Super Track. The Evolution of the Split Flow Emergency Department. John D Angelo, MD, FACEP Northwell Health

Transcription

1 Super Track The Evolution of the Split Flow Emergency Department John D Angelo, MD, FACEP Northwell Health Robert Masters, AIA, NCARB, LEED AP CannonDesign

2 Agenda 1. Emergency Department Flow 2. Evolution of the Super Track Model at Northwell Health 3. Case Studies: Flow Meets Design a. Southside Hospital b. Huntington Hospital 2

3 Learning Objectives 1. The value of the Super Track split-flow organizational approach in emergency departments as an effective lean process re-design strategy. 2. The implications of the Super Track approach on the planning and design of emergency departments, both for renovations and new construction. 3. Examples of how design can impact throughput and average length-of-stay in the emergency department. 4. Strategies that enhance design team and medical team collaboration for better operational and clinical outcomes. 3

4 Northwell Health Emergency Medicine Service Line 4

5 Emergency Medicine Service Line Clinical Operations 5 Tertiary Emergency Departments 11 Community Emergency Departments 2 Affiliate Tertiary Emergency Departments 1 Free-Standing Emergency Departments 33 Northwell Health-Go Health Urgent Care Centers CVS Minute Clinic Partnership Volume ~ 900,000 Annual Emergency Department Visits >70% of all system inpatient admissions via Emergency Departments Workforce Over 340 Full Time/Part Time Physicians (plus another 215 Per-Diem) Non Physician Staff ~1,600 FTEs 5

6 Emergency Department Flow 6

7 Emergency Service Work Flow Every System is Perfectly Designed to Achieve the Results it Achieves And this is where our ED workflow redesign team went insane. 7

8 What s new since most of todays ED s were built? Lean Process Re-design: Split flow, super tracks, team triage Vertical patients, not every patient needs a room Greater scrutiny on clinical coverage (cost and availability) Regulatory: CMS reporting requirements (LOS, door to X measures) P4P IT: EMR, Tracking boards, WOWs, CPOE, biometrics, RTLS, telemedicine Consumer focus - At home check in apps, no wait EDs, entertainment options Registration Kiosk, tablets, Prescription Kiosk delivery services Real time dashboards Population Health / Payer Influence Management of frequent utilizers Shift of lower acuity patients out to alternative providers (PCPs, UCCs, Retail) Consumerism: Wait time apps and billboards Alternative choices: FSEDs, UCCs, Retail Patients Satisfaction P4P Medical Advances and Trends Radiology CT, MRI, Bedside US Telemedicine, E-ICU Observation Medicine Specialty EDs or design components: Geriatrics, Pediatrics, Cancer, Bariatric Surge, Infection control (Ebola like processes) 8

9 What s not new? Rising Volumes Increase in Behavioral Health issues Hospital Closings Tight staffing Shrinking inpatient capacity Budgetary constraints Rising Acuities And so on... 9

10 The Case for Workflow Redesign Improved: Patient Satisfaction Staff Satisfaction Quality of Care IMPROVE CAPACITY!!! Reduce Risk Department Capacity Finances Source: Studer Group and CEP 10

11 Throughput: Typical ED Flow There are essentially three components to a patient s visit to the ED INPUT Patient arrives THROUGHPUT Stuff happens OUTPUT Patient leaves Complex Processes Plagued By Bottlenecks 11

12 Eliminating Bottleneck & Delays Input: Door to Provider (MD or MLP) Parallel rather than sequential processes Direct to bed / treatment area Triage bypass / Short Triage Quick Registration Bedside Registration Provider in Triage Team Triage Super Track / Split Flow 12

13 Eliminating Bottleneck & Delays Throughput: Provider to Disposition Align the rest of the organization with ED success Lab and Rad Turn Around Time (TAT) Super Track Results Waiting Area / Sub-waiting / other servers Keep vertical patients vertical Output: Disposition Decision to Departure Improve Admission process Greatest Challenge and Impact on capacity, throughput and patient safety in most EDs Set goals and organize people around them 13

14 The Split Flow Process Process: The Split Flow process is an evidenced based principle of bed conservation where resources are matched with patient flow in order to alter the care process. Replace Triage with Quick Look Clinical Assessment for Incoming Patients Split Patient Flow Vertical/low acuity patients don t own beds rapid treatment Capacity to meet volume using queuing analyses 14

15 The Development of the Split Flow Model Banner Health new ED model for patient flow (2006) Rapid triage of each patient by clinical team Accelerated treatment (lower acuity patient) Quicker admission (higher acuity patient) Eight EDs adapted to the two-track patient flow model 1. Faster time to treatment: reduced by 58% 2. Fewer walk-out patients: reduced from 7.1% to 1.7% 3. Reduced ED length of stay: reduced by 14% 4. Enhanced capacity to serve patients: increased by 1% 15

16 Matching Our Service Delivery to our Incoming Patient Stream Triage (verb) Brief RN Assessment ESI Level / Acuity Low Acuity Pathway ESI Levels 4, 5, some 3 s Moderate Acuity Pathway Most ESI Level 3 s High Acuity Pathway ESI Levels 1 and 2 ~ 30-40% ~ 50-60% ~ 10% 16

