Strategies for Improving
Emergency Department
Throughput
Connecticut’s Only Public Academic Health Center
3 Schools:
Patient Care
School of Medicine
School of Dental Medicine
Graduate School of
Biomedical Sciences
John Dempsey Hospital
University Dentists
University Medical
Group
Residency Training
(Graduate Medical
Education)
Biomedical
Sciences and
Research
Mission
To serve through healing, teaching and research.
Vision
UConn Health will be nationally recognized for improving the health of the
citizens of Connecticut through innovative integration of research, education, and
clinical care.
UConn Health Fast Facts
• Home to the Farmington Valley’s One and Only full-service 24/7 Emergency
Department
• 30,000 Number of patient visits in FY 2013 to UConn Health’s Emergency
Department
• 23 Average number of inpatient admissions per day
• 234 Bed hospital (108 medical/ surgical beds)
• 107 Average Daily Census
• 4.6 Average days for inpatient LOS
• 8,600 Number of patients admitted to John Dempsey Hospital in FY 2013.
• 450 Number of providers in more than 50 specialties in the UConn Medical Group,
the largest medical practice in Greater Hartford.
Our Journey
Where We Began….
2011
• ED LOS 570 minutes (average)
• Door to Doc times 57 minutes (average)
• Door to Decision times >195 minutes (average)
• LWBS rates > 4% (>national average)
• Low Patient Perception Scores 30th Percentile
• Changes in management
• Staff turnover/poor staff satisfaction (NDNQI graph)
• Long waiting room times
Staff Satisfaction/Engagement….A Major Focus
Emergency Department (Lowest Rating 2011)
Adapted Index of Work Satisfaction 2011
<40=low satisfaction, 40-60=moderate satisfaction, >60=high
satisfaction
Professional Status
Autonomy
Decision Making
RN-MD Interactions
RN-RN Interactions
25
Emergency 2011
Median Academic 2011
RN-RN Interactions
61
71
35
45
RN-MD Interactions
47
62
55
Decision Making
29
50
65
Autonomy
25
56
75
Professional Status
45
64
85
ED CMS Core Measures – Inpatient/Outpatient
January 1, 2012
ED 1a: Arrival to departure times admitted patients, Overall rate
ED 1b: Median time arrival to departure admitted patients
ED 2a: Admit decision time to ED departure time for admitted patient, Overall rate
OP 18: Median time of ED arrival to ED departure for discharged patients
OP 20: Door to diagnostic evaluation by a qualified medical personnel
OP 22: Left without being seen
The Journey Begins…
• November 2011…ED Performance
teams formed
• Charter established/3 teams formed
• Multidisciplinary off site meetings
• Collaboration with Yale Health System
– Site visit
– Information sharing/conference calls
– Maximize use of similar bed
management system
– Adopt best practices
Baseline Data for Nurse Driven Protocols:
Most Frequently Seen Complaints
•
•
•
•
•
Abdominal pain
Back pain
Chest pain
Emotional Illness
Fall
• Fever
• Motor Vehicle
Accident
• Shortness of Breath
• Weakness
Admission Destinations
ICU
13%
SURG
14%
MED
66%
PSYC
13%
TRANSITION ORDER SET SCREENSHOT
2012:
Everyone’s Plate
is Full
• ED renovation of upfront area: March 2012
• Changed paradigm of Triage…”Pull to Full”
• Quick upfront patient registration → full
bedside registration
• Nurse Driven Protocols
• Monthly multidisciplinary meetings → ED
and Inpatient teams
• Addition of 24/7 ED clerical support staff
Studer Engagement
• ED assigned a dedicated Studer coach… Angie Esbenshade
• ED assessment and formation of committees for
Angie
monthly meetings
• Formal AIDET training/competencies
• Hourly and Leader Rounding
Hurdles
• Lack of nursing buy- in (ED and Inpatient)
• Staff perception →finances/performance times were taking
precedence over quality and patient safety
• General feeling that patients were being “pushed” to the units
• Inpatient RNs were accustomed to controlling the flow
• House staff felt a loss of control as well
• Psychiatric patient throughput
Overcoming Hurdles
• Patient centric Safety Huddles
• Bi-weekly meetings: ED and Inpatient nurses
discussed wins and opportunities to improve
• Empowerment: gave a voice to frontline nurses
• Hospitalist/Resident morning report daily→
reviewed concerns over the previous 24 hours
• Change in Level of Care logs
• Bi-weekly meetings with ED Throughput team
(ongoing)
Breakthroughs for Admitted Patients
• Bed assignment by ED Case Manager in March 2013
– Decision to depart times ↓ 30 minutes in one month (207 mins ↓
177 mins)
• Medicine and Cardiology patients: 3 way call between ED MD,
Hospitalist and admitting Resident/Fellow to discuss admissions
– ED MD enters Transition orders on all patients admitted to the
hospitalist service 11/2013 and Cardiology service 7/2014
• Residents/Cardiology Fellows evaluate patients on the inpatient
floors…..NOT in the ED !!
