supertrack swarm tampa general hospital · 2014-12-22 · supertrack swarm . tampa general hospital...

SUPERTRACK SWARM TAMPA GENERAL HOSPITAL

Publication Year: 2014

SUMMARY: Design and implementation of a split flow ED with a mid-track, including leadership “swarm” meeting for rapid improvement and sustainability. SUBMISSION CATEGORY: Flow and Efficiency

HOSPITAL: Tampa General Hospital LOCATION: Tampa, FL CONTACT: Melissa D. Cole MSN, ARNP, ANP-BC Director of Emergency & Trauma Services, [email protected]

CATEGORY: A: Arrival C: Clinician Initial Evaluation &

Throughput

HOSPITAL METRICS: Annual ED Volume: 85,000 Hospital Beds: 1018 Ownership: Private, Not-For-Profit Trauma Level: 1 Teaching Status: Yes, Primary Affiliate USF

College of Medicine KEY WORDS: Door-to-Doc ESI Fast Track Lean Left-

Without-Being-Seen

Queuing Rapid Intake

Registration Triage Wait Times

TOOLS PROVIDED: Prescriptive Plan Flow Progress ED Punch List Results and Images

CLINICAL AREAS AFFECTED: Ancillary Departments ED EMS Environmental Services Inpatient Units Laboratory Radiology Registration Triage

STAFF INVOLVED: Administrators Ancillary

Departments Case Management Clerks Clinic Registration

ED staff IT staff Nurses Pharmacists

physicians Registration

Staff Technicians

Copyright © 2002‐2014 Urgent Matters

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Innovation To address long arrival to provider times and high‐left‐without‐being‐seen rates we developed a split flow emergency department. As part of this split flow model, separating vertical patients from horizontal patients, we created a combined low acuity/mid‐track area which we called “Supertrack” for vertical patients. We converted our 4 triage rooms into patient exam spaces and converted a specified portion of the waiting room into a results pending lounge. Additionally, we converted a dedicated area of 10 private rooms, into a flexible treatment space for those vertical patients who needed to be temporarily horizontal, for procedures or other needs. We utilized projected arrival patterns to flexibly staff this area using attending physicians, advanced practice clinicians, residents and scribes. We built a real time data dashboard in our EMR to help charge nurses and managers better identify and respond to flow challenges rapidly.

Background Patients presenting to our ED suffered from long wait times and they frequently left prior to seeing a health care provider. We had tried using LEAN methodology and split flow solutions in the past but with only moderate improvement and frequently suffered from a lack of sustainability. The process we designed works by reducing triage times while still accurately placing patients into the correct track. The Supertrack area was able to reduce waiting times for all patients by effectively utilizing virtual capacity for vertical patients. Previous change attempts had been derailed by too much variability in flow decisions; in order to combat this we created a prescriptive guideline to provide parameters for our nurses and physicians to make smart and reliable decisions. We selected this solution because it allowed for maximum flexibility in patient movement and creation of virtual capacity. Triage was a process that took nearly 15 minutes; we truncated the process and focused on obtaining information relevant to appropriate placement of the patient.

Innovation Implementation Triage is now a sorting process that consists of 5 questions taking approximately 3 minutes which we call pivot. While we continued to use traditional ESI levels we split level 3 patients into vertical and horizontal calling them “3V” and “3H”. We also made some minor modifications to our existing triage rooms placing slim computers for nursing as well as exam tables in order to use them as patient evaluation rooms. Additionally, we purchased new recliners to convert a part of our waiting room into a results pending lounge. SuperTrack sees ESI level 5,4 and “3V” patients, while the main ED sees ESI levels “3H”,2 and 1. The Supertrack process involved simultaneous evaluation by nurse and provider of a patient in their single exam room. We implemented the use of scribes in Supertrack to allow for improved concurrent assessments. The provider writes orders while a scribe documents the note. The nurse completes their documentation and the patient transitions out of the room to the next phase of their care. We created a dedicated space for phlebotomy, a 10 bed procedure area, and an area to complete registration. By limiting the patient’s time in the evaluation room the next patient could be evaluated in that space sooner. After initial testing, the patient is moved to the result pending recliners to await results or for further testing. As much as possible IV utilization was limited in favor of oral and IM medications. Once results were back the patient was returned to the exam room for reevaluation and disposition. We reserved 10 private rooms in one ED pod for patients who required procedures, privacy or brief monitoring so as to keep the front rooms free. There were multiple providers utilizing these 4 exam rooms with a maximum of 5 providers at peak hours. We changed our staffing matrix for physicians and nurses to better align with arrival patterns and stressed direct bedding. By caring for vertical patients in Supertrack rather than in a bed we created more bed spaces for the horizontal patients who required them. Our leadership team for the ED process consisted of a medical director, associate medical director, nursing director, and nurse manager in addition to 7 nurse clinicians to cover charge responsibilities for each shift. The leadership team was especially visible throughout the first 6 weeks of implementation to answer questions and trouble‐shoot the new process with staff.


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We began planning for the change in July of 2013 to create/improve data reports in anticipation of a large 2 day Comprehensive Process Redesign meeting in September. That meeting was focused on redesigning the process and had representatives, both leadership and frontline staff, from all stakeholders present. At the conclusion of that meeting we had a sketch of what the plan would look like and began to hold weekly flow meetings with frontline staff to create a prescriptive guideline for flow in the emergency department including the new split flow Supertrack area. We spent time with the newly built reports and data to arrange staffing models to staff both the super track area and acute ED based on patient arrival times. We conducted two Supertrack tests on one day at peak times in late October as a proof of concept for the improvement. We continued to meet weekly with the process improvement team and went live on December 3rd 2013. After going live, we began a daily rapid leadership meeting (ED executive swarm) which included hospital and physician executive leaders from multiple involved disciplines to actively trouble shoot issues. These disciplines included supply management, information technology, facilities, housekeeping, and transport. The meetings were no more than 30 minutes in length. The previous day’s performance was reviewed for underlying causes potential solutions. As we moved away from go‐live we continued these swarms but moving to twice weekly and then weekly times. We also continued the weekly flow meeting with frontline staff to modify the prescriptive guideline and ensure accountability from all team members. In order to implement the change the resources were minimal. The resources included 20 recliners, 2 phlebotomy chairs, 4 exam tables, 8 computers and minimal construction of the triage space. Staffing was essentially reallocated and not added. In order to sustain the updated workflow, construction was recommended and started to optimize patient flow. ARRIVAL TO PROVIDER TIME

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DISCHARGE PATIENT TOTAL LENGTH OF STAY

Timeline Medical Director hired February 2013 Nursing Director hired June 2013 Report building and data verification started in June 2013 and completed by October 2013 Preparation meeting for Comprehensive Process Redesign (CPR) workshop began in July 2013 Provider in triage trial started in July with modification in August 2013 CPR workshop September 2013 that included multiple disciplines and front line staff Weekly flow meetings began October 2013 to implement the action plan for preparation of go‐live New work flow trial November 2013 Triage room construction end of November 2013 Staff and provider education the last weeks of November Go live of new front end process December 3, 2013 Daily swarms with executive leaders began December 7, 2013 Weekly flow meeting continue to present time

Cost/Benefit Analysis The cost of the new flow design was minimal. There were some costs to convert the existing triage rooms and some IT equipment which was approximately $10,000. There was no increase in nurse staffing matrix as part of the plan, we simply redistributed resources. Scribes were introduced at a cost of approximately $175,000 for the year. There was an increase in provider hours, both physicians and advanced practice clinicians which was offset by increase in arrival volume. In fact there was a slight increase in adjusted patients per hour but within expected parameters of productivity. The reduction in left without treatment yielded a significant financial benefit estimated at $1.4 million annually. Advice and Lessons Learned Managing the change with staff and providers proved to be the most challenging aspect of this undertaking. While much of it was handled well, in hindsight there are things that we would have done differently. When we implemented the change, we excused the pediatric section of the ED out of the overall design, as the focus was the adult emergency department. We did include them in the education but underestimated the impact the change would have on their

