Operational Efficiency in the ED: Fundamental Considerations in Flow

Dan Smith, MD Studer Group Coach International Speaker

Why do patients come to ED?

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How do I utilize this precious real estate in a more efficient manner?

Incoming Flow Patterns Are Predictable Desert Samaritan Medical Center Emergency Department

Patient Arrivals October 2001 compared to Registrar Schedule

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Proposed Registrar schedule December 2001Registrar schedule (previous) 2001Patient Arrivals per hour per day

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Stasis

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Flow Tactics

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Sequential Flow

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Who cares?

! Bad things happen in waiting rooms ! ED consumers desire timely care ! Complaints often rooted in excessive wait times ! Contractual obligations for ED physician groups ! CMS to cite throughput metrics-$ linkage in future ! Patient perception of care linkage to LOS ! Time sensitive core measures

! AMI door to balloon <90 min ! CAP blood cultures and antibiotics <6 hrs

Transparency

! Australia: ! 4 hour rule ! 30-minute Offload

! USA: ! Median time from arrival to departure for admitted

patients (door to admit) NQF 0495 ! Median time from admit decision to departure for

admitted patients (dispo to admit) NQF 0497

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Tenets of Flow Efficiency

! Flow patterns are often predictable ! Staffing and physical space is known ! Flow efficiency is therefore manageable ! Keep vertical patients vertical and moving ! Have caretakers at each point in the transition ! Diagnose the problem ! Collaboration must be the norm

Consider ED Transit as Three Components

! Front End Flow (Door to Bed) ! Middle Flow (Bed to Disposition) ! Back End Flow (Dispo to Discharge or Admit)

“Houston, we have a problem” (Diagnose)

! ED throughput metrics are high; % LOS <4 hrs low ! Missed opportunities (LWBS/DNW/LAOR high) ! Burdens of volume are placed in certain areas of

the ED ! Burdens of volume occur during periods of the day ! Patient satisfaction is low despite hardwired

communication tactics and good culture ! Path of the patient reveals multiple non-value

added steps ! Sentinel events occur in the waiting area

Front End Issues

! Ask: ! Is triage efficient? ! Is a patient immediately bedded if a bed is open? ! Does the provider see the patient quickly after they

are bedded? ! Does the ED have open beds to place patients?

Middle Issues

! Ask: ! Is the unit clerk able to enter orders timely? ! Is the nurse able to execute orders timely? ! Do essential services execute in timely fashion? ! Is the doctor able to expedite the disposition? ! Do admitting physicians call back timely?

Back End Issues

! Ask ! Does an inpatient bed exist to admit? ! Does the ED nurse give report timely? ! Does the inpatient nurse accept report timely? ! Does the inpatient floor accept the patient timely? ! Does some doctor write admitting orders timely? ! Does the admitting doctor hold the patient in ED? ! Does the hospital have a prediversion plan? ! Does the hospital have code purple protocol?

Provider in Triage (PIT)

! Scenario: Log-jammed ED, docs no patients to see in back, waiting room swells, small area in triage available

! Rationale: Patients better off seen by provider than not, can “treat and street” some, makes docs more productive

! Need: small work space, basic tools, nurse, doc ! Limitation: often divert back to WR, limited work-

ups

Fast Track

! Scenario: Surge of low acuity at known times, can dedicate a provider, dedicated beds/spaces

! Rationale: Lower acuity patients need dedicated care area to rapid cycle test and treat with dedicated staff and providers, lower LOS and throughput metrics

! Need: Dedicated care areas, normal FT equipment, nurse and doctor/MLP

! Limitation: Limited ability and capacity for high acuity cases, some patients feel rushed

Segmentation Flow Model (Split flow)

! Scenario: Volume surges are met with no core or FT beds, log-jammed ED with all acuity of patients, could rearrange care spaces or find real estate for a capacitance “result pending” (RP) space

! Rationale: Most patients can remain vertical and moving after initial evaluation, your ability to move them out of care areas ultimately avails these beds and promotes bed turns, decompresses the ED

