things walk in the door. So, don’t start procedures that could maybe wait an hour or two. 

NEWStat: How do you triage when clients and patients first walk through the door?

KP: At our hospital we have a two-tier program: Tier 1 is patients who are considered relatively stable, in which case owners can fill out their paperwork and we can get them checked in. Once they‘re in our computer system we’ll do an overhead page and say “Patient ready for triage.” That alerts the triage technician that it’s time to come in and get the patient’s vital signs, get their history, and get things moving. 

A lot of clinics will use walkie-talkies or headsets, but sometimes only certain staff members have those. We like using an overhead paging system because it alerts everybody in the building. It lets everybody know instantaneously, “Hey, this is happening right now in the building, and it needs attention.”

NEWStat: What’s tier 2?

KP: Tier 2 is patients who are obviously not stable and require immediate attention. 

For those cases, we would do an overhead page that says “Tech to the front.” That basically means, “Hey, I need a technician to come up here right now and assess this patient and decide if they need to come straight to the back.”

NEWStat: How do you prioritize patients in that kind of chaotic environment? 

KP: The first step is having a really good triage tech who can evaluate all those incoming patients and determine who needs to be seen right away versus who can wait. 

If you have several different types of emergencies that are coming in, and the veterinarians on duty have different skill sets, maybe give the more straightforward cases to the vets who are less experienced. Whereas if you‘ve got something that needs major surgery, maybe that‘s a case that can be managed by your more experienced emergency vet. 

If pets come in for a specific purpose—an ultrasound, for example—maybe have the veterinarian who’s had more experience take those.

NEWStat: What’s your best timesaving tip?

KP: One thing that we‘ve found that really saves time is to get diagnostics approved as the pets are being triaged. It requires a very experienced triage staff member to have that conversation. For example, if you‘ve got a one-year-old dog that‘s in for vomiting after they chew up a toy at home, you know obviously that the concern is that there’s a blockage somewhere and we‘re going to want to start with some X-rays. So having a technician who can triage make that assessment and say to the pet owner, “Hey,  the doctor‘s going to ask for X-rays just so that we can rule some things out. Is it OK for us to go ahead and do that to get started?” And then they also can quote them for the diagnostics so the owner knows what they’re looking at in terms of cost.

Then they‘ll get the patient’s vitals and bring the chart back to me and say, “I‘ve got this case here, it‘s a one-year-old dog, he‘s been vomiting, he chewed up a toy at home, I talked to the owners about X-rays and gave them a quote and they said that was OK, if that‘s what you want to do.” Then I can go ahead and order the X-rays and when they’re done I can go in and talk to the owner about the results.

The upside is that you save a lot of time and it‘s much more efficient. The downside is you have less DVM/client interaction. That doesn’t mean the owner doesn’t get talked to, it’s just means that you’re skipping that particular conversation. 

NEWStat: It sounds like the triage tech can open the door to that conversation so it can be a shorter conversation.  

KP: Yes, exactly.  Because pre-COVID, when I’d go into the room to do my exam, I’d talk with the owners and they’d say, “My pet is vomiting,” and then I’d have to come up with a list of differentials that can cause their pet to vomit, and tell them why I would recommend X-rays, and if X-rays don’t show anything then we’re going to potentially do some blood work, and then these are your options.

But if we can go ahead and get the primary diagnostics out of the way, I can just come in and say, “Hey, this is what we found on X-rays.” Maybe we’ll already have an answer. Regardless, it just saves a little bit of time and then we can have that conversation about all the other things that could be going on. 

NEWStat: The owner could be thinking these things over already, and whether they want to give permission or not while you‘re still in the other room with another patient. 

KP: Exactly. It just gets things started quicker. Blood work is the same way.  

NEWStat: The triage tech seems to be a really key position. What make a good triage tech?

KP: A good triage tech has to first and foremost be a good communicator and very empathetic. This is going to be the first person who really establishes a connection with your practice to this owner. And working emergency, it‘s not like this is a client that we‘ve known for 10 years and they know everyone on staff. We have to get them to trust us with their pet’s care from the get-go. So your triage person should be someone capable of making an immediate connection. 

They should also have enough experience in emergency veterinary medicine that they can help calm pet owners down, because emergencies are usually really stressful. Pet owners come in to the ER experiencing all different levels of anxiety so having somebody who can help reassure and comfort them is important.

They should also have enough medical knowledge to give the pet owner at least some answers initially about what‘s going on, and then take them through the next step. 

NEWStat: The ability to discuss costs sounds pretty important, too.

KP:  Yes. A lot of times owners haven‘t prepared financially for this type of thing. They‘re encountering a large medical expense, and sometimes in a life-threatening situation in which they have to make a decision pretty quickly. 

I think that sometimes getting into long financial conversations is not something that’s best done by the doctor, so having your triage tech or a really strong staff member educated and trained in having these financial discussions is really important. They can start those discussions early in the process.

Usually it comes up naturally at the beginning of a conversation. When they first say we‘d like to do some radiographs, here‘s a rough cost for that, the client might say,  “Oh, there‘s no way I can afford that.”  Or they might say, “Yes, I can do that, but that’s all I can do.”

So you have a sense for what owners are going to be able to do or not do financially, and that in and of itself may change your recommendations. 

For instance, if the pet is stable and the owners just say, “I just can‘t afford any diagnostics,” then we know then that we‘re essentially going to be looking at outpatient treatment and so that case is going to be moved along a little bit quicker, just because we‘re not doing any diagnostics.

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