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Marko Duic, MBA, MD, CCFP(EM), FCFPSt. Joseph’s Health Centre
Regina, 27 October 2007
EMERGENCY FLOW AND EMERGENCY FLOW AND EFFICIENCY ENHANCEMENTSEFFICIENCY ENHANCEMENTS
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The Main Waiting Room at any timeThe Main Waiting Room at any time
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OutlineOutline
Hospital OverviewPerformance MetricsStrategies for Managing Patient Flow Flexible Physician SchedulingManaging Physician PerformanceClinical Decision Unit
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Total ER VisitsTotal ER Visits
48,504 48,274 49,376 50,39553,934
56,58959,124
66,499 64,144
74,884
82,10786,500
71,312
1995-1996
1996-1997
1997-1998
1998-1999
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
2004-2005
2005-2006
2006-2007
2007-2008
SARS
projected
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Performance characteristics of St. Performance characteristics of St. JosephJoseph’’s method s method
Highest volume ED in the Greater Toronto Area (GTA) in last few yearsFastest growing ED in the GTA…even though…Shrinking catchment area (gentrification leading to more space for fewer, smaller families)Highest number of ambulances in GTALowest percentage of ambulances in GTA (i.e., greatest percentage of self-arrivals = voluntary patients)Fastest offloads in GTA most monthsLowest % LWBS in GTA (and as far as we know, in Canada)High rates of patient satisfactionExcellent medical outcomes (based on few studies, though)
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Ambulance In Hospital Time: OffAmbulance In Hospital Time: Off--LoadingLoadingToronto Central West Emergency NetworkToronto Central West Emergency Network
Q1 50 51 65 62 68 71 71Q2 48 52 63 68 71 72 80Q3 51 52 71 68 67 73 81Q4 53 56 76 70 69 83 82
SJHC Hospital 1 Hopital 2 Hospital 3 Hospital 4 Hospital 5 Hospital 6Minutes
2006/07
79756967695351Avg.
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Ambulance Volumes vs. Offload Times Ambulance Volumes vs. Offload Times Toronto Central Emergency NetworkToronto Central Emergency Network20062006--2007 Q12007 Q1--Q4Q4
0
2000
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SJHC Hosp 1 Hosp 2 Hosp 3 Hosp 4 Hosp 5 Hosp 6
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amb volumes offload min
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Percent Left Without Being Seen By ER PhysicianPercent Left Without Being Seen By ER PhysicianToronto Central West Emergency NetworkToronto Central West Emergency Network
Q1 2.6% 3.3% 4.5% 5.2% 6.7% 5.6% 6.0%Q2 2.8% 3.5% 3.8% 5.8% 5.1% 6.9% 7.1%Q3 2.6% 3.3% 6.1% 5.0% 6.4% 6.1% 6.9%Q4 2.7% 3.4% 4.5% 5.4% 7.6% 6.1% 6.6%
SJHC Hospital 1 Hospital 2 Hospital 3 Hospital 4 Hospital 5 Hospital 6
3.4% 6.7%6.2%6.5%5.4%4.7%2.7%Avg.
2006/07
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Patient Experience Of Care Patient Experience Of Care Toronto G.T.A. Community HospitalsToronto G.T.A. Community Hospitals
2003‐2004 2004‐2005 2005‐2006
Overall Quality of Care (% Positive) 75.1 75.6 83.3
GTA Community Hospital Average 72.9 75.1 73.7
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Length of Stay Over Four YearsLength of Stay Over Four Years
2003‐2004 2004‐2005 2005‐2006 2006‐2007
Total Visits 64,144 71,312 74,884 82,107Average LOS 8.0 hours 7.4 hours 6.9 hours 6.5 hoursTotal Out‐Patient Visits 55,677 62,940 67,075 73,467Average LOS 5.4 hours 5.1 hours 5.0 hours 4.8 hoursPaediatric Visits 10,396 12,435 13,662 14,205Average LOS 3.1 hours 3.1 hours 3.0 hours 2.9 hoursMental Health Visits 4,427 3,996 3,670 4,560Average LOS 17.7 hours 21.1 hours 23.4 hours 16.3 hoursOut‐Patient Stretcher Visits 8,567 10,004 11,661 11,546Average LOS 10.4 hours 10.0 hours 9.5 hours 9.0Stretcher Admissions 7,151 7,084 6,338 6,555Average LOS 23.5 hours 21.8 hours 17.4 hours 20.2 hoursAmbulatory/Fast Track 33,586 37,709 39,464 44,598Average LOS 4.2 hours 4.1 hours 3.9 hours 3.9 hours
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Total Visits and Length of StayTotal Visits and Length of Stay
0
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2003/04 2004/05 2005/06 2006/07
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Visits
LOS
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Discharged Patient Visits and LOSDischarged Patient Visits and LOS
0
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2003/04 2004/05 2005/06 2006/07
4.5
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4.9
5
5.1
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5.5
Visits
LOS
