Improving Throughput in Emergency Departments

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Improving Throughput in Emergency Departments

• Leslie S Zun, MD
• Professor and Chairman
• Department of Emergency Medicine
• Chicago Medical School
• Mount Sinai Hospital
• Jackie Conrad, VP Patient Care Services
• Mount Sinai Hospital
• Ed Rafalski, VP Planning, Marketing PR
• Sinai Health System

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Objectives

• To review the literature on ED throughput
• To understand the data needs for analyzing
  throughput
• To exam the a model to reduce throughput times

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Problems with ThroughputOvercrowdingAnn Emerg
Med 200342167-172

• Survey of 250 EDs for March 12, 2001
• RNs caring for 4.2 pts
• MDs caring for 9.7 pts
• 11 of hospital on diversion
• 73 of EDs had 2 or more boarded patients
• 59 use halls for pts
• 38 double up pts in rooms
• 47 use non-clinical space for pt care

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JCAHO Requirement

• Standard LD 3.10
• The leaders develop and implement plans to
  identify and mitigate impediments to efficient
  patient flow throughout the hospital
• Elements of performance
• Assessment
• Planning
• Accountability
• Measurements
• Results
• Improvements in inefficiency or unsafe practices

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Emergency Department Factors

• Planning and process
• Tracking systems and data
• Flow diagrams and establishment of benchmarks
• Techniques

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Planning and process

• Who needs to be involved?
• What is the level of authority?
• What committee structure?
• Who needs to be in agreement?
• Buy in and role of the line staff?
• Decide on the process improvement technique?
• Quick fixes

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Planning and processData

• What data is needed?
• What type of tracking system?
• How to obtain good data?
• What data analysis is needed?
• How is the data used?
• Hospital, emergency department or both?

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Data

• Critical Success Factors Healthcare Finance
  Manage 20005454-59
• Pt door to MD time
• MD to disposition time
• Laboratory and radiology tests per 1000 ED visits
• Room to dispo without tests
• Test results to departure time
• Variables Affecting Throughput in Academic ED Am
  J Med Quality 199712183-186.
• Significant
• of inpatient admissions
• Daily ED census
• Pediatric volume
• of ambulances
• Not significant
• Nursing hours worked
• Day of the week

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Benchmarks

• Establishment of benchmarks
• Agreement of throughput times
• Monitor times

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Benchmarks Healthcare Finance Manage
20005454-59

• Treatment rooms 1 room/2,000 pts
• Physician productivity 2.0-2.5 pts/hr
• Nursing productivity 1.7-2.1 pts/hr
• Registration clerk 0.4-0.5 hrs/pt

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BenchmarksHealthcare Finance Manage
20005454-59

• minutes
• Access to room 15
• Room to physician 15
• Pharmacy 20
• CBC 30
• CXR 35
• Room to disposition 75
• ED 180
• Urgent 150
• Non-urgent 60
• Overall 140

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BenchmarksVHA data from 2004

• Arrival to triage 6 min
• Triage to room 23 min
• Arrival to MD 53 min
• Arrival to admit 253 min
• Arrival to discharge 139 min
• Lab turnaround 49 min
• Radiograph turnaround 47 min
• LWOT 2.3
• Pts per MD hour 2.25 pts/hr

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Techniques

• Models
• Interventions and the literature
• Overload and Surge

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Techniques

• Computer Modeling Ann Emerg Med 198918134-140
• Computer simulation model of emergency department
  operations
• If of RNs increased, the patient throughput
  decreased to a certain point
• If of MDs increased, the patient throughput
  decreased to a certain point
• Increasing of exam rooms did not change the
  throughput
• Role of the medical student Acad Emerg Med
  19991741-43.
• Precepting medical students does not change
  patient throughput times.
• Pysch EDs ED Management Feb 2005
• Psych ED speeds throughput

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Techniques

• Interventions Ann Emerg Med 200341173-185
• Increased MD coverage 25
• Policy on delays for consultations and
  disposition decisions
• Transfer to ward within one hour
• Mixed sex rooms No more type specific wards
• Interventions J Emerg Nurs 199420355-360
• Notification of registration
• Charge nurse role
• Medical consultant call-back
• Old records to the ED
• Telephone system

