emergency department throughput : the...
TRANSCRIPT
Emergency Department Throughput : The Cambridge Health Alliance Experience
Assaad J. Sayah, MD, FACEPSr. V.P. & Chief Medical Officer
President, CHA Physician Organization
Cambridge Health Alliance
IHI 2016
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Overview of Cambridge Health Alliance:
Hospital:
3 campuses with 24-hour Emergency Services: – The Cambridge Hospital
– Somerville Hospital (7/1/96)
– Whidden Memorial Hospital (7/1/01)
Community-based Primary Care and Mental Health
Services:– services at hospital campuses
– 12 neighborhood health centers, 4 school-based health centers
Academics:– Teaching affiliations with:
Harvard Medical School
Tufts Univ. School of Medicine
Harvard School of Public Health Teaching Affiliate
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Regional Safety Net Provider
Largest proportional provider of care to low income
individuals in the State. (64% State Payment
sources; 19% Medicare; 17% Insurance/HMO)
Care for uninsured patients from over 230 MA
communities
Leading state-wide acute hospital provider of
inpatient psychiatry
10% of all statewide inpatient mental health stays
27% of all statewide mental health stays for the
uninsured.
greater than 30% of our patients and 53% of our
mental health patients come from outside our 7-town
primary service area
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Why Change at CHA ?
Change in Healthcare environment
Change in Healthcare reimbursement
No Growth
Poor patient satisfaction
Inefficiencies
Facility Challenges
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All MA
Hosp DB 20K-30K State
N=961 N=205 N=33
Cambridge Hospital 7/1/06-9/30/06
Waiting time before noticed arrival 3 2 1
Helpfulness of first person 3 1 1
Personal/Insurance Info 3 1 1
Somerville Hospital 7/1/06-9/30/06
Waiting time before noticed arrival 27 17 34
Helpfulness of first person 43 28 53
Personal/Insurance Info 42 29 59
Historical State
28,979 28,800
27,983
29,10028,510 28,155
20,000
22,500
25,000
27,500
30,000
FY02 FY03 FY04 FY05 FY06 FY07
Projected
CH Registered ED Visits
FY07 Projected represents the fist 5 months annualized
•Annual visit
volume has
averaged ~28.5k
visits per year
•Through 5 mos,
volume is down
2% from the PY
Historical State
Time on diversion: 8.5%
LWBS: 4.04%
Median door to provider time: over 60
minutes
Median total length of stay: over 200 minutes
Poor core measure compliance
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Essential Elements
Leadership Team
– Constitution
– Alignment
– Commitment
– Communication
Administration Support
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ED Vision for the Future
Process StaffingCapital
Investment
•Patient Flow Project•ED Flow
•Inpt. Discharges
•MD & RN communication
between ED and Inpt. Unit
•Triage/Registration
•Laboratory TAT
•Transfer Leakage
•MD Staffing/Productivity
•Nursing
•Clinical Support
•Administrative
•Registration
•ED Information System•Tracking Board
•Electronic Medical Record
•ED Front End Redesign
•Wireless Bedside
Registration
Current State
•Best Practice Patient Satisfaction
•Door to Doc (30 mins / 90%)
•Increased volume and capacity
Future State (2-3 yrs)
Patient Flow Project
System Project Teams
Cambridge Health Alliance
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Patient Flow is a Hospital-Wide Concern
Every hospital unit has a
part to play—the ED
cannot solve the flow
problem alone.
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Patient Flow Project Goals
Improve patient flow on all 3 campuses
Do so in a timely, safe, effective, efficient, and patient-centered manner
Implement best practices
Utilize improvement methodologies, tools, and measures
Utilize a multi-disciplinary, multi-campus single solution approach
Engage hospital staff
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Focus is Across the Continuum
12
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Fundamental Mission of Teams
Team Mission
ED Patient Flow Minimize time patients spend in the ED
through the application of “best practices”
Laboratory
Turnaround Time
Manage the ordering, collecting, testing, and
verification of lab work through improved and
standardized procedures
No Delay Nurse
Report
Transport admitted patients to inpatient unit
within 30 minutes of ED nurse giving report
Physician
Admitting Orders
Expedite completion of admitting orders for
admitted ED patients
Inpatient
Discharges
Decrease length of stay through effective
discharge planning activities
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Project Methodology
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Recommendations
Input Reengineering / Rapid Assessment
– Patient partner
– Establish Mini Registration
– 100 % Bedside Registration
– Elimination of triage
– Maximization of bed utilization
Engage patients in the improvement project (Press-
Ganey comments reviewed monthly with staff and
posted in ED)
Input Reengineering
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All MA
Hosp DB 20K-30K State
N=961 N=205 N=33
Cambridge Hospital 7/1/06-9/30/06
Waiting time before noticed arrival 3 2 1
Helpfulness of first person 3 1 1
Personal/Insurance Info 3 1 1
Somerville Hospital 7/1/06-9/30/06
Waiting time before noticed arrival 27 17 34
Helpfulness of first person 43 28 53
Personal/Insurance Info 42 29 59
ED Patient Partner
ED Patient Access Representative
– Ambassador to patients in the waiting area
– Mini registration to facilitate patient flow
Part of a response to deficiencies in Press Ganey
patient satisfaction scores related to arrival and
personal issuesPress Ganey Percentile Rank
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Rapid Assessment Overview
The purpose of the unit is to facilitate rapid
assessment and treatment at the point of arrival in the
Emergency Department
Eliminate traditional Express Care, Triage and
Registration and utilize the space for Rapid
Assessment (RA)
Combine nursing resources from Express Care and
Triage – offers the ability to care for multiple patients
at once
Physician Assistant in RA.
