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Emergency Department Directors Academy – Phase II
The Front End: Strategies to Improve Door-to-Provider Time
May 2011
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“Fixing The Front End”
Shari Welch MD, FACEPsjwelch56@aolcom
Today’s Travels
►Background Information►The Case for “Door to Doc”
Improvement►Improving Door to Doc Times at Two
Community Hospitals►New Intake Models►New Intake Models►New Technology
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Background Information
►The Volumes►The Beds►The Nurses►The Patients
How Many ED Visits?
20% ian
ds)
115,000increase
r of v
isits
(in
thou
sa
80 00085,00090,00095,000
100,000105,000110,000
Source: National Center for Health Statistics, National Hospital Ambulatory Medical Care Survey, 1992-2000Courtesy: Robin M. Weinick, Ph.D. - AHRQ
Num
ber
75,00080,000
1992 1993 1994 1995 1996 1997 1998 1999 2000
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How Many Hospital Beds?
16% decrease4,547 EDs1200
1300
4,177 EDs
900
1000
1100
Source: American Hospital Association, Hospital StatisticsCourtesy: Robin M. Weinick, Ph.D. - AHRQ
800
How Are Hospitals Staffed?
26% decreaseduat
es 100,00026% decrease
mbe
r of n
ew R
N g
rad
70,000
80,000
90,000
Courtesy: Robin M. Weinick, Ph.D. - AHRQ
Tota
l num 60,000
1995 1996 1997 1998 1999 2000
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Age and Complexity of Acute Care
0.80
0.90
Prop
ortio
n of
com
plex
pat
ient
s
0.50
0.60
0.70
Sprivulis P. A pilot study of emergency department workload complexity. Emergency Medicine. 2004, 16:59-64Courtesy: Peter Sprivulis MBBS PhD
20 30 40 50 60 70 80 90
Age
0.40
Longer LOS
►Older More Tests & Treatments
►More Tests & Treatments Longer LOS
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Adult Admissions Through E.D.
60%
50%
40%
30%
20%
10%
53%64%
32%
Perc
ent
10%
0%
1983 1993 2008
We are the Front Door to the Hospital!
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Why Does it Matter?The Case for Door to Doc Improvement
The Case for “Door to Doc”
►Crowding, Capacity and Flow►Metrics►Regulatory : Joint Commission,
CMS►Dirty Capitalist Pig$►Patient Satisfaction►The Public Eye
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Overcrowding
Patient safety is always a concern
Crowding is associated with:
►Higher adverse event rates
►Higher morbidity and mortality
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►The dialogue has changed
►It is all about Flow!
Metric Driven Management
Cycle Time ManagementCyc e e a age e t►Door to doctor►Doctor to data►Data to decision►Decision to disposition►Decision to disposition
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Regulatory
►Joint Commission Flow Standards►Joint Commission Flow Standards►National Quality Forum Endorsed Performance Measures
NQF Endorsed Measures►Door to Departure Discharged►Door to Departure Admitted►Decision to Departure Admitted Patients►Door to Provider
L ft With t B i S► Left Without Being Seen
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Let’s Be Dirty Capitalist Pigs
►$250 – 500 for►$250 – 500 for discharged patients
►$7000 admitted patients
“Show me the money Jerry!”
►3% LWBS
► 40K a year visits
►1,200 patients a year walk
►Admission rate 20%d ss o a e 0%
►$300 discharged patients, $7k admitted
Almost $$$ 2 million!
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Why Door to Doc Focus?
Short Times Correlate With…
►Better Patient Satisfaction
►With Lower LWBS
With I d►With ImprovedThroughput
The Public Eye► Death in Kings County
Psychiatric ED Waiting Room ►Room
► Chest Pain Death in Vista Medical Center became a Homicide Case
► Bowel Perforation Death in LA as woman
.
Death in LA as woman calls for Ambulance to Another ED
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Improving Door to Doc Times at Two Community Hospitalsy p
Two Tales
►The DataTh P l►The People
“You can get a lot farther with a kind word and a gun than
ith ki d dwith a kind word alone.”
