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See Patients Faster in The Urgent Care

This post is geared towards the urgent care providers who are having trouble increasing their patient turnover. I know only 1 other doctor who might be able to see patients faster than me so I’m claiming this podium to write from.

To see patients faster while doing telemedicine requires a few technology fixes and I’ll do a post about that soon but this will be mostly for the Urgent Care clinician who is practicing F2F medicine.

 

Seeing Patients Faster

Let’s clarify something. You can see patients really fast and just either throw a bunch of medicines at them or do nothing for them and discharge them. Either of these methods will create problems for you down the road.

When I am referring to seeing patients fast I’m not talking about practicing shitty medicine. We are talking about practicing the kind of medicine where you can hold your head up after someone reviews your chart.

The criteria I expect from a fast and effective Urgent Care provider are:

  1. being at least 2x as fast as your average colleague
  2. having high patient satisfaction scores
  3. practicing some antibiotic stewardship
  4. focused SOAP note with a proper MDM
  5. good patient outcomes with low bounceback rates

 

1. Twice As Fast As Your COlleagues

The reason I use a factor of 2x is because a modern urgent care is already pretty efficient and you are often limited by nurses and the number of exam rooms you have.

If those aren’t limiting factors then you should be able to see patients 3.5x faster than your colleagues in a moderate acuity Urgent Care.

To give you an idea of what the numbers mean, during a 10-hour shift the average doctor sees 24 patients while you will see 50 patients. The ceiling here is hit because your nurses are slow due to lack of competency or you are limited by how many exam rooms you have.

If you are working in an Urgent Care that’s actually designed to be earn money – ie, efficient – then you should be able to see 80 patients fairly easily.

For those of you who have never worked in a high-volume private Urgent Care, the average number of patients seen are 5/hour and go up to 9/hour during the busy season.

2. High Patient Satisfaction Scores

If you are churning 8 pph but are getting 6 complaints per shift then you might as well throw in the towel. I’d recommend a job in medical billing or medical assisting because what’s the point if you can see patients faster but are providing a poor quality of care.

If you are seeing 2 pph and still having trouble with patient satisfaction scores then you are either practicing real medicine, for which we have no room here in the US, or you have major communication issues – this post won’t help you with either problem.

As you increase your pace you will need to match your energy and your patient engagement. If a patient feels like they are in a bar/lounge or that they have a soap box to vent about the front desk staff then you will start to fall behind.

That said, never push your own agenda on the patient. If their main intention is to vent then you have to let them. The more you fight a patient the longer time you’ll have to take to convince them.

Which brings us to the next topic – convincing the patient of a diagnosis and treatment. I know that sounds pushy but as I’ve written before, 80% of the Urgent Care patients don’t really need to be there. My mission is to reassure them and sell them the right diagnosis and management.

The better salesperson you are the higher your patient satisfaction scores. No, you don’t have to be a charlatan. You can be honest and legit but yes, you will need to market the shit out of the visit.

Treat each patient like the individual they are. If someone is shy and timid then treat them with that characteristic in mind. If they are bold and compensating then you need to play into that as well.

3. Antibiotic Stewardship

If you pump and dump 10 pph but your audit team tells you that you are the highest antibiotic prescribing physician then you’ll look like a fool and you won’t feel good about yourself.

It’s important for you to review your own criteria for when antibiotics are needed and when they aren’t. If you’re unsure then refer to the infectious disease society of America and the CDC website.

Next, figure out what your breaking-point is. How hard and for how long will you go t2t with a patient before you give in or end the conversation? Sometimes it’s better to give in than continue the battle. More antibiotic prescriptions means more repeat customers – unfortunate for the patient but fortunate for the income side of medicine.

Don’t give into the argument that someone else will give them antibiotics – you don’t want to go home feeling like a sellout. Let the next doctor give them Levaquin for a mild sinus infection – that’s fine. But don’t think you can just walk out without an explanation, neither. You’ll have to repeat the virus vs bacteria lecture every-single-time because this will affect your patient satisfaction scores.

Yes, the patient is pissed that they didn’t get the antibiotic they wanted but in their lecture they heard you say that it would harm them if you would have prescribed it and you didn’t because you cared about their health – it’s hard to give your doctor shitty scores when their intentions were good.

4. SOAP Notes With MDM

Are you a fast typer? Okay, then you need to dictate.

If you are a fast typer then use your autocorrect to turn HSM into ‘hepatosplenomegaly’. And PxRx into ‘Patient informed of medication side effects and benefits’.

If you are going to dictate don’t fall into the trap of being verbose and for dog’s sake, talk fast. Why are you talking like you just had a seizure? Voice recognition software can pick up your speech even at 3x.

