Strategies for Improving Emergency Department Throughput

Strategies for Improving Emergency Department Throughput

Connecticut s Only Public Academic Health Center 3 Schools: School of Medicine School of Dental Medicine Graduate School of Biomedical Sciences Patient Care 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 30 th 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 35 45 55 65 75 85 RN-RN Interactions RN-MD Interactions Decision Making Autonomy Professional Status Emergency 2011 61 47 29 25 45 Median Academic 2011 71 62 50 56 64

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 monthly meetings Formal AIDET training/competencies Hourly and Leader Rounding Angie

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

Number of Patients 40 UConn Health Average LOS >10 days July 2013 - June 2014 Implementation of STAT rounds 5/6/14 35 30 25 20 Implementation of LOS rounds 2/18/14 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 Volume Average Daily Census Monthly ED Volume 2800 2700 2600 2500 2400 2300 2200 2571 83 Volume Average Daily Census 2635 2649 2581 2511 2517 2486 2454 2444 2360 85 2333 81 83 83 78 79 81 76 81 88 2778 2692 103 96 110 105 100 95 90 85 80 2100 76 2126 75 2000 70 1900 65

Bringing Down the Door to Doc Times 27 National Average = 27 mins (1/1/2012 9/30/2012) 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) ED Waiting Time Waiting Time Waiting Time Likelihood of Quarterly Report Before Noticed I was to Treatment shocked Area at how I was to See treated Doctor- (and in Recommending a GREAT Time Periods Arrival way!) Dec 2010 - Feb 2011 1 27 18 27 Mar 2011 - May 2011 32 50 18 36 Jun 2011 - Aug 2011 5 5 1 5 Sep 2011 - Nov 2011 1 5 1 5 Dec 2011 - Feb 2012 10 11 1 8 Mar 2012 - May 2012 5 30 1 25 Jun 2012 - Aug 2012 5 29 10 14 Sep 2012 - Nov 2012 47 53 37 58 Dec 2012 - Feb 2013 55 50 35 45 Mar 2013 - May 2013 Best emergency 72 room experience 61 that I have 39 61 Jun 2013 - Aug 2013 ever been a 40 part of! 55 45 40 Sep 2013 - Nov 2013 78 56 33 56 Dec 2013 - Feb 2014 72 94 75 83 Mar 2014 - May 2014 84 87 76 73

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

Senior leadership engagement is essential Takeaways 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 coyne@uchc.edu (860)679-4577 Mary Laucks Director, Care Coordination and Patient Flow UConn Health/John Dempsey Hospital laucks@uchc.edu (860)679-1651