Impact of Process Flow Tool on Wait Times

from Emergency Department to ICU

.

Presenter: Pratik Doshi, MDAssistant Professor,

Director of Emergency Critical CareDepartment of Emergency MedicineDivision of Critical Care Medicine,Department of Internal Medicine

University of Texas Health Science Center, Houston, Texas

Conflict of interest

None

Overview

● 65,000 Emergency Department visits per year

▪ 37% admitted to hospital

▪ 10% of admitted patients admitted to ICU

● Delayed ICU transfer (>4 hours from care complete to ICU arrival)

▪ Increased hospital mortality

▪ Increased hospital LOS

▪ Increased ICU LOS

Chalfin et al. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit care med 2007; 35: 1477-83.

Overview

Baseline Data March 08- February 09

<4 hours >4 hours

Patients 345 314

% of total patients 52% 48%

Mortalty Rate 14% 17%

Hospital LOS 9.10 10.30

CMI 2.33 2.60

Age 55 58

% Male 52% 48%

% Female 48% 52%

30 day readmits 40 32

30 day readmits-- Same DRG 12 7

Care Complete to Depart MICU Admits

Mortality 18% higherLength of stay 11% higher

Overview

Largest Variation : Care complete to departure

Overview

Overview

Methods

Prospective case Controlled Trial from 2/2008-9/2010

In Phase 1:Compare the outcomes of medical ICU admissions between those with ED to ICU wait times < 4 hours with those > 4 hours

In phase2: compare similar outcomes after introducing a qualifying admissions tool designed to reduce wait times to admission

An admission pre-qualifying checklist, standardized nurse documentation, and accelerated bed management process redesign was introduced

Actions

Creation of standard operating procedure with an admission algorithm

Checklist of contraindications for MICU admission to be filled out on all patients admitted to MICU by EM faculty

Standardization of nursing documentation of times of departure

Defect log in MICU Educated Faculty, residents, and nursing staff to

highlight problems and clarify processes

Flow chart for MICU admission

Contraindications to MICU Admission1) Does the patient have an ICH/CVA? Yes □ No □

2) Does the patient have extensive burns or Stevens-Johnson syndrome (BSA > 15%, 2nd and 3rd degree){Please examine the patient’s entire body}

Yes □ No □

3) Does the patient have severe Heart Failure potentially requiring Intra-aortic balloon pump(IABP)

Yes □ No □

4) Is the patient s/p Cardiac Arrest requiring therapeutic hypothermia

Yes □ No □

5) Has the patient been evaluated by another service for ICU admission and rejected for admission?

Yes □ No □

Results

Mean time from Emergency room care complete to MICU admission decreased by 2.04 hours(37 %), from 5.53 hours to 3.49 hours

Results

Mean time for Emergency department arrival to departure decreased by 1.98 hours(22%) from 8.81 hours to 6.83 hours.

Results

CC to Depar  

Baseline Feb 08-Mar 09 

 Sept 09-Apr 10  

Total Change

P-Value 

CC to Depart xx.xx hrs 5.53 (±5.16) 3.49(±3.49)     0.0001

CC to Depart hh:mm5:32

(+5:10) 3:29 (+3.29)      

CC to Depart min 332 209 123 37%  

CC to Depart <4 hrs 346 (52%) 474 (74%) 22%    

CC to Depart >4 hrs 314 (48%) 169 (26%)      

Results

   

Feb 08 to Mar 09 (Baselin

e) Sept 09-

Apr 10  Total Δ  % Δ p value

Total 

660 643     

Arrival to Depart xx.xx hrs

8.81 (± 5.77) 6.83 (±4.20)    0.0001

Arrival to Depart

mean (hh:mm)

8 hrs 49 min 6 hrs 50min

1 hr 59 min -22%  

Arrival to Depart SD (hh:mm) 5 hrs 46 min 4 hrs 12 min      

Arrival to Depart min 529 410 119 -22%  

Results

ResultsBefore After p-Value

MICU bed Avail 9 hrs 21 min 6 hrs 34 min 0.0001

MICU bed not Avail 7 hrs 45 min 8 hrs 43 min 0.2352

Results

Results

   Before  After  Total Δ  %Δ  p-Value

Length of stay mean days 9.67 8.13 1.54 -16% 0.0035

Length of stay SD (+11.33) (+7.25)      

Mortality Rate   15% 15%      

DRG wt (CMI)   2.45 (+2.68) 2.38 (+2.37)     0.5836

Age Mean 56.4 55.7      

Age SD (+18.4) (+18.6)      

Conclusions

Boarding of critically ill patients in the Emergency department has an association with worse outcomes

Emergency room based process flow tool can be effective in reducing the wait times for patients admitted to the ICU

This decrease in boarding times seems to be associated with decreased hospital length of stay

Conclusions

Mortality rates remained stable More patients in the lower mortality and LOS

group translates into potential lives saved and definite hospital days saved

The hospital days saved total a potential of 990 days, at a rate of 1.54 days for the 643 admissions after the process was instituted, which results in a conservative estimate of $1,039,500 of cost avoidance over the year.

Key Learning

No Magic Bullet Walk the process Solution should be the result of process, not

pre-conceived Solution may just be “leaning” the process

Team Members Brent King, MD: Chair, Department of Emergency Medicine James McCarthy, MD: Medical Director, Department of Emergency

Medicine Bela Patel, MD: Medical Director, Medical ICU Yashwant Chathampally, MD: Department of Emergency Medicine Ruth Siska, RN and Tammy Campos, MSN: Medical ICU Sylvia Reimer, RN and Janice Hughes, RN: Emergency Department Katharine Luther

Questions?