the need to re-engineer the way hospitals work and respond national cme emergency management...
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The Need to Re-Engineer The Need to Re-Engineer the Way Hospitals Work the Way Hospitals Work
and Respondand Respond
National CME Emergency National CME Emergency Management AudioconferenceManagement Audioconference
July 22July 22ndnd, 2008, 2008
Brent Asplin, MD, MPHBrent Asplin, MD, MPHHead, Department of Emergency MedicineHead, Department of Emergency MedicineRegions Hospital, St. Paul, MNRegions Hospital, St. Paul, MNAssociate Professor & Vice ChairAssociate Professor & Vice ChairUniversity of Minnesota Dept of University of Minnesota Dept of Emergency MedicineEmergency Medicine
Statement of TaskStatement of Task
The objectives of this study are The objectives of this study are to: to:
(1) examine the emergency care (1) examine the emergency care system in the U.S.; system in the U.S.;
(2) explore its strengths, (2) explore its strengths, limitations, and future limitations, and future challenges; challenges;
(3) describe a desired vision (3) describe a desired vision of the emergency care system; and of the emergency care system; and
(4) recommend strategies (4) recommend strategies required to achieve that vision. required to achieve that vision.
Key FindingsKey Findings
Between 1993 and 2003:Between 1993 and 2003:– ED visits grew 26% to 114 ED visits grew 26% to 114 million annuallymillion annually
– The number of EDs decreased by The number of EDs decreased by 400400
– The number of operating hospital The number of operating hospital beds decreased by nearly 200,000beds decreased by nearly 200,000
Key Findings Key Findings
Crowding and diversionCrowding and diversion Fragmentation: limited Fragmentation: limited coordination of the regional coordination of the regional flow of patientsflow of patients
Lack of system accountabilityLack of system accountability Inadequate emergency Inadequate emergency preparednesspreparedness
Recommendations: Recommendations: Areas of EmphasisAreas of Emphasis
A new era of operations A new era of operations management in U.S. hospitalsmanagement in U.S. hospitals
Improving emergency Improving emergency preparednesspreparedness
A New Era of Operations A New Era of Operations Management in U.S. Management in U.S.
HospitalsHospitals Hospitals: Adopt operations Hospitals: Adopt operations management techniques and IT management techniques and IT improvements to enhance patient improvements to enhance patient flow, supported by training and flow, supported by training and certification organizations.certification organizations.
CEOs: Lead the effort to improve CEOs: Lead the effort to improve patient flowpatient flow
Hospitals: Hospitals: End inpatient boarding End inpatient boarding in the ED and ambulance in the ED and ambulance diversiondiversion, supported by CMS , supported by CMS working group, Joint Commission.working group, Joint Commission.
Hospital Wide View of Hospital Wide View of Patient FlowPatient Flow
The goal:The goal:Develop a system-wide view of Develop a system-wide view of patient flow and operations patient flow and operations management with clear lines management with clear lines of responsibility of responsibility
– Is your CEO on board?Is your CEO on board?
High Impact Strategies High Impact Strategies for Improving Patient for Improving Patient
FlowFlow American College of Emergency American College of Emergency Physicians (ACEP) Task Force Physicians (ACEP) Task Force Report on BoardingReport on Boarding– April 2008April 2008
What selected strategies have What selected strategies have been shown to improve patient been shown to improve patient flow and alleviate ED boarding?flow and alleviate ED boarding?
http://www.acep.org/WorkArea/http://www.acep.org/WorkArea/downloadasset.aspx?id=37960downloadasset.aspx?id=37960
High Impact Hospital-High Impact Hospital-Wide StrategiesWide Strategies
Full capacity protocolFull capacity protocol
Elective surgery smoothingElective surgery smoothing
Earlier inpatient dischargesEarlier inpatient discharges
Full Capacity Full Capacity ProtocolProtocol
Pioneered at Stony Brook Pioneered at Stony Brook University HospitalUniversity Hospital
Also called “Adopt a Boarder”Also called “Adopt a Boarder” Strategy designed to distribute Strategy designed to distribute boarding patients to inpatient boarding patients to inpatient units, rather than keep all of units, rather than keep all of them in the EDthem in the ED
The majority of patients either go The majority of patients either go directly to an inpatient bed or directly to an inpatient bed or are placed in a bed within one are placed in a bed within one hour of arriving on the unithour of arriving on the unit
Elective Surgical Elective Surgical FlowFlow
Managing artificial Managing artificial variation in demandvariation in demand
The secret: you reduce The secret: you reduce delays AND you can do more delays AND you can do more surgeries!surgeries!