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model. The pediatric staff felt as though they were ignored and had staffing changes related to the updated flow model. Additionally, we did not include radiology in much of the conversation and found that the new model affected the times and way the radiology department processed patients. In spite of education tying our metric goals to real patient care we underestimated front line staff resistance to feeling as though we only focused on the numbers. As we realized this we altered the content and structure of some of our communications, linking metrics such as arrival to provider to patients and focusing more on some non‐metric based outcomes as well. As mentioned, the flow model consists of separating the “not so sick” from the “very sick” which increased the acuity level in the main ED pods. Although this was a known, we underestimated how challenging the higher acuity pods became to manage. We had a 20% nurse vacancy rate at go‐live which exacerbated the stress felt with the changes. It would have been great to wait for staffing to improve but our patients could not wait for us. The strength of the physician and nurse dyad was crucial during this change. Additionally, the support of the executive leadership was essential at times to push the team through difficult stretches. Sustainability three phases of the throughput project. Since the go‐live in December, the ED has partnered with laboratory, radiology, and the admitting units to enhance the efficiency of patient flow. In order to continue to drive success the following continue to occur:

The executive leadership members continue to huddle or “swarm” regularly in the department to continue to problem solve issues.

The weekly flow meetings with staff and leadership with updates to the prescriptive guidelines as needed. These meeting also, at times, include updates from our partners in other departments.

Daily Metric emails to the leadership team Began an executive steering committee meeting where the leaders from the ED, laboratory, radiology,

transport, environmental services, information technology, and the admitting units come together monthly to report progress

Nursing and Medical Director with frequent rounding in the department. Frequent joint updates from Nursing and Medical Director regarding improvements and progression of

metrics toward goals Celebrate when we achieve the goals that were set from the beginning. We have had a one month gift

card for all the staff and ancillary department. Most recently, we are celebrating our six month’s achievements with a carnival celebration.

Tools to Download Prescriptive Plan Flow Progress ED Punch List Results and Images


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Prescription for Tampa General Hospital’s New ED Page 1 of 14

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* Patients Requiring Procedural Sedation Should Not Be Placed in Pod 2

Pivot Process – Splitting the Flow

I. Rapid Assessment and assign ESI

a. 6 Items

i. Chief Complaint

ii. Allergies

iii. Immunosuppression

iv. Vitals Signs

v. Primary triage assessment (Airway; Breathing; Circulation; Disability)

vi. Assign ESI level (include v3 and h3)

b. Indication & Communication of next location via ESI level in EPIC

c. Vertical to SuperTrack V3,4,5 Some Chest pain to the front if low risk by pivot

d. Horizontal to back 1,2,H3 DIRECT BED THESE PATIENT WHEN ABLE

e. Please note attached considerations/guidelines for care areas

f. Patients should be directed to appropriate area of the lobby only if the need to wait to

be seen (SuperTrack Lobby or Acute Care Lobby)

g. Pediatric patients will also be sorted at the pivot desk and the pediatrics area will pull

pediatric patients to their care area. See Pediatric Patient section

h. PIVOT NURSE may have patients seen quicker by expressing a desire in the comments

section for patients to be seen in a particular order.

i. Registration should be continuous. No intentional slowing down to wait for PIVOT

NURSE.

j. All Adult and Pediatric Patients shall have the questions asked (be pivoted) up front and all ages

shall have a temperature taken.

II. What to do if pivot is backed up?

a. Second area is located behind glass

i. Activate second area for pivot if there are more than 4 patients waiting for

pivot

ii. Use the Flow Nurse as second pivot nurse

b. “Protect the Quarterback” – pivot nurse is the quarterback

i. Patients should sorted from visitors and visitors should be kept away from pivot

desk

ii. Patients waiting for pivot should be directed to the appropriate seating area

c. On occasions SuperTrack exam rooms may be filled ahead of pivot can pull clear low

acuity visits to exam room and skip pivot

III. EMS Arrivals: Same Process 2 locations

a. Pivot triage of EMS traffic done by the Charge nurse

i. Same information collected and documented as listed above in part I.

ii. Patients arriving by EMS may also go through SuperTrack


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IV. Patient identified as needing immediate intervention

a. Examples include but not limited to: acute stroke, unstable vital signs, respiratory

distress, under 30 days old with fever.

b. The pivot nurse will vocera overhead or appropriate unit to notify staff that there is a

critical patient being brought to an acute care bed

c. The pivot nurse or tech will bring the patient back to the appropriate acute care space

SuperTrack – Swarm to one of 5 decisions

I. Nurse, Provider and Scribe (when available) see patients as much as possible as a team

utilizing on room at the front (triage room) as their exam room

II. One nurse/provider team will be team lead 7am shift start and 5pm attending start

a. Nurse or Provider may pull next patient into their exam room

i. Focus on the patients that are “pivoted” to SuperTrack (Vertical Patients)

ii. Horizontal patients to be seen/care initiated if no Vertical patients are waiting

1. more details in load balancing

iii. Call patients from lobby by their last name

iv. LOCK AND LOAD: PCT’s in the LOBBY/WAITING ROOM will place patients in

chairs located outside the active Triage/Exam Rooms. That patient will be “on-

deck” and may then be pulled into the room by the provider/nurse team

quicker.

b. Team will enter the room together as much as possible and obtain the history and

perform necessary physical exam including GU exams as required

c. Computer Use

i. Wall mount – Nurse (Exam 4 nurse will also utilize rover no wall mount)

ii. Full size rover – Provider

iii. Laptop on wheels – Scribe

d. Provider will enter orders; scribe documents medical record; nurse documents

e. The provider will make a choice for 1 of 5 destinations for the patient

More details of the process for each of these 5 groups follow (sections III-VII)

i. Home – no testing required patient can be discharged

1. Essential to be sure they are registered before leaving ED

ii. Results pending area in the lobby

iii. Pod-2

1. Patients going to the Results pending lobby or Pod 2 will continue to be

cared for by the original provider

iv. Acute care ED (Pods 3-5)

1. This is an opportunity for secondary triage not for second guessing!

PLEASE REMEMBER THAT THE PIVOT NURSE MADE THE BEST DECISION

WITH THE INFORMATION AVAILABLE

2. These patients must be moved to the acute care area as a priority

options for beds must include trauma, halls, moving other patients to


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hall spaces. The flow/charge nurse should make these placements.

SuperTrack nurse will flag in EPIC by changing ESI.

v. Admit from SuperTrack

III. Destination Home

a. Documentation completed by scribe; attested and signed by Provider

b. Provider enters disposition Rx and AVS (D/C instructions)

c. Rx and AVS printed provided to patient

d. Nursing finishes documentation to include medications

e. Nurse completes disposition documentation and charges making sure that registration is

completed

f. Patient is provided with Rx (if not e-prescribed) & IF NOT REGISTERED YET ESCORTED TO

REGISTRATION OFFICE TO COMPLETE REGISTRATION

IV. Destination Lobby Results Waiting

a. Orders entered by provider

i. Try to limit IV orders when straight stick lab draw is appropriate

ii. If blood is ordered patient will be moved to a chair just behind sub-triage along

wall between Pod-2 and Pod-3 to have blood drawn by PCT

1. Specimens labeled and sent to Lab

2. POC labs completed including obtaining urine

iii. Radiology

1. Patient will be located by radiology in the lobby results pending area

and brought for imaging

2. Patient may drink PO contrast in the lobby results pending area

3. Radiology process for

a. Dressing/undressing

b. MRI screening

c. Call backs for + results

b. Patient will be given a sticker before being returning to the lobby to indicate that they

are a patient who has been seen by a provider.

c. SuperTrack exam rooms 1-4 are denoted 2000T1, 2000T2, 2000T3, 2000T4 respectively.

