Suzanne Horton, RN, MBA

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Inertia to Action Real Doctors, Real Hospitals,
Real Change

• Suzanne Horton, RN, MBA
• Director of Nursing Administration

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Hours of Diversion
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Overload
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Behavior Changes in the ED

• Redirected energy to patient care
• Developed new relationship with EMS
• Improved patient relations
• Focused on improving processes and efficiency

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Process Changes

• Express Admission Unit
• Saves time and allows for
• Completion of admission paperwork
• Diagnostics
• Stat intervention
• First dose of medication
• Expanded from 16 to 24 hours, Monday to Friday
• Reallocated resources, no effect on the budget

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Results

• Express Unit Admission
• Decreased ED wait time and crowding
• Allowed ED staff and physicians to focus on
  patients
• Decreased workload on floor
• Increased patient and physician satisfaction

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ED Holding Hours
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Big Picture
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ED High Leverage Changes

• Adjusted physician hours
• Matched staff to volume
• Increased number of shifts
• Staggered shift changes

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ED High Leverage Changes

• Added triage nurse during peak times
• Added paramedic during peak times
• Expanded triage protocols
• Revised Fast Track criteria

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ED High Leverage Changes

• Committed to Fast Track through
• Staffing
• Facility improvements
• Enlarged
• Added separate entry
• Added mini waiting room
• Expanded hours
• Data micro-management

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Series Process
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Fast Track Average LOS vs. Patient Volume
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ED Discharge Patient LOS
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Emergency Department Visits
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Percentage of Patients Leaving ED Before Being
Seen
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Overall Satisfaction Score for Baptist Memphis ED
(January-June)
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The River Flowed Backwards
The fault line across the Mississippi River
cracked open, causing the land to the north to
drop and that on the south to rise. A waterfall
10 to 15 feet high appeared in the river in the
New Madrid Bend, causing a backflow that spread
out over low-lying land to partially aid in
creating the lake. (Reelfoot Lake) December 6,
1811 Night Riders of Reelfoot Lake The Untold
Story by R.C. Forrester and Betty Burdick Wood
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The River Flowed Backwards

• Patients held in the ED for days, waiting for an
  ICU bed
• Patients held in the PACU for days, waiting for
  an ICU bed
• Surgery delayed because of no ICU beds
• Transfer patients from regional hospitals refused
  because no ICU beds were available
• March 2002, no diversion made a
• community standard

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Creating ICU Capacity
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Seamless Flow Through the Continuum

• ICU improvements coincided with flow initiatives
• Changes stimulated by
• Implementation of the intensivist program
• Commitment to improvement
• Participation in IHIs IMPACT collaborative

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Commitment to Improvement

• Started multidisciplinary rounds

• Covered 38 beds
• Led by ICU medical director
• Daily goals set for
• each patient
• Reduced oversights
• and delays in action

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Team Members Include

• Pharmacist
• Dietician
• Respiratory Therapist
• Physical Therapist
• Care Coordinators
• Social Worker
• Palliative Care Nurse
• Infection Control Nurse
• Patients Nurse

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Commitment to Improvement

• Evening rounds
• Held 7 nights a week
• Led by an intensivist and includes
• Nursing
• Respiratory Therapy
• Focus of rounds
• Best practices
• Moving patients to appropriate levels of
• care

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Implementation of Best Practices

• Pain and Sedation
• Readiness to Wean
• Lines and Tubes Out
• Appropriate Level Of Care
• BUNDLES
• Ventilator Bundle
• Central Line Bundle
• Urinary Tract Infection Bundle

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Ventilator Bundle

• HOB 30 Degrees
• PUD Prophylaxis
• DVT Prophylaxis
• Mouth care Q2H
• Sedation Vacation Q24H
• Is patient ready to wean?

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Central Line Bundle

• MD and all staff assisting with insertion must
  disinfect hands before procedure.
• MD must wear mask, sterile gown, sterile gloves
  and cap.
• All personnel assisting with procedure must wear
  gloves and mask. Patient should also don mask.
• Prep site with Chlorahex prep stick.
• Drape site with sterile drape.
• Dress site immediately with CVC sterile dressing
  kit and apply bio-patch medicated disc to site.

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Urinary Tract Infection Bundle

• Can urinary catheter be removed?
• Change out catheter if pt having symptoms, insert
  silver coated catheter
• Drainage bag must be kept lower than pts bladder
  at all times
• All urinary catheters must be secured to decrease
  movement of catheter
• Strict hand washing
• Peri-care daily and after each bowel movement

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Outcome ICU Mortality
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Outcome Hospital ICU LOS
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Overall Mortality for Patients with ICU Stay
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Patients with Ventilator Associated Pneumonia in
ICU
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Patients with Central Line Associated BSI in ICU
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Cost Savings
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Working Conditions Across IHI Collaborative
ICUs Patient Safety Climate Survey - December,
2003
 
of respondents within an ICU reporting positive
working conditions
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Lessons Learned

• Conduct small tests of change
• Educate staff
• Design processes to prevent harm
• Create independent redundancies to
• ensure compliance
• Create a culture of collaboration

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Lessons Learned, continued

• Improved outcomes are real
• Structure for sustaining improvement is getting
  stronger
• People involved are more satisfied with the care
  they give
• Continue value stream process

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Patient Centered Care Management 2004

• Identification of Patient Needs and Reduction in
  Variation
• Access Care Management
• Multidisciplinary Rounds in Patient Care Units
• Orchestrated Discharges
• MRT

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Overall Hospital Medicare HSMR
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• You must be the change you wish to see in the
  world. Mohandas Gandhi