Natural vs. Natural vs. Artificial DemandArtificial Demand
Natural variationNatural variation– Stochastic and predictable using Stochastic and predictable using queuing theoryqueuing theory
Artificial variationArtificial variation– Wide variations in demand created by Wide variations in demand created by scheduling bottlenecks (e.g. OR scheduling bottlenecks (e.g. OR block schedules)block schedules)
– Creates greater variation in demand Creates greater variation in demand than the predictably unpredictable than the predictably unpredictable demand for emergency admissionsdemand for emergency admissions
Variability in DemandVariability in Demand
Program for management of Program for management of variability in health care variability in health care deliverydelivery– http://management.bu.edu/research/http://management.bu.edu/research/hcmrc/mvp/index.asphcmrc/mvp/index.asp
Litvak, Long, Cooper, and McManus. Litvak, Long, Cooper, and McManus. Emergency department diversion Emergency department diversion causes and solutions. Acad Emerg causes and solutions. Acad Emerg Med. 2001 Nov;8(11):1108-10. Med. 2001 Nov;8(11):1108-10.
Earlier Inpatient Earlier Inpatient DischargesDischarges
Requires senior leadership Requires senior leadership support to hold inpatient support to hold inpatient managers accountable for goalsmanagers accountable for goals
Project management and data Project management and data support are criticalsupport are critical
Find an “early adopter” unit Find an “early adopter” unit with a key inpatient with a key inpatient physician and nurse manager physician and nurse manager
Daily Operations and Daily Operations and Emergency Emergency
PreparednessPreparedness For events that are ultimately For events that are ultimately managed by your hospital, your managed by your hospital, your disaster response will be more disaster response will be more effective if it represents scaling of effective if it represents scaling of daily operations daily operations
New processes rarely work well during New processes rarely work well during a disastera disaster
Important caveats:Important caveats:– This changes as the scale of the event This changes as the scale of the event increasesincreases
– This limitation can be mitigated (to This limitation can be mitigated (to some extent) with regular practice and some extent) with regular practice and disaster drillsdisaster drills
High Census ProtocolsHigh Census Protocols
Tiered operational responses to Tiered operational responses to daily surges in patient demand daily surges in patient demand
Excellent opportunity to scale Excellent opportunity to scale communication, transport, and communication, transport, and ancillary operationsancillary operations
These capabilities will These capabilities will translate into better emergency translate into better emergency preparednesspreparedness
ED Boarding ED Boarding and Disaster and Disaster PreparednessPreparedness
Most disaster response plans call Most disaster response plans call for the immediate transfer of ED for the immediate transfer of ED boarders to inpatient unitsboarders to inpatient units
If we do not allow boarders to sit If we do not allow boarders to sit in ED hallways during disasters, why in ED hallways during disasters, why do we let it happen every day?do we let it happen every day?
A hospital that is boarding A hospital that is boarding inpatients in the ED is less inpatients in the ED is less prepared to respond to a disaster prepared to respond to a disaster than it otherwise would bethan it otherwise would be
Take Home PointsTake Home Points
The IOM has called for a new era of The IOM has called for a new era of operations management in our operations management in our hospitalshospitals
Day to day surges in demand are good Day to day surges in demand are good opportunities to scale hospital opportunities to scale hospital operations and practice components operations and practice components of a disaster response planof a disaster response plan
Hospitals that have reduced or Hospitals that have reduced or eliminated inpatient boarding in the eliminated inpatient boarding in the ED are better prepared for disasters ED are better prepared for disasters than those who haven’tthan those who haven’t
