University of California San Diego TC Chan, J Killeen, GM Vilke, D Kelly, D Guss Department of Emerg

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University of California San DiegoTC Chan, J
Killeen, GM Vilke, D Kelly, D GussDepartment of
Emergency Medicine, University of California, San
Diego
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UCSD Medical Center ED

• Located in urban corridor of San Diego
• Academic teaching hospital
• Approximate bed capacity of 300 average daily
  census of 250-280.
• Only state-designated comprehensive ED in San
  Diego and Imperial Counties
• Only Level I Trauma Center and Regional Burn
  Center
• Annual Census 40,000
• Total Beds 24 (4 fast track)

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Patient Makeup

• UCSD serves 9 of overall SD market, but 42 of
  uninsured portion
• Significant urban homeless, substance abuse
  population
• 1 in 11 ED patients are undoc. immigrants
• No County hospital in region
• Requests for specialty care transfers from up to
  100 miles away

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Hospital / ED Closures

• SD region pop growth of 12.3 from 1990-2000
• 6 hospitals with EDs have closed (3 within UCSDs
  catchment)
• 15.2 decline in hospital beds
• 19.7 decline in ED beds

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UCSD ED
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The Problem

• Increasing LOS
• Increasing Wait Times
• Increasing LWBS
• Flat ED Census

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Process Improvement Approach

• ED Team
• Improve ED Entry
• Initiate Care Earlier
• Inpatient Team
• Overcome barriers to admit process
• Improve Admission/Discharge process

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ED Entry
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Intervention Elements

• Rapid Entry
• Electronic Sign-in
• Quick Registration Process (name, dob, sex)
• Patient ID Wristband / Barcoding on arrival
• Open Bed Policy
• Triage-driven Bed Placement
• Bedside Registration
• ACT (Accelerate Care at Triage)
• MD-initiated evaluation, care at triage

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IT Culture Change

• Major EMR Revisions
• Electronic Sign-in
• Interface with hospital registration system
• Patient identification barcode system
• Wireless ED
• Mobile laptops for staff, registration
• Vocera instant communication system
• Staff Changes
• Change in Entry Culture (RN, MD, AP)

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Integration

• Ability to Initiate Simultaneous Activities
• Bar-code system allowing evaluation to proceed
  without prior registration (tracking,
  error-reduction)
• Integration of multiple computer systems/programs
  for each of the ancillary services
• ED EMR
• Hospital Computer System
• Registration (ADT)
• Radiology (IDX-Rad, PACS)
• Laboratory Interface (CCA)

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ACT

• Philosophical and cultural change in ED Triage
• Initiate evaluation and care at Triage
• Change ED patient flow from SERIES of steps to
  one in which steps occur in PARALLEL

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Traditional Ambulatory ED Flow
Laboratory
Triage
Radiology
MD Evaluation
Registration
MD Reevaluation Rx
Disposition
Ancillary Studies
Patient Wait Time
Patient Room Time
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• Increased utilization leads to increased numbers
  of patients waiting in a queue and increased
  waiting time
• - Queuing Theory

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Waiting Room Census and Ancillary Lab Studies by
Time of Day
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Patient Flow with ACT
Registration
Laboratory
ACT Triage Evaluation
MD Evaluation Treatment
Disposition
Radiology
Ancillary Studies
Patient Wait Time
Patient Room Time
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ACT Process
Rapid ID Barcode System
ED EMR Webcharts
Integration of multiple computer systems (lab,
rad, hosp)
Registration

Triage Nurse/ MD Eval Orders
Lab specimens collected, sent
EMT
Coordinate imaging studies
Other ancillary studies obtained
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ED Entry
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Rapid Entry Intervention
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Results
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Results
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Results
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Results
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Results
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Findings

• Improved ED Entry
• Decreased wait times, LOS, LWBS even with higher
  census
• No registration errors identified
• Mislabeled laboratory specimens reduced by 90
• Initiated Care Earlier
• Decreased LOS
• Many studies expedited from triage (10-20 of
  patients) including XR, CT, US, labs
• Small but not insignificant s of patients
  discharged from triage

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Lessons Learned

• Information technology and integration
  facilitated process improvements, but staff
  buy-in and culture change on all levels critical
  to implementation and success
• AP new integrated, wireless registration
  process
• RN new triage philosophy and ED entry process
• MD initiate evaluation earlier and at triage