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Stretcher Visits Ultimately Discharged Stretcher Visits Ultimately Discharged and LOSand LOS
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2003/04 2004/05 2005/06 2006/07
8
8.5
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Visits
LOS
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Ambulatory and Fast Track Volumes Ambulatory and Fast Track Volumes and LOSand LOS
0
5000
10000
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50000
2003/04 2004/05 2005/06 2006/07
3.75
3.8
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3.9
3.95
4
4.05
4.1
4.15
4.2
4.25
Visits
LOS
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Paediatric Visits and LOSPaediatric Visits and LOS
0
2000
4000
6000
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12000
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2003/04 2004/05 2005/06 2006/07
2.8
2.85
2.9
2.95
3
3.05
3.1
3.15
Visits
LOS
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Stretcher Patients Ultimately Admitted Stretcher Patients Ultimately Admitted and LOSand LOS
5800
6000
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7000
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7400
2003/04 2004/05 2005/06 2006/07
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LOS
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Mental Health Visits and LOSMental Health Visits and LOS
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2003/04 2004/05 2005/06 2006/07
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Visits
LOS
Strategies for Managing Strategies for Managing Patient FlowPatient Flow
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Triage ProcessTriage Process
90 second triage
No patients in waiting room = no resources wasted on patient observation
Extended triage done by primary nurse in destination area
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What is What is ““StreamingStreaming””??
Streaming patients to three main areas:Patients Arrive
Ambulatory ED (ED2)
• Mostly triage 2s and 3s, with complicated 4s
• Ambulatory patients
Main ED (ED1) “Normal” Acute ER
Stretcher Area• Examinations and assessments• Ordering of tests and evaluation of
results• Observation
Minor Treatment Area• Bumps, sprains, lacerations• Pts not requiring bloodwork or
advanced imaging• IV antibiotics• Follow ups
• Triage 1, some 2s
• Non-Ambulatory Triage 3s, 4s, (5s)
• “one touch” 3s and 4s, all 5s
Note: At SJ, we also “stream off” all the kids and most of the behaviourdisordered patients into their respective separate areas
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The Main Waiting Room at any timeThe Main Waiting Room at any time
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Ambulatory AreaAmbulatory Area
Used as overflow for Urgent Area stretcher patients
5 exam rooms; 120 patients/day
Flexible nurse to patient ratio
Nurse immediately:Completes triageDoes primary assessmentInitiates protocolsCalls MD for non-protocol orders (pain, asthma, non-directive XR)
Physician assessment
Flow achieved through moving patients between stretchers and ambulatory waiting room
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Treatment Room UtilizationTreatment Room Utilization
Ambulatory Fast Track
Average Patients/Day 75 patients 33 patients
75% of patients seen 1000‐2400 56 patients 25 patients
Average LOS 4.2 hours 3.5
Treatment Room Hours (rooms x hours) 70 28
Patient Capacity – Traditional Model 17 8
Percent capacity ‐ Traditional Model 30 32
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RN and EP Culture ShiftRN and EP Culture Shift
Ambulatory:
Resistance to Ambulatory process because of need to move sick patients from stretchers to chairs.
Nurse to patient ratio managed through introduction of float nurse, realignment of shifts with patient volumes, and reassignment of nurses as required.
Concerns overcome through ability to care for more patients in a timely manner.
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Waiting rooms for waitingWaiting rooms for waiting
Treatment rooms for treatment
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EMS Patients Transferred To Ambulatory EMS Patients Transferred To Ambulatory AreaArea
24%52076%1,65015.2%2,17014,276Total8%292%2428%2693CTAS‐519%8081%33328.7%4131,438CTAS‐423%35871%1,17819.8%1,5367,746CTAS‐341%8059%1154.1%1954,791CTAS‐20%00%00%0208CTAS‐1
%EMS Visits to
Ambulatory Area
Transferred to Alternate
Area
%EMS Visits to
Ambulatory AreaWho Remain
%EMS Visits to
Ambulatory Area
Total EMS Visits
By CTAS
2006‐2007
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Thoughts about Thoughts about ““streamingstreaming””
