Welch, Shari J. MD
Dr. Welch is the quality improvement director in the emergency department at LDS Hospital in Salt Lake City, a clinical faculty member at the University of Utah School of Medicine, a quality improvement consultant to Utah Emergency Physicians, and a member of the Emergency Department Benchmarking Alliance.
Perceived waiting time is the most important variable contributing to patient satisfaction, and numerous studies have demonstrated the relationship between wait time and patient satisfaction. (Ann Emerg Med 1993;22:586; 1996;28:657; 2004;26:13.) The tools and concepts of quality improvement have been shown to reduce the length of stay effectively when applied to emergency department operations. (J Emerg Med 1995;13:847; Ann Emerg Med 1999;34:368.) With this in mind, the process for treating wounds in my emergency department, LDS Hospital in Salt Lake City, UT, was analyzed and modified to streamline it and improve turnaround time.
LDS Hospital has had a robust quality improvement program in its emergency department since 1998. The routine analysis of operational data frequently leads to initiatives to improve the efficiency of care for subsets of patients. Quality improvement has been successful for acute coronary syndrome, endotracheal intubations, pain management, and fever in children, to name a few. Routine analysis of turnaround time for patients by chief complaint revealed that patients presenting with simple lacerations waited an average of 127 minutes to be treated. A root-cause analysis revealed several contributing factors for these delays, and a process model was designed to remedy them.
In the 1950s, Joseph Juran, MD, considered by many to be the father of quality improvement, began implementing and promoting these QI concepts. Revisions of his book are still used widely in business and industry. (Juran's Quality Handbook [5th Ed.], New York: McGraw-Hill. 1999.) His DMADV methodology (define-measure-analyze-design-verify) is shown in the schematic (Table 1), and is widely used at our institution in process improvement initiatives.
The DMADV Roadmap
For our ED's problem with throughput for simple lacerations, we defined the problem as the inefficient treatment of lacerations and wounds in the emergency department. We then measured the throughput time for patients presenting with the chief complaint of laceration. A team was formed to analyze the problem, and it found that physicians frequently felt unable to break away from sicker patients to perform simple wound closure. In addition, many steps were required to prepare a patient for the physician to perform wound closure, further confounding delays.
Next, the team devised solutions to improve the overall process, including an education module, a change in the wound care process model, and the development of a suture supplies roster. Continued monitoring of turnaround times for lacerations was performed, which verified a 37-minute reduction in the time to treat lacerations. This training module has been repeated yearly for the benefit of new staff, and 30 minutes of this initial gain has been maintained.
LDS Hospital is a tertiary care hospital with the highest case mix index, a measure of acuity, in Utah. Lacerations make up between three percent and four percent of our chief ED complaints (roughly 1400 a year). Routine analysis of turnaround time by chief complaint suggested that this subset of patients was not being treated expeditiously.
The team of physicians and staff concluded that patients with wounds frequently experienced delays because higher acuity patients kept the physician from breaking away to repair the lacerations. The physicians noted that getting a patient set up for sutures often required several trips to that patient's bedside, only to find that the supplies, set up, and patient were not ready. From the staff side, the nurses and ED technicians noted that there was significant variation in the supplies used by each physician and that the staff would have to find the physician to ask what size gloves were needed and what suture would be used.
The work group devised three remedies for these delays. An education module was developed to train staff in how to prepare a laceration for repair and to anticipate the needs of the physician in completing the task. Particular attention was paid to supplies and positioning of the patient.
This module is taught through a PowerPoint presentation and hands-on wound care techniques using pigs' feet. The staff learned to prep and irrigate wounds, to anticipate the needs of the physicians during wound closure, and to understand the principles of anesthesia, tetanus prophylaxis, dressings, and splints. Nurses also were trained in injecting local anesthesia. The module has been hugely popular among staff, and included mechanism of injury/wound assessment, tetanus guidelines, local anesthesia, wound preparation, and risk factors for infection.
A new wound care process model also was designed to eliminate steps in wound care based on the education module (Figure 1.) The staff and physicians created a roster indicating the glove sizes and suture preferences for each physician, which the staff could consult instead of asking the physician each time. The roster includes the physician's glove size, suture preferences for dermal and subcuticular sutures, and guidelines for suture size based on location of the laceration.
The turnaround time for lacerations in the emergency department went from 127 minutes before the initiative to a low of 89 minutes. (Table 2.) Each year the staff was educated in the principles of wound management, and all staff were trained by the third year. This resulted in the best turnaround times. Although there was slight recidivism noted, most of the gains have been held.
By applying the methodology of continuous quality improvement, in particular the DMADV method, we were able to identify operational inefficiency, streamline processes, and realize quantifiable improvement. Quality improvement can provide emergency physicians with tools for improving operational efficiency, and its concepts and ideology should be embraced. This initiative is an example of how QI tools can be applied to operational and process problems in the ED with excellent results. Such focused QI projects and small local datasets collected at institutions around the country make the case for quality improvement and its modest success stories.
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