17 Increase Capacity: Add Space Does every patient require a bed? Vertical Patients Ambulatory Well / Low Acuity Younger Perceived Urgency or Convenience Driven Value (Starbucks) Speed Convenience Other non-medical factors What about a chair? Horizontal Patients Arrive by Ambulance Sick / High Acuity Older Serious or Life Threatening Condition (real or perceived) Value (Traditional Healthcare) Safety Preserve Life or Limb 17

18 Parallel vs. Sequential Front End Process Quick Look Triage Main ED Pt. Arrives RN / Provider / Tech Team Quick Reg Super Track Testing Station Rx / Minor Procedures Results Waiting Area Discharge Area 18

19 Summary: Potential Super Track Advantages 1. Reduce square footage requirements from traditional ED concept 2. More efficient throughput and reduced ALOS 3. Keep vertical patients vertical 4. Separate lower acuity patients from higher acuity level patients 19

20 Evolution of the Super Track Model at Northwell Health 20

21 Long Island Jewish Medical Center LSGS Architects/Perkins Eastman LSGS Architects/Perkins Eastman ED Modernization ,000 sq. ft. clinical addition Comprehensive, multi-phased renovation Critical Care, private treatment rooms, Imaging, Behavioral Health, Pediatrics 21

22 Long Island Jewish Medical Center: Adult ED Volume 110,000 Adult ED Volume Trends 100,000 90,000 80,000 70,000 60,000 50,000 40,000 30,000 20, Projected Adult ED Volume Split Flow Capacity Current Capacity 2017 Projected 22

23 Long Island Jewish Medical Center: Door to Provider Time 140 Door to Provider Time Change Implemented Door to Doc Mean UCL LCL

24 Long Island Jewish Medical Center: Treat & Release LOS 400 Treat and Release LOS Change Implemented T&R LOS Mean UCL LCL

25 Long Island Jewish Medical Center: LWOBEs 0.06 LWOBE Percentage Change Implemented LWOBE Mean UCL LCL

26 Long Island Jewish Medical Center: Likelihood to Recommend 75 Likelihood to Recommend (Top-Box) Change Implemented LTR Mean UCL LCL

27 Long Island Jewish Medical Center Adult ED Split Flow Floor Layout 27

28 Long Island Jewish Medical Center Volume LWOBE 98,820 5% Increase 47% Decrease 93, Jan. Sept. 3.9 Pre Improvement Statistical Analysis of Door to Doctor LOS March 2016 Sigma Score 1.2, mean time 94 mins. 358 T&R LOS 16% Decrease 302 Jan. Sept. Door to Provider % Decrease 68 Jan. Sept. Post Improvement Quid 16 hours/7 days Door to Doctor LOS September 2016 Sigma Score 1.8, mean time 68.5 mins. 28

29 Lenox Hill Hospital Lenox Hill Emergency Department: Sees nearly 56,000 patients. The new space (south side) had a larger footprint, added privacy, multipurpose rooms, and replaced most stretcher spaces with recliner chairs. 29

30 Lenox Hill Hospital Design FT NORTH SIDE SOUTH SIDE 30

31 Lenox Hill Hospital New South Side design Chairs replace most stretchers New Omnicell New curtains Procedure room Adjacent to X-ray

32 Lenox Hill Hospital: Door to Provider Time 50 Door to Provider Time Change Implemented Door to Doc Mean UCL LCL

33 Lenox Hill Hospital: Treat & Release LOS 270 Treat and Release LOS Change Implemented T&R LOS Mean UCL LCL

34 Lenox Hill Hospital: LWOBEs LWOBE Percentage Change Implemented LWOBE Mean UCL LCL

35 Long Island Jewish Medical Center: Likelihood to Recommend 90 Likelihood to Recommend (Top-Box) Change Implemented LTR Mean UCL LCL

36 Flow meets Design! 36

37 Who is CannonDesign? Our single-firm, multi-office approach offers our clients access to full resources from offices worldwide San Francisco Vancouver Los Angeles Phoenix St. Louis Chicago Toronto Pittsburgh Montreal Buffalo DC NYC Baltimore Shanghai Mumbai Boston 100 years of legacy 16 offices with over 900 personnel 550 health care staff Single firm, multi-office (SFMO) approach 3rd largest practice in the world in volume Top 5 ranked healthcare practice for past 20 years Fully-integrated Architecture / Engineering / Planning / Interiors / Cost Estimating / Facility Optimization In-house Operations, Clinical, and Research capabilities

38 Super Track Model Differentiator Fixed x-ray unit located adjacent to triage accelerates plain film imaging for walk-in patients 38

39 Super Track Model Differentiator Placing a physician at triage substantially expedites Arrival-to-Physician evaluation times 39

40 Southside Hospital Walk-In Entrance Ambulance Entrance Existing Emergency Department: Area: 11,000 square feet Construction: mid-1970s 22 Treatment Bays Original volume: 30,000 visits Modular addition: 2007 (9 Fast Track Bays) 56,000 visits 1 bed : 1,800 visits Project Kick Off ,000 visits 1 bed: 2300 visits 2021 projections 90,000 visits Existing Emergency Department 40

