measuretarget baseline 5/1/15 current 5/29/15 % change or improved ed length of stay for patients...
TRANSCRIPT
Measure TargetBaseline5/1/15
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
stay8 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%
Clinical Integration
IMPROVEMENT BULLETINChest Pain – Outpatient Stress testing from the EDStart 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 it’s 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/DATAMETRICS/DATA
Health Provider Services Organization
Questions? Contact Jeff Johnson, MD at [email protected]
See page 2 for information on the process improvements that were made.
Next StepsNext StepsTask 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 – 8:30pm, to nights and weekends too
Increase access(Decrease waiting) TBD Planning in
process
Clinical Integration
IMPROVEMENT BULLETINThe 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 StepsOptions 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 8:30 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
Health Provider Services Organization
Find more bulletins on the Clinical Improvement Corner on the Medical Staff website.Email us at: [email protected]. For internal distribution only.
Last rev. 06-01-2015