1. Emergency efficiency requires senior management support.
2. If you get 8 hour stretcher turnover, you need about 1 stretcher/1000 stretcher-requiring patients*year.
3. Stretcher requiring patients are• Patients who can’t sit• Patients who require monitoring• Patients who require procedural sedation and
other supine interventions
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Thoughts about Thoughts about ““streamingstreaming””
4. Emergency congestion = arrivals * LOS
# of available stretchers
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Thoughts about Thoughts about ““streamingstreaming””
5. Patients not requiring stretchers are not relevant to emergency congestion; diversion of low-acuity patients does not relieve congestion
6. Congestion solutions all fall into one of two categories:1. Decrease LOS of stretcher-requiring patients2. Increase number of available stretchers (improve
flow through the hospital)(This assumes only stretcher-requiring patients are
using stretchers)
Flexible Physician SchedulingFlexible Physician Scheduling
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Hourly vs. Fee for ServiceHourly vs. Fee for Service
Patients come to the ED for services, not physician hours.
Physicians are driven by professional obligations (they want to help patients).
Physicians are people too. They work better when their incentives are aligned with patient needs.
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Physician Speeds and Patient VolumesPhysician Speeds and Patient Volumes
0
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h
02468
1012141618
00 :00 -02:0 002 :00 -04:0 004 :00 -06:0 006 :00 -08:0 008 :00 -10:0 010 :00 -12:0 012 :00 -14:0 014 :00 -16:0 016 :00 -18:0 018 :00 -20:0 020 :00 -22:0 022 :00 -24:0 0
+1 SD
Line 2
-1 SD
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Standard ED Scheduling AssumptionsStandard ED Scheduling Assumptions
1. Patient numbers are predictable. There are no days when it is unusually busy or unusually quiet. Therefore the shift times can be determined months in advance.
2. All emergency physicians work at the same speed. Therefore,
a. Any physician can work any shift. b. Physicians trading shifts does not affect
patient flow.
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Flexible Physician Scheduling Flexible Physician Scheduling AssumptionsAssumptions
1. Patient volumes are more predictable than physician speeds, but still vary considerably.
2. The relevant reference is a patient LOS period, not daily or monthly volumes.
3. Fast and slow physicians do not differ in medical outcomes or patient satisfaction.
4. Each EP has a speed at which s/he works most comfortably. These speeds can vary threefold or more.
5. Attempts to get EPs to work at an uncomfortably fast or slow speed leads to poor work satisfaction and may lead to medical errors.
6. The relevant reference in advance scheduling is physician patient processing capacity, not physician hours.
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What Do Emergency Physicians What Do Emergency Physicians Want From Their Daily Schedule?Want From Their Daily Schedule?
1. Pride that patients are not waiting very long.
2. Predictability re when they are working and when they are not.
3. In a FFS system, no idle time.
Like so many things in life, you can’t have it all: only two of these three are possible.
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St. JosephSt. Joseph’’s Emergency Service s Emergency Service StandardsStandards
Service standards apply after medical needs are met.
FROM TRIAGE:• <15 min in FT (works out to STAT):
Includes police arrivals• <30 min for spine boards
• <60 min in Paeds.
• <120 min for any stable patient (max wait).
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Resulting ScheduleResulting Schedule
Different numbers of “physician responsibility periods” each day depending on speed.
Two fixed shift starting times: midnight and 0700.
All other shifts have a negotiated start time.
All shifts have a negotiated end time.
Responsibility period may extend beyond shift end and result in EP recall after early departure.
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Resulting Schedule (ContResulting Schedule (Cont’’d)d)
At any one moment, one physician is in charge of ensuring adequate EP availability.
Charge EP negotiates start time with next EP; negotiates stop time with previous EP.
When next EP comes in, takes over charge.
EP manpower dynamically guided each hour by current and anticipated patient waits and service standards.