Team using exam room 1 should use SuperTrack results pending areas 2001W1-2001W9




d. Each of the groups of chairs corresponding to an exam room will have a color assigned

i. Exam room 1 team – Red

ii. Exam room 2 team – Blue


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iii. Exam room 3 team – Yellow

iv. Exam room 4 team – Green

e. Team needs to periodically review the track board of their patients to evaluate which

patients are ready for disposition (also see huddles)

f. Patient should be brought back to exam room for re-exams and disposition discussions

ideally team is together for these

V. Destination Pod-2 (temporary horizontal patients)

a. IV access and lab draw can be obtained in Pod-2, eliminating stop in sub-triage blood

draw area.

b. Length of stay in Pod-2 should be targeted to 60 minutes or less

i. May be moved back to lobby; shell; acute area at the end of this 60 minutes

c. See attached guidelines for appropriate patients to Pod-2

d. An RN and a PCT may be assigned to POD2 to manage patients.

VI. Destination acute care area

a. Patients destined for the acute care ED will be handed off to a provider in that area

b. The SuperTrack nurse will change the ESI to be an indication that the patient is no longer

appropriate for a vertical treatment area.

c. The charge nurse will identify this visual cue and call the SuperTrack team to let them

know where the patient is going to be placed. If no call is received in SuperTrack in 5

minutes then SuperTrack nurse will call the Charge Nurse.

d. Provider note ideally should be completed by the provider in SuperTrack especially if

there is a scribe

VII. Admission from SuperTrack

a. In general patients who are expected to be admitted should be placed in the acute care

area

b. Certain patients can be seen and admitted in a rapid fashion and are still vertical (not

requiring an acute care bed)

c. Once decision for admission is made and appropriate service and level of care is

determined call admit service

i. May be from exam room or once certain labs/imaging back

ii. Be sure PCP is identified

iii. Consult care coordinator early if admit is suspected

iv. Move patient to appropriate care area in ED to await admit orders and

processing

VIII. Special situations in SuperTrack

a. Chest Pain

i. Low Risk only should be triaged here


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ii. POC troponin, if ordered, should be obtained RAPIDLY following EKG and

assessment

iii. If low risk and able to be admitted either to CPOC or obtain CCTA then proceed

rapidly to this following other tests (eg CXR)

iv. Patient may wait in pod 2 or shell for CCTA or CPOC orders

v. If a patient is brought to the sub-triage area for an EKG and there is a readily

available SuperTrack attending physician the EKG should be reviewed by them,

and a decision made for patient destination. If no attending is immediately

available the EKG should be brought to the Pod-3 attending physician. If Pod-3

attending physician is not available then proceed to Pod-4, then to Pod-5 if the

Pod-4 attending physician is also not available.

b. Psychiatric patients

i. If they do not appear to be a harm to themselves or others they may proceed to

SuperTrack

ii. Suicidal and/or Homicidal patients are NOT appropriate for SuperTrack

Acute Care Area

I. Pod-5 physician will serve as lead doctor of the day

a. Responsible for leading in solving flow related issues if need arises with surge plan

b. Also responsible for other questions affecting the entire department from charge nurse.

II. Pod-4 physician will be responsible for responding to result notes area in EPIC for late

arriving results

III. Pod-3 physician will be the primary initial acute care physician for STEMI/NO STEMI EKG

interpretation from sub triage if not seen by SuperTrack physician.

IV. Flow Nurse

a. Responsible for aiding outflow of patients from the department

b. Rounds with rover working with physician, nurses and PFA to move

admissions/discharges out of beds to open them for new patients

c. This includes moving patients to hallway spaces in order to open rooms for new

patients. These patients may be admitted or mid work-up. The physicians and nurses

should be proactive in moving potential patients to the hall when able. If there are care

spaces available and patients waiting; the spaces will be filled. The flow nurse will ask

for roomed patients that are able to be moved to the hall; if none can be identified by

the physician-nurse team then the new patients will be placed in the hall.

d. The CT shell is a space that can be used for intent-to-admit & admitted patients waiting

for orders and/or placement.

e. Serves as secondary pivot nurse when necessary.


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f. The CHARGE NURSE will be the FLOW NURSE. Whoever would have been the FLOW

NURSE will instead be the COMM PIVOT NURSE.

V. Physicians in this area will alternate taking patients in the resuscitation area

a. If there is more than one resident staffed with an attending when there is a patient

placed in the trauma/resuscitation area, one of the residents should remain in the pod

and continue seeing patients in this area. The resident may BRIEFLY go to the

resuscitation to see if there are procedures required which require more than the single

resident and attending but then should return to the pod immediately

b. If there is an expected delay in a patient being seen by a provider in the acute care area

and emergent intervention is required nursing should initiate appropriate protocols

based on assessment criteria.

Pod transitions and patient handoffs

I. Closing SuperTrack and patient handoffs

a. SuperTrack will be closed at 1am by the attending physician working the 5pm-1am shift

b. Will continue to see new patients until 12:30am

i. If surge plan is activated and additional physician/provider hours are required it

is likely this shift may be asked to stay late

c. The late shift APC may begin to transition to the acute area between 11pm and 1am

pending the needs in SuperTrack and Acute Care Area (likely to Pod-4)

d. Remaining patients in SuperTrack past 1am will be managed by the late shift APC using

the attending in Pod-3. Any patients remaining in the SuperTrack Lobby will be moved

to Pod-2, provided nurse staffing can support this area. If there are not sufficient

resources these patients will be moved to pod 4

e. When the POD 4 attending comes on they will begin seeing new patients and the

Providers in PODs 3/5 will keep their existing patients.

II. Pod 4 physician leaving at midnight

a. Remaining patients in Pod-4 will be signed out to Pod 3&5 physicians

b. If it is a day when there is an APC past midnight will be floating in the acute care area

but may see patients in Pod-4

c. If there are a high number of admit holds, including “intent-to-admit” (more than CT

shell) they should be grouped in Pod-4 and then Pod-2 in order to maximize the

efficiency of the nurses and providers in Pods 3&5.

Huddles

I. Opportunity to be sure that patients who are ready for disposition do not wait

a. Must be a balance between seeing new patients and patient dispositions

b. Helps keep the whole team on the same page

c. See huddle check list


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d. Should be used in both SuperTrack and Acute Care Area

Staffing & Load Balancing – Priority and Flexibility

I. Staffing SuperTrack MUST BE THE PRIORITY. ONLY PULL SUPERTRACK STAFF AS AN

ABSOLUTE LAST RESORT.

a. If pulling SuperTrack staff manager on call should be notified

II. Pediatrics should routinely have at least 2 RN in staffing and one ancillary support .

II. If the SuperTrack staff is at a point of low utilization they should temporarily assist staff in

areas that are over-utilized. This applies to both provider and nurse staff.

a. This may include situations where few patients are waiting to be seen in SuperTrack and

more than one provider in SuperTrack and there are multiple high acuity new arrivals in

the acute ED

III. After a horizontal patient has been in the Waiting Room for more than 45 minutes they will

have nursing protocols put in by the FLOW CHARGE NURSE. If the patient is in a POD bed

and has not seen a provider for 45 min the POD leaders will begin the nursing protocols.

IV. Also if necessary SuperTrack may be split with 1 or 2 providers seeing typical vertical

patients while the others see higher acuity visits (horizontal patients) through the front. In

general this should be avoided and reserved for situations where there are very few if any

vertical patients waiting to be seen but there are horizontal patients waiting and NO BEDS in

any acute care area. Before deciding to do this the SuperTrack teams should huddle and

discuss with flow or charge RN and possibly physician lead for the day.

V. Admit holds and ICU holds should ideally be located in proximity to improve efficiency.

a. New patients should be placed in areas in close proximity to the provider, ideally Pods

3&5 at times when there is not a direct attending physician in Pod-4.

VI. Moving remaining SuperTrack patients to Pod-4 when SuperTrack closes (after 1am) may be

done in situations when nursing staffing is less than prescribed and Pod -2 is unable to be

staffed to continue care of SuperTrack patients.