– The role of the PA is to rapidly assess and when applicable,
treat and release the patient without entering the Acute ED.
– May also play a role in the initial assessment and ordering of
diagnostics for acute patients.
Space Utilization
“A room is a room is a room”: Eliminate
specialty rooms
Avoid pooling
Centrally locate high-risk patients
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Recommendations
Redefining roles of staff
– RNs and PAR IIs draw labs
– Charge Nurse Role
– RN’s discharging patients
– Create MD Order Sets
This has streamlined order entry
– Create RN Order Sets (MD Standing Orders)
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Recommendations
IT:– EPIC / ASAP
– PACS
– MUSE
System Integration:– PCP Initial notification
– Heads up from PCP and EMS
– Medical record access
– Access to ED workup
– Referral
Standardization of:– P &P, Guidelines
– ED documents
– Equipment
– Material
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Recommendations
Process to improve quality of care
Throughput:
– Early identification of admissions
– Maximize utilization of all inpatient capacity
– Early assignment of inpatient beds
– Early handoff to the admitting service
– Passive nursing report for admitted patients
– Early transport to the floors
– Escalation process
Back up
Code Help
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Outcomes
Results are overwhelming
– ED TAT reduced
– A 70% reduction in the number of patients leaving without being
seen
– Patients have noticed a difference
– The reception area has remained empty during peak times
– “This was the quickest emergency room visit I've ever had”
ED Staff feels like the ED is “calmer” – less chaotic
100% of patients are registered at bedside
Budget neutral
– Reallocated existing staff and space
– Zero up front capital costs
ED Diversion Hours /% of Time on Diversion
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ED Turnaround Time
ED LWBS/Elope Rate (%)
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28,979 28,800
27,983
29,10028,510 28,155
20,000
22,500
25,000
27,500
30,000
FY02 FY03 FY04 FY05 FY06 FY07
Projected
Historical Volume Trends
CH Registered ED Visits
FY07 Projected represents the fist 5 months annualized
•Annual visit
volume has
averaged ~28.5k
visits per year
•Through 5 mos,
volume is down
2% from the PY
ED Visits & Admissions
28,51028,792
30,343
31,864
33,392
3,369
3,687
3,155
2,892
3,123
26,000
27,000
28,000
29,000
30,000
31,000
32,000
33,000
34,000
FY06 FY07 FY08 FY09 FY10
Vis
its
2,000
2,500
3,000
3,500
4,000
4,500
5,000
ED
Ad
mis
sio
ns
Registered Visits ED Admissions
Cambridge ED Press Ganey Patient Satisfaction Overall Mean Score
Cambridge ED Patient Satisfaction: Overall Quarterly Means & Percentiles
84.2
81.3
83.3
85.6
83.3
85.7
83.6
86.8
84.7
76.177.0
78.6 78.279.9
81.0 80.9
78.9
85.0 84.485.6
56
44
72
25
65
38
78
43
26
6 68
11
23 23 23
15
65
57
64
70.0
75.0
80.0
85.0
90.0
95.0
100.0
Q4
FY06
Q1FY07Q2FY07Q3FY07Q4FY07Q1FY08Q2FY08Q3FY08Q4FY08Q1FY09Q2FY09Q3FY09Q4FY09Q1FY10Q2FY10Q3FY10Q4FY10 Q1FY11Q2FY11 Q3
FY11
mean
sco
re
0
10
20
30
40
50
60
70
80
90
100
perc
en
tile
TCH Mean Score Mean Score Goal 20-30K %ile Rank
Rapid Assessment
started 4/1/08
Peer Group Changed
7/1/08 to 30K-40K visits/yr
CHA ED Press Ganey Patient Satisfaction Overall Mean Score
CHA Emergency Medicine Patient Satisfaction: Overall Quarterly Means & Percentiles
79.980.6 80.8
81.983.0
84.8
83.2 83.0
85.9 85.8 85.8 86.2
83.9
86.087.3
83.8
82.381.5
82.781.8
23 22
57
63
74
55
71
43
66
75
49
53
41
46
4343
3127
49
46
70.0
75.0
80.0
85.0
90.0
95.0
100.0
Q4 FY06 Q1FY07 Q2FY07 Q3FY07 Q4FY07 Q1FY08 Q2FY08 Q3FY08 Q4FY08 Q1FY09 Q2FY09 Q3FY09 Q4FY09 Q1FY10 Q2FY10 Q3FY10 Q4FY10 Q1FY11 Q2FY11 Q3 FY11
mean
sco
re
0
10
20
30
40
50
60
70
80
90
100
perc
en
tile
CHA Mean Score Mean Score Goal All Hospital DB %ile Rank
Average ED Sensitive Quality Core Measures Indicator Rates
AMI ( ASA on arrival, B Blocker on arrival)
CAP (Abx within 4 hours, BC prior to Abx)
Why a New ED at Whidden ?
