Prioritisation skills in the ED


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Authors: Luke Regan, Michael Gale, Gregg Neagle, Michelle Clarkson / Codes: CC4, CC5, CC7 / Published: 11/02/2015

Recently I heard Atul Gawande announce that we are leaving the ‘Century of the Molecule’ and embarking on the ‘Century of the System’…a rather anthemic way of labelling the transition from the optimistically reductionist medical science of the 20th century into the depressingly layered and interconnected world of 21st century medical science. Systems it seems are all around us.

We have a lot of systems in Emergency medicine. Unlike others perhaps, we tend to employ them to draw simplicity, function and purpose out of the complexity our patients confront us with every day.

Systems to check ourselves. Systems to ensure conformity of practice across many sites and consecutive patients. We particularly like to have systems to help us navigate rapidly through time critical, life-threatening events.

Embark on the resuscitation of an arrested patient and you’re likely to find yourself within a system something like the below happy flow chart:


It reminds us how to prioritise airway and electricity and compressions over less meaningful or evidenced interventions.

Roll up to the scene of prehospital mayhem with as yet uncounted casualties with unknown injuries and you’re very likely to find yourself within a system something like the below brightly coloured boxes:


This system reminds us how to prioritise the living over the dead, the salvageable over the non-salvageable and navigate an otherwise stressful environment.

The college curriculum is particularly good at driving us to learn systems of prioritising situations such as an overflowing in-box at the start of a consultant shift, whilst junior doctors are given lectures on how to prioritise a ward round or list of jobs at the beginning of a pan-hospital night shift. All this teaching and training on how to prioritise seems useful, even though it is comparatively rarely that I am faced with any of these scenarios

It struck me that I’d never been taught (that I could remember – which is the definition of being taught properly…) a system for prioritising the most common high threat clinical situation we face. Every day we deal with periods where there are multiple sick patients and less than the best number of clinicians immediately available to treat them. The ‘cross-your-fingers-cover-your-eyes-and-trust in triage’ system is about all I could think of, and I know full well that not a single shift has gone by where I have done that from start to finish.

Is this yet another crucial area of practice that we leave in the box marked ‘pick this up with experience’? In that box so recently were housed communication skills, critical thinking, team-working and situational awareness, with all now moved out and setting up happy new homes in junior medical or even undergraduate training.

So just in case this is something worth us reflecting on and improving, I have deconstructed as best I can how I approach this frequently encountered challenge. At least how I approach it when I think I do so with a system that reduces risk, maximises patient benefit and avoids the pitfalls of hubris and trusting to luck to save me.

See what you think. Compare to your own practice. Compare to your own system. Do we need one? Do you have one? Do you teach one?? Enjoy the eighties style theme tune.


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