flow. [ flō ] your role in emergency wait times brendan munn calgary emergency medicine grand...
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FLOW. [ flō ]your role in emergency wait times
Brendan MunnCalgary Emergency Medicine Grand RoundsOctober 29 2009
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
Disclosure
Disclaimer
Eternal Thanks
Other than being a total control freak I have no conflicts of interest to declare.
Too much to be boring, too little to do the subject justice.
Dr. Grant Innes Dongmei WangDr. Lester Mercuur Edith Lundrigan
Jodi Gibson
Objectives (Overt)
1. discuss a conceptual model of flow
2. define crowding and metrics
3. review the literature on flow causes
effects
solutions
4. relevance to calgary and the individual
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( )
Objectives (Covert)
1. crowding is a (the) major ED issue
2. crowding mostly due to hospital factors, but the ED definitely has room for improvement
3. you are a unique and special flower, and have a role to play
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CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
Crowding [kraʊdɪŋ]
Boarding [bɔrdɪŋ]
Access Block [ˈæksɛs blɒk]
Priapism [prī'ə-pĭz'əm ]
debated, unclear and variable
“the process of holding patients in the ED for extended periods of time”
bad news
“the prolonged wait for an inpatient hospital bed after ED treatment”
Conceptual Model Of Flow
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Asplin, Ann Emerg Med 2003
Conceptual Model Of Overflow
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long term care
ward
waiting room
ED
contention #1“crowding is easy to define”
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How Crowded is Crowded? Hwang, Acad Emerg Med 2004
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“A situation in which the identified need for emergency services outstrips available resources in the ED. This situation occurs in hospital EDs when there are more patients than staffed ED treatment beds, and wait times exceed a reasonable period. Crowding typically involves patients being monitored in non-treatment areas (eg hallways) awaiting ED treatment beds or inpatient beds. Crowding may also involve and inability to appropriately triage patients, with large numbers of patients in the ED waiting area of any triage assessment category”
ACEP Crowding Task Force 2002
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“the number of hours in which patient census exceeds designated patient care areas”
Welch, Acad Emerg Med 2006
“hard to define, but I know it when I see it” Potter Stewart, Supreme Court Justice, 1964
contention #2“ED backlog is NOT a safety
valve”
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waiting room
ED
Negative Effects of Crowding
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Delays to Treatment
Hip # Pain - Hwang 2006 (VOL)Hip # Surg - Richardson 2009 (BT)ABx Pneumonia - Fee 2007 (VOL)ACS Chest Pain - Pines 2009 (OCC)NSTEMI - Diercks 2007 (LOS)High Acuity - McCarthy 2009Abdo Pain - Mills 2009Pain Tx - Pines 2008Lytics - Schull 2004 (DIV)
Mortality
Wait TimesMedical Errors
Miro 1999 (VOL)Sprivulus 2006 (OCC)Richardson 2006
The effect of emergency department crowding on clinically oriented outcomes. Bernstein, Acad Emerg Med 2009
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Ambulance Diversion
Ambulance Availability
Patient Elopement
Patient Satisfaction
Less Teaching
Provider Satisfaction
Violence
Financial
Hospital Length of Stay
Bayley 2005 (LOS)Falvo 2007 (OCC)
Burt 2005 (DIV)Redelmeier 1994
Eckstein 2004 (OOS)Schull 2003 (DIV)
Hobbs 2000 (VOL)Polevoi 2005 (OCC)
Jenkins 1998 (WT)
Krochmal 1994 (BT)Liew 2003 (LOS)Richardson 2002 (LOS)
Pines 2008 (LOS, BT, WT)Vieth 2006 (OPIN)
Rondeau 2005 (BT)Williams 2007 (OPIN)
Shayne 2009 (VOL)
Waiting Room Stats Calgary
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LOS Calgary
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LWBS Calgary
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Causes and Solutions
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Emergency department crowding: old problem, new solutions. Bernstein, Emerg Med Clin North Am 2006.
Improving access to emergency care: addressing system issues. Govt of Canada, Physician Hospital Care Committee, 2006
Hospital-based emergency care: at the breaking point. Committee on the Future of Emergency Care in the United States Health System, 2006
Ten solutions for emergency department crowding. Derlet, West J Emerg Med 2008.
Systematic review of emergency department crowding: causes, effects and solutions. Hoot, Ann Emerg Med 2008.
Input
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increasing volume
increasing acuity
lack of alternatives
surge
Tracking emergency
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“Tracking emergency department crowding in a tertiary care academic institution”. Bullard, Healthcare Quarterly 2009.
