operational efficiency in the ed: fundamental …...incoming flow patterns are predictable desert...
TRANSCRIPT
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Operational Efficiency in the ED: Fundamental Considerations in Flow
Dan Smith, MD Studer Group Coach International Speaker
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Why do patients come to ED?
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How do I utilize this precious real estate in a more efficient manner?
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Incoming Flow Patterns Are Predictable Desert Samaritan Medical Center Emergency Department
Patient Arrivals October 2001 compared to Registrar Schedule
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Proposed Registrar schedule December 2001Registrar schedule (previous) 2001Patient Arrivals per hour per day
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i ~ i a l l:l I
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Stasis
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Flow Tactics
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Sequential Flow
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Who cares?
! Bad things happen in waiting rooms ! ED consumers desire timely care ! Complaints often rooted in excessive wait times ! Contractual obligations for ED physician groups ! CMS to cite throughput metrics-$ linkage in future ! Patient perception of care linkage to LOS ! Time sensitive core measures
! AMI door to balloon <90 min ! CAP blood cultures and antibiotics <6 hrs
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Transparency
! Australia: ! 4 hour rule ! 30-minute Offload
! USA: ! Median time from arrival to departure for admitted
patients (door to admit) NQF 0495 ! Median time from admit decision to departure for
admitted patients (dispo to admit) NQF 0497
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Tenets of Flow Efficiency
! Flow patterns are often predictable ! Staffing and physical space is known ! Flow efficiency is therefore manageable ! Keep vertical patients vertical and moving ! Have caretakers at each point in the transition ! Diagnose the problem ! Collaboration must be the norm
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Consider ED Transit as Three Components
! Front End Flow (Door to Bed) ! Middle Flow (Bed to Disposition) ! Back End Flow (Dispo to Discharge or Admit)
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“Houston, we have a problem” (Diagnose)
! ED throughput metrics are high; % LOS <4 hrs low ! Missed opportunities (LWBS/DNW/LAOR high) ! Burdens of volume are placed in certain areas of
the ED ! Burdens of volume occur during periods of the day ! Patient satisfaction is low despite hardwired
communication tactics and good culture ! Path of the patient reveals multiple non-value
added steps ! Sentinel events occur in the waiting area
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Front End Issues
! Ask: ! Is triage efficient? ! Is a patient immediately bedded if a bed is open? ! Does the provider see the patient quickly after they
are bedded? ! Does the ED have open beds to place patients?
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Middle Issues
! Ask: ! Is the unit clerk able to enter orders timely? ! Is the nurse able to execute orders timely? ! Do essential services execute in timely fashion? ! Is the doctor able to expedite the disposition? ! Do admitting physicians call back timely?
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Back End Issues
! Ask ! Does an inpatient bed exist to admit? ! Does the ED nurse give report timely? ! Does the inpatient nurse accept report timely? ! Does the inpatient floor accept the patient timely? ! Does some doctor write admitting orders timely? ! Does the admitting doctor hold the patient in ED? ! Does the hospital have a prediversion plan? ! Does the hospital have code purple protocol?