Subjective: You’re writing too much for the positive and not enough pertinent negatives. Focus on the pertinent (-)’s and you’ll have to spend less time on the (+)’s. “Patient has no SOB and no exertional CP, no LE swelling” – if you wrote that then who cares that they were on a flight from here to Mars.

Objective: Forget prepopulated physical exam forms because they will never make you faster. I don’t know a single doctor who does such a thorough exam that they need a pre-populated PE form to painstakingly click +/- on.

Assessment: all you need here is the diagnosis and how it relates to the patient’s presenting symptoms. Make it easy on yourself and if the patient has an elevated HR or a low O2 then add that as a diagnosis so that when you go to write your assessment/plan you don’t forget to comment on it.

Plan: This is the one place where it’s really good to have pre-populated sentences such as ‘patient agrees with management’ or ‘medication side effects reviewed with the patient’ and ‘alternative options discussed with patient’. Type fast and speak faster. Be verbose here and explain yourself and list your DDx here. It doesn’t need to be neat – I won’t look at your plan when I see your bounceback and the lawyers can dissect the data out just fine when you are facing a malpractice suit.

5. Good Patient Outcomes, Low Bounceback Rates

Good patient outcomes means that your colleagues won’t text you that the ‘pneumonia’ you saw with the clear chest xray is now in the hospital with respiratory failure due to a PE.

Bouncebacks for antibiotic request can be ignored. I see plenty of patient bouncebacks who are worse and now want antibiotics because they are tired of OTC meds.

But if you don’t explain things well and the patient with low back pain keeps coming back then you’ve wasted your time, the patient’s, and your colleagues’.

One of the best ways to decrease bouncebacks is to answer the questions that the patient didn’t even think to ask:

  • How long to expect for symptoms to last
  • What to do in case of xyz
  • What things to try OTC if things don’t improve
  • Whom to contact in case of xyz

In this next section I’ll talk about a few basic skills to master to keep the Urgent Care flowing smoothly. These are my tricks and if you have your own please share them in the comment section below.

Keep in mind that in an urgent care you are sharing resources with your colleagues. If you go slow then the waiting room fills up, you sequester too many nurses, you piss off the front desk staff, and you are making your efficient colleagues fall behind.

 

Always Start By Triaging

What I love about being an Urgent Care doctor is that I can triage up and I can triage down.

If my 47-year-old female patient comes in with fatigue, no cough, no fever, intermittent exertional chest pain, and constant nausea then I’m doing a focused cardiovascular exam, reviewing the vitals, getting an EKG and calling medical transport.

Regardless of what I can rule in or rule out, I cannot and should not rule out a cardiac cause or a PE in the urgent care. Further exams and questions are a waste of resources.

  • “Have you recently traveled to Guam?” 
  • “Do you feel the chest pain is worse with acidic foods?”
  • “Have you taken any supplements, herbals, or eaten new foods in the past 24 hours?”
  • “Do you have any diarrhea or joint pains?”

Triage Up

The patient above is having a heart attack or PE until proven otherwise. They need troponins and serial EKG’s and should have a stress test arranged upon discharge if the CTA is negative.

The high acuity patients should be the easiest patients to see. You need to obtain the pertinent information, stabilize them, and transfer them to the appropriate higher acuity facility.

Many Urgent Care providers are the most stressed by the high acuity patients because they feel the need to work them up. That energy is better spent on decreasing the door-to-table time.

Triage Down

If a patient comes in with a laundry-list of chronic problems it’s good to address them instead of blowing the patient off. But it’s not necessary to delve too deep into each one. Often times patients just want to be heard and sadly don’t care much about actionable points.

A cute little old lady with knee pain, incontinence, irritation of the corners of her mouth, scalp itching, and a bitter taste for several months doesn’t need a full workup.

I can examine her knee and recommend a safe OTC pain medication and some exercises. I can treat the angular cheilitis and recommend a shampoo to help with the scalp itching and I can recommend that she cut out any foods with pine nuts.

My nurse can then make an appointment for her with her PCP or give her a list of FP’s who can see her in the next few weeks.

 

Identify All Available Resources

You should know about all the resources that are available to you including community referrals, specialty departments, and how these departments manage patients.

If you have a patient that comes in from a work injury then it makes little sense for you to waste 10 minutes to get a complex history and come up with a management plan when all you need to do is provide a work note and refer them to occupational medicine.

As a bonus, know how long it takes for each department to see your patient. Having this information handy will make you look stellar and makes the patient trust you more.

 

Dealing With Problem Patients

The patient who refuses to go to the ER seems to be a particularly hard problem for clinicians. I’ve seen docs huff and puff and consult 7 colleagues to figure out what to do about the lady who is having cardiac pains but doesn’t want to go to the ER because she has to go back home and feed her cats.

