resuscitating the emergency center to improve …...resuscitating the emergency center to improve...
TRANSCRIPT
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Resuscitating the
Emergency Center
to Improve Efficiency
Paul F. Mansfield, MD
Professor and Deputy Chair Department of Surgical Oncology,
Head Emergency Services
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Oncologic
perforation
bleeding
obstruction
Iatrogenic
sepsis
postoperative
treatment specific
What Are We?
A Trauma Center (sort of)
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21,000 patient visits per year
> 90% of visits are existing patients
1,200 visits are new patients
failing before scheduled appointment
no scheduled appointment
> 40% admission rate
U.T. MD Anderson Cancer Center The Numbers
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Cancer center, component of U.T. System
Late 1980’s – early 90’s Station 19
Mid 1990’s – Emergency Center
2007 – new dedicated space
Increasing complexity and volume of patients
Increasing hospital occupancy
History
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70
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110
Sep
tNov Ja
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arM
ay Jul
Sep
tNov Ja
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arM
ay Jul
Sep
t
Nov Ja
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ar
Average Hospital Occupancy (%) by Month 9/2007 – 4/2010
2007 2008 2009
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Dealing with a Challenge
Five Stages
Denial
Anger
Bargaining
Depression
Acceptance
Kubler-Ross, On Death and Dying, 1979
Alternative Stages
Recognition
Response
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Task Force convened 5/09
Analyzed problems and unique situation
Report accepted
Implementation begun 9/1/09
Recognition
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EC role in the institution
EC responsibility for patients
Responsibility to community at large
Realizing strengths
Partnering
Recognition
Environmental
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Complexity of patients
Underlying comorbidities
Complications of cancer
Complications of treatment
Survivorship
Recognition Patient Factors
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Change of nursing reporting relationship
Emergency Services reporting to PIC
Communication and integration across institution
Inpatient support and Department of Emergency
Medicine
Response
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Emergency Center Urgent Priorities
1) Critical staffing analysis
2) EDIS
3) Overcrowding
4) Diagnostic services support
5) Process Improvement
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0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
1/2
1/6
1/1
0
1/1
4
1/1
8
1/2
2
1/2
6
1/3
0
2/3
2/7
2/1
1
2/1
5
2/1
9
2/2
3
2/2
7
3/3
3/7
3/1
1
3/1
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3/1
9
3/2
3
3/2
7
3/3
1
4/4
4/8
4/1
2
4/1
6
4/2
0
4/2
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4/2
8
5/2
5/6
5/1
0
5/1
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5/1
8
5/2
2
5/2
6
5/3
0
6/3
6/7
6/1
1
6/1
5
6/1
9
6/2
3
6/2
7
7/1
7/5
7/9
7/1
3
7/1
7
7/2
1
7/2
5
7/2
9
EC
Occu
pan
cy
Date
EC Occupancy by Day
Max of EC Occupancy Min of EC Occupancy
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EDIS
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Emergency Services Emergency Department
Information System (EDIS)
EDIS to optimize patient through-put
Reduce handoff errors
Billing compliance
Maintain an electronic record
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Emergency Services Emergency Department
Information System (EDIS)
Work-flow and detailed functional analysis
completed
Infrastructure/Technology analysis
completed
Evaluating response from vendor
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Overcrowding
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Emergency Services Overcrowding – Contributing Factors
• EC as a back door for planned
admissions
• Inappropriate referral to the EC
• Inpatient census exceeding capacity
• Communication problems
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Communication - Vocera
Within EC
Between EC and
Clinics
ICU
Radiology
Transportation
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Emergency Services Overcrowding – Solutions
• Treat appropriate patients in clinics or ATC