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Techniques

• In-Room Registration Ann Emerg Med
  200445128-133
• 209 weekly intervals with an avg length of stay
  2.2. to 3.8 hours
• In-room registration reduced length of stay 15.0
  minutes
• Fast Track Efficiency J Quat Improvement
  200026503-514.
• Registrar dedicated to fast track
• Dedicated support staff
• Dedicated attending physician

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TechniquesRapid Process Redesign Ann Emerg Med
200239168-177

• 48,000 academic ED
• ED throughput reduced from 4 hrs 21 minutes to 2
  hrs 55 minutes
• 92 decrease in LWOTs
• Approximately 1 million for staff

• Decreased nursing ratios from 61 to 41
• Rearranged nursing zones to create one zone with
  no unmonitored patients
• Added 5 hallway beds
• Doubled clerk staff
• Separated telephone and paperwork
  responsibilities

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TechniquesRapid Process RedesignAnn Emerg Med
200239168-177

• Status board monitors in triage
• Brief triage and place patient in room
• In-room registration
• Doubled registration staff
• Two way radio communication

• Electronic order entry
• Tripled dedicated ED radiology staff
• Located radiology printer in ED
• Radiographs hung immediately
• Electronic order entry
• Bar-coding labeling in ED
• Bright visual cue for lab
• ED labs take priority

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TechniquesJCAHO-ED Managing Patient Flow 2004

• Real time tracking
• Early warning indicators
• Admission process
• Bed czar
• Bed briefing committees
• Cycle time eg. radiology
• Smoothing and queuing
• Demand capacity management system

• Fast track
• Enhanced communication
• Access to patient information
• Computerized order entry
• Output measures
• Additional staff
• Adding space

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Techniques

• Overload and Surge
• No literature
• Bed alert and surge protocols

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Pathways

• Flow Diagrams
• Reduces variability
• Establishes time frames
• Provides standard for measurement

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Flow Diagrams
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Hospital Factors

• RN shortage
• Inadequate or inflexible nurse to pt ratio
• Over reliance on intensive care and telemetry
  beds
• Inefficient diagnostic and ancillary services

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Hospital Factors Managing Patient Flow 2004

• JCAHO
• Adding space
• Hospitalist service
• Adding bed capacity
• Discharge centers
• Smoothing direct admissions
• OR scheduling

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Hospital Factors

• Overcrowding Ann Emerg Med 200342173-180.
• Lack of inpatient beds
• Isolation precautions
• Delays in cleaning rooms
• Inefficient diagnostic and ancillary services
• Delay in discharging patients
• Short Stay Units Acad Emerg Med 199631113-1118
• Stable internal medicine patients for conditions
  that need lt72 hours
• of pts waiting for beds decreased 9.6 to 4.2
  pts/day
• Some reduction in throughput

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Drawbacks

• Too quick customer service
• Risk and quality concerns
• Cost concerns

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Keys to Success

• Full engagement from the top down
• Involvement of management in all departments
• Commitment from the medical staff
• Consultants who can pull the patient upstairs
• Good data, good data and more good data

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Importance of Sinais Emergency Department The
Business Case for Improving Operations

• Located on the Near West Side of the City of
  Chicago
• Level I Trauma Center
• Mount Sinai admits 20,500 patients annually
• gt50 of these patients are seen in Sinais
  Emergency Department
• Sinais ED treats 45,000 patients annually 25
  of these convert to inpatients
• Patients first impression is significantly
  driven by the ED experience
• ED Service Line Committee formed in 2003 to
  address volume growth in financial turnaround
  effort with a focus on the four walls of the ED

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ED Overall Quality
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Emergency Department Overall Quality Key Drivers
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ED Patient Satisfaction Key Drivers

• Most Closely Correlated with Quality Perceptions
• Nurses Understanding Caring
• Cleanliness
• Pain Management
• Key Driver Among Dissatisfied Patients
• Long Waits 27 of patients list this as the
  reason quality of care was not excellent or very
  good.
• These patients become LWOTs (Left without Being
  Treated)

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Patient Perception of Short Wait Time
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Identification of an Opportunity Development of
a Dashboard
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Dashboards Continued - Control Charting LWOTs
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Early Analytical Approaches Volume LWOTs

• Correlation studies were performed along a series
  of variables influencing LWOT rates including
• Overall volume of patients
• Trauma volume
• The number hours ED beds were closed due to low
  RN staffing
• RN hours worked
• ED inpatient admissions
• Total MSH inpatient census.
• It was determined that trauma volume (correlation
  coefficient 0.23) and ED inpatient admissions
  (correlation coefficient 0.21) were most closely
  associated with increases in LWOT rates.