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Resulting Schedule (ContResulting Schedule (Cont’’d)d)
Fast EPs prefer to see volumes, thus they like overlapping with slow EPs.Slow EPs are afraid of being overwhelmed, thus they like overlapping with fast EPs.If more than the usual number of fast EPs is scheduled any day, the number of shifts is cut.If more than the usual number of slow EPs is scheduled any day, the number of shifts is increased.Responsibility for patient waits is transferred from schedulemaker (months before) to front line physicians at the time of service
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Department of Emergency Medicine:Department of Emergency Medicine:Physicians SchedulePhysicians Schedule
Shift Alpha Beta Lambda Gamma Delta Mu Epsilon OmegaMonday 1 Kim Lau ------------- Pilon Rhee ------------- Falcioni MoffattTuesday 2 Sommer Gagnon Duic Pilon Lau ------------- Falcioni MoffattWednesday 3 Duic Pilon Kim SueAQuan Falcioni ------------- Lau RheeThursday 4 Duic SueAQuan ------------- Gagnon Pilon ------------- Lau RheeFriday 5 Falcioni Lai ------------- Pilon Lau ------------- SueAQuan GagnonSaturday 6 Rhee Pilon ------------- Sommer Kanhai SueAQuan Kuld FalcioniSunday 7 Rhee Pilon ------------- SueAQuan Kanhai Yue Gagnon KuldMonday 8 Kim Yue ------------- Haas Rhee ------------- Falcioni MoffattTuesday 9 Kim Pilon ------------- Falcioni Gagnon ------------- Rhee MoffattWednesday 10 Kim Pilon ------------- Falcioni Sommer ------------- Kuld MoffattThursday 11 Haas Duic ------------- SueAQuan Rhee ------------- Kuld KimFriday 12 Rhee Falcioni Sommer Kuld Duic ------------- Pilon KimSaturday 13 Rhee Lai ------------- xxxxxxx Duic ------------- Kanhai FalcioniSunday 14 Kim Pilon ------------- Duic Kuld ------------- Rhee SommerMonday 15 Duic Falcioni ------------- Yue Rhee ------------- Kuld MoffattTuesday 16 Kim Falcioni ------------- Pilon Mussani ------------- Yue MoffattWednesday 17 Sommer Kim ------------- xxxxxxx Mussani ------------- Rhee MoffattThursday 18 Kuld Duic ------------- SueAQuan Rhee ------------- Gagnon KimFriday 19 Sommer Kuld ------------- Pilon Duic ------------- SueAQuan KimSaturday 20 Sommer Lai ------------- Falcioni Gagnon ------------- Mussani SueAQuanSunday 21 Mussani Haas Rhee Falcioni Sommer ------------- Gagnon KuldMonday 22 Duic Kanhai ------------- Yue Sommer ------------- Falcioni MoffattTuesday 23 Kim Kanhai ------------- Falcioni Mussani ------------- Kuld MoffattWednesday 24 Duic Falcioni ------------- Kuld Kim ------------- SueAQuan MoffattThursday 25 Duic Gagnon ------------- SueAQuan Kuld ------------- Mussani KimFriday 26 SueAQuan Gagnon Lai Falcioni Lau ------------- Kuld KimSaturday 27 Duic Falcioni ------------- xxxxxxx Sommer ------------- Kuld MussaniSunday 28 Kim Yue ------------- Kuld Rhee ------------- Gagnon LauMonday 29 Duic Kanhai ------------- Rhee Kuld ------------- Mussani MoffattTuesday 30 Kim Falcioni ------------- Kuld Lau ------------- Gagnon MoffattWednesday 31 Mussani Gagnon ------------- SueAQuan Kim ------------- Lau Moffatt
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Monitoring For ResultsMonitoring For Results
Unit clerk makes rounds of each area, records numbers waiting and times. Reports violations of service standards to charge RN who discusses plan with charge EP.If charge RN not impressed with plan, establishes call between Chief and charge EP.Number of times call has been established in 2006 = 0; in 2005 = 2.Results are reviewed with charge EPs (if necessary) a day laterShorter waiting times resulted in higher patient expectations.
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Possible Actions When Service Possible Actions When Service Standards Approached/ExceededStandards Approached/Exceeded
1. Next EP(s) come in early (most days, once).
2. Current EP(s) stay.
3. Recall of EP who left within responsibility period.
4. Call in non-scheduled physician (approx 15/year).
5. Call in Chief (never yet).
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The RulesThe Rules
Rule 1 Description: Focusing on patient wait times takes focus off shift start and stop times.
Rule 1 Verbatim: No physician has to come to work at any particular time, or at all.
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The RulesThe Rules
Rule 2 Description: The schedule indicates PORs, not working time.
(POR = period of responsibility).
Rule 2 Verbatim:The times indicated on the schedule are times of
departmental responsibility.During these times, the indicated physician is responsible for working to make sure service standards are being met.If he is not in the department, must call in every 1-2 hours and speak to the charge physician about whether he needs to come and help.
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The RulesThe Rules
Rule 3 Description: The charge physician is the most recently arrived, regularly scheduled EP; when the next one arrives, role is transferred.
Rule 3 Verbatim: The charge physician responsibility is borne by the most recently arrived, regularly scheduled doctor in the department. He accepts this responsibility on arriving and starting to work, and relinquishes it as soon as the next regularly scheduled physician arrives and starts to work. He bears the primary responsibility for making sure service standards are met. He is responsible for negotiating working times with other physicians, to increase or decrease physician staffing in a dynamic way to provide patients timely service. He will negotiate with incoming physicians to advance or delay the start of their work; and he will negotiate with physicians nearing the end of their shifts to have them stop earlier or continue working longer.