VII. Implement Surge plan as necessary

Pediatric patients

I. If there is an empty bed then patient bypasses pivot and is directed to the unit

a. Pediatrics should routinely have at least 2 RN in staffing and one ancillary support


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II. If unit is full then patient goes through pivot rapid assessment outlined above including vital

signs and assessment of immune status

III. The following should be treated as patients requiring immediate intervention and be

brought back immediately. This should follow the same flow as outlined above in the pivot

section. The pivot nurse should vocera pediatrics and let them know that they have a

patient in need of immediate bedding.

a. any patient less than 30 days of age b. an infant less than 8 weeks old with a fever of greater than 99.6 taken by temporal

artery thermometer or tympanic thermometer c. any child with a respiratory rate above the normal range for age and obvious respiratory

distress d. any child for whom the chief complaint is inconsolability and the patient seems

inconsolable at the time e. any patient who is immune-compromised; is a transplant patient; or a Hematology-

Oncology patient (they often say that Dr. Tebbi or Dr. Rico is their physician)

SPECTRALINK PHONES

I. Spectralink Phones will be maintained by the Unit Coordinators and must be signed IN/OUT

by giving them your keys. This is to ensure they do not go missing.


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TRIALS 12/11/2013 – These are changes to the Prescriptive Plan that are being trialed. They may at a later date be permanently incorporated into the Plan.

I. An RN to be assigned to POD2 to manage patients. II. Spectralink Phones will be maintained by the Unit Coordinators and must be signed

IN/OUT by giving them your keys. This is to ensure they do not go missing. III. After a horizontal patient has been in the Waiting Room for more than 45 minutes they

will have nursing protocols put in by the FLOW CHARGE NURSE. If the patient is in a POD bed and has not seen a provider for 45 min the POD leaders will begin the nursing protocols.

IV. The CHARGE NURSE will be the FLOW NURSE. Whoever would have been the FLOW NURSE will instead be the COMM PIVOT NURSE.

V. PIVOT NURSE may have patients seen quicker by expressing a desire in the comments section for patients to be seen in a particular order.

VI. LOCK AND LOAD: PCT’s in the LOBBY/WAITING ROOM will place patients in chairs located outside the active Triage/Exam Rooms. That patient will be “on-deck” and may then be pulled into the room by the provider/nurse team quicker.

VII. When the POD 4 attending comes on they will begin seeing new patients and the Providers in PODs 3/5 will keep their existing patients.

TRIALS 12/18/2013 – These are the changes to the Prescriptive Plan that are being trialed. They may at a later date be permanently incorporated into the Plan.

I. If there are 7 horizontal patients in the waiting room the Attending who has the most time left on their shift will begin seeing those horizontal in their SuperTrack room. (This being replaced by a new trial as of 1/8)

II. Registration should be continuous. No intentional slowing down to wait for PIVOT NURSE.

TRIALS 1/8/2014 – These are the changes to the Prescriptive Plan that are being trialed. They may at a later date be permanently incorporated into the Plan.

I. At any time there are no horizontals waiting and there are verticals waiting the verticals will be

placed in available POD beds.

II. If 7+ horizontals waiting then initiate a “blitz”. If POD4 has doc then the Admits will be

cohorted into POD4 and the POD4 provider with an RN will go to POD2 and see horizontals in a

SuperTrack fashion in POD2 (out of 1-2 POD2 Rooms). If POD4 does not have a provider then a

provider resource from POD3 will see horizontal patients in a SuperTrack fashion in POD2 (out

of 1-2).

TRIALS 5/7/2014 – These are the changes to the Prescriptive Plan that are being trialed. They may at a later

date be permanently incorporated into the Plan.

I. A workflow will be developed and trialed for “Direct Bedding” in the mornings involving PCT’s

pulling patients back to beds.

II. SuperTrack Movement Tracking: A clipboard will be placed in the SuperTrack Area. Every

time somebody leaves the area they will need to write down why they are leaving. This will be to

get an idea why people are leaving whether it be for supplies, etc. and so that those needs can try

to be met within the area.


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III. Express Lane: The APC would see patients that are 5’s, 4’s, and 3V’s (that order represents

preference) in Room 4

IV. Back Pivot Bed Placement: The back pivot nurse will direct all bedding.

TRIALS 5/14/2014 – These are the changes to the Prescriptive Plan that are being trialed. They may at a later

date be permanently incorporated into the Plan.

I. POD 4 open 24/7 with NO COHORTING.


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Huddle Check List

Should take 5 minutes or less

All members of care team participate (To include scribe when present)

Every 2 hours on even hours MINIMUM

1) Nurse and physician “run board” review each patient identifying:

a. Those patients eligible for disposition or only needing single action by ED staff (eg re-

evaluation)

i. After huddle prioritize this action admit or discharge

b. Patients whose disposition is delayed by outstanding studies taking longer than normal

i. Address delays

Examples:

1. Call CT or other imaging

2. Call Lab

3. Call Orthopedic tech for splint

4. Recall consults/admits if waiting for orders

ii. Follow up and disposition patients as these items are resolved

iii. Seek other resources to aid in resolving these delays including flow or charge RN

c. Be sure all intent to admit/admit hold patients have been moved to Shell holding area

and if this is full should be moved to the hall to allow for new patients to be seen in

rooms

d. Also identify other already seen patients for movement to hallway care spaces

e. Potential ICU admits should be identified (even if early in their stay) and communicated

to Flow Nurse

2) Look at patients waiting to be seen (Especially key in SuperTrack)

a. Identify which patients should be seen next based on protocol (wait time/acuity)

3) Review quickly overall state of your area relative to the department see if there are ways for

your team to assist the other areas

4) Implement Surge Plan (phone tree) as indicated


12/2/13


Surge Plan – Phone Tree

I. For 5 or more patients in the Lobby/WR with > 1 hour wait time the Charge Nurse notifies

the Patient Flow Administrator & Pod 5 Physician leader to begin finding a solution to

enhance flow.

II. For 5 more patients in the Lobby/WR with > 2 hour wait times the Charge Nurse notifies the

ED Nurse Manager on call. The ED Nurse Manager on-call will notify the ED Associate

Medical Director if physician resources are needed.

III. For 5 or more patients in the Lobby/WR with > 3 hour wait time the ED Nurse Manager on

call notifies the ED Nursing Director. The ED Nursing Director will notify the ED Medical

Director if physician resources are needed. The ED Nursing Director will notify the NAOC.

IV. For 5 or more patients in the Lobby/WR with > 4 hour wait time the ED Nursing Director

notifies the Chief Nursing Officer.

V. Suggestions for topics to think about and discuss:

a. Staffing needs

b. Radiology and Lab turnaround times

c. Hall bed use, cohort admit holds

d. Transport issues

e. Housekeeping needs


12/2/13


SUPER TRACK PATIENTS VERTICAL (Lobby) VS. HORIZONTAL (Pod)

Admit, Observe, Urgent = Horizontal

General:

1. Initial determination of Vertical (Lobby) vs. Horizontal (Pod) patients is at the discretion of the Pivot Nurse, and may not be criticized.

2. A patient’s level of care may be modified, as information is obtained, i.e. if a patient needs to be moved from the lobby to a pod for higher severity.

3. In general, patients are considered Horizontal rather than Vertical if:

a. They will clearly be admitted to the hospital (except stable chest pain patients with

negative EKG and negative troponin who may be admitted from the lobby)

b. They must be closely observed (e.g. suicidal ideation, intoxication, elderly fall risk).

c. They must be urgently evaluated (e.g. on backboard after trauma, testicular pain,

pregnant with abdominal discomfort) 4. Patients that are ESI 3, 4, and 5 are generally Lobby patients. Patients that ESI 1 and 2 are

generally Pod patients.