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Provider in Triage (PIT)
! Scenario: Log-jammed ED, docs no patients to see in back, waiting room swells, small area in triage available
! Rationale: Patients better off seen by provider than not, can “treat and street” some, makes docs more productive
! Need: small work space, basic tools, nurse, doc ! Limitation: often divert back to WR, limited work-
ups
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Fast Track
! Scenario: Surge of low acuity at known times, can dedicate a provider, dedicated beds/spaces
! Rationale: Lower acuity patients need dedicated care area to rapid cycle test and treat with dedicated staff and providers, lower LOS and throughput metrics
! Need: Dedicated care areas, normal FT equipment, nurse and doctor/MLP
! Limitation: Limited ability and capacity for high acuity cases, some patients feel rushed
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Segmentation Flow Model (Split flow)
! Scenario: Volume surges are met with no core or FT beds, log-jammed ED with all acuity of patients, could rearrange care spaces or find real estate for a capacitance “result pending” (RP) space
! Rationale: Most patients can remain vertical and moving after initial evaluation, your ability to move them out of care areas ultimately avails these beds and promotes bed turns, decompresses the ED
! Need: Buy-in for vertical model, RP ward, dedicated nurse for RP, lack of “boarded” ED
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Split Flow Model of Care
! “Vertical” model ! Paradigm Shift from Traditional Inefficient Flow ! ED Real Estate is precious ! No patient should “own” a bed ! No provider “owns” a bed ! Anterograde flow ! Use a bed only for active care management
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What • Evidence Based Practice • Vertical Care Model
Why • Improved Operational Efficiency • Improve Safety, Quality and Perception of Care
How • Flow Map Current Process and Physical Plant • Define Roles and Expectations of Key Stakeholders • Timeline to Inception
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Triage is a process NOT a place
! Quick Look nurse and technician ! Quick Look Assessment
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Quick Look Nurse at Triage
! First point of contact: nurse ! Five questions ! Goal of quick look triage <3 minutes ! Assign ESI/CTAS level ! Coordinates with Nurse Hawk/Charge Nurse as to
bed assignment in ED
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Triage “no-no’s”
! Full history ! Med Rec completion ! Retrograde flow back to waiting area ! Non-clinician as first point of contact with patient ! Non-usage of available space in ED
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Quick Look Assessment: Nurse
! 5 questions ! Name ! Age ! Allergies ! Major PMHx ! Chief complaint
! <3 minutes ! Simultaneous quick registration
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Quick Look Assessment: Tech
! Assists RN ! Vitals/pulse ox ! ECG/Accucheck ! Transportation of patient to back of ED
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Acuity and Placement
Rapid Treatment/Intake &
Procedure Core Bed
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Intake Procedure
! ESI Vertical 3,4 and 5 (low suspicion for admit) ! Midlevel providers often utilized ! Same rules of engagement on real estate ! Example
! Musculoskeletal inuries ! Simple infections ! Low operative suspicion abdominal pain ! Back Pain ! Migraine
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Intake/Procedure
! Target time: 30-60 minutes ! Secondary assessment and med rec completion ! Patients remain here for period of time to do initial
H & P, pelvic exam, etc ! Then….when intial lines/labs are completed: split
patient to the “Results Pending” area
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Core Area
! ESI 1,2, horizontal 3 (higher suspicion for admit) ! Need the real estate ! Need to be “bedded” or “horizontal” ! Need time ! Examples
! Those not vertical 3,4 or 5
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Core Area (Acute Care/Major)
! Few changes in this area ! Sicker cohort need the real estate and time ! Some from Core may split to Results Pending if
clinical status is downgraded or they become non-emergent
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Results Pending
Your ultimate asset to decompress a busy ED
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Result Pending
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Result Pending
! Dedicated nurse and assistant ! Not a “dump zone” or internal waiting area ! Area for patients to complete work-ups/meds ! Low likelihood of admission ! Patients may split to this area from the core or
intake/procedure ! Ancillary services may perform tasks here
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Result Pending
! RN and assistant work collaboratively ! Await study completion/improved status ! Original physician/MLP retain care duties ! Round on patients for basic comfort needs ! Adjunctive treatments ! Informs provider of tests/status ! “discharge specialist” (reduce dispo>d/c) ! Informs doctors/MLP when studies complete
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Patient Flow Coordinator
! “Nurse Hawk” ! Akin to air traffic controller for ED ! Active bed management and tracking board
assessment ! Inquires often to RN/Physicians on ability to split
patients to RP ! Better as dedicated position ! Some ED’s: dual role as charge nurse
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Critical Questions
Does my patient need to occupy precious
real estate?
Is my patient likely to be discharged to
home?
Could my patient be split to Results
Pending?
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A Sequenced Plan
! Roles and responsibilities of the flow team ! Delineate physical plant space and flow map ! Revisit current staffing model ! Define roles and expectations for staff and
physicians ! Table top flow exercise: old way vs. Split Flow ! Develop educational plan ! Timeline to inception/test of change
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Performance and the Team
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