The oldest facility
– Whidden 1968, Somerville 1987, Cambridge 1998
Small (18 patient care spaces)
No privacy/ Open ward ( Same at SH)
No Growth ( Same in all three EDs)
Most potential for growth
The New Whidden ED
Design follows function
30,126
31,953
38,424
41,232
43,010
45,459
35,644
33,530
5,578
5,243
4,504
4,270
4,463
4,131
3,802
3,512
20,000
25,000
30,000
35,000
40,000
45,000
50,000
CY05 CY06 CY07 CY08 CY09 CY10 CY11 CY12
Vis
its
3,000
3,500
4,000
4,500
5,000
5,500
6,000
ED
Ad
mis
sio
ns
Registered Visits ED Admissions
New ED
Partially Open
New ED
Fully Open
Patient
Partner
Rapid
Assessment
ED Visits & Admissions
10
20
30
40
50
60
70
80
Q1
2005
Q2
2005
Q3
2005
Q4
2005
Q1
2006
Q2
2006
Q3
2006
Q4
2006
Q1
2007
Q2
2007
Q3
2007
Q4
2007
Q1
2008
Q2
2008
Q3
2008
Q4
2008
Q1
2009
Q2
2009
Q3
2009
Q4
2009
Q1
2010
Q2
2010
Q3
2010
Q4
2010
Q1
2011
Q2
2011
Q3
2011
Q4
2011
Q1
2012
Q2
2012
Q3
2012
Q4
2012
New ED
Partially Open
New ED Fully
Open
Patient
Partner
Rapid
Assessment
Median Door to Provider Time (min)
100
120
140
160
180
200
220
240
260
280
Q1
2005
Q2
2005
Q3
2005
Q4
2005
Q1
2006
Q2
2006
Q3
2006
Q4
2006
Q1
2007
Q2
2007
Q3
2007
Q4
2007
Q1
2008
Q2
2008
Q3
2008
Q4
2008
Q1
2009
Q2
2009
Q3
2009
Q4
2009
Q1
2010
Q2
2010
Q3
2010
Q4
2010
Q1
2011
Q2
2011
Q3
2011
Q4
2011
Q1
2012
Q2
2012
Q3
2012
Q4
2012
New ED
Partially Open
Rapid
Assessment
Patient
Partner
New ED Fully
Open
Median Total Length of Stay (min)
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
Q1
2005
Q2
2005
Q3
2005
Q4
2005
Q1
2006
Q2
2006
Q3
2006
Q4
2006
Q1
2007
Q2
2007
Q3
2007
Q4
2007
Q1
2008
Q2
2008
Q3
2008
Q4
2008
Q1
2009
Q2
2009
Q3
2009
Q4
2009
Q1
2010
Q2
2010
Q3
2010
Q4
2010
Q1
2011
Q2
2011
Q3
2011
Q4
2011
Q1
2012
Q2
2012
Q3
2012
Q4
2012
New ED
Partially OpenNew ED Fully
Open
Patient
Partner
Rapid
Assessment
ED Left Without Being Seen (% of Total Volume)
Press Ganey Patient Satisfaction Overall Mean Score
84.3
78.880
85.3
80.6
8384.1
88.9 88.3 87.789.5
88.2
84.7
87.482.8
78.6
77.8
79.9 80.1
82.3
77.9
8182.5
81.280.6
82.5
88.2
88.9
81.5
84.6
82.7
90.4
12
9
15 16
32
11
23
41
35
31
54
61
48
16
19
62
18
44
92
97
26
57
36
4850
9997
88
81
91
85
76
60.0
65.0
70.0
75.0
80.0
85.0
90.0
95.0
100.0
05-Q
1
05-Q
2
05-Q
3
05-Q
4
06-Q
1
06-Q
2
06-Q
3
06-Q
4
07-Q
1
07-Q
2
07-Q
3
07-Q
4
08-Q
1
08-Q
2
08-Q
3
08-Q
4
09-Q
1
09-Q
2
09-Q
3
09-Q
4
10-Q
1
10-Q
2
10-Q
3
10-Q
4
11-Q
1
11-Q
2
11-Q
3
11-Q
4
12-Q
1
12-Q
2
12-Q
3
12-Q
4
mean
sco
re
0
10
20
30
40
50
60
70
80
90
100
perc
en
tile
WH Mean Score 40-50K visits %ile
New ED Partially
Open
Rapid
AssessmentPatient
Partner
New ED
Fully Open
This can be your billboard too!
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www.challiance.org
text message "ertime" to 41411
Media Coverage
Working together to change the culture
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Challenges
ACO /PCMH collaboration
Sustain and continue improvements
Keep the staff engaged
Output output output….
Questions
Cambridge Health Alliance
Assaad Sayah, MD, FACEP
(617)665-2356