From Access to Success in the Emergency Department

Improving Access to the Emergency Department at Penticton Regional

Hospital

Penticton and Area

2/24/2014 Footer 2

∗ 32,000 residents in the City of Penticton

∗ In the summer the population doubles to 60,000

∗ Penticton Regional Hospital serves 79,000 people in the Okanagan Similkameen Hospital District

∗ 137 beds ∗ Services: Orthopedic and General Surgery, Intensive

Care, Medical, Obstetrics, Pediatrics, Neurology, Rehab ∗ Regularly107-116% over capacity

Penticton Regional Hospital

2/24/2014 Footer 3

PRH Emergency

2/24/2014 Footer 4

∗ 13 bed Emergency Department

∗ 24 hour physician coverage ∗ 32,500 visits per year ∗ 80-100 patients per day ∗ 100-130 patients per day in

the summer ∗ Average wait time to see

physician for CTAS 2, 3, 4 and 5’s:

65 minutes

Emergency Physicians brought concerns forward: 1. Department congested with admitted patients

2. Physicians ready to see waiting patients but no

space to assess them

What is the problem?

2/24/2014 Footer 5

What to do?

∗ Decision by the Director of Acute Care Services to enter into a Continuous Quality Improvement project

∗ September 2012: Initial Access and Flow committee

brought together

∗ Early 2013: Emergency Department working group brought together to process map the patients journey.

∗ Data was captured around time to physician assessment

0

50

100

150

CTAS 2 CTAS 3 CTAS 4 CTAS 5

Time From Registration to Initial Physician Assessment

2011/2012

Time (Minutes) CTAS Guideline

What Did We Find?

0%

10%

20%

30%

40%

50%

60%

2009/10 2010/11 2011/12CTAS 2 CTAS 3 CTAS 4 CTAS 5 LWBS/Unspec

84% of patients that come through PRH ED are not admitted!

Are the Admitted Patients Really The Problem?

ED Activity Profile – CTAS distribution

To improve the acute care patient flow through the Emergency Department while maintaining quality of care, despite competing demands and constrained resources.

BY Creating a care area designed to meet the needs of the lower acuity ambulatory patients that don’t need a bed, utilizing existing physical and staffing resources

Let’s focus!

Streaming: Project Objective

“Implement a streaming model of care delineating 4 distinct care areas that patients

may be assigned to immediately following triage with the goal of improving the time from

registration to Emergency Physician assessment by December 2013”

11

Streaming

• CTAS Level 3, 4 5 medical

• Patients that are independently mobile

Initial Triage

Quick triage Patient demographics Brief and focused

history

Patient assessment Assign triage score Assign Patient Care

Area

Minor Treatment

• CTAS Level 4s and 5s

• Lacerations • Cut fingers • Sprained ankles

Acute ED Stretchers

• CTAS Level 2s and 3s

• Patients that are not independently mobile

Trauma/ Resuscitation

• CTAS Level 1s

and 2s

Streaming: How it works

12

Streaming - How it Works

∗ 14 chairs and 4 exam spaces available for

Streaming and Minor treatment ∗ Patients triaged to the chair area must

independently mobile ∗ Patients who are too ill or too frail to sit in a

chair are not appropriate for Streaming ∗ Streaming runs similar to a Physicians office or

clinic ∗ Patients on stretcher only when receiving care

from RN or MD ∗ Patients may walk to diagnostic imaging and

back once studies have been ordered

Why Stream?

∗ More efficient use of minimal space 14 patients can be seen out of three stretcher spaces

∗ Decreased time waiting for a stretcher bay decreases wait to see the physician increasing patient satisfaction: Patients come to see the Dr. ∗ Improved time to diagnostic/treatment orders

∗ Patients are more willing to come back if condition worsens due to decreased wait time

∗ Number of people Leaving Without Being Seen decreases ∗ Mitigates the worries of leaving a sick person in the waiting room

out of sight and un-assessed, increasing staff satisfaction ∗ Recruitment and retention is enhanced

Streaming as a care area

24/02/2014 14

Program Design

∗ Inclusion/exclusion criteria ∗ Physical space allocation ∗ Patient flow ∗ Staffing Model ∗ Equipment needs

One Month Education Blitz

∗ Mandatory one hour education sessions for all ED staff ∗ Education sessions for physicians ∗ Presentations to support services DI, Lab, Nursing

Supervisors, Registration

Creating Buy In

24/02/2014 15

APRIL 15th, 2013 Went live with Streaming Trial

∗ Daily Evaluations

∗ Daily communication reports and status updates

∗ Revisions, revisions, revisions!!!!

Go Live!

2/24/2014 Footer 16

Challenge: Culture Shift

2/24/2014 Footer 17

How do we go from this….

To this?

Challenge: Concerns About Patient Dignity

Challenge: Who will change the sheets?

2/24/2014 Footer 19

Challenge: Staffing Model

2/24/2014 Footer 20

∗ Need to remove one RN on days to dedicate to streaming

∗ Team nursing model cherished

∗ How to cover breaks ∗ Staff mix

How Did We Do??

2/24/2014 Footer 21

0

20

40

60

80

100

120

140

CTAS 2 CTAS 3 CTAS 4 CTAS 5

Pre Project

Benchmark

Post Project

Time saved

Pre and Post Streaming Time to Physician Assessment

Wait times CTAS 2, 3, 4, 5

2/24/2014 Footer 22

Pre Streaming Average wait to see the

physician

65 Minutes

Post Streaming Average wait to see the

physician

42 Minutes

∗ “ As a PCC I don’t feel that constant worry about where I am going to put the next chest pain”

∗ “I love streaming…they’re in, they’re out, just like that!” ∗ “I can’t see how we would be functioning now if it was

not for streaming.” When the team was asked recently by an administrator what they were most proud of as a team they said:

STREAMING!!!

Staff Satisfaction!

2/24/2014 Footer 23