6 Limit interruptions. They are dangerous and inefficient. Chisholm and colleagues noted that emergency physicians are interrupted every six minutes and have a “break in task” (an interruption resulting in the physician dropping what they are doing to tend to a different task) every nine minutes.² It is conceivable, and all too common, for multiple breaks in task to occur in series so that it isn’t reasonable to expect someone to remember their initial, uncompleted task.

7 We’ve all heard the phrase “time is money.” Well, in the ED, money isn’t our currency—time is. We should all be mindful that saving time is important, but creating time is critical to a successful shift. Spend it when it helps you reach a decision point (as recommended in Principle 1) and provides added value. Any other use of time is wasteful. Time spent on these things is valuable:

1. Decision making
2. Communicating with patients to clarify expectations and anticipate questions
3. Communicating your plan to the ED staff—entering orders in the EMR is simply not enough
4. Advising others of what is outstanding during a handoff

8 When the decision has beenreached, execute.

1. The most valuable commodity in the ED is a disposition. When you know, it’s time to go!

9 If the decision will be the same regardless of the results, don’t order the test.

10 Tell people the value they are getting by trading tests for your expertise.

1. Perception is the reality you create; you’re in charge. For example, you could say:
   • “I’ll get you home quicker if we order fewer tests.”
   • “When starting the IV, we’ll attempt to get the blood at the same time.”
   • “We can get you an answer without tests. We’ll save you time.”
   • “Do you think you’ve broken your back? I don’t either. X-rays only show the bones [oversimplification] and won’t help you today. Let’s avoid exposing you to ionizing radiation.”
2. However, if you do less, plan for others to challenge your decision when you aren’t present to defend yourself (ie, preemptive damage control). For example:
   • “My doctor ordered a chest X-ray and treated me with antibiotics for bronchitis.”
   • “Bronchitis doesn’t show up on an X-ray.”
3. If you are excluding a diagnosis without a test, tell patients they don’t have it and why.

11 The weakest diagnostic link is the slowest test you order and can nullify the value of point-of-care testing.