flow. [ flō ] your role in emergency wait times brendan munn calgary emergency medicine grand...

FLOW. [ flō ]your role in emergency wait times

Brendan MunnCalgary Emergency Medicine Grand RoundsOctober 29 2009

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS


Disclosure

Disclaimer

Eternal Thanks

Other than being a total control freak I have no conflicts of interest to declare.

Too much to be boring, too little to do the subject justice.

Dr. Grant Innes Dongmei WangDr. Lester Mercuur Edith Lundrigan

Jodi Gibson

Objectives (Overt)

1. discuss a conceptual model of flow

2. define crowding and metrics

3. review the literature on flow causes

effects

solutions

4. relevance to calgary and the individual


( )

Objectives (Covert)

1. crowding is a (the) major ED issue

2. crowding mostly due to hospital factors, but the ED definitely has room for improvement

3. you are a unique and special flower, and have a role to play



Crowding [kraʊdɪŋ]

Boarding [bɔrdɪŋ]

Access Block [ˈæksɛs blɒk]

Priapism [prī'ə-pĭz'əm ]

debated, unclear and variable

“the process of holding patients in the ED for extended periods of time”

bad news

“the prolonged wait for an inpatient hospital bed after ED treatment”

Conceptual Model Of Flow


Asplin, Ann Emerg Med 2003

Conceptual Model Of Overflow


long term care

ward

waiting room

ED

contention #1“crowding is easy to define”


How Crowded is Crowded? Hwang, Acad Emerg Med 2004


“A situation in which the identified need for emergency services outstrips available resources in the ED. This situation occurs in hospital EDs when there are more patients than staffed ED treatment beds, and wait times exceed a reasonable period. Crowding typically involves patients being monitored in non-treatment areas (eg hallways) awaiting ED treatment beds or inpatient beds. Crowding may also involve and inability to appropriately triage patients, with large numbers of patients in the ED waiting area of any triage assessment category”

ACEP Crowding Task Force 2002


“the number of hours in which patient census exceeds designated patient care areas”

Welch, Acad Emerg Med 2006

“hard to define, but I know it when I see it” Potter Stewart, Supreme Court Justice, 1964

contention #2“ED backlog is NOT a safety

valve”


waiting room

ED

Negative Effects of Crowding


Delays to Treatment

Hip # Pain - Hwang 2006 (VOL)Hip # Surg - Richardson 2009 (BT)ABx Pneumonia - Fee 2007 (VOL)ACS Chest Pain - Pines 2009 (OCC)NSTEMI - Diercks 2007 (LOS)High Acuity - McCarthy 2009Abdo Pain - Mills 2009Pain Tx - Pines 2008Lytics - Schull 2004 (DIV)

Mortality

Wait TimesMedical Errors

Miro 1999 (VOL)Sprivulus 2006 (OCC)Richardson 2006

The effect of emergency department crowding on clinically oriented outcomes. Bernstein, Acad Emerg Med 2009


Ambulance Diversion

Ambulance Availability

Patient Elopement

Patient Satisfaction

Less Teaching

Provider Satisfaction

Violence

Financial

Hospital Length of Stay

Bayley 2005 (LOS)Falvo 2007 (OCC)

Burt 2005 (DIV)Redelmeier 1994

Eckstein 2004 (OOS)Schull 2003 (DIV)

Hobbs 2000 (VOL)Polevoi 2005 (OCC)

Jenkins 1998 (WT)

Krochmal 1994 (BT)Liew 2003 (LOS)Richardson 2002 (LOS)

Pines 2008 (LOS, BT, WT)Vieth 2006 (OPIN)

Rondeau 2005 (BT)Williams 2007 (OPIN)

Shayne 2009 (VOL)

Waiting Room Stats Calgary


LOS Calgary


LWBS Calgary


Causes and Solutions


Emergency department crowding: old problem, new solutions. Bernstein, Emerg Med Clin North Am 2006.

Improving access to emergency care: addressing system issues. Govt of Canada, Physician Hospital Care Committee, 2006

Hospital-based emergency care: at the breaking point. Committee on the Future of Emergency Care in the United States Health System, 2006

Ten solutions for emergency department crowding. Derlet, West J Emerg Med 2008.

Systematic review of emergency department crowding: causes, effects and solutions. Hoot, Ann Emerg Med 2008.

Input


increasing volume

increasing acuity

lack of alternatives

surge

Tracking emergency


“Tracking emergency department crowding in a tertiary care academic institution”. Bullard, Healthcare Quarterly 2009.