People don’t push back against the
change itself
• They push back because change is unsettling
• They push back because they equate
uncomfortable with bad
Best Practice
Direct Nurse to Nurse Handoff
Right
Floor
Right
Patient
Right
Care
Right
Outcome
Opening the Door to the Hospital
Throughput Initiatives
• Centralizing patient flow
• Daily STAT Rounds (Safe Transition and
Throughput)
• High Risk LOS rounds twice weekly
• Hospitalist attention to discharge times
UConn Health Average LOS >10 days
July 2013 - June 2014
Implementation of
STAT rounds
5/6/14
40
35
Number of Patients
30
25
Implementation
of LOS rounds
2/18/14
20
15
10
5
0
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
May-14
Jun-14
Continued Success with Bumps on the Slope
Median Time - ED Arrival to Departure for Admitted Patients
452
310
National Average = 274 mins
(1/1/2012 – 9/30/2012)
256
Left Without Being Seen (LWBS)
National Average = 1.9%
(1/1/2012 – 9/30/2012)
1.3
0.97
0.13
Monthly ED Volume
Volume
Average Daily Census
2700
Monthly Volume
2600
110
2778
2692
2635
2649
2581
2571
2511
2486
2400
2300
2200
2100
2360
88
2333
83
81
95
90
85
81
83
96
2454
2444
85
83
100
2517
2500
105
103
78
79
76
81
76 2126
80
75
2000
70
1900
65
Average Daily Census
2800
Bringing Down the Door to Doc Times
National Average = 27 mins
(1/1/2012 – 9/30/2012)
27
21
14
Median Time - ED Admit Decision to Departure for
Admitted Patients
226
National Average = 96 mins
(1/1/2012 – 9/30/2012)
108
90
Patient Perception Of Care Scores
Connecticut ER/ED: JDH ED Percentile Rank
(100=Best; 1=Worst)
Waiting Time
ED
Waiting Time
Waiting Time
Likelihood of
Before
Noticed
Quarterly Report
“I was
shocked Area
at how I was
treated
a GREAT
to Treatment
to See
Doctor- (and in
Recommending
Arrival
Time Periods
way!)”
1
27
18
27
Dec 2010 - Feb 2011
32
50
18
36
Mar 2011 - May 2011
5
5
1
5
Jun 2011 - Aug 2011
1
5
1
5
Sep 2011 - Nov 2011
10
11
1
8
Dec 2011 - Feb 2012
5
30
1
25
Mar 2012 - May 2012
5
29
10
14
Jun 2012 - Aug 2012
47
53
37
58
Sep 2012 - Nov 2012
55
50
35
45
Dec 2012 - Feb 2013
“Best
emergency
room
experience
that
I
have
72
61
39
61
Mar 2013 - May 2013
ever been a 40
part of!”
55
45
40
Jun 2013 - Aug 2013
78
56
33
56
Sep 2013 - Nov 2013
72
94
75
83
Dec 2013 - Feb 2014
84
87
76
73
Mar 2014 - May 2014
Quality
•
UCONN Health receives American Heart Association
Mission Lifeline Silver award for STEMI and First
Medical Contact Times
•
•
Outstanding collaboration between EMS, ED and Cath Lab
2012 Joint Commission Award for Top Performer on Key
Quality Measures
• Reflects outstanding work in the treatment of patients
with heart attack, heart failure, pneumonia, and surgical
care
•
Only Program in greater Hartford to receive recommendation
Phase 1: Honeymoon
Phase 2:
Reality Sets In
Phase 3: The
Uncomfortable
Gap
Phase 4:
Consistency
PHASE 3
THE UNCOMFORTABLE GAP




Performance gap is evident
Tougher decisions must be made
Process improvement increases
Inconsistencies obvious
PHASE 4: CONSISTENCY
 High performing results
 Everyone understands the keys to
success
 Disciplined people and disciplined
processes
 Proactive leadership
• Ramp up focus on arrival to depart for admitted
patients
• Trial dedicated provider in upfront area to
decrease door to discharge times (median time 178
min/national average 138 min)
• Centralize patient flow and bed assignment
• Sustain the change: move to hardwired consistency
• Scheduled appointments
Performance Metrics
•
•
•
•
Department movement
ED Pulsecheck metrics
Daily Portal report
Admission and discharge
median times by unit
→Discharge goal 25% by
noon/75% by 2 PM
Takeaways
• Senior leadership engagement is essential
• Patients cannot move out and up until the hospital
recognizes the ED as a customer
• Involve and engage frontline staff both ED and inpatient
• Huddle often….communicate wins and losses !!
• Always give the “why”…why a decision is made or idea is rejected
• Lead, stay strong and navigate through the noise
• Team Building is key
• Break down the silos”……get comfortable with the uncomfortable
• Thank and appreciate your Studer coaches !!
Thank You!
Kathleen Coyne
Director, Critical Care Nursing
UConn Health/John Dempsey Hospital
[email protected]
(860)679-4577
Mary Laucks
Director, Care Coordination and Patient Flow
UConn Health/John Dempsey Hospital
[email protected]
(860)679-1651