jon morris, md, facep, mba wellstar health systems

EMERGENCY ROOM OF THE FUTURELEVERAGING IT AT WELLSTAR HEALTH SYSTEM:KENNESTONE EMERGENCY DEPARTMENT

Jon Morris, MD, FACEP, MBAWellStar Health Systems

September 18, 2008

Agenda

Introduction Kennestone Emergency Department Metrics More Metrics- Exit Phase Even More Metrics- Non-ED Physicians So far…

To Err Is Human

Patient Safety Issues: IOM report Nov. 1999

> 44,000 – 96,000 deaths related to preventable medical errors/year

$17B - $29B cost

2000 – Leapfrog Group

Example: 2007 Adverse Drug Events

The Need For Change

“The definition of insanity is to continue to do the same thing over and over again

and expect different results”

Albert Einstein

Kennestone ED

Kennestone Emergency Department

  Adult Fast Track PediatricHours 24/7 11A-11P 24/7Levels 4 1 1Beds 61 8 9

Hall beds 9 0 2Total 70 8 11

>102,000 Annual patient volume

40% of Kennestone admissions

24.38% admit rate (July 08)

October 2007: ED Online

ED Flow “Before”

Paper ED Record

Completed ED Evaluation - Waiting For MD

October 2007: Kennestone ED Live Online Documentation and Order Entry

“Sole Source” strategy- McKesson 18 month build

ED Tracking Board Online Clinical Documentation (Horizon

Emergency Care – HEC) Online Order Entry (Horizon Expert

Orders - HEO)

ED Flow “After”

WSKH ED Applications

ED Tracking Board

Patients Waiting For MD

ED Patients: Status & Tasks

WSKH ED Applications

Documentation

Online Documentation

Always Available Real-time Legible Automated Date & Time All Clinical Documentation In One Place More Complete

ED MD Charting

Paper vs. HEC- MD Note

WSKH ED Applications

Order Entry

Definition: CPOE

Provider Enters Orders

Clinical Decision Support Easier to do the right thing Harder to do the wrong thing

Immediate Order Transmission

Tools: I-Forms

Tools: Order Outlines

“Easier To Do The Right Thing:” Weight-based Dosing

“Easier To Do The Right Thing:” Weight-based Dosing

Leveraging CPOE: Automation

“Harder To Do The Wrong Thing”

Allergy Checking

Allergy Alert

CPOE: A Process

Multiple applications Provider Nursing Pharmacy Ancillary Services, i.e., Laboratory, Medical Imaging

Global process - multiple stakeholders

KLAS: 17.5% US Hospitals > 200 beds in 2007

CPOE- Financial Gains

CPOE in Community Hospitals: ADE cost Renal dosing errors Unnecessary / Redundant diagnostic

studies IV to PO conversion

$2.7M Reduction in Cost, 26 month payback*

* Feb 08 MA CPOE Initiative Report

The Competition

Goals- WellStar Health System

Improve Care

Lower Costs

CPOE Using HEO

Two Years To First Facility Go-live

100% Physician Adoption Two Years Post-

live

WSKH ED

Implementation

Challenges in Implementing HEC-HEO

Development

Training

Deployment

Adoption

Reporting

Implementing HEC-HEO

The Good-

The Bad-

And the Ugly Truth.

One solution…

“In the middle of every difficulty lies opportunity”- Albert Einstein

A Better Way: Metrics

Throughput Analysis

Neglected value of ED applications Acquire data from HEC & TB. Quarantine invalid data Report data compliance, i.e., reporting

efficacy and accuracy. Select and study throughput intervals. Identify high-yield opportunities.