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The RulesThe RulesRule 4 description: Collegiality and Equality.
Rule 4 Verbatim: It is the charge physician’s responsibility to do his duty (modulating physician availability) with the greatest possible collegiality and equity. Thus if he advances the arrival time of a physician, he must be prepared to stay later to help; if he delays the arrival of a physician, he must be prepared to cut back his own work. Each two responsibility periods may have an overlap period. The charge physician may not delay, against the incoming physician’s preferences, the arrival time of the incoming physician past the middle of the overlap period. Once the incoming physician arrives, he of course becomes the charge physician, and has the responsibility to decide when the previous charge physician should stop seeing patients.
There may be slow times when the potentially incoming physician would prefer to not come in, and the charge physician is happy to continue working. Such an arrangement cannot be mandated by the charge physician but must be by mutual consent. The (not) incoming physician must continue to call in every 1-2 hours until the end of his responsibility time.
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The RulesThe Rules
Rule 5 Description: EPs may not stop working until service standards are met.
Rule 5 Verbatim: Notwithstanding the end of a physician’s period of responsibility, he may not stop seeing new patients until service standards are comfortably achieved. If he needs to leave at a specific time and it appears that he will not be able to without violating service standards, he must negotiate with colleagues to provide additional physician resources so that service standards are met at the time he wants to leave.
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The RulesThe Rules
Rule 6 Description: EPs may leave early but must return if it gets busy.
Rule 6 Verbatim: If physicians leave the department prior to the end of their time of responsibility, they must continue to maintain frequent contact with the charge physician and return to the department if patient demands require it. (for example, if the responsibility time for Gamma POR is 1300-2100, and the physician leaves at 1730 because there is no work, he must return if a bus arrives at 1830 and service standards are exceeded at 2030, rather than having a call-in).
Managing Physician PerformanceManaging Physician Performance
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The Emergency Physician 360The Emergency Physician 360
Implemented a performance management system for emergency physicians in November 2005.
Comprehensive feedback to each EP from:All emergency physicians Chief, Emergency MedicineSelf-assessmentNurses, team leadersConsultants
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The Emergency Physician 360: The Emergency Physician 360: MethodMethod
24 point questionnaire.EPs participated in writing and validating the questions.Each question involves 7-point score and mandatory comment.Computer collation of questionnaires with output of all answers for each EP.Review of results with Chief.Results known only to EP and Chief.Chief shared his 360 results to demonstrate commitment to performance improvement.
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The Emergency Physician 360: The Emergency Physician 360: Survey Questions for EPsSurvey Questions for EPs1. Up to date medical knowledge.2. Promotes patient satisfaction.3. Sharing With Colleagues:
Shares when slowCalls for help when appropriateHigh quality handoversNo room blocking in AmbulatoryCommunicates during shifts for work flowReliable call-ins and start timesAppropriate departure timesKeeps office tidy
4. Promotes patient flow.5. Prompt reassessments.6. Avoids unnecessary tests.7. Takes initiative to get equipment fixed, supplies re-stocked, rooms cleaned.8. Teaching: students, residents, nurses, colleagues.9. Departmental contributions: audits, clinical days, hospital committees, research,
projects etc.10.Charts: legibility and usefulness.11.Overall evaluation and comments.
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The Emergency Physician 360: The Emergency Physician 360: Survey Questions for RNsSurvey Questions for RNs
1. Cognitive skills
2. Manual Skills
3. Interpersonal Skills with patients/families;
and with nurses
4. Teamwork with Nurses
5. Managing the Department
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The Emergency Physician 360: The Emergency Physician 360: Survey Questions for ConsultantsSurvey Questions for Consultants
1. Application of Knowledge
2. Referral Pattern
3. Collegiality
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The Emergency Physician 360: The Emergency Physician 360: ResultsResults
50% of EPs had some results that fell numerically below 1 SD cf. their colleagues.
These became improvement objectives.
Improvement will be measured on next survey.
Surveys to be completed by RNs and consultants now in progress.
Aim is to have an annual 360 for all EPs.
Certain behaviour changes in some EPs as result of this survey have been remarkable to other EPs (legible handwriting? Him? Really??).
Clinical Decision UnitClinical Decision Unit
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Clinical Decision Unit: Our ModelClinical Decision Unit: Our Model
Five-bed virtual unit in the ED:Prior to opening, many admitted pts spent 1-2 days in ED; therefore minimizing additional nursing costsPhysician stipends of $45/reassessment; $90/dischargeNo capital costs
22 protocols utilized.
48 hour, 5 reassessment limit.
