1. VERTICAL UNIT Emergency Department Case Studies

2. Objective Answer the following questions: –“What is a Vertical Unit?” –“Why did we implement?” –“How did we implement?” –“What were our results?” –“Did we sustain?” –“What were the lessons learned?”

3. Research shows that emergency departments can work extremely well, but if there is a significantly long wait to see the physician, it is almost impossible to please your patients and increase patient satisfaction- The Definitive Guide to ED Operational Improvement by Jody Crane, MD & Chuck Noon.

4. Mercy Muskegon Emergency Departments Current State: 2 Hospitals –Mercy –Hackley Important Metrics Future State: A Single Medical Tower Metric (Baseline) MercyHackley Visits (2015)49,83661,065 Door-Doc22 minutes Door-Discharge146 minutes134 minutes Left Before Exam (LBE)4.16%1.07%

5. Our Goals-Why Did We Do This? Improve the patient experience Reduce Door-Doctor times Reduce Door-Discharge times Reduce LBE Move patients through the ED more quickly and efficiently Preparation for consolidation

6. Vertical Unit Different process to move patients through the ED Keep “less sick” (low acuity) patients upright –Goal is to keep these patient flowing, rather than waiting in the waiting area –Patients remain vertical as much as possible Patient does not own a bed Majority of patients are not undressed Patients wait for their lab and other test results outside of the flow of other patients

7. Why Does It Work? It forces us to think about our patient flow It promotes focused exams and treatments It makes you function as a team Moves front end wait time to back end wait time –Cleveland Clinic Case Study

8. How did we do this? Rapid Improvement Event (RIE) Front line staff Providers Patients

9. RIE Agenda Day 1 –Review current state analysis –Identify barriers –Create future state vertical unit work flow –Prep for simulation Day 2 –Simulate vertical unit with team –Test in “real time” Day 3 –Make adjustments –Test in “real time” –Create standard work –Create communication & implementation plan –Report out

10. Vertical Unit Flow Patient Enters Emergency Department RN in Triage Assigns ESI LEVEL Quick Registration Main ED ESI Level 1,2,3ESI Level 4,5 Vertical Unit Acute Care Room Continuing Care Room Waiting To Be Seen Results Room

11. Patient Enters ED Patient presents to main ED entrance Patient is quickly registered Triaged & assigned ESI Level –ESI Levels 1.Requires immediate life-saving intervention 2.High risk 3.2 or more resources 4.1 resource 5.0 resources Resources defined as: Xrays, CT, US, MRI, lab draws, IV fluids, specialty consult, ECG, angiography

12. Continuing Care Rooms Patient arrives from Triage Tasks include: – Vitals –Provider exam –Interventions Blood draws Medications Splints/casts –Registration

13. Waiting to be Seen/Results Waiting Patient waits for available Continuing Care Room –Eliminates perceptions from main waiting area Patient moved from Continuing Care Room to wait results –No one owns a chair –May be placed here by RN, Provider, or Imaging Tech –If only, Provider will give results of initial orders –May be pulled into a Continuing Care Room for results Patient exists from Continuing Care Room or Results Waiting Area

14. Measuring Success

15. Results

21. Patient Comments “We were brought back very fast.” “What took you guys so long to get this program up and running. Keep up the good work.” “Thank you for moving us in and out.” “Great care! Thank you for seeing us right away.” “My son was in terrible pain. We got in quickly. He was given pain meds through IV & he started feeling better. Thanks.” “I’ve never been in and out of Hackley hospital so fast!” “Hope you keep this going.” “I love the new way, you are out so fast.” “They were very nice and it was very fast. They treated me with kindness and seemed like they really cared.”

22. Sustainment

25. Continuous Improvement Ongoing discussions about radiology and lab draw prioritization Registration Infection control concerns Personnel variability

26. Lessons Learned-Elements of Success RIE format Input from all stakeholders Monitoring the data in real time Standard work

27. Objectives A Vertical Unit keeps patients vertical. Vertical Unit has helped to increase patient satisfaction, decrease ED length of stay, and decrease LBE. The Vertical Unit was implemented through a RIE. Our results have helped to accomplish our goals. Sustainment is always a work in progress.

28. QUESTIONS