Welch, Shari J. MD
Dr. Welch is a fellow with Intermountain Institute for Health Care Delivery Research, an emergency physician with Utah Emergency Physicians, and a member of the board of the Emergency Department Benchmarking Alliance. She has written two books on ED operational improvement; the latest, Quality Matters: Solutions for the Efficient ED, is available from Joint Commission Resources Publishing.
Patients who present to the ED are older, sicker, and more complex than they were 20 years ago. As U.S. demographics change over the next decade, they will get even older and sicker, and we will do more for them in the emergency department.
This will continue to result in more critical care being provided in the emergency department, requiring one-on-one physician care at the bedside and often an entire team of nurses, technicians, and other staff. Though many career emergency physicians enjoy delivering critical care in the emergency department, it always involves a cost to the department at large. The typical emergency department operates as a zero-sum game. If personnel are delivering critical care in Room 1, they are not tending to 25 other patients. As ED lengths of stay have increased and boarding patients continues to be a problem, this critical care becomes a drain on emergency department resources.
Intermountain Medical Center in Salt Lake City developed a new protocol called ED-ICU Priority One to cope with this issue. The tertiary care trauma center sees 75,000 ED visits each year. Overall length of stay is 225 minutes, and length of stay for admitted patients is 300 minutes. After spending more than four hours caring for a critically ill patient with septic shock, Steven Souter, MD, a 20-year emergency physician decided to tackle the problem.
He met with intensivists, nurses, managers, and administrators, and led a process change that enables the emergency physician to expedite the admission process of critical care patients. Following the Rapid Response Team Model used so successfully elsewhere, a simple process was developed. When a patient meets critical care criteria, an ED-ICU Priority One is called. Critical care sends a team to the ED to accept the handoff (face-to-face communication) and transport the patient to the ICU. The admission process is expedited to the good of the patient and the emergency department.
The process model has been successful, an example of how process improvement occurs by innovation at the front line, not by committee. It also shows how one committed individual organizing a team of stakeholders can move an institution. The results: Length of stay for Priority One patients was under 60 minutes (previously 300 minutes). The ED-ICU priority call triggers are simple: intubation, respiratory extremis with intubation pending, hypotension, pressors, lactate greater than 4 mmol/L, and physician discretion. The emergency physician decides which ICU is appropriate for the patient, arranges a brief conference call with a critical care attending by calling a special beeper, Priority One is activated by an overhead page, and the ICU team is deployed to the ED.
This improvement initiative is also an example of how change management techniques can be used to roll out a new process. As the process was being developed by a task force of stakeholders, physicians and staff were brought on board with email updates and information at staff meetings. The whole project was short and focused. Before full-scale rollout of the change, the protocol was tested in the ED to look for process flaws. This is a step often skipped when improvement projects and change are being introduced. By running a trial, glitches in the process can be identified before they sink the change, and feedback was given to staff as the process details were reworked. When the process had been refined by the team, it was rolled out with much fanfare, including announcements at department meetings, emails, posters, and the distribution of laminated cards and magnets scattered around the department for rapid reference. These reminded staff how to activate the protocol. From inception to execution, Dr. Souter, his team, and Intermountain Healthcare carried out this improvement project flawlessly.
The process is streamlined and simple, and provides the best care for the patients while decreasing the critical care burden on the ED. It is also an example of how one committed individual can lead a small team through change and improvement and eventually move the institution.
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