Clinical Integration

1
Clinical Integration IMPROVEMENT BULLETIN
Health Provider Services Organization
Chest Pain Outpatient Stress testing from the
ED Start Date Sept 1, 2014 Sponsors Jeff
Johnson, MD HPSO Team Peter Grape, MD
(Harbor) Vinny Mangili, MD (HPSO) Chris Dindy,
RN (Cardiovascular Clinic) Jody Clergy, RN
(Cardiovascular Clinic) Cheryl Coveney (Patient
Access) Kathleen Sheehan (Patient Access) Laura
Hickey (IS) Ruth Dzialo (IS) Joshua Forgue
(IS) Tom Gormley, Lean Facilitator Background
Patients arriving to the ED with symptoms of
chest pain can spend 20 hours in the Observation
unit (at an average cost of 3,000) undergoing
standard diagnostics (labs, enzymes, and stress
test) to rule out acute coronary syndrome (ACS).
According to an SSH ED provider survey,
approximately 40 of ED patients with chest pain
are low risk for ACS and would be candidates for
outpatient stress testing at much lower total
expense (as little as 500) and with less
waiting. Problem ED providers do not have an
easy, reliable way to offer the outpatient
option. Goals Create an easy, reliable process
to increase the use of outpatient, regular,
exercise stress testing for ED patients
presenting with low acuity chest pain, from 0 to
40 (based on SSH ED provider estimates). Improve
the patient experience and satisfaction of ED
patients with low acuity chest pain. Progress
Implemented and tested first on May 7th. ED
providers report its easy to use and average
turnaround time is well under the 15-minute
expectation. ED LOS for these patients reduced
to an average of 8 hours. All patients completed
their outpatient tests and were 100 satisfied
according to exit surveys in the Cardiovascular
Clinic. Total expense savings including patient
and insurance payer costs to date (5/29) are
approximately 32,500. Next Steps Continue
study to confirm results and standardize the
process Extend outpatient appointment scheduling
to 24/7.
METRICS/DATA
Measure Target Baseline 5/1/15 Current 5/29/15 change orimproved
ED length of stay for patients presenting with low acuity chest pain (a fit for outpatient, regular exercise stress test) 5 hours 20 hourswith Obs stay 8 hours 60
of outpatient regular exercise treadmill test (ETT) orders with turnaround time from ED order to appointment scheduled and call back to ED provider, of less than 15 minutes 100 n/a 100 100
of ED chest pain patients needing a regular, exercise stress test, who get a scheduled, outpatient test rather than an Observation stay (as of 5/29) 40 0 39 39
of outpatient, regular exercise stress tests canceled by patient, or no show 0 n/a 0 100
Patient satisfaction (13 patients as of 5/29) 100 n/a 100 100
Next Steps
Task Impact When Status
Track usage of outpatient regular ETT compare with prior expectations. Break down data by provider. Facilitate adoption by ED providers June 15 In process
Expand appointment scheduling from weekdays 7am 830pm, to nights and weekends too Increase access (Decrease waiting) TBD Planning in process
Questions? Contact Jeff Johnson, MD at
Jeffrey_Johnson_MD_at_sshosp.org
See page 2 for information on the process
improvements that were made.
2
Clinical Integration IMPROVEMENT BULLETIN
Health Provider Services Organization
The table below is a summary of the challenges or
barriers encountered, and the process
improvements made to enable the outpatient
option.
Problem Causes Countermeasures Results Next Steps
Options for management of patients deemed to be at low risk for myocardial ischemia as a cause of their chest pain are too limited, resulting in some patients being unnecessarily placed on observation. Change in process had not been considered or requested until now, in part because there was no way to offer patients an outpatient option. Survey ED providers regarding their potential to utilize an expedited outpatient stress test process if it were developed and made available. Develop, share, and standardize a method for risk stratification based on American Heart Association guidelines ED providers informed of new outpatient option. 5 out of 65 ED providers (8) have chosen the outpatient option for one or more patients Reminders to ED providers as needed. Track usage of the outpatient regular exercise treadmill test option by provider.
No easy, reliable method for ED providers to order an outpatient stress test Order is not available in hospital EMR (Meditech) Requires complex, multi-disciplinary collaboration with IS, Patient Access, and the Cardiovascular Clinic Work with ED, Patient Access, IS, and Cardiovascular Clinic staff to develop an easy, reliable process from ED order request to outpatient stress test completion Educate staff in the ED, Patient Access, and Cardiovascular Clinic Meditech system built by IS, has been well received by ED providers (easy to use) Patient Access team notifying ED providers within 4.5 min (below target of 15 minutes) ED provider entry of appointment time into the discharge instruction packet is inefficient 100 patient satisfaction One patient suggested improving directions to CV Clinic Sustain and spread use to all ED providers Pursue easier ways to capture appointment times Update directions to CV clinic in patient instructions
Scheduling (Patient Access) is only available 7am to 830 pm, M-F Existing staffing model. Need for off hours is not prioritized To be determined, based on analysis and prioritization None yet None yet
No ability to schedule the outpatient test at an ambulatory office in the community Ambulatory office scheduling staff are not 24x7 No access to ambulatory office scheduling systems To be determined, based on analysis of alternatives None yet None yet
Find more bulletins on the Clinical Improvement
Corner on the Medical Staff website.Email us at
hpso_at_sshosp.org. For internal distribution only.
Last rev. 06-01-2015