Examples:

Vertical Horizontal Headache with no meningismus, no fever, or patient with typical migraine

Worst headache of life or headache with fever or abnormal vitals

Weakness with normal vitals and less than age 50 Pt with upper and lower extremity lateralizing numbness or unsteady gait or facial droop/ slurred speech

Pregnant patient with vaginal bleeding and less than 20 weeks with no pain

Pregnant patient with abdominal pain

Vertical Horizontal Dizziness with normal vitals and less than age 50 with no other neurological symptoms

Dizziness with abnormal vitals or additional neurological symptoms or greater than age 50

Flank pain with normal vitals and less than 65 Flank pain with abnormal vitals than 65 and > 65 Isolated Dysuria in a male patient Testicular pain Stable and low risk chest pain, unremarkable EKG, Negative troponin

Chest pain with abnormal vitals, ischemia on ekg, or + troponin

Moderate abdominal pain and vitals Severe abdominal pain with abnormal within normal limits vitals

Walk-in trauma patient with minor injuries and no backboard

Trauma patient on backboard with collar

Mild asthma Pt requiring immediate and multiple duonebs for asthma or lasix/NTG for CHF

Extremity pain with good pulses and sensation Cold or pulseless extremity


12/2/13


Criteria for Pod 2 Procedures, Privacy, IV Pain Meds = Pod 2

Guidelines:

1. Pod 2 beds are designated for patients seen in the Super Track and followed by the providers in the Super Track, but should not be cared for in the Super Track Lobby.

2. Pod 2 beds are not intended for patients likely to stay longer than 60 minutes. Patients

likely to be admitted are placed in other pods, or admitted straight from the Super Track Lobby.

3. Patients that should generally utilize Pod 2 include:

a. Patients requiring procedures (e.g lacerations, splint placements, abscess incision

and drainage). b. Patients requiring high dose IV pain medications (e.g. sickle cell patients’ not usually

requiring admission, kidney stone patients with intractable pain after Toradol). c. Patients for whom privacy is essential (e.g. copious vaginal bleeding, intractable

vomiting, migraine headache). Examples:

Laceration Repair Abscess Incision/Drainage

Fracture Splinting Patient Requiring Slit Lamp Typical Migraine Headache Epistaxis

Copious Vaginal Bleed Kidney Stone Patient Requiring Opiates

Sickle Cell Patients Not Usually Admitted

DECEMBER SUN MON TUES WED THURS FRI SAT SUN MON TUES WED THURS FRI SAT SUN MON TUES WED THURS FRI SAT SUN MON TUES WED THURS FRI SAT SUN MON TUES 2013 2012Date(s) 1-Dec 2-Dec 3-Dec 4-Dec 5-Dec 6-Dec 7-Dec 8-Dec 9-Dec 10-Dec 11-Dec 12-Dec 13-Dec 14-Dec 15-Dec 16-Dec 17-Dec 18-Dec 19-Dec 20-Dec 21-Dec 22-Dec 23-Dec 24-Dec 25-Dec 26-Dec 27-Dec 28-Dec 29-Dec 30-Dec 31-Dec DEC DEC ∆

Door-to-Doc (All) 39.31 59.30 26.05 79.57 74.92 47.6 42.63 29.28 37.52 38.44 36.63 56.25 25.53 33.5 17.38 75.85 15.93 24.98 30.70 32.02 25.82 35.88 49.90 22.78 13.90 70.16 66.19 39.97 18.62 48.64 31.80 35.07 62.62 -27.55D/C Total LOS (A) 294.50 340.00 230.00 290.50 245.50 283.00 254.00 173.50 307.00 210.00 244.00 217.00 222.00 266.00 204.00 298.00 184.00 192.50 256.00 241.00 191.50 233.00 265.00 194.00 158.00 299.00 263.00 188.00 188.00 220.00 222.00 240.00 310.00 -70.00

LWBS (A) 2.03% 8.26% 0.00% 3.25% 2.22% 4.56% 1.05% 0.93% 7.33% 1.41% 1.44% 1.49% 0.00% 0.52% 1.30% 2.94% 0.00% 0.00% 0.00% 0.00% 0.54% 1.69% 0.48% 0.52% 0.00% 7.23% 1.20% 2.65% 0.00% 1.28% 1.68% 1.98% 7.34% -5.36%Adult Volume 187 211 205 237 215 227 183 206 232 202 200 202 180 192 145 224 185 182 180 171 174 169 202 190 156 239 242 218 172 221 173 6,122 6,110 12.00Ped Volume 38 50 51 46 51 45 31 59 45 44 52 41 40 53 43 45 38 32 40 30 38 41 38 36 34 51 37 29 45 52 35 1,310 1,527 -217.00

Total Volume 225 261 256 283 266 272 214 265 277 246 252 243 220 245 188 269 223 214 220 201 212 210 240 226 190 290 279 247 217 273 208 7,432 7,637 -205.00

JANUARY WED THURS FRI SAT SUN MON TUES WED THURS FRI SAT SUN MON TUES WED THURS FRI SAT SUN MON TUES WED THURS FRI SAT SUN MON TUES WED THURS FRI 2014 2013Date(s) 1-Jan 2-Jan 3-Jan 4-Jan 5-Jan 6-Jan 7-Jan 8-Jan 9-Jan 10-Jan 11-Jan 12-Jan 13-Jan 14-Jan 15-Jan 16-Jan 17-Jan 18-Jan 19-Jan 20-Jan 21-Jan 22-Jan 23-Jan 24-Jan 25-Jan 26-Jan 27-Jan 28-Jan 29-Jan 30-Jan 31-Jan JAN JAN ∆


LWBS (A) 1.82% 1.31% 2.33% 2.06% 6.04% 5.14% 3.98% 0.00% 0.00% 4.85% 0.55% 0.00% 6.06% 2.40% 1.02% 3.90% 0.00% 0.00% 0.00% 1.37% 1.40% 1.00% 0.00% 0.50% 3.89% 1.95% 4.84% 1.39% 0.00% 0.00% 3.86% 2.13% 8.86% -6.73%Adult Volume 208 223 213 189 178 210 194 177 194 216 179 184 252 199 190 221 176 157 167 211 207 203 189 190 163 192 242 210 193 192 196 6,115 6,492 -377.00Ped Volume 54 39 31 43 39 32 38 41 50 41 25 28 49 39 40 33 34 42 36 45 35 41 32 45 46 42 41 33 44 32 36 1,206 1,492 -286.00

Total Volume 262 262 244 232 217 242 232 218 244 257 204 212 301 238 230 254 210 199 203 256 242 244 221 235 209 234 283 243 237 224 232 7,321 7,984 -663.00

FEBRUARY SAT SUN MON TUES WED THURS FRI SAT SUN MON TUES WED THURS FRI SAT SUN MON TUES WED THURS FRI SAT SUN MON TUES WED THURS FRI 2014 2013Date(s) 1-Feb 2-Feb 3-Feb 4-Feb 5-Feb 6-Feb 7-Feb 8-Feb 9-Feb 10-Feb 11-Feb 12-Feb 13-Feb 14-Feb 15-Feb 16-Feb 17-Feb 18-Feb 19-Feb 20-Feb 21-Feb 22-Feb 23-Feb 24-Feb 25-Feb 26-Feb 27-Feb 28-Feb FEB FEB ∆

Door-to-Doc (All) 29.68 30.40 60.07 51.25 45.45 56.12 27.53 24.29 36.72 55.35 56.37 63.22 45.67 31.77 27.02 52.06 100.62 68.05 52.36 65.63 65.68 83.34 32.95 69.67 46.36 62.58 45.52 36.78 46.66 56.00 -9.34D/C Total LOS (A) 234.00 223.50 246.50 293.00 224.00 256.00 226.5 228.5 222.00 267.00 274.00 316.00 261.50 234.50 243.00 278.50 322.00 310.00 304.00 260.50 291.50 295.00 248.00 285.00 259.00 262.00 245.00 274.00 263.00 322.00 -59.00

LWBS (A) 3.37% 1.62% 2.95% 8.47% 3.69% 2.69% 1.52% 0.50% 0.49% 1.79% 0.42% 1.46% 0.00% 1.14% 1.14% 4.88% 3.28% 3.75% 1.88% 4.03% 0.44% 5.53% 2.15% 2.05% 1.54% 3.80% 0.48% 2.29% 2.60% 6.37% -3.77%Adult Volume 198 179 237 220 208 212 185 190 200 214 224 195 204 168 165 192 227 230 202 239 212 224 173 231 248 226 203 212 5,818 5,515 303.00Ped Volume 36 32 42 50 47 39 41 42 34 39 46 56 50 34 46 33 46 36 46 47 52 44 41 53 40 37 29 28 1,166 1,297 -131.00

