Improvement Report: Eliminate Overcrowding in the Emergency Department

Baptist Memorial Hospital
Memphis, Tennessee, USA
 
Team
Suzanne Horton RN, Director of Emergency Services (Pilot Team Leader)
Chris Andershock, MD, Medical Director, Emergency Department (Physician Champion)
CR Patterson, MD, Physician Champion
Carole Miller, RN, Quality Memphis
Gloria Lamb, RN, Director of Surgery
Kathy Graham, RN, Quality System
Chuck McGlasson, RN, Assistant Director, Emergency Department Trudy Beyersdorf, RN, Head Nurse, Intensive Care Unit
Tonya Marbry, RN, Manager, Post Anesthesia Care Unit
Dana Manley, RN, House Supervisor
Kay Gibson, RN, Case Manager
Rita Eden, RN, Emergency Department Physician Group
Betsy Brooks, RN, Manager, Surgical Oncology and Myelosuppression
Julie Goodman, Social Worker
Jerry Kaplowitz, RN, Manager, Surgical
Vicky Petrowski, RN, Manager, Orthopedics
 
Aim
Improve the percent of patients placed from the emergency department (ED) to an inpatient bed within one hour of decision to admit by 44 percent.
 
Measures
 
Changes
  • Reviewed all patients who met criteria for Express Admission Unit (EAU) but did not go to EAU on a daily basis to problem solve barriers
  • Faxed Emergency Department (ED) transfer report to one unit
  • Implemented huddle meetings with Emergency Department staff weekly to problem solve high-leverage changes, remove barriers, and communicate game plan
  • Implemented transportation proactively in retrieving stretchers for Emergency Department
  • Tested patients being taken straight to a room without triage when rooms available
  • Spread additional units to Emergency Department, faxed transfer report
  • Shifted resources to provide 11 PM to 7 AM transporter in Emergency Department
  • Increased Emergency Department physician coverage
  • Implemented process to call critical lab values to Emergency Department physicians
  • Developed comprehensive Fast Track Triage Criteria
  • Spread faxing Emergency Department transfer report to all units house-wide
  • Tested nurse/paramedic staffing in Fast Track; saw 18 patients from 11 AM to 5 PM with 1.3 hours turnaround time
  • Provided email to all Emergency Department and ICU staff for consistent communication
  • Micromanaged turnaround time data daily to identify barriers with staff
  • Expanded the hours of operation of express admission unit to 24 hours Monday through Friday
  • Mentored Fast Track staff, triage, and charge nurses at each triage nurse shift change by Emergency Department Head Nurse
  • Mentored mid-level providers to align Fast Track vision and actions
  • Installed computer in Fast Track to allow bedside registration
  • Implemented five-chair waiting area outside Fast Track for patients waiting on lab results prior to discharge
  • Expanded Fast track time by 1 hour (close at 12 midnight rather than 11 PM) and added second staff person (paramedic, intern, RN) to Fast Track staffing
  • Implemented Intensivist program
  • Initiated huddle meeting between neurosurgical Intensive Care Unit (ICU) and neurosurgical floor
  • Initiated huddle meetings in all Intensive Care Units to identify potential transfers every morning
  • Implemented multidisciplinary rounds in the ICU 3 days per week on Units 1 and 2
  • Tested one physician rounding in lower levels of care prior to rounding in ICU
  • Implemented morning huddle meetings with House Supervisor, bed assignment staff, ICU, and Post Anesthesia Care Unit (PACU) charge nurses, providing more information to plan the day and focus on PACU bed assignments given in advance, when possible
  • Added afternoon bed assignment huddle meeting to know PACU afternoon status, and added additional units
  • Revised fax report format used by Emergency Department based on feedback from PACU nurses and receiving units
  • Tested fax transfer report for PACU to one nursing unit and spread the use of fax reports to all units for PACU transfers
  • Initiated orchestration of discharge with one physician on one unit (surgical oncology)
  • Spread orchestration to all of this surgeon’s patients
  • Identified three additional surgical units to spread orchestration of discharge as soon as physician champions established
  • Implemented chest pain Emergency Department based on evidence-based medicine to provide the right care at the right level based on placement into four tracks
 
Results
Graph_BaptistMemphis_EDtoInpatientBed.jpg 
 
Summary of Results / Lessons Learned / Next Steps
Implementing best practice processes in flow have demonstrated the importance of process improvement across the entire continuum in order to reap results in any one area. Physician champions and administrative buy-in has been critical to the culture change that has taken place, allowing rapid cycle change to positively impact patient care and outcomes.
 
Other lessons learned include:
  • Start small, become comfortable doing a test of change daily if needed
  • Communication to all stakeholders is critical
  • Celebrate small successes
  • Improving processes improves patient satisfaction
  • Utilize data to affirm changes
 
Contact Information
Suzanne Horton , RN, MBA
Director of Emergency Services and Pediatrics Organization
Suzanne.Horton@bmhcc.org
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