I got burnt only 1x in my career with a patient who refused to go to the ED for new onset type 2 DM. The only reason I got burnt was because I didn’t document anything! I didn’t create a chart for this patient – not sure what I was smoking.

Had I documented the facts that the patient refused to go to the ED and that I discussed the pro’s and con’s then I wouldn’t have had anything at all to worry about.

A patient could be having a dissecting aortic aneurysm, if they don’t want to go to an ER and they are sane enough to make that decision and you document the facts then there is nothing else to do.

Now, if you want to sit there for 1.5 hours and convince them otherwise, feel free to do so but understand that you forced at least a handful of patients to leave the UC because they couldn’t stand the wait anymore and they ended up suffering with their UTI for another day because you couldn’t efficiently handle your patient flow.

A simple trick is to have your staff call the patient’s next of kin or family and have them talk to the patient, with their permission of course, or call the medical transport team and have the patient refuse the transport team.

 

Develop Workflows

Developing a workflow is not only important for the cold & flu patient but also the chest pain, shortness of breath, back pain, and first trimester vaginal bleed patient.

Developing a workflow means that every patient in whom you suspect gallbladder disease gets LFT’s and a Lipase level to help you decide how aggressive you need to be with their management.

Any woman under age 50 with abdomen pains gets a urine pregnancy test. When you stick to these workflows it allows you to focus your energy on more complicated cases and not have to think each and every case through.

The acute back pain is either red flag case or a non red flag case. EVERY back pain gets a lower extremity neurovascular exam. And even if you’re feeling lazy, you get up and go back in that room and do it and you document it because then you’ll have no reservations about discharging that patient.

  • Uncomplicated UTI’s get macrobid, bactrim, cipro in that order. That’s a workflow.
  • A male with dysuria gets a prostate exam unless he refuses.
  • A patient with eye issues gets a visual acuity exam even if your nurse was too lazy to do it.

I have workflows for drug seekers, for antibiotic seekers, and for frequent fliers.

Testing & Intervention

Many urgent cares are run by providers like mini-ER’s which means a ton of IV’s, xrays, blood tests, CT’s, and minor surgical procedures.

Ingrown toenails aren’t an emergency and can be referred to a podiatrist.

Few abscesses need to be drained and most aren’t even abscesses.

IV’s

IV’s – O-M-G… what’s with all these IV’s in the urgent care?

Do you believe that this patient has such a severe sepsis that they will 3rd space any oral fluid? They have shortgut syndrome? Forget IV’s – really, forget IV’s.

The patient who needs an IV should have one hooked up to them on the way to the ED. Have you seen outpatient nurses starting an IV? It’s a 7-person procedure and you’ll never hear the end of it because now that nurse can’t do anything because she has to babysit her sideways 22-gauge IV.

Abscesses

Most abscesses aren’t abscesses – they are epidermoid cysts and the other ones are carbuncles. Why are you draining so many abscesses? And why are you taking 45 minutes to drain one? Was it a submandibular abscess? Did you have to do buccal incision?

Consider low dose doxycycline 20mg BID for inflamed epidermoid cysts. Or inject 20mg of kenalog for the cyst. There is no need to culture the sebaceous secretions of a cyst – it’s a cyst. The epidermis is red because it’s inflamed not because it’s infected.

Leave the draining abscesses alone and give the patient instructions on how to care for it. Consider antibiotics only if there is cellulitis or you suspect MRSA.

Lacerations

Why place sutures in animal bite wounds? Every orthopedist and surgeon will advise you against that.

Why repair the 2cm laceration that’s well-approximated? It’s not over a joint.

The scalp laceration doesn’t need staples. If they insist then apply topical lidocaine, let them wait while you see the next patient and place 2 little staples.

Sure, a larger scalp laceration can benefit from local anesthesia but not most of what I see in the urgent care.

 

Anticipate Complications

Complications usually arise from unnecessary interventions or when you do too much for a frequent flier. Suddenly that IM Toradol is causing breathing problems in your frequent flier. Or the patient is feeling chest pains after that unnecessary bag of saline you IV’d.

If you’re working with a skeleton crew or you have end-stage weak support staff then it’s probably not a good idea to manage hypoxic patients or workup a chest pain or septic patient – send those out to the ED.

 

Don’t Rely on Your Staff

Sometimes you will be short-staffed and sometimes your staff is in a mood to argue with every other patient.

It’s important to recognize when your staff is hurting your work-flow and step in to do the work yourself. This might help them feel a little less stressed or at least pick up the pace when they see you working independently.

Slow Staff

When your staff is too slow to check patients in or check them out then do it yourself. The problem is that when you keep the patients waiting then you lose their trust, you’ll have to hear even more complaining from them, and you’ll just sit around while your nurse suddenly returns with 5 vital sheets instead of giving them to you one by one.