Total Volume 234 211 279 270 255 251 226 232 234 253 270 251 254 202 211 225 273 266 248 286 264 268 214 284 288 263 232 240 6,984 6,812 172.00

MARCH SAT SUN MON TUES WED THURS FRI SAT SUN MON TUE WED THU FRI SAT SUN MON TUE WED THU FRI SAT SUN MON TUE WED THU FRI SAT SUN MON 2014 2013Date(s) 1-Mar 2-Mar 3-Mar 4-Mar 5-Mar 6-Mar 7-Mar 8-Mar 9-Mar 10-Mar 11-Mar 12-Mar 13-Mar 14-Mar 15-Mar 16-Mar 17-Mar 18-Mar 19-Mar 20-Mar 21-Mar 22-Mar 23-Mar 24-Mar 25-Mar 26-Mar 27-Mar 28-Mar 29-Mar 30-Mar 31-Mar MARCH MARCH ∆


LWBS (A) 1.42% 1.03% 3.39% 1.32% 6.38% 1.05% 0.00% 1.02% 3.78% 6.40% 5.31% 2.46% 1.50% 2.79% 6.25% 5.82% 0.00% 1.28% 2.93% 1.27% 0.44% 5.17% 3.41% 4.73% 1.75% 1.35% 0.98% 1.65% 2.26% 2.50% 3.40% 2.78% 7.79% -5.01%Adult Volume 203 185 228 219 227 178 199 184 175 248 236 193 191 205 201 175 233 224 228 225 210 220 191 265 218 206 194 231 171 187 225 6,475 5,960 515.00Ped Volume 34 53 45 38 57 55 42 53 35 49 41 51 48 37 52 46 39 53 55 47 57 43 56 55 50 43 44 51 41 56 48 1,473 1,438 35.00

Total Volume 237 238 273 257 284 233 241 237 210 297 277 244 239 242 253 221 272 277 283 272 267 263 247 320 268 249 238 282 212 243 273 7,948 7,398 550.00

APRIL TUE WED THU FRI SAT SUN MON TUE WED THU FRI SAT SUN MON TUE WED THU FRI SAT SUN MON TUE WED THU FRI SAT SUN MON TUE WED 2014 2013Date(s) 1-Apr 2-Apr 3-Apr 4-Apr 5-Apr 6-Apr 7-Apr 8-Apr 9-Apr 10-Apr 11-Apr 12-Apr 13-Apr 14-Apr 15-Apr 16-Apr 17-Apr 18-Apr 19-Apr 20-Apr 21-Apr 22-Apr 23-Apr 24-Apr 25-Apr 26-Apr 27-Apr 28-Apr 29-Apr 30-Apr APRIL APRIL ∆

Door-to-Doc (All) 64.78 56.99 38.41 52.36 58.13 27.82 90.65 53.15 63.95 61.37 86.3 51.68 116.87 132.91 34.37 37.56 51.78 47.28 28.37 40.32 46.39 51.32 45.28 70.65 53.08 64.82 55.2 63.02 54.48 58.73 53.83 80.73 -26.9D/C Total LOS (A) 321.00 283.50 240.00 268.50 247.00 277.00 294.50 222.00 319.00 272.50 358.00 249.50 377.00 403.00 242.00 259.00 248.50 303.00 232.00 248.00 243.00 238.00 240.50 317.00 326.00 333.00 262.00 310.00 246.00 253.00 280.00 354.00 -74.00

LWBS (A) 0.00% 0.82% 4.41% 3.20% 2.61% 0.50% 6.98% 0.89% 2.99% 3.21% 6.82% 0.95% 8.37% 7.89% 0.00% 0.90% 1.40% 1.34% 0.00% 0.00% 1.65% 1.29% 0.92% 2.09% 5.34% 4.85% 4.12% 2.81% 2.75% 0.00% 2.72% 9.19% -6.47%Adult Volume 218 233 210 209 216 189 250 216 218 226 210 190 219 215 191 203 205 212 181 171 234 226 204 227 198 221 176 246 238 201 6,355 6,129 226.00Ped Volume 57 57 55 47 37 51 43 45 54 46 39 52 48 43 39 52 47 40 42 35 51 34 44 42 53 51 63 49 53 49 1,418 1,390 28.00

Total Volume 275 290 265 256 255 240 293 261 272 272 249 242 267 259 230 255 252 252 223 206 285 260 248 269 251 262 239 295 291 250 7,773 7,519 254.00

MAY THU FRI SAT SUN MON TUE WED THU FRI SAT SUN MON TUE WED THU FRI SAT SUN MON TUE WED THU FRI SAT SUN MON TUE WED THU FRI SAT 2014 2013Date(s) 1-May 2-May 3-May 4-May 5-May 6-May 7-May 8-May 9-May 10-May 11-May 12-May 13-May 14-May 15-May 16-May 17-May 18-May 19-May 20-May 21-May 22-May 23-May 24-May 25-May 26-May 27-May 28-May 29-May 30-May 31-May MAY MAY ∆


LWBS (A) 0.96% 2.19% 1.83% 0.50% 1.71% 2.16% 1.78% 3.49% 4.39% 0.00% 0.00% 0.87% 0.40% 3.21% 4.43% 0.49% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.45% 0.00% 1.13% 0.00% 5.32% 5.31% 2.76% 2.63% 0.00% 1.70% 5.95% -4.25%Admit Order/Leave ED (A) 251 2.76 168 81 116 129 211 204 171 136 120 87 143 133 140 146 209 144 114 136 130 116 156 101 108 169 118 131 134 240 238 6155.00 4973.00 1182.00

Admit Total LOS (A) 4.99 6.20 5.58 4.42 4.67 5.05 5.28 5.49 5.38 4.40 4.62 4.90 4.72 5.82 5.56 4.75 5.22 5.30 3.77 4.05 4.73 4.12 7.10 5.62 5.63 4.22 4.68 4.83 5.60 5.20 5.05 5.30 6.07 -0.77ED RAD TAT (All) 184 250 237 171 149 239 203 229 177 269 233 164 158 159 201 213 261 164 140 228 206 111 172 161 199 114 150 125 145 158 167 199.00 198.00 1.00ED Lab TAT (All) 81 87 83 77 93 84 85 80 80 71 77 79 86 82 85 74 76 76 75 75 82 73 77 77 68 72 75 71 72 79 76 79.00 71.00 8.00Adult Volume 202 216 206 185 225 220 209 214 215 195 181 224 241 208 197 197 209 170 203 212 204 240 217 197 172 179 244 214 207 223 191 6,473 5,990 483.00Ped Volume 43 44 41 45 46 38 64 63 39 35 44 35 40 35 40 42 43 55 35 47 52 43 31 32 32 32 43 44 48 27 40 1,298 1,247 51.00

Total Volume 245 260 247 230 271 258 273 277 254 230 225 259 281 243 237 239 252 225 238 259 256 283 248 229 204 211 287 258 255 250 231 7,771 7,237 534.00

JUNE SUN MON TUE WED THU FRI SAT SUN MON TUE WED THU FRI SAT SUN MON TUE WED THU FRI SAT SUN MON TUE WED THU FRI SAT SUN MON 2014 2013Date(s) 1-Jun 2-Jun 3-Jun 4-Jun 5-Jun 6-Jun 7-Jun 8-Jun 9-Jun 10-Jun 11-Jun 12-Jun 13-Jun 14-Jun 15-Jun 16-Jun 17-Jun 18-Jun 19-Jun 20-Jun 21-Jun 22-Jun 23-Jun 24-Jun 25-Jun 26-Jun 27-Jun 28-Jun 29-Jun 30-Jun JUNE JUNE ∆