– Lovenox, IVF’s or blood products, and
procedures
– CAD workgroup addressing
• Use of Discharge Waiting Area
• Accordion space
• Full Capacity Protocol
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70
80
90
100
110
Sept
Nov Ja
nM
arM
ay Jul
Sept
Nov Ja
nM
arM
ay Jul
Sept
Nov Ja
nM
arM
ay Jul
Average Hospital Occupancy (%) by Month 9/2007 – 8/2010
Feb. 2010
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Process Improvement
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Diagnostic Testing and Lab
Medicine
POC testing
Cross training for ECG’s
Streamlining Transfusion Services
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Diagnostic Imaging
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Median Times EC Order to CT Report Call
14
8
11
26
34
22
7.5
2
11.5
5
7
33.5
5
6.5
62
15
20
16
13
15
61
18
34
29
11
15
48
39
63.5
0 50 100 150 200 250 300 350
Abdomen / Pelvis
Brain
Chest
EC Physician Order to Entered in CARE Entered in CARE to Protocoled by DI Protocoled by DI to DI Nurse Sees Protocol
DI Nurse Sees Protocol to Hand Off Call Hand off Call to Request to Transportation Submitted Transport Request Submitted to Patient Pick Up
Patient Pick Up to Arrival at CT Arrival at CT to Begin Procedure Begin Procedure to End Procedure
End Procedure to Report Call to EC Physician
Total Time = 196.0 minutes
Total Time = 308.5 minutes
Total Time = 148.0 minutes
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Diagnostic Imaging Working Group
Prioritization
Streamlining imaging protocols
Contrast delivery
Transportation
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Sepsis
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Early Goal Directed Therapy (EGDT)
Aim
Improve Compliance with EGDT for sepsis from 36% to 70%
Through measurement of urine output
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The CS&E Team • Team Members
– CS&E Participant: Terry Rice, MD
– CS&E Participant: Katy Hanzelka, PharmD
– Team Member: Debra Ruiz, RN
– Team Member: Marie Hariri, RN
– Team Member: Nada Fadul, MD
– Team Member: Carmen Gonzalez, MD
– Team Member: Imrana Malik, MD
– Team Member: Debra Smith, RT
– Facilitator: Larry Vines
• Sponsor
– Susan Gaeta, MD
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Surviving Sepsis Campaign
Guidelines
Early Goal-Directed Therapy (EGDT 6Hrs)
Central venous pressure (CVP) 8–12 mmHg
Mean arterial pressure (MAP) 65 mmHg
Urine output (UO) 0.5 mL/kg/hr
Mixed venous oxygen saturation 65%
MDACC - ICU sepsis related mortality increased
from 32% to 35% to 41% in 2004, 2005, and
2006 respectively
38
Dellinger RP, et al. Surviving Sepsis campaign: international guidelines for
management of severe sepsis and septic shock. Crit Care Med 2008;36(1):296-
327.
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Implementing the Change
• Education
– Physician, Respiratory therapist, Patient service
coordinator, Nursing
• Sepsis Protocol
• Sepsis Documentation Tool
• Point of care blood gas and lactic acid
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RN Documentation Form
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Sepsis Documentation Tool
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Results
Before n = 106 After n = 26
Serum lactate measured within
1 hour 64 (60%) 16 (61%)
Intravenous fluid in EC (mL) 1979 ± 1081 2507 ± 50
Goal MAP within 6 hours 78 (74%) 23 (88%)
Urine output recorded 38 (36%) 17 (65%)
Vasopressor administered 62 (58%) 13 (50%)
Time to Vasopressor (hours) 4.15 ± 3.01 3.21 ± 1.35
28 day mortality 39 (36.8%) 3 (11.5%)*
Unless otherwise indicated, data mean +/- SD
*P=0.01
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EGDT Conclusion
• Better documentation improved EC use
communication with ICU
• POC Lactic acid for early recognition of severe
sepsis and septic shock
– Average time to LA 5.5 hours to 1.5 hour
• Improvement in mortality
– Possible difference in severity of illness
– Small sample size
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1) For many patients the EC is the lynchpin
2) Changes can occur
3) Requires
1) Commitment
2) Communication
3) Continuous process improvement.
Resuscitating an EC Conclusions
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1) Changing Expectations
2) Changing Processes
3) Changing Culture
1) Within the EC
2) Within the institution
Resuscitating an EC Conclusions
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