1. European Emergency Department needs a new management ! Eric REVUE, MD Head of Emergency Medicine Department and Prehospital Emergency Medicine EMS (SMUR) Louis Pasteur Hospital, Chartres, France Secretary of the International Council of the French Society of Emergency Medicine (SFMU) Chair of the Website of the European Society for Emergency Medicine (EuSEM) erevue@ch-chartres.fr www.eusem.org No conflict of interest

2. Louis Pasteur Hospital – Chartres (France) 40,000 visits in ED (2012) + 10,000 pediatrics 1700 EMT prehospital (SAMU) 150 personnel in ED (30 Drs 50 N) 6 EP day /4 night) 2 HMU (SMUR)

3. … number of ED visits and lenght of stay still increase 2008 2009 20102011

4. Situation in 2011…. Every day everywhere … Is it a curse ?

5. Analysis of overcrowding factors in our ED No Triage, No physician at Triage No procedures for dispatching The waiting area for patients on stretchers was used as Observation Unit LOS in the Observation Unit > 48 hours No bed management The short track was closed after midnight The patients paper file contained 8 documents (lab prescription physician’s nurses files, prescription) Demotivated physicians and nurses staff ……

6. Consequences : “Snowball effect” Observation Unit 100 % + mean LOS> 48hWaiting Area 100 % + mean LOS > 24hShort track closed at midnightLong track: waiting First Physician Contact Waiting on stretchers in hallways

7. Objectives Crush the mean length of stay within a year - Zero patient on stretchers in the hallways ! - priority goes to the fluidity in the ED - Patients sit (in particular the elderly) - Turn the Observation Unit in what it should be - Cut down on useless IV lines and blood samples - > 1 bed should be available at all times - delay of 4 hours in the ED a decision must be taken Rules of the Emergency Department : An elderly on a stretcher for several hours = ABUSE ! Patients stocked without monitoring in hallway = INACCEPTABLE

8. Ospina MB, CJEM, 2007

9. Lean Process in the ED flow Trigger Walk in Patient/ Ambulance Trigger : 10 vs 30 mn Reg desk 7 mn (9 AM-6 PM) Trigger : Triage Team Time :10 mn Trigger take to room Flow time 5 mn Trigger: 2 nd nurse contact 20 mn Trigger EP contact 10 vs 120 mn Limitation of IV lines Procedure lab X Ray Flow time 65 mn Trigger ordered signal if complete Trigger : waiting area Short Stay Unit 24h vs 72h Admission rate 35 %

10. Boarding area L 1L 2 Immediate Fast < 15 mn Fast < 15 mn Urgent < 30 mn Urgent < 30 mn Triage Nurse/ Physician Ward for lying patients Short 80 % < 4 h Shock Room Non Urgent < 1 h Non Urgent < 1 h Consultation > 2 h Consultation > 2 h 10 % Free L 3 L 4L 5 Free 5 %

11. Decrease number of patients on 24 h

12. Effects of new Management on LOS in Chartres ‘s ED in 2012

13. Comparative LOS in Louis Pasteur Hospital ED from 2008 -2012 2008 2009 2010 2011 2012

14. 5 months later : reducing of the LOS by -50 %...

15. Conclusions ED management : new strategies for conceptual European model Improve care process : throughput and NOT the input Focus on Flow orientation Reduction in unnecessary stay in the ED Decrease waiting time to bee seen : Team Triage, Fast Track Decrease variability in waiting times Participation of all co-workers : EMT Organization of the ED …and of the hospital !!! Short cuts ! (ACS, Stroke, ICU, palliative care….) Alternatives to the admission ? Home care ? Short stay Unit < 24- 48 h Increase proportion in bed request : Bed manager Development of GP’s houses ? Mobile Geriatric Unit in the ED Polyvalent Medicine department close to ED with LOS < 5 days Protocols +++ (IV lines, blood tests, X rays…) Computerize model and data ….

16. WashingtonParis Parthenon, Athens Thank you