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Clinical Decision Unit: Business Case Clinical Decision Unit: Business Case 2004/20052004/2005
*Assumes a 20% admission rate Note: These costs include direct care costs only
$304.00437*16 Hours
$132,860Clinical Decision
Unit
$243.0054716 Hours
$132,860ClinicalDecision
Unit
$819.671223 Days$100,000Actual
In-patient
Medicine
Cost/Per Patient
Patients/Bed/YearLOSCost/Bed/YearArea
Page 59
Clinical Decision Unit Pilot: Clinical Decision Unit Pilot: Financial Results*Financial Results*
Review of 177 Patients Discharged:CDU average LOS: 16 hoursCIHI ALOS: 3.507 Days (84 hours)
Cost Savings/Avoidance:
177 Patients x $961.54 = $170,193 Actual in-patient cost177 Patients x $819.67 = $145,071 Assumed in-patient cost177 Patients x $304.00 = $53,808 Assumed CDU cost177 Patients x $153.31 = $29,076 Actual CDU cost
*2004/2005 costs.
Page 60
Questions?Questions?
Page 61
Daily Access Indicator Report:Daily Access Indicator Report:Patients left without being treated (%)Patients left without being treated (%)
0%1%2%3%4%5%6%7%
1/1
2/1
3/1
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5/1
6/1
7/1
8/1
9/1
10/1
c
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Daily Access Indicator Report :Daily Access Indicator Report :Emergency Visits (number)Emergency Visits (number)
0
50
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350
1/1
2/1
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Daily Access Indicator Report:Daily Access Indicator Report:Discharged in <4 hours (%)Discharged in <4 hours (%)
0%10%20%30%40%50%60%70%80%90%
100%
1/1
2/1
3/1
4/1
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Daily Access Indicator Report:Daily Access Indicator Report:Patients Admitted (number)Patients Admitted (number)
05
1015202530354045
1/1
2/1
3/1
4/1
5/1
6/1
7/1
8/1
9/1
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Page 65
Daily Access Indicator Report:Daily Access Indicator Report:Admitted patients: Triage to unit in < 8 hours (%)Admitted patients: Triage to unit in < 8 hours (%)
0%
10%
20%
30%
40%
50%
60%
1/1
2/1
3/1
4/1
5/1
6/1
7/1
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9/1
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f
Page 66
Daily Access Indicator Report:Daily Access Indicator Report:Admitted patients: Triage to decision to admit in < 4 hours (%)Admitted patients: Triage to decision to admit in < 4 hours (%)
0%5%
10%15%20%25%30%35%40%
1/1
2/1
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4/1
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Page 67
Daily Access Indicator Report: Daily Access Indicator Report: Admitted patients: Decision to admit to unit in < 4 hours (%)Admitted patients: Decision to admit to unit in < 4 hours (%)
0%
20%
40%
60%
80%
100%
120%
1/1
2/1
3/1
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5/1
6/1
7/1
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Page 68
Daily Access Indicator Report:Daily Access Indicator Report:Admits Admits ‐‐ no bed (number)no bed (number)
0
5
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30
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2/1
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6/1
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8/1
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Page 69
Daily Access Indicator Report:Daily Access Indicator Report:Patients left before 11:00 am (%)Patients left before 11:00 am (%)
0%10%20%30%40%50%60%70%80%
1/1
2/1
3/1
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5/1
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8/1
9/1
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Daily Access Indicator Report:Daily Access Indicator Report:Patients left before 2:00 pm (%)Patients left before 2:00 pm (%)
0%
20%
40%
60%
80%
100%
120%
1/1
2/1
3/1
4/1
5/1
6/1
7/1
8/1
9/1
10/1
Page 71
St. JosephSt. Joseph’’s Health Centres Health CentreLocated in Toronto, OntarioLocated in Toronto, Ontario
350 Bed Acute Care Community Teaching Hospital.
The characteristics of our local community include:
Highest population density in TorontoHigher % of seniors who live alone2nd highest % of low income households in Toronto2nd highest % of non English or French speaking residents
in TorontoHigher mortality rates than the rest of Toronto
Our Vision: To be the best community teaching hospital in Canada.
Page 72
Emergency Department ProfileEmergency Department Profile
Single site Emergency Department.
82,000 patient visits in 06/07
New facility opened in 2002:
Paediatric treatment area (5 treatment rooms)Secure behavioural area (12+ spots)Ambulatory area (5 treatment rooms)Dedicated Fast Track (2 treatment rooms)Sub‐waiting rooms available24 of 29 acute/urgent stretchers have cardiac monitorsDedicated X‐Ray suite.
Highest number of emergency crisis placements in Toronto.
Largest mental health visit volume in Toronto.