Al Capone
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Quality Improvement
ClinicalInformation ClinicalMedicine
Information Technology
Intermountain Healthcare
►The Technologic Infrastructure
►Thirty Years of Investment in IT
►Homegrown Technology
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Integrated Tracking System
Dashboards
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Door to Doc Times
► LDS Hospital 23
►CW Hospital 51
►AV Hospital 47
(Time in Minutes)
Biggest Constraint:
► “Culture eats Process Improvement for Lunch”
--- Kirk Jensen, MDIHI ED Collaborative
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Stretch Goals
►Bring Door to Doc Ti t U d 30Time to Under 30 minutes at each site
►See 80% of►See 80% of patients in under 30 minutes
The Team
►Medical Director►Nurse Manager►Head Registration
Clerk►Head Technician
Because Process Improvement is a Team S t!
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QI Strategies & Tools
►Improve Process (R W t )(Remove Waste)
►Prompts, Reminders
►Education
►Feedback Loop
Remove Waste
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Intake Process Before
►Inefficient►Inefficient
►Processes in Series
►Long Door to Doc time
►Repetitive for Patient►Repetitive for Patient
LDS Intake Process After
MD toMD toPatient’s Room
Labs SentX-Rays Ordered
RegistrationNurse Intake
Patient Presents To Triage
Patient to Treatment Room
Treatment Begun
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Remove Waste
Prompts and Reminders
►Signage►Tracking System
Prompts►Posters►Staff became the
drivers for changedrivers for change
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►Inservice Training for th St ff
Education
the Staff►Packet of Articles for
Physicians
New Concepts
►Think Processes not Places►Think Parallel not Sequential►Almost every thing you think “has to”
happen, doesn’t ►Think the Most Important Event of an ED
EncounterEncounter
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The Psychology of Waiting►Unoccupied time feels Longer than occupied time► Pre-process waits feel Longer than in process
waits►Anxiety makes waits seem Longer►Uncertain waits are Longer than known waits►Unexplained waits are Longer than explained waits
THE FEEDBACK LOOP
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Feedback Loop
►Physicians are M d b D tMoved by Data
►Physicians are Performance Driven
Education
►Inservice Training►Email Notices►Articles mailed to
Physicians►Individual Data
Mailed to PhysiciansMailed to Physicians
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Door to Doc Results
►CW 51 to 31 minutes
►AV 47 to 27 minutes47 to 27 minutes
Results
►CW►CW LWBS: 2.0 % to .8%
►AV LWBS: 1 2% to 4%LWBS: 1.2% to .4%
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Results:
►CW LOS : No change
►AV LOS : No Change
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The Other Story
Salt Lake Emergency Physicians:Salt Lake Emergency Physicians: Strong QI History
Utah Emergency Physicians: No QI culture
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The Other Story
“It is great that you love quality improvement Shari, but for me the importance is down here…”
“The way to get things done is not to mind who gets gthe credit for doing them.”
Benjamin Jowett
1817-1893
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The Other Story
“I have this idea for a QI Project.
Can you help me?”you p
The Future:New Intake ModelsNew Intake Models
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New Processes
►Traditional Triage Staffing►Midlevel Triage►Doc in Triage►Team Triage►No Triage, “Pull to Full”►Pivot Nurse/Abbreviated Triage►Pivot Nurse/Abbreviated Triage►Triage to the Diagnostic Waiting Room
Triage Staffing Based on Volume►<20,000 0-12 hours nurse triage/day
►20-40k 12-24 nurse triage hours a daygreeter 12 hours
►40-60k 24-36 hours a daygreeter + tech 12-24 a daygreeter + tech 12 24 a day
►60-80k 36-44 nurse triage hours a daygreeter 24 hours, tech 24-36 hours**
**From VHA
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The ED Volume Curve
Traditional Triage Circa 1985
►18,000 ER Visits, 2 patients per hourpatients per hour
►Dedicated rooms►12 to 20 Minute
Triage ► Lengthy sorting
processprocess
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Triage 2009►Today 40,000 ER
Visits
►Arriving in Surges that Mimic Mass Casualty
►A Bottleneck of our Own Design
Midlevel Provider in Triage
►Reduced WaitsR d d Th h t►Reduced Throughputs
►Reduced LWOBS
(Fottler 2002, Sakr2003,Wilson 2008)
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Physician in Triage► TRIAD Study: Triage Rapid Initial Assessment by
Doctor . Decreased Throughput by 38% With No Addi i l S ffAdditional Staff
► Taylor and Bennett, Emerg Med Journal 2004 Physician in Triage decreased LOS, reduced LWOBS, increased staff satisfaction.