WS KH ED - Throughput Intervals

•Arrival to Triage

•Arrival to Bed

•Arrival to EDMD Assigned

•Arrival to EDMD At Bedside

•Bed to EDMD at Bedside

•EDMD at Bedside to EDMD Decision to Disposition

•EDMD Decision to Disposition to RN Disposition

•RN Disposition to Exit

•LOS

ED Metrics

The Good: Reliable ED Metrics

ERK - July 2008

The Bad: Delays in Seeing EDMD

Admitted Patients:

Patient Arrival to MD At Bedside: 61 minutesPatient in Bed to MD At Bedside: 42 minutes

The Ugly: Delays in Exit From ED

July 2008 EDMD Decision to Admit to Exit from ED:

Exit Phase = EDMD Decision to Admit → Patient Exit From ED

162 + 10 = 172 minutes

39-47% Average ED Patient LOS (Jan – July 2008)

Progress: Bed to MDATBEDJul 08: Additional 1P EDMD shift present on 12/31 (38.7%) days

90% August dates have 1P ED MD Coverage

Exit Phase Delays

Admitted ED Patients: 3 Steps

1. Get Into An ED Bed

2. Receive ED Treatment &/Or Evaluation

3. Move to Next Level of Care

Getting Into An ED Bed:

Available ED Bed and Resources Clinical Staff, i.e., RN, tech, etc. Open Beds Patients Must Be Able To Leave

ED MD Must Be Available Appropriate ED MD Staffing

Treatment &/Or Evaluation:

Treatment Laboratory Tests Medical Imaging Studies Consultation for Admitted Patients

ED Process Improvement Committee

Moving to the Next Level:

Receive Admitting Orders, then…

Additional ED Orders Call For Bed (Next Level Of Care) Bed Assignment Inpatient RN Staff Available to Receive

Report ED Staff Available to Move Patient

Moving to the Next Level:

Exit Phase: Begins With EDMD Decision To Admit Ends With Patient Exit From ED

158-251 minutes January – August 2008

39-47% of LOS

Exit Phase: Study Intervals

How long did it take to receive orders? Consult Interval [EDMD Decision to Disposition] to Admit

Orders Received (AOR)

Exit Phase: Study Intervals

How long after AOR did patient leave EDTB? ED Inpatient Admit Interval AOR to Exit (ED bed available)

Exit Phase Study: May – September 2008

May 2008 June 2008 July 2008 Sep 2008Total #

Admissions1531 1348 1613 1578

Admission Rate

23.05% 23.41% 24.42% 23.54%

Admit Record Compliance

51.67% 54.15% 53.81% 55.32%

Total # Compliant Records

791 730 868 873

Average Consult

Interval (min.)86 (1-1360) 90 (0-1376) 92 (0-2391) 110 (0-1467)

Averaged 86-110 minutes just to get admit orders Haven’t even called for a bed.

(Practice & provider-specific data available)

Results- Consult Interval

Results- Inpatient Admit Interval(additional studies in progress)

ED Metrics

Admitting (Non-ED) physicians

Average ED Consult Intervals May-July 2008

Practice

# Admits

A 696

B 245

C 202

D 105

E 92

F 72

G 63

H 50

I 49

J 41

Selected Average Consult IntervalMay – July 2008(EDMD Decision to Disposition to AOR*)

*AOR = Admit Orders Received

But…

Admitting Strategies

Cardiology- Average Consult IntervalMay – July 2008(EDMD Decision to Disposition to AOR)

Cardiology Admissions

Significant variation in consult intervals exists between cardiology practices.

• Two of three cardiology practices, Practices “A” and “C,” account for 22.7% of all ED admissions. These practices almost exclusively admit only following consultation and evaluation in the ED.

• Practice “B” routinely phones in orders and evaluates the patient on the floor if they left the ED by the time they arrive.

• This is reflected in patients’ consult intervals and LOS:

Cardiology- Average ED LOSMay – July 2008(EDMD Decision to Disposition to AOR)

In Progress:

Medical Staff Admit Strategies

Staffing Changes and Allied Health

Professionals

EDMD Calls For Bed

Admit Holding Area

Summary

Introduction Kennestone Emergency Department Metrics More Metrics- Exit Phase Even More Metrics- Non-ED Physicians So far…

Questions?

Contact Information:

Jon Morris, MD, FACEP, MBA

WellStar Health SystemsJon.morris@wellstar.org