Page 73
Hospital and Hospital and AmbulanceAmbulance VolumesVolumesToronto Central West Emergency Network Toronto Central West Emergency Network 20062006‐‐2007 Q12007 Q1‐‐Q4Q4
Total Visits Ambulance Volumes
St. Joseph’s Health Centre 82,107 14,281Hospital 1 57,182 10,440
Hospital 2 48,771 10,272
Hospital 3 45,731 11,545
Hospital 4 45,873 9,769
Hospital 5 42,154 9,210
Hospital 6 32,518 8,946
Demonstration Project:Demonstration Project:Application of Lean PrinciplesApplication of Lean Principles
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FOCUSING ON UP TO 8FOCUSING ON UP TO 8‐‐12 HOURS OF 12 HOURS OF DELAY IN THE EMERGENCY DEPARTMENTDELAY IN THE EMERGENCY DEPARTMENT
*Largest block of time experienced by every patient evaluated in the ERSource:NACRS (6/05‐5/06); EDIS August 2006; lab/DI data from 12 hours of patients (November 2006); chart reviews of 60 patients (random) from November 30, 2006; team analysis
Area of focus*
ER ALOSDischarged: 4h 40mAdmitted: 17h 10m
MD re‐evaluation
Discharge
Admitorders written
MD Calledto re‐eval
Triage
Registration
Nurseassessment
20m
35m
1h 10m 1h 40m 45m
5‐10m
4h 45mup to 5h
up to 3h 30m
7h
(89% patients)
(11%patients)
ER physician initialevaluation & DI work‐up
Lab work
Obtain & perform consultation To floor
Departhospital
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The Emergency Department has launched a number of The Emergency Department has launched a number of targeted initiatives to reduce delaystargeted initiatives to reduce delays
Initiative Discoveries to dateArea
•Introduce Flow Nurse role to coordinate the flow of information, patients, and activities
•Create role and responsibility cards
Coordination and control within the ED•Charge Nurse duties (e.g. covering triage) allowed limited time to coordinate patient flow
•Accurate date and time stamping is an issue throughout patient stay need for ongoing education about Schwartz report and repercussions for SJHC
Overall Process
• Improve registration process (e.g. separate OHIP and non‐OHIP patients, etc.)
• “Push” stretcher patients to DI within a set time (e.g., 20 min) of entering order
• Manage/monitor the re‐assessment process (“pink sheet” process) and display performance data to encourage improvement
Completion of labs/DI and physician assessments (Emergency and Consulting)
•Consult escalation policy exists within ED, but is not used
2Triage to Admission
•Trigger the process to move patients to inpatient units earlier (e.g., when bed is being cleaned)
•Work with Bed Booking to turn patients from green to red to blue in EDIS to create trigger
Interface between ED and Admissions•Current admission process/paperwork isn’t capturing all required information for Bed Booking to make a confident bed assignment
3Admission to Bed Ready
1
•Streamline portering process and ensure accountability for timely completion
•Transfer responsibility for cleaning stretcher area to Housekeeping
Bed Ready to Discharge
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Moving patients upstairs faster by reducing bed assignment Moving patients upstairs faster by reducing bed assignment time by 60% and time by 60% and porteringportering time by 70%time by 70%
-63%
120
45
…EDAs are wheeling patients up shortly
after bed is readyDelay from when bed is ready to whenpatient arrives on floor, minutes
-63%
120
4545-63%
120
Available beds are assigned muchfaster…
Delay from when previous patient leaves thebed to when the bed is reassigned to the nextpatient, minutes
30
Feb 5 ‐ 21
‐70%
Oct 15 –Feb 5
100
45
Baseline weekday(Dec 06)
Currentweekday (Feb 07)
‐63%
120
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…… Decompressing the ER for incoming patients and reducing Decompressing the ER for incoming patients and reducing ALOS for admitted patients by approximately 2 hoursALOS for admitted patients by approximately 2 hours
Gets patients to ideal level of care earlier
Allows us to serve our most severely ill patients sooner
10.217.2
Sept 1 ‐ Oct 15
10.9 13.1 24.0Oct 15 – Feb 6*
9.8 12.422.2Pilot**
Triage to Admission Admission to Unit
‐7%, 1.8 hours
7.0
* From October 15th to February 5th; excludes patients admitted to CDU and PSYCH (Admit Specialty or Admit Unit) ** From February 6th to February 20th; excludes patients admitted to CDU and PSYCH (Admit Specialty or Admit Unit)