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Early Analytical Approaches LWOTs and Triage
Volume

• One-way ANOVA analysis was then used to analyze
  hourly LWOTs and the number of patients beings
  triaged. It was determined that significant
  differences existed between various ranges of
  patient triage volumes by hour
• Once the number of patients reached nine or more
  the LWOT rate increased significantly
• In an effort to more intelligently apply
  resources, a surge protocol was developed that
  called for deploying physician assistants once
  the number of patients waiting in the ED reached
  ten or more.

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The Business Case for Focusing on ED Efficiency

• Significant source of patients, particularly
  urban hospitals
• Improved throughput allows for volume growth
• Fewer LWOTs
• More capacity for treating additional volume
• Patient perceptions of hospital quality begin in
  the ED
• Perception of wait time a key driver selecting
  goals
• Marketing of the ED dependent on management of
  patient expectations and delivering on the
  service promise
• Sinai has not yet made the promise to the
  marketplacebut were getting close. Meeting a
  door to doctor time of 30 minutes 95 of the
  time is the threshold established.

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Are you ready to kick it up a notch?

• MP 30
• Moving patient in 30 minutes

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Moving patient in 30

• MP 30 Initiative Key Success Factors
• HUGE stretch goals become the lever for
  organization wide change
• Top down bottom up
• The burning platform
• Teaming breaking down silos
• Focus on the Mission, Vision of the Health system
• Blame is off the table
• Everyone matters
• We WILL succeed
• TRUST

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Moving patient in 30

• MP 30 Initiative Structure
• Steering Committee
• Set the stretch goals
• Provide direction to the initiative
• Stakeholder Meetings
• Everyone invited
• Weekly reporting on each depts data
• Fun, high energy meetings
• Teach change management, appreciative inquiry
• Internal communications
• I Pod giveaways
• Turn key event
• MP 30 Newsletter
• Communicate, communicate, communicate

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Moving patient in 30

• Feb LWOT Rate 10.1
  (GOAL lt2.0)
• Door to ED Room 72 min
  (GOAL 30 min)
• Door to Fast Track Room 57 min
  (GOAL 30 min)
• Decision to Bed 159 min
  (GOAL 1 Hour)
• Door to Disposition for ED Pts 6.8 hrs
  (GOAL 3.0 Hours)
• Door to Disposition for FT Pts 3.4 hrs
  (GOAL 1.5 Hours)
• Stats are based on ED data from 2/15-2/18, all
  stats from door to x time include time from
  pre-registration to triage.

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Moving patient in 30

• Sinais Mission
• To improve the health of the individuals and the
  community we serve
• Sinais Vision
• To become the national model of urban healthcare
• Sinais Values
• Teamwork
• Respect
• Integrity
• Quality

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Moving patient in 30

• Reporting Depts
• Laboratory
• Environmental Services
• Admitting
• Nursing
• Pharmacy
• Risk Management
• Emergency Room
• Behavioral Health
• Social Service
• Security
• Medical Records
• Infection Control
• Engineering

• Reporting Depts
• Radiology
• Interpreter Services
• Respiratory Therapy /Nuc Med
• Materials Mgt
• Physical Therapy
• Bed Resource/ Staffing Office
• Administrative Supervisors
• Human Resources
• Rehab Services
• Nutritional Services
• Transport
• Cardiology

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Moving patient in 30
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Moving patient in 30
Dashboard for the First Week of May, 2006
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Moving patient in 30
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Moving patient in 30
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Moving patient in 30

• Preliminary Results
• For the first 100 days of the initiative
  Comparing Feb to May
• ED throughput reduced by 30
• Walkouts reduced by 60
• Teamwork in action Silos are torn down
• Staff are engaged and aware I want an iPod

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Moving patient in 30

• Next Steps
• Departments achieving goals for gt 4 weeks are
  kicking it up a notch with tougher stretch
  goals
• All department goals will be reevaluated and
  renegotiated with the ED leadership staff
• Celebrate, share stories of success. Success
  breeds success.

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Happy MP Thursday! Wooo! Wooo!
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Questions

• Contact info
• zunl_at_sinai.org
• conj_at_sinai.org
• rafe_at_sinai.org