2000 2007
Volume
Acuity
contention #3“it is not the input itself, but what
we do with it that counts”
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inappropriate patientssurge capacity
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Schull, Ann Emerg Med 2007Khane, Ann Emerg Med 2009
CTAS 4/5 represented 30% of visits but only 5% of stretchers
10 low complexity patients per 8 hours increased mean LOS by 5 mins for others
Vertesi, CJEM 2004
Low Acuity Patients
contention #4“we have the beds, they have the diseases -- why are they apart?”
dynamic logisticalsurge
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CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
Patients Registered
Patients Admitted
=
Hour of Day
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usable
(throughput)
admitted
(output)
13.7
35.3
+ 8 MET
FMC total annual ED high acuity bed utilization in hours
57 beds
49
_______
Throughput
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Type of Center
Triage
Staffing
Ancillary Services
Information Technology
Layout
contention #5“it behooves us to develop
operational efficiency”
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for ourselvesfor patientsroom to movelimitationstemporizeeconomies of scalethe future
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“investigations and consultations are important independent predictors of ED length of stay”
Yoon, CJEM 2003
116
176
28255
(minutes)
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“EDs with combinations of low inpatient census, in-room registration, point of care testing and an urgent care area demonstrated increased patient throughput”
Analysis of the literature on emergency department throughput. Zun, West J Emerg Med 2009.
“successful strategies to improve patient flow are distinguished by an organization wide commitment to measurement, transparency in data reporting and sustained management attention”
Enhancing work flow to reduce crowding. Siegel, Jt Comm J Qual Patient Saf 2007.
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Quality ImprovementApplying systems engineering principles in improving health care delivery. Kopach-Konrad, J Gen Intern Med 2007.
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Manufacturing : LEAN and Six Sigma
Modeling
Use of LEAN in the emergency department: a case series of 4 hospitals. Dickson, Ann Emerg Med 2009.
Discrete event simulation of emergency department activity: a platform for system-level operations research. Connelly, Acad Emerg Med 2004.
Forecasting emergency department crowding: an external, multicenter evaluation. Hoot, Ann Emerg Med 2009.
_____________________________________________
Queuing Theory
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Han, Acad Emerg Med 2007 Khare, Ann Emerg Med 2009
increasing the number of beds in the ED does not
decrease patient length of stay
alternative triage methods can increase efficiency
special units and even bed closures can increase
throughput Kelen, Acad Emerg Med 2001
bedside registrationtriage physician
Output
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Boarding
Boarding
Boarding
Outpatient Follow Up
Occupancy Calgary
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Generally agreed that boarding is the major culprit in ED crowding
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Emergency department crowding. General Accounting Office of the United States, 2003
Estey, CJEM 2003Schull, Acad Emerg Med 2003 Fatovich, Emerg Med J 2005Olshaker, J Emerg Med 2006Rathlev, Ann Emerg Med 2007
“Changes to ED structure and function do not address the underlying causes or major adverse effects of overcrowding… [these] lie outside the ED.”
Richardson, Med J Aust 2006
contention #4a“crowding is an ED problem”
contention #4b “crowding is a non-ED problem”
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rest of the hospital, 1990-2009
emergency department, 2003-current
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daily average ED LOS increased 18 minutes per 10% increase in hospital occupancy
elective surgery volume predicts ED gridlock
Forster, Acad Emerg Med 2003
McManus, Anesthesiology 2003 Litvak, Acad Emerg Med 2001 OR Manager, 2004
ED Wait Times 60 -> 40 mins, ED LOS dec by 45 minutes
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shared boarding has demonstrated safety and the benefits of ownership of the crowding problem
“changes the inpatient units’ attitude toward flow… the result is better flow through the entire hospital”
targeted discharge planning, active bed management and improved follow-up outpatient resources are important
Pines, Ann Emerg Med 2009
Viccellio, Ann Emerg Med 2009
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Review the ‘put1. flow depends on in/through/output
output is the major contributor but the ED has work to do in Calgary
2. crowding difficult to definesimplest measures probably the best
3. solutions are multi-pronged, hospital-wide and dynamic in nature
4. intervene and evaluate benchmarks
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Throughput and the Individual
In Direct Control Out of Direct Control Speed ED Factors Service Use (DI, Lab, Consult) Services Themselves Teaching Output
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Review You1. this is our… all our… THE problem
2. how is your operational efficiency?
3. know your committeesyou are ideally situated to suggest areas of improvement
4. get involvedbugle horns are $7.50 at Wal-Mart
5. patients & providers are beneficiaries
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Questions?