At the Institute for Healthcare Improvement, 25 emergency departments are currently participating in the ED Innovation Community (also called the ED Collaborative). Led by Dr. Kirk Jensen, these EDs are pushing the envelope in improving operational efficiency and ED flow. Using web technology, virtual conferencing, and collaborative learning models, the ED Collaborative teams are spread from Okinawa to Vancouver and Fredericksburg to Providence on a two-year mission to bring new practice models to our specialty.
Dr. Jody Crane of Mary Washington Hospital in Fredericksburg, VA, started redesigning traditional ED processes in his 100,000 annual visits department when walkaways topped six percent (twice the national average), the length of stay exceeded five hours, and one-third of the staff turned over due to stress and dissatisfaction. All levels of leadership realized that there were significant process problems, and Dr. Crane and his colleagues began reinventing ED operations using Lean principles.
Because his department frequently struggled with long door-to-doctor times (because they were over capacity during peak hours every day), they redesigned their processes and launched the “Lose the Wait” campaign. Dr. Crane is now on the faculty at IHI, and some ED teams in the ED Innovation Community are pushing the traditional boundaries with new patient care paradigms. In the next two columns, I will highlight a few of the exciting innovations proving successful as well as several ideas newly out of the box.
SOME PATIENTS IN THE ST. JUDE ED DON'T WAIT IN BEDS, BUT ARE SENT TO A WAITING ROOM TO AWAIT TEST RESULTS
Part of Mary Washington's redesign involved creating service lines within the department. At the time this was done, their department was trying to see 80,000 visits in 22,000 square feet as one big enterprise. As noted in this column before, all emergency departments are now big-volume operations or well on their way to becoming such, and new strategies are required. Mary Washington's vision included three distinct service lines:
▪ Super Track: This track is for ESI 4 and 5 patients who typically need one test or x-ray and have a very low likelihood of needing admission.
▪ Tweener Track: This service line is for ESI 3 patients needing more complex workups, whose stays are anticipated to be less than six hours, and who have a low probability of admission.
▪ Mega-Track: This track is for ESI 1 and 2 patients with a greater than 50 percent chance of admission who need more intensive diagnostic and therapeutic interventions.
The first focus was the Super Track service line because most of the changes would be under the control of the ED itself and therefore easier to trial, implement, and maintain. The cultural changes required for more comprehensive redesign schemes would be in place for the next round of changes, involving more complex and acute patients. It was hoped that success would build upon success.
According to preliminary data, 17 percent of their ED patients needed no testing at all, and another 23 percent required minimal testing. The newly designed Super Track utilized four beds, with two medical teams rotating back and forth between the beds and everything occurring as one flow: nurse/provider assessment, treatment, and often discharge took place in one location with supplies well stocked and right at hand. Moving the patient around the department was minimized, and equipment and supplies were carefully moved and maintained at their point of use.
Patients who needed to wait for a lab or x-ray were put in a waiting area. The process changes were trialed using rapid-cycle testing methodology, and right off the bat the Super Track patients showed a throughput time reduction of more than 60 percent! In its final iteration after several improvement cycles, the process involved two teams with a midlevel provider, a nurse, and four beds seeing 7.2 patients per hour! With a walkaway rate of under two percent and a remarkable decrease in length of stay, most patients spent under an hour in the Super Track, and the staff was giddy with success! Waits and complaints were replaced with efficiency and compliments, and the staff exodus which had bedeviled them came to a halt.
Another big sweeping change being trialed at IHI and around the country involves making the doctor-patient encounter take place as quickly as possible and expediting the intake process. There are data to support placement of the highest level of training in triage/intake. Paramedics correctly predict whether patients will need to be admitted from the ED 62 percent of the time. (J Emerg Med 2006;31:1.) In another study, nurses performed similarly. (Am J Emerg Med 2001;19:10.) On the other hand, there is a growing body of evidence in the literature that demonstrates that physicians' assessments of outcome and disposition are highly reliable, with 85 percent to 95 percent accuracy. (Aust Health Rev 2007;31:33; Crit Care Med 2004;32:1165; Am J Emerg Med 2005;23:782.)
Dedicating a physician to the intake process has a number of advantages. Studies have shown that placing a physician in triage decreases length of stay and walkaways and increases staff satisfaction. (Ann Emerg Med 2005;46:491; Emerg Med J 2006;23:262; Emerg Med Australas 2004;16:41.) Approximately one-third of patients can be rapidly discharged using few or no resources. (Eur J Emerg Med 2006;13:342.)
In Fullerton, CA, St. Jude Medical Center under IHI leadership is trialing a model being dubbed the “Doc Track,” with early success. The physician does a quick assessment and decides who needs to come straight back, who can go to the fast track, and who can have a workup started and go back to the waiting room until the results are ready. In their model, patients are quickly assessed by a physician and a care plan is started, though the patient ultimately may be assigned to another physician. Also part of this ideology is the idea of “no bed waiting.”
The ED leadership has made staff particularly aware of wasted bed minutes. As I have pointed out in previous columns, bed minutes are a precious resource. Most EDs have maximized the number of available beds in their departments, even using space in the hallways for permanent stretchers with numbers on the walls. Each stretcher equates to approximately 1,500 bed minutes in the ED everyday. How will you utilize those bed minutes? St. Jude has made the commitment to utilize beds for diagnostics and therapeutics only. Patients will not wait in beds; rather they are sent back to the results waiting room to await test results. These are “virtual beds” where patients can pass the time with more freedom, and they are not tied to a stretcher in a hospital gown for their entire length of stay. The waiting room has been made more comfortable for this purpose, with a much more relaxed visitation policy. This is a new paradigm for emergency practitioners. In the old model, a patient occupied a bed until final disposition. In this day of overcrowding and nursing shortages, a new strategy is in order.
INTAKE AT MARY WASHINGTON HOSPITAL IN FREDERICKSBURG, VA, TAKES LESS THAN SIX MINUTES. WITH TWO INTAKE STATIONS, TRIAGE STAFF SEE A NEW PATIENT EVERY THREE MINUTES.
Though this model was devised to remedy the overcapacity bed problem, a remarkable benefit has been realized. Less nursing staff is required when patients are waiting in a results waiting room than when they are made invalids by real bed placement! By triaging patients back to the waiting room, theoretically it would be possible to even close ED beds down and utilize fewer nursing hours! How is that for a radical idea?
Remember, for the majority of EDs, more than 80 percent of patients will be discharged. As we try to ferret out which 13 percent to 16 percent of patients will be admitted, couldn't they be made comfortable in a diagnostic waiting area? Shouldn't we redesign waiting areas with televisions, laptops, magazines, books, and games to accommodate families? Part of the success of this model rests on dedicating staff to watch for results, and from them to bring the results of the completed workup to the attention of the physician in a systematic way. So far, St. Jude has reduced the door-to-doctor time from 85 to 36 minutes, and walkaways were reduced by two-thirds! Early results also are showing a process that is more efficient, requires less staff, and yields improved patient satisfaction.