! Need: Buy-in for vertical model, RP ward, dedicated nurse for RP, lack of “boarded” ED

Split Flow Model of Care

! “Vertical” model ! Paradigm Shift from Traditional Inefficient Flow ! ED Real Estate is precious ! No patient should “own” a bed ! No provider “owns” a bed ! Anterograde flow ! Use a bed only for active care management

What •  Evidence Based Practice •  Vertical Care Model

Why •  Improved Operational Efficiency •  Improve Safety, Quality and Perception of Care

How •  Flow Map Current Process and Physical Plant •  Define Roles and Expectations of Key Stakeholders •  Timeline to Inception

Triage is a process NOT a place

! Quick Look nurse and technician ! Quick Look Assessment

Quick Look Nurse at Triage

! First point of contact: nurse ! Five questions ! Goal of quick look triage <3 minutes ! Assign ESI/CTAS level ! Coordinates with Nurse Hawk/Charge Nurse as to

bed assignment in ED

Triage “no-no’s”

! Full history ! Med Rec completion ! Retrograde flow back to waiting area ! Non-clinician as first point of contact with patient ! Non-usage of available space in ED

Quick Look Assessment: Nurse

! 5 questions ! Name ! Age ! Allergies ! Major PMHx ! Chief complaint

! <3 minutes ! Simultaneous quick registration

Quick Look Assessment: Tech

! Assists RN ! Vitals/pulse ox ! ECG/Accucheck ! Transportation of patient to back of ED

Acuity and Placement

Rapid Treatment/Intake &

Procedure Core Bed

Intake Procedure

! ESI Vertical 3,4 and 5 (low suspicion for admit) ! Midlevel providers often utilized ! Same rules of engagement on real estate ! Example

! Musculoskeletal inuries ! Simple infections ! Low operative suspicion abdominal pain ! Back Pain ! Migraine

Intake/Procedure

! Target time: 30-60 minutes ! Secondary assessment and med rec completion ! Patients remain here for period of time to do initial

H & P, pelvic exam, etc ! Then….when intial lines/labs are completed: split

patient to the “Results Pending” area

Core Area

! ESI 1,2, horizontal 3 (higher suspicion for admit) ! Need the real estate ! Need to be “bedded” or “horizontal” ! Need time ! Examples

! Those not vertical 3,4 or 5

Core Area (Acute Care/Major)

! Few changes in this area ! Sicker cohort need the real estate and time ! Some from Core may split to Results Pending if

clinical status is downgraded or they become non-emergent

Results Pending

Your ultimate asset to decompress a busy ED

Result Pending

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Result Pending

! Dedicated nurse and assistant ! Not a “dump zone” or internal waiting area ! Area for patients to complete work-ups/meds ! Low likelihood of admission ! Patients may split to this area from the core or

intake/procedure ! Ancillary services may perform tasks here

Result Pending

! RN and assistant work collaboratively ! Await study completion/improved status ! Original physician/MLP retain care duties ! Round on patients for basic comfort needs ! Adjunctive treatments ! Informs provider of tests/status ! “discharge specialist” (reduce dispo>d/c) ! Informs doctors/MLP when studies complete

Patient Flow Coordinator

! “Nurse Hawk” ! Akin to air traffic controller for ED ! Active bed management and tracking board

assessment ! Inquires often to RN/Physicians on ability to split

patients to RP ! Better as dedicated position ! Some ED’s: dual role as charge nurse

Critical Questions

Does my patient need to occupy precious

real estate?

Is my patient likely to be discharged to

home?

Could my patient be split to Results

Pending?

A Sequenced Plan

! Roles and responsibilities of the flow team ! Delineate physical plant space and flow map ! Revisit current staffing model ! Define roles and expectations for staff and

physicians ! Table top flow exercise: old way vs. Split Flow ! Develop educational plan ! Timeline to inception/test of change

Performance and the Team

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