Patient First: Efficient Patient Flow Management Impact on the ED

Memorial Regional Hospital
Hollywood, Florida, USA

Team

Memorial Regional Hospital is a participant in IHI’s Learning and Innovation Community on Operational and Clinical Improvement in the Emergency Department.

  • Mel Stibal, Administrative Director, ED/Trauma
  • Jennifer Reilly-Miller, Director, ED
  • Maria Wojoknowksi, ED Clinical Manger
  • Stacey Silverman, ED Clinical Manager
  • Stacy Caschette, ED Clinical Manager
  • Errol Charles, ED Clinical Manager
  • Jennifer Dunn, ED Clinician
  • Dr. Randy Katz, Associate Medical Director, ED
  • Dr. Fred Keroff, Medical Director, ED
  • Debbie Tedder, COO/CNO (Team Sponsor)

 

 

Aim

Improve care and service in the adult emergency department (ED) by focusing on key operational, clinical, and service improvement strategies that will result by January 2008 in:

  • 25 percent reduction in treated and released length of stay (LOS) [Goal: 210 minutes]
  • 25 percent reduction in admission LOS [Goal: 270 minutes]
  • Reduce rate of patients who left without treatment (LWOT) to below 2 percent 
  • Be at top deciles of CMS/HQI measures associated with community-acquired pneumonia (CAP)
  • Be at top deciles of CMS/HQI measures associated with acute myocardial infarction (AMI)
  • Patient satisfaction greater than 75 percent

 

Measures

  • Operational Length of Stay: Fast Track
  • Operational Length of Stay: Treat/Release
  • Operational Length of Stay: Admitted
  • Operational: Walkaways/LWOT
  • Clinical – AMI: Percent Compliance Aspirin (ASA) Treatment on Arrival
  • Clinical – AMI: Percent Compliance Beta Blockers on Arrival
  • Clinical – AMI: Door-to-Balloon Time (time between patient’s arrival in the ED and balloon angioplasty)
  • Clinical – CAP: Percent Compliance with Oxygen Assessment
  • Clinical – CAP: Percent Compliance with Blood Cultures Prior to Antibiotics
  • Clinical – CAP: Percent Compliance with Antibiotics Within Four Hours of Arrival
  • Operational/Clinical – Patient Satisfaction: Measured by Press Gainey Patient Satisfaction Survey
  • Operational/Clinical – Staff Satisfaction: Measured by Management Science Associates


Changes

The Memorial Regional Multidisciplinary ED Team began many of their changes in 2004 and initially focused on building the right team to be able to drive improvement from a human resources perspective (i.e., having the right people on the team). These changes included:

  • Formal/informal leaders without appropriate skill set taken out of charge and replaced; instituted Charge Nurse Course
  • Staff held accountable for actions
  • Leadership held accountable for outcomes
  • Developed behavioral expectations for all staff; they were tied to performance review
 
The team was then able to move forward by focusing on execution of the ED change package specifically in the areas of demand/capacity management, improvements in the ancillary areas, and the application of reliability tools to decrease variability in clinical care (CMS Core Measures). These improvements also served to drive increased patient and workforce satisfaction.
 
The changes were part of a carefully executed plan that held all stakeholders accountable and included the following:
  • Daily shift gatherings
  • Putting the patient at the center of the equation
  • Formulating teams for specific measures
  • Bi-monthly accountability meetings for ED leadership team
  • Weekly updates/graphs for staff; displayed in public areas
  • Effective communication to staff of the fact that initiatives were going to make their lives better
 
Behavioral changes that were instituted included:
  • Patient service representative
    • Rounding
    • Focus on hallway and treat-and-release patients
  • Call backs
    • Retired nurses
    • Staff relief
  • Bedside report
    • Just like the old days
  • Leader rounding
    • Executive
    • ED leadership
    • Middle management
    • Documentation
  • Use of StuderGroup principles, including structured patient interaction formats (for example, AIDET: Acknowledge-Introduce-Duration-Explanation-Thank You)
  • 30/60/90-day designs
    • Timeframes for quality improvement cycles established to convey to staff the expectations for pacing
    • Meetings at 30/60/90-day intervals to review progress
 
Operational strategies included:
  • Plan Capacity to Meet Demand (tested September 2006-January 2008)
    • Using an ED Predictive Model, the team evaluated clinician scheduling patterns to match patient arrival times. Adjustments to meet patient demand were made and are continuously monitored to reflect seasonal changes in census; staffing is increased or decreased as needed.
    • Team-based care was instituted. Teams were identified as A-B-C-D and assigned to geographic zones; this was used to organize admissions to the ED. The ED Team worked to determine the appropriate assignment for each team and did PDSAs to assess implementation. This work pattern allows continuous assignment of patients as opposed to separating patients into segments by diagnosis.
 
  • Early Warning and Response to Large Fluctuations in Capacity (tested February 2006-January 2008)
    • Initiated the “bed ahead” program, in which bed requests are generated once an inpatient admission is determined rather than waiting for the order to be documented by the physician.
    • Utilized “patients waiting” as a trigger to initiate increase staffing needs; a “triage alert” was utilized whenever more than two patients were in the queue, with response by Clinical Manager and Charge Nurses.
    • Collaborative improvement cycles were initiated between radiology and laboratory to decrease turnaround times (TAT). New computerized tomography (CT) dosing protocol was put in place; this reduces dosing time from 195 to 60 minutes for exams, excluding differential diagnosis of appendicitis or diverticulitis, and reduced dosing time from 195 to 90 minutes for these exams. There are very few "re-takes" due to inadequate contrast. A positive patient ID bar code system pilot was initiated which also notifies phlebotomist when labs are ordered.

 

 

Results

 

Graph_MemorialRegionalLOSDischargedPts.jpg 
 
Graph_MemorialRegionalLOSFastTrack.jpg 
 
Graph_MemorialRegionalLOSAdmittedPts.jpg 
 
Graph_MemorialRegionalWalkaways.jpg 
 
Graph_MemorialRegionalDoor-to-BalloonTime.jpg 
 
Graph_MemorialRegionalCompliancewithAspirinTreatment.jpg 
 
Graph_MemorialRegionalCompliancewithBetaBlockerTreatment.jpg 
 
Graph_MemorialRegionalBloodCulturesDrawn.jpg 
 
Graph_MemorialRegionalAntibioticforPneumonia.jpg 
 
Graph_MemorialRegionalPatientSatisfaction.jpg 
 

 

Summary of Results / Lessons Learned / Next Steps
Clinical Improvements
  • Changes regarding acute myocardial infarction procedures
    • Percutaneous Coronary Intervention (PCI) Taskforce was put in place to address door-to-balloon times
    • AMI kits were placed in Pyxis
    • Atomic clocks were installed in ED to ensure reliable times. New route developed for patients going to Cardiac Catheter Lab (CCL)
    • Field changes in collaboration with Emergency Medical Services (EMS)
 
  • Changes regarding procedures for community-acquired pneumonia (tested September 2006-January 2008)
    • CMS Coordinator assigned to ED to assist in meeting measures
    • Despite many changes, work continues to reach 100 percent
 
Next Steps
The Memorial Regional Team has achieved numerous substantial improvements. However, in the spirit of continual improvement, we will work to attain the goals not yet met, including LOS for both treat-and-release and admitted patients. We also have identified the following new aims as we move forward:
  • Overall improvement of Quick Care
  • Improve utilization of available resources
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