Go out the waiting room, bring the patient back, get the pertinent vitals, do your exam/management and you can discharge the patient back to the waiting room.

I recommend discharging your own patients because patient always have ‘one other question’ and if you answer the question it will save you a lot of time as opposed to waiting for your nurse to relay the questions to you and then you having to have that nurse to relay it back to the patient.

Clinically Incompetent Staff

Don’t rely on your staff to put that chest pain patient in the room. They might leave that person out in the waiting room because they were ‘arguing’ with the opioid seeker.

Keep an eye out on your schedule and if you see a red flag case then go out there and eyeball the patient or even turn them away to the ED if they are obviously too sick to be in the UC.

 

Avoid Consulting Specialists

When you have your staff page the ophthalmologist to discuss a patient who has shingles on their face and you want to rule out the possibility of ocular involvement then you will slow down the workflow.

It’s much better to understand exactly what your community specialists do when faced with such cases. Have your nurse do the visual acuity, do a general exam, next do a fluorescein slit lamp exam, and now you have something definitive to take to the specialists should you still need to page them.

The best time to learn these things are during the slower months. Page every specialist you want during such slow times to understand how your referrals are handled.

Don’t ask the specialist an open-ended question. Instead it’s “Hi, Dr. Mo here, I have a patient with shingles, normal visual acuity, and some eye redness with no signs of corneal lesions on fluorescein slit lamp. I am starting them on acyclovir and just want to make sure that you can see them in your office in the next 24 hours.”

Even worse is paging the oncologist about a chemo patient who now has a rash, fever, and weakness. What will they tell you? They are going to be conservative and recommend a 2-hour workup. Instead, that patient would be far better off in the emergency room instead of sequestering your little exam room and your staff’s time.

 

Multitasking

Every ER doctor understands multitasking but quite a few Urgent Care doctors have a problem adopting this mentality in the outpatient setting.

You can order an xray and send that trauma patient off to the radiology suite while you go to do a field block with lidocaine in the other room and order some blood tests for your young patient with abdominal pains.

You then go get the rest of the history from the trauma patient and discharge them. You complete the procedure on the lido’d patient and discharge them as well. Then you go into the room with the abdominal pain patient and figure out the exams you need to do and interpret the lab results.

Close Your Charts

I don’t leave my charts open. I have a very particular system which I follow in order to not miss anything when it comes to documentation.

Every single thing that I find on the patient worth addressing I place in the diagnosis field. If they have a fever and a rash then I enter ‘fever’ and ‘rash’ in the diagnosis field which forces me to comment on it when I close the chart.

If I order a particular test then I add the following sentence to my MDM right away ‘EKG shows ***’. Most EMR’s have such place-holders which prevent you from being able to close the chart until you fill in those asterixis. It forces me to comment on it otherwise someone will come along and say that you never commented on the EKG.

By closing my charts right away I avoid getting calls from the ED, the pharmacy, or the front desk as the patient is shipped to a new destination. All the relevant information is included and that saves me time. This helps me see patients faster without allowing myself to be interrupted.

 

Don’t Get Interrupted

I never let my staff interrupt me because they don’t think on a continuum but are task-based. They think in terms of yes/no and don’t know how many items I’m running simultaneously in my mind.

This will sound mean but don’t let your incompetent colleague interrupt you, either. They also think in terms of finite differential diagnosis and cannot grasp the idea of multitasking. And since they don’t value their own time nor the patient’s, they are likely to to sequester your time in the same inefficient manner.

Your competent colleagues won’t hold you hostage with an inefficient question and can always tell how many things you have calculating up in your head just by looking at your face. My buddy Dr. S. and I have this down to a science – except when we’re fucking with each other of course which is fun in its own way. I’ll be running around like a chicken with my head cut off and he’ll jump up on his chair, cross his legs, and ask patiently “So hey, tell me about your day”.

 

Ask for Help

When I was working on my own and didn’t have Dr. S to bounce ideas off of I started feeling the pressure of work x10.

Avoid going to incompetent colleagues for help because they will send you on a wild goose chase. I remember once going to a colleague who brought up Horner’s Syndrome – not that I really considered it but it threw me for such a loop and it was so unrelated that I nearly purged all my multitasking thoughts.

If you are on the dispensing end of advice to a colleague then pay attention to their face. If they are competent then they are just needing a push in one direction or another – their face will tell you which. They know something is wrong with their UC patient, they are debating admitting them – just agree and you’ll have taken 100 lbs off their shoulders.

Sometimes we just need another person to talk out loud to. For whatever reason our internal monologue device is inefficient that day.

 

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