Door-to-Doc (All) 24.66 41.06 24.26 46.64 54.37 35.53 13.67 24.20 49.65 45.88 23.22 32.55 28.23 19.83 31.87 60.81 70.03 34.32 24.03 63.08 101.18 17.91 48.97 31.37 23.05 37.37 36.12 40.36 30.98 45.50 34.14 45.62 -11.48D/C Total LOS (A) 220.00 237.00 183.50 245.00 260.00 263.00 207.00 238.00 320.00 239.00 196.00 242.00 325.00 187.50 240.00 338.00 306.00 238.50 251.00 332.00 330.00 232.50 270.50 240.00 210.50 215.00 191.50 218.50 242.00 228.00 254.00 301.00 -47.00

LWBS (A) 1.05% 0.45% 0.85% 1.90% 1.67% 0.88% 2.91% 0.49% 6.45% 2.97% 0.99% 2.10% 0.48% 1.07% 0.52% 3.44% 5.53% 0.90% 1.33% 1.26% 5.49% 0.00% 2.80% 0.47% 0.92% 3.13% 0.89% 0.00% 0.96% 2.98% 2.04% 5.07% -3.03%Admit Order/Leave ED (A) 155 188 183 178 238 197 167 152 133 167 97 343 239 160 163 233 217 218 391 241 207 197 204 266 139 119 234 170 147 115 6550.00 4340.33 2209.67

Admit Total LOS (A) 4.58 5.49 4.38 5.35 5.22 6.22 4.38 5.10 7.23 6.75 3.83 5.32 5.92 4.93 4.83 6.38 6.10 5.18 6.85 6.39 6.02 4.97 5.62 5.05 4.38 4.25 5.22 5.33 5.33 4.73 5.45 5.72 -0.27ED RAD TAT (All) 173 168 133 107 107 210 193 149 150 91 108 146 182 223 158 156 129 108 132 170 193 131 132 100 128 129 158 130 153 177 178 195 -17.00ED Lab TAT (All) 80 76 74 72 75 84 72 72 90 64 67 71 86 74 68 83 76 72 65 87 73 69 70 73 67 73 79 70 80 78 77 73 4.00Adult Volume 185 214 224 201 232 218 168 197 239 221 196 227 199 174 181 254 223 213 216 232 229 172 237 205 204 220 207 189 195 226 6,323 5,789 534.00Ped Volume 45 39 38 44 33 48 34 37 26 45 33 44 43 44 37 33 44 29 32 36 40 43 38 34 44 28 50 39 39 33 1,153 1,059 94.00

Total Volume 230 253 262 242 265 266 202 234 265 266 229 271 242 218 218 287 267 242 248 268 269 215 275 239 248 248 257 228 234 259 7,476 6,848 628.00

JULY TUE WED THU FRI SAT SUN MON TUE WED THU FRI SAT SUN MON TUE WED THU FRI SAT SUN MON TUE WED THU FRI SAT SUN MON TUE WED THU 2014 2013Date(s) 1-Jul 2-Jul 3-Jul 4-Jul 5-Jul 6-Jul 7-Jul 8-Jul 9-Jul 10-Jul 11-Jul 12-Jul 13-Jul 14-Jul 15-Jul 16-Jul 17-Jul 18-Jul 19-Jul 20-Jul 21-Jul 22-Jul 23-Jul 24-Jul 25-Jul 26-Jul 27-Jul 28-Jul 29-Jul 30-Jul 31-Jul 7/1-7/21 JULY ∆

Door-to-Doc (All) 61.56 52.82 31.48 14.27 43.77 20.38 31.02 32.59 35.48 53.15 46.67 17.97 25.90 31.18 29.22 34.43 63.45 27.98 23.28 16.82 50.88 18.06 31.15 19.33 38.27 26.70 22.13 32.35 70.28 -37.93D/C Total LOS (A) 259.00 266.00 223.00 212.00 279.00 188.00 255.00 215.00 216.00 257.00 424.00 244.00 328.00 294.00 299.00 254.00 303.00 263.00 229.00 204.00 253.00 192.00 254.00 239.00 267.00 227.50 230.00 250.50 363.00 -112.50

LWBS (A) 1.24% 1.35% 0.87% 0.00% 2.70% 0.52% 2.15% 1.26% 0.00% 1.70% 1.63% 1.07% 1.00% 0.41% 2.13% 4.47% 1.57% 1.70% 1.45% 0.00% 0.40% 0.00% 1.62% 0.00% 1.25% 0.00% 0.00% 1.37% 6.11% -4.74%Admit Order/Leave ED (Sum) 157 198 255 193 164 159 197 122 174 128 164 135 182 170 136 195 166 129 127 144 192 172 192 168 160 185 94.5 3934.60 6217.00 -2282.40

Admit Total LOS (Med) 5.13 5.37 5.21 4.93 5.18 4.68 5.25 4.08 4.77 4.93 7.07 5.75 5.46 4.89 4.98 5.28 5.46 5.12 4.47 4.30 6.64 4.29 5.87 5.37 6.25 6.22 5.45 6.48 6.68 -0.20ED RAD TAT (All) 167 131 161 164 137 110 120 107 139 123 141 180 167 200 123 157 165 145 158 157 152 169 181 191 177 152 118 160 238 -78.00ED Lab TAT (All) 80 73 76 64 73 64 69 66 70 67 76 61 71 69 77 81 76 74 65 64 76 81 71 67 68 71 69 72 74 -2.00Adult Volume 228 212 222 160 215 186 227 229 230 225 235 178 190 227 228 234 250 222 199 188 238 225 236 203 229 206 175 4,530 6,154 -1624.00Ped Volume 33 30 33 34 40 43 29 33 29 36 43 44 35 42 38 41 32 39 31 43 34 41 32 30 32 34 43 762 1,112 -350.00

Total Volume 261 242 255 194 255 229 256 262 259 261 278 222 225 269 266 275 282 261 230 231 272 266 268 233 261 240 218 5,292 7,266 -1974.00

Actual Actual Actual Actual ActualUHC

Median*UHC Best Quartile

34.87 41.02 48 Min 30 Min239.00 251.00 241 Min 184 Min1.77% 2.23% 2.20% 1.60%

2013 2014 2014 2014 2014 2014 2014 2013 2012 2014 2013 2014 2013 2014 2013 2014 2013 2014 2013 2014 2013DEC JAN FEB MARCH APRIL MAY JUNE 12 - '13 13 - '14 ∆ FY 12/13 DEC DEC ∆ JAN JAN ∆ FEB FEB ∆ MARCH MARCH ∆ APRIL APRIL ∆ MAY MAY ∆ JUNE JUNE ∆

Door-to-Doc (All) 35.07 42.50 46.66 51.06 53.83 36.82 32.83 69.32 42.08 -27.24 60.40 35.07 62.62 -27.55 42.50 78.89 -36.39 46.66 56.00 -9.34 51.06 68.90 -17.84 53.83 80.73 -26.9 36.82 58.95 -22.13 32.83 45.62 -12.79D/C Total LOS (A) 240.00 251.00 263.00 276.00 280.00 255.00 255.00 336.00 260.00 -76 328.00 240.00 310.00 -70.00 251.00 348.00 -97.00 263.00 322.00 -59.00 276.00 343.00 -67.00 280.00 354.00 -74.00 255.00 320.00 -65.00 255.00 301.00 -46.00

LWBS (A) 1.98% 2.13% 2.60% 2.78% 2.72% 1.70% 2.05% 8.11% 2.30% -5.81% 6.64% 1.98% 7.34% -5.36% 2.13% 8.86% -6.73% 2.60% 6.37% -3.77% 2.78% 7.79% -5.01% 2.72% 9.19% -6.47% 1.70% 5.95% -4.25% 2.05% 5.07% -3.02%Admit Order/Leave ED (A) 5287.26 45,733 6155.00 4973.00 1182.00 5287.26 4340.33 946.93