Source:EDIS October 15, 2006 to February 20, 2007; pilot data from February 6th to 20h, 2007; team analysis
Now reducing ER activities
Average Length of Stay for Admitted Stretcher Patients Hours
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Also improving IntraAlso improving Intra‐‐ER processes to save almost 4 ER processes to save almost 4 hours per stretcher patient discharged to homehours per stretcher patient discharged to home
Before Pilot
5.2During Pilot**
‐42% or 3.8 hours
9.0
Stretcher patients’ dispositionPercent
Percentage of patients discharged home in < 4 hours has doubled from 28% to 57%Patients are able to get home faster, reducing the likelihood of adverse events
* Excludes patients discharged to: detox; another hospital; chronic care facility; morgue; unknown; etc.** From February 6th (beginning of Flow Nurse pilot) to February 20thSource: EDIS October 15, 2006 to February 20, 2007; pilot data from February 6th to 20h, 2007; team analysis
ALOS for stretcher patients discharged to homeHours**
Admitted32
Discharged to other
7
Discharged to home*
61
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The Daily Access Indicator ReportThe Daily Access Indicator Report
Accurate information on a daily basisDelivers an “end‐to‐end”perspective Allows diagnosis of bottlenecks and troubled areasTaking action early to prevent bed crunches later in the day
Source: Daily Access Indicator Report
Patients admitted (number)
05
10152025303540
1/1
1/8
1/15
1/22
1/29 2/
52/
122/
192/
26 3/5
3/12
Admitted patients: Triage to unit in < 8 hours (%)
0%5%
10%15%20%25%30%35%40%45%
1/1
1/15
1/29
2/12
2/26
3/12
f
Discharged patients: Discharged in < 4 hours (%)
0%10%20%30%40%50%60%70%
1/1
1/15
1/29
2/12
2/26
3/12
Area MetricsBaseline
(Oct 15 - Nov 14, 2006)
Yesterday (Tue, 17/04/07)
Average for 11/04/07 to
17/04/07 (7 days)Target
ED visits (number) 217 242 226Ambulance offload (minutes) 11.6 18.0 10.0 30Patients left without being treated (%) 2% 2% 2% 2%Discharged patients: Discharged in < 4 hours (%) 55% 59% 53% 80%Patients admitted (number) 22 27 23Admitted patients: Triage to unit in < 8 hours (%) 10% 15% 11% 70%Admitted patients: Triage to decision to admit in < 4 hours (%) 6% 11% 11% 70%Admitted patients: Decision to admit to unit in < 4 hours (%) 36% 37% 39% 70%Admits - no bed (number) 12 7Patients discharged (number) OVERALL 24 30 27
Patients discharged (number) Medicine 14 15 14Patients discharged (number) Surgery 10.0 15 14
Patients left before 11:00 am (%) OVERALL 20% 43% 37% 50%Patients left before 11:00 am (%) Medicine 22% 47% 25% 50%Patients left before 11:00 am (%) Surgery 18% 40% 48% 50%
Patients left before 2:00 pm (%) OVERALL 57% 83% 73% 80%Patients left before 2:00 pm (%) Medicine 50% 87% 65% 80%
Patients left before 2:00 pm (%) Surgery 66% 80% 81% 80%Average length of stay (days) - non-6G Medicine units 8.0 7.1 5.4Average length of stay (days) - Surgery units 5.5 3.1 3.5Planned discharges vs Actual discharges (%) OVERALL* NA 67% 63% 75-125%Planned discharges vs Actual discharges (%) Medicine NA 73% 57% 75-125%Planned discharges vs Actual discharges (%) Surgery NA 60% 70% 75-125%Bed assigned to next patient in (min) OVERALL* - MEDICINE FLOORS NA #DIV/0! #DIV/0! 70
*Data available from January 6th, 2007
Admissions and Discharges
ED
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Daily Access Indicator ReportDaily Access Indicator Report
MetricsAverage for 01/01/07 to 21/10/07
ED visits (number) 235Ambulance offload (minutes) 10.3Patients left without being treated (%) 2%Discharged patients: Discharged in < 4 hours (%) 53%Patients admitted (number) 23Admitted patients: Triage to unit in < 8 hours (%) 15%Admitted patients: Triage to decision to admit in < 4 hours (%) 10%Admitted patients: Decision to admit to unit in < 4 hours (%) 40%
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Daily Access Indicator Report:Daily Access Indicator Report:Ambulance Offload (minutes)Ambulance Offload (minutes)
0102030405060708090
100
1/1
2/1
3/1
4/1
5/1
6/1
7/1
8/1
9/1
10/1
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Clinical Decision Unit: Length of StayClinical Decision Unit: Length of Stay
Pilot 2006/2007
Admit to Discharge 16 Hours 20.9 Hours
% Admission to in-patient 20 16