2000 2007

Volume

Acuity

contention #3“it is not the input itself, but what

we do with it that counts”


inappropriate patientssurge capacity


Schull, Ann Emerg Med 2007Khane, Ann Emerg Med 2009

CTAS 4/5 represented 30% of visits but only 5% of stretchers

10 low complexity patients per 8 hours increased mean LOS by 5 mins for others

Vertesi, CJEM 2004

Low Acuity Patients

contention #4“we have the beds, they have the diseases -- why are they apart?”

dynamic logisticalsurge



Patients Registered

Patients Admitted

=

Hour of Day


usable

(throughput)

admitted

(output)

13.7

35.3

+ 8 MET

FMC total annual ED high acuity bed utilization in hours

57 beds

49

_______

Throughput


Type of Center

Triage

Staffing

Ancillary Services

Information Technology

Layout

contention #5“it behooves us to develop

operational efficiency”


for ourselvesfor patientsroom to movelimitationstemporizeeconomies of scalethe future


“investigations and consultations are important independent predictors of ED length of stay”

Yoon, CJEM 2003

116

176

28255

(minutes)


“EDs with combinations of low inpatient census, in-room registration, point of care testing and an urgent care area demonstrated increased patient throughput”

Analysis of the literature on emergency department throughput. Zun, West J Emerg Med 2009.

“successful strategies to improve patient flow are distinguished by an organization wide commitment to measurement, transparency in data reporting and sustained management attention”

Enhancing work flow to reduce crowding. Siegel, Jt Comm J Qual Patient Saf 2007.


Quality ImprovementApplying systems engineering principles in improving health care delivery. Kopach-Konrad, J Gen Intern Med 2007.


Manufacturing : LEAN and Six Sigma

Modeling

Use of LEAN in the emergency department: a case series of 4 hospitals. Dickson, Ann Emerg Med 2009.

Discrete event simulation of emergency department activity: a platform for system-level operations research. Connelly, Acad Emerg Med 2004.

Forecasting emergency department crowding: an external, multicenter evaluation. Hoot, Ann Emerg Med 2009.

_____________________________________________

Queuing Theory


Han, Acad Emerg Med 2007 Khare, Ann Emerg Med 2009

increasing the number of beds in the ED does not

decrease patient length of stay

alternative triage methods can increase efficiency

special units and even bed closures can increase

throughput Kelen, Acad Emerg Med 2001

bedside registrationtriage physician

Output


Boarding

Boarding

Boarding

Outpatient Follow Up

Occupancy Calgary


Generally agreed that boarding is the major culprit in ED crowding


Emergency department crowding. General Accounting Office of the United States, 2003

Estey, CJEM 2003Schull, Acad Emerg Med 2003 Fatovich, Emerg Med J 2005Olshaker, J Emerg Med 2006Rathlev, Ann Emerg Med 2007

“Changes to ED structure and function do not address the underlying causes or major adverse effects of overcrowding… [these] lie outside the ED.”

Richardson, Med J Aust 2006

contention #4a“crowding is an ED problem”

contention #4b “crowding is a non-ED problem”


rest of the hospital, 1990-2009

emergency department, 2003-current


daily average ED LOS increased 18 minutes per 10% increase in hospital occupancy

elective surgery volume predicts ED gridlock

Forster, Acad Emerg Med 2003

McManus, Anesthesiology 2003 Litvak, Acad Emerg Med 2001 OR Manager, 2004

ED Wait Times 60 -> 40 mins, ED LOS dec by 45 minutes


shared boarding has demonstrated safety and the benefits of ownership of the crowding problem

“changes the inpatient units’ attitude toward flow… the result is better flow through the entire hospital”

targeted discharge planning, active bed management and improved follow-up outpatient resources are important

Pines, Ann Emerg Med 2009

Viccellio, Ann Emerg Med 2009


Review the ‘put1. flow depends on in/through/output

output is the major contributor but the ED has work to do in Calgary

2. crowding difficult to definesimplest measures probably the best

3. solutions are multi-pronged, hospital-wide and dynamic in nature

4. intervene and evaluate benchmarks


Throughput and the Individual

In Direct Control Out of Direct Control Speed ED Factors Service Use (DI, Lab, Consult) Services Themselves Teaching Output


Review You1. this is our… all our… THE problem

2. how is your operational efficiency?

3. know your committeesyou are ideally situated to suggest areas of improvement

4. get involvedbugle horns are $7.50 at Wal-Mart

5. patients & providers are beneficiaries


Questions?

flow. [ flō ] your role in emergency wait times brendan munn calgary emergency medicine grand...

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