41 Southside Hospital Current State: 2013 Volume = 70,634 visits Admission rate 16% Current department has 33 beds Traditional ED capacity model 1 bed for every 1300 patients / yr Current volume 70,634 visits / 1300* = ~ 54 beds Projected 2021 volume 87,769 visits / 1300* = ~ 68 beds (~55,000+ sq ft) Problem: Volume exceeds capacity! 41

42 Southside Hospital Problem: Volume exceeds capacity Solution: Increase Capacity! How do you increase capacity? - Add space, i.e. treatment units (ex. beds) - Improve throughput / decrease LOS Recommendation: Do both! 42

43 Southside Hospital Ambulance Entrance ED Expansion Design: Infill addition Expansion into Brackett Pavilion to the west Behavioral Health Entrance New walk-in entrance on the south of the ED Dedicated Super Track Results Waiting Dedicated Behavioral Health Evaluation Area Walk-In Entrance Targeted renovations in the existing ED: Expanded Trauma & Critical Care Expanded Imaging Expanded Isolation 43

44 Southside Hospital ESI LEVEL Behavioral Health Entrance Ambulance Entrance Gradient of Care: Concentrating low acuity care at the walk-in entry Higher acuity & specialty care radiates from the Super Track hub Critical Care Corridor and Isolation Suite developed off of Ambulance entry Walk-In Entrance 44

45 Southside Hospital Super Track ED: 1 Clinical greeter 2 Intake Rooms 3 Super Track bays 4 Super Track rooms Flexible to Urgent 5 Results Waiting 6 Low acuity X-Ray Room 7 Sub-wait 1 Super Track ED: Clinical Low-Acuity Results Greeter Waiting Sub-Waiting Treatment for the Bays Vertical Patient 45

46 Southside Hospital Phase 1B ED Expansion: Isolation Suite Resuscitation Rooms Trauma Room Critical Care Imaging 16-bed Observation Unit Phase 2 ED Expansion: Renovating the balance of the existing ED Rightsizing support space for Critical Care Expanding Emergent Pod to the south Flexible Pediatrics area 16-bed Observation Unit 46

47 Go Live Preparation Town Hall Meetings Share designs and plans with frontline staff; discuss new split flow model Respond to staff questions Staffing adjustment New workflows require changes to the staffing ratios Staff Simulation / Training Space and workflow walkthrough for staff followed by simulating their new workflows with volunteers as patients

48 Southside Hospital: Door to Provider Time 120 Door to Provider Time Change implemented Door to Doc Mean UCL LCL

49 Southside Hospital: Treat & Release LOS 400 Treat and Release LOS Change implemented T&R LOS Mean UCL LCL

50 Southside Hospital: LWOBEs 0.08 LWOBE Percentage Change implemented LWOBE Mean UCL LCL 2E

51 Southside Hospital: Likelihood to Recommend 90 Likelihood to Recommend (Top-Box) Change implemented LTR Mean LCL LCL

52 Huntington Hospital Existing Emergency Department: Construction: 1983 Area: 14,400 DGSF Current treatment beds: 36 Existing Treatment Positions Existing volume: 52,000 visits 1 Bed for every 1450 visits 52

53 Huntington Hospital Current State ESI Acuity Total Percent total How many Main ED Beds are needed for Moderate to High Acuity? % % % % % 33 % of all Patients???? = ESI 1 s, 2 s, 50 % of 3 s = ~ 21,500 visits = ~ 18 beds based on 1:1200 ratio = ~ 21 beds based on 1:1000 ratio 50 % of all Patients???? = ESI 1 s, 2 s, 80 % of 3 s = ~ 32,500 visits = ~ 27 beds based on 1:1200 ratio = ~ 32 beds based on 1:1000 ratio 53

54 Huntington Hospital ED Renovation Design: Addition and partial renovation of existing administrative space Dedicated Super Track Results Waiting New Imaging area Ambulance Entrance Walk-In Entrance 54

55 Huntington Hospital Gradient of Care: Concentrating low acuity care at the walk-in entry Higher acuity & specialty care radiates from the Super Track hub Public corridor separates lower and higher acuity patients 55

56 Huntington Hospital Super Track ED: 1 Clinical Greeter 2 Intake Rooms 3 Super Track bays 4 Super Track rooms 5 Results Waiting 6 2 X-Ray Rooms and 1 CT Scan Room 5 2 Construction Progress: Results Clinical IntakeTrack Super Rooms Greeter Waiting Bays 1 56

57 Huntington Hospital Results Waiting in Super Track: Results Waiting 57

58 Key Takeaways The solution to your efficiency needs is not always a bricks & mortar solution Don t be afraid to be innovative with your design concepts When you are considering a design or re-design: Optimize flow Focus on process engineering Use improvement science-driven implementation and iteration Leverage technology to meet your needs Interdisciplinary collaboration will lead to a stronger solution 58

59 Super Track The Evolution of the Split Flow Emergency Department Presented by: John D Angelo, MD, FACEP, Northwell Health Robert Masters, AIA, NCARB, LEED AP, CannonDesign 59