Admit Total LOS (A) 5.43 Dec 5.30 6.07 -0.77 5.43 5.72 -0.29ED RAD TAT (All) 174 208 199.00 198.00 1.00 174 195 -21.00ED Lab TAT (All) 77 79 79.00 71.00 8.00 77 73 4.00Adult Volume 6,122 6,115 5,818 6,475 6,355 6,473 6,298 30,206 37,357 7151 71,731 6,122 6,110 12.00 6,115 6,492 -377.00 5,818 5,515 303.00 6,475 5,960 515.00 6,355 6,129 226.00 6,473 5,990 483.00 6,298 5,789 509.00Ped Volume 1,310 1,206 1,166 1,473 1,418 1,298 1,152 7,144 7,871 727 15,891 1,310 1,527 -217.00 1,206 1,492 -286.00 1,166 1,297 -131.00 1,473 1,438 35.00 1,418 1,390 28.00 1,298 1,247 51.00 1,152 1,059 93.00

Total Volume 7,432 7,321 6,984 7,948 7,773 7,771 7,447 37,350 45,228 7878 87,622 7,432 7,637 -205.00 7,321 7,984 -663.00 6,984 6,812 172.00 7,948 7,398 550.00 7,773 7,519 254.00 7,771 7,237 534.00 7,447 6,848 599.00Patient Satisfaction Mean Score 79.9% 82.2% 81.8% 80.4% 82.0% 78.6%

18 Mo. Goal (June)

Door-to-Provider (Adult ALL) 53.90 60 Min 50 Min 40 Min 30 Min 25 Min

MEDIAN TIMES Quarter (9/1 - 11/30) 1 Mo. Goal (Jan) 3 Mo. Goal (March) 6 Mo. Goal (June) 12 Mo. Goal (December)

230 MinLWBS (Adult) 6.14% 6.50% 5.50% 4.50% 3.00% 2.50%D/C Total ED LOS (Adult) 340 Min 345 Min 300 Min 270 Min 240 Min

82% *2012 Cycle Time Proj.

December 3 - June

Patient Satisfaction (Adult) 77.80% 78% 78% 80% 81%

STAFFING – MELISSA

Professional Services – Cheryl Eagan, Dustin Pasteur, & John Scolaro

Date Added Item/Description Status

05/02/2014 Construction – was supposed to begin on 4/23 but was delayed.

• 5/2 – Dustin emailed Chad from construction and will follow up. Per Cheryl, one issue is that a check needs to be cut to the contractor for work to begin and she will look into that.

• 5/5 – Per Cheryl, money located and approval should occur this afternoon.

• 5/7 – Need wayfinding in the ED now that the “purple door” won’t be able to be used as a marker.

• 5/7 – There are lots of items that are in the construction areas that need to be removed by Friday

05/05/2014 Recliner “graveyard” - The recliners that were purchased for the SuperTrack area are breaking at an alarming pace. They are under warranty but that appears to only consist of the company sending us free parts for us to fix them on our own.

• 5/5 –Dustin and Melissa to explore. • 5/7 – Cheryl will talk with Mark about the issue.

05/05/2014 Transport & EVS Issues • 5/5 – Some transport and EVS issues over the weekend. Might have been related to boluses of patients due to inclement weather. Will monitor.

• 5/7 – Still having issues with EVS especially during the ½ hour before and ½ hour after shift change which becomes a dead zone as far as coverage. Also breaks are still an issue with the EVS staff not communicating

5/07/2014 Stretchers – Running out • 5/7 - Per Reginald Chatman, transporters are always supposed to bring a stretcher with them when they answer a call in the ED. He will do some re-education.

5/07/2014 TUBES • 5/7 – cannot keep enough tubes in the stations throughout ED. Cheryl said she will look into it

•

Supplies – Mark Campbell


05/02/2014 Supply stock outs. • 5/2 - Keep running out of supplies. Hall closets particularly. Button-pressing system isn’t reliable. Desire to explore weighing shelves system.

• 5/5 – Melissa met with Mark on Friday to discuss. Either need more space (not really an option) or more frequent stocking. Chris is a 1.0 FTE but based on current needs may need 1.5 FTE which is something Mark and Melissa will explore. Also need an organization system in SuperTrack.

• 05/02/2014 Blanket Warmers • 5/2 – Request that when they are restocked that they

be restocked as full as allowable. •

5/7/2014 Issues with catheter sizing and kinds of syringes • 5/7 – Some of the supplies are off. Certain types of catheters have wrong sizes mixed in and some of the syringes that are used by the ED aren’t showing up.

5/07/2014 PILLOWS • 5/7 – Never enough pillows. 5/07/2014 Black Capped Tubes • 5/7 – Having difficulty keeping them in stock as they’re

backordered. 5/07/2014 Gowns with snaps • 5/7 – staff request gowns with snaps on them as so

many patients have IV’s in them

Laboratory & Radiology – David Robbins


05/02/2014 Phlebotomist in the ED Trial • 5/2 – June begins trial of phlebotomists in the ED for blood cultures

• 05/02/2014 CT Shell • 5/2 - Needs to be shielded. RFP for scanner began on

05/01. • 5/5 – Quote is in and working on the RFP with

purchasing •

•

Technology – Balaji Ramadoss & Gary Calhoun


05/02/2014 Vocera – issues with coverage: charge nurses were complaining they could not get coverage at the communications desk

• 5/2 – Balaji/Gary to look into. • 5/5 – Per Balaji there will be some testing of the

coverage this week. • 5/7 – Made some configuration changes.

05/05/2014 Cardiac Monitors • 5/5 – RFP goes out to all vendors today. • 5/7 – ED needs to determine a central monitoring

station •

Items to Discuss:

• Electronic Patient Satisfaction Board – Desire to have electronic boards that could display ED Stats

Steps of Flow Prior to Implementation

Arrive

Pivot

Quick Reg

RN Triage 15 ?s

ED Bed Placement

Provider Exam

Testing & Medications

Decision Admit or Discharge

Identify Admitting Provider

Admission Orders

Assign Bed

Handoff Transport

Leave ED

Door to Doctor- Front End Decision to Disposition Disposition to Leave ED

Steps Eliminated with Implementation

Arrive

Pivot

Quick Reg

RN Triage 6 ? 15 ?s Split “H”

vs “V”

ED Bed Placement

Provider Moved to Triage

Testing & Medications

Decision Admit or Discharge

Identify Admitting Provider

Admission Orders

Assign Bed

Handoff Transport

Leave ED

Door to Doctor- Front End Decision to Disposition Disposition to Leave ED

Overview of Split Flow

Arrival to Provider time year over year improvement by month

35.07

42.5 46.66

51.06 53.83

36.82 34.14

62.62

78.89

56

68.9

80.73

58.95

45.62

0

10

20

30

40

50

60

70

80

90


Median arrival to provider timeafter change (min)

Median arrival to provider timebefore change (min)

Discharge patient total length of stay year over year improvement by month

240 251

263 276 280

255 254

310

348

322 343

354

320 301

0

50

100

150

200

250

300

350

400


Median total length of stayfor discharged adultpatients after change (min)

Median total length of stayfor discharged adultpatients before change(min)

% left prior to medical screening exam year over year improvement by month

1.98% 2.13% 2.60% 2.78% 2.72%

1.70% 2.04%

7.34%

8.86%

6.37%

7.79%

9.19%

5.95%

5.07%

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

8.00%

9.00%

10.00%


% of adult patients wholeft prior to a medicalscreening exam afterchange

% of adult patients wholeft prior to a medicalscreening exam beforechange

Total and % change over 7 months from go-live

Before Change After Change

Overall change 12/3-6/30 (2012-2013 vs 2013-2014) Dec`12-Jun`13 Dec`13-Jun`14 % change

Adult Volume (arrivals) 40591 42325 4.27%

% adult patients who left prior to medical screening exam 7.56% 2.35% -68.98%

Median Arrival to provider (min) 62.87 42.02 -33.16%

Median total length of stay for discharged adult patients (min) 329 260 -20.97%

Estimated Financial Impact of Process Redesign

Admitted Discharged Annualized Gain

Additional Patients Seen

940 1672

Net Gain per Case $1,278 $123

Total $1,201,320 $205,656 $1,406,976

supertrack swarm tampa general hospital · 2014-12-22 · supertrack swarm . tampa general hospital...

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