A thi d t 45% f ti t t t d d l d f t i► A third to 45% of patients treated and released from triage area.
A True Story
►Arrowhead Memorial Hospital►Arrowhead Memorial Hospital
►Part of California ED Diversion Project
►Astounding Census Growth over 5 Years
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Annual StatisticsAnnual Statistics
Annual CensusAnnual Census20022002 58 000 seen and treated58 000 seen and treated20022002 58,000 seen and treated58,000 seen and treated20042004 70,00070,00020062006 96,00096,00020072007 110,000110,000
Arrowhead Memorial 2002
P f D tPerformance Data►Door to Doc 4 Hours►LWBS 20%►Unhappy Staff
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Intake RedesignIntake Redesign
Ph i i / Midl lPhysician/ Midlevel Initial Evaluation
L A it P bl S d t b d f
50% 30% 20%
Low Acuity Problem:Discharge homeAfter Complete
Registration
Radiology or LabPhlebotomist and/or Escort to Radiology
Send to bed forhigher acuity treatment or
physical exam
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Statistics Statistics Arrowhead Arrowhead MemorialMemorial
Door Door to Doc timeto Doc time2002 2002 over 4 hoursover 4 hours2004 2004 120 minutes120 minutes20072007 5050--60 minutes60 minutes20082008 March 31 minutes March 31 minutes ((97% under 120 minutes)97% under 120 minutes)
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LWBS LWBS Arrowhead Arrowhead MemorialMemorial
20022002 20%20%20042004 9%9%20062006 2%2%20072007 1.5 to 3.5%1.5 to 3.5%20082008 March under 1%March under 1%20082008 March under 1%March under 1%
Team Triage► Team Triage and Treatment (T3)
Thom Mayer, Fairfax Inova Hospital in Virginia Unpublished data: 34% discharged from triage decreasedUnpublished data: 34% discharged from triage, decreased LOS, improved patient satisfaction, decreased time to pain management
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No Triage: “Pull ‘til Full”
►UCSD Ted Chan and Jim Killeen►UCSD Ted Chan and Jim Killeen REACT: Rapid Entry and Accelerated Care at Triage Reduced LOS Reduced LWOBS
Abbreviated Triage►Taking less than 6 minutes►Fast Documentation►Fast Documentation►May get Vitals on the Back End►Pivot Nurse Concept
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Case Study: Mary Washington
► 100,000 visits a year
► 14 letters to the editor in local paper
► 5 Hour LOS
► COMPLAINTS!!!
► 1/3rd of staff quit
Mary Washington Hospital
► Can intake new patients at a► Can intake new patients at a rate of 20 an hour
► Double triage 24/7
► 3 Service Lines
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Abbreviated Triage
► Single Phrase Chief ComplaintComplaint
► Allergies► Pain Scale► Vital Signs► ESI Level
Mary Washington Hospital
SUCCESS!SUCCESS!
►Throughputs down from 5 hours to 3
►Patient Satisfaction Up
► LWBS Down
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Triage to the Diagnostic Waiting Room
► Keeping Patients VerticalVertical
► Creating Different Spaces
► Being More Selective b d lAbout Bed Placement
The Diagnostic Waiting Room, Bannock
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Bed Minutes
Your Most Precious Commodity!!!
►For Diagnosis►For Treatment
New Technology
►Bio Identification Techniques► Intake Kiosks►Medical ID Cards/Smart
Cards and Computerized Self Check-In
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Computerized Self Triage
Computerized Self Check-In► University of Western Ontario/New London Health
Sciences Center
► Self Check In using computer
► Took Five Minutes 32 seconds for first time users in pilot study
► Outperformed Physician in terms of data elements for abdominal pain
► 92% would use again!
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Bio Identification
PASSPatient Access Secured System
Near-infrared camera
Palm vein image
Match name, DOB, MR
Quick ID
< 15 seconds
Prevents duplicate MR
The Point is …
This Has to Go!
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Change
“Yo can get a lot“You can get a lot farther with a kind word and some data than with a kind word alone.”
Shari Welch