Optimizing Emergency Department Utilization Presented by Brenda Lee, R.N., M.S.N.

TEAM MEMBERS CS&E Session 13 Participants Joan Hall, Quality Don Hunt, CNO Dr. Gregory Johnson, Medical Director of ED -ED Staff, Physicians, and Residents

Background The mean # of patients LWBS is 12 per month (ADV 40) Patient Satisfaction scores for wait time and informed about delays were two areas needing improvement Triage process variation between shifts Patient safety and risk concerns (urgent patients not receiving care, EMTALA violations, and financial loss) Information regarding factors associated with patients, physicians, and environment (acuity, length of stay, resource utilization, long wait time, non-urgent patients with improved condition, etc.) was not available

What We Are Trying to Accomplish? PROJECT AIM STATEMENT Reduce the number of patients who leave without being seen (LWBS) in the Emergency Department by 50% (approximately 6 patients) per month.

How Will We Know That a Change is an Improvement? Reduced # of patients who leave without being seen by a physician Accurate correlation of triage level to patient wait and disposition Improved patient satisfaction for wait times and delays

Contributory Factors: In accurate patient count secondary to inconsistent sign-in process Patients were not being informed about delays Expectations were not addressed and patients were angered by other patients being seen prior to them No follow-up process creating risk concerns

Time of Day LWBS April 2009 – April 2010 Matches national data regarding ED peak demand times. Clinics sending patient to ED. Patients seeking treatment after school, work, etc.

Predictable secondary to high demand for clinic apts after weekend.

Assumption was made that the process variation was prior to the physician exam; this was disproved by the data. This created the shift in focus to the physician characteristics for discharge and admission.

Interventions Create a paradigm shift for ED staff to optimize throughput for all patients (not just emergent) Design a standardized sign in process Develop follow-up process for patients that LWBS to identify associated patient characteristics Address patient expectations for wait time and implement a process for communicating delays Analyze data related to physician and environmental characteristics (triage, resource utilization, etc.)

Triage accuracy does not consistently correlate to diagnosis evidenced by mean 13% of patients being admitted on 7am – 7pm shift and mean 28% on 7pm – 7 am shift . Acuity of both sifts are almost equal with mean 66% (7a-7p) and 69% (7p-7a) non urgent ; 32% (7a-7p) and 28% (7p-7a) urgent and 1% (7a-7p) and 1.8% (7p-7a) emergent. The 7a-7p shift sees 67% of patients while the 7p-7a shift sees 33% of patients. 7p-7a shifts does have more seasoned staff that are familiar with the ESI 5 level system while the 7a-7p shift does not have a dedicated triage nurse until noon.

The 7 am to 7 pm mean LOS for admitted patients decreased from 281 minutes to 153 minutes (Figure 6). The doctor to admit times contributed 67 minutes to this decrease secondary to the admission process change for the day shift. Door to discharge patients did not change significantly. Low acuity (non-urgent) patients were not being treated based on a “fast track” model. We recognize the need for an innovative way to manage the large patient subset that seeks emergency care but who do not need substantially different care than those in a traditional fast track model. Results of directive for expedited transfer of patients being admitted during the 7a.m. to 7p.m. shift was addressed with the medical staff.

Results Patients who left without being seen decreased from a mean of 12 per week to 0-1 per week. ANY patient that leaves without being seen has a chart audit for follow-up.

Average ED Visit cost $450 per patient X 157 patients = *$70,650 *Annualized Potential Revenue for Patients that LWBS

Conclusions/What’s Next Process change for admitting patients during the day shift decreased ALOS for these patients however, mean wait time for discharged patients did not demonstrate a significant decrease. Addressing expectation of wait times is instrumental in deterring patients from leaving without being seen. Data validated the need for implementation of the ESI 5 level triage system to standardize staff utilization of resources and further increase efficiency of patient treatment; particularly for potential admissions. Staff will plan the design and implementation of a parallel process flow utilizing nurse initiated protocols while “keeping patients vertical” and moving to decrease the length of stay for non-urgent patients that are expected to only increase in the future. Overall patient satisfaction results did not vary significantly and is also attributed to unchanged mean wait time and ALOS for patients discharged. However, informed about delays is not longer a top ten priority on the improvement opportunity list.

Questions?