Emergency Department Throughput : The Cambridge Health Alliance Experience
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1 Emergency Department Throughput : The Cambridge Health Alliance Experience Assaad J. Sayah, MD, FACEP Sr. V.P. & Chief Medical Officer President, CHA Physician Organization IHI 2016 Cambridge Health Alliance
2 Overview of Cambridge Health Alliance: 2 Hospital: 3 campuses with 24-hour Emergency Services: The Cambridge Hospital Somerville Hospital (7/1/96) Whidden Memorial Hospital (7/1/01) Community-based Primary Care and Mental Health Services: services at hospital campuses 12 neighborhood health centers, 4 school-based health centers Academics: Teaching affiliations with: Harvard Medical School Tufts Univ. School of Medicine Harvard School of Public Health Teaching Affiliate
3 Regional Safety Net Provider Largest proportional provider of care to low income individuals in the State. (64% State Payment sources; 19% Medicare; 17% Insurance/HMO) Care for uninsured patients from over 230 MA communities Leading state-wide acute hospital provider of inpatient psychiatry 10% of all statewide inpatient mental health stays 27% of all statewide mental health stays for the uninsured. greater than 30% of our patients and 53% of our mental health patients come from outside our 7-town primary service area 3
4 Why Change at CHA? Change in Healthcare environment Change in Healthcare reimbursement No Growth Poor patient satisfaction Inefficiencies Facility Challenges 4
5 Historical State 30,000 27,500 CH Registered ED Visits 28,979 28,800 29,100 27,983 28,510 28,155 Annual visit volume has averaged ~28.5k visits per year 25,000 22,500 Through 5 mos, volume is down 2% from the PY 20,000 FY02 FY03 FY04 FY05 FY06 FY07 Projected All MA Hosp DB 20K-30K State N=961 N=205 N=33 Cambridge Hospital 7/1/06-9/30/06 Waiting time before noticed arrival Helpfulness of first person Personal/Insurance Info FY07 Projected represents the fist 5 months annualized Somerville Hospital 7/1/06-9/30/06 Waiting time before noticed arrival Helpfulness of first person Personal/Insurance Info
6 Historical State Time on diversion: 8.5% LWBS: 4.04% Median door to provider time: over 60 minutes Median total length of stay: over 200 minutes Poor core measure compliance 6
7 Essential Elements Leadership Team Constitution Alignment Commitment Communication Administration Support 7
8 ED Vision for the Future Current State Process Staffing Capital Investment Patient Flow Project ED Flow Inpt. Discharges MD & RN communication between ED and Inpt. Unit Triage/Registration Laboratory TAT Transfer Leakage MD Staffing/Productivity Nursing Clinical Support Administrative Registration ED Information System Tracking Board Electronic Medical Record ED Front End Redesign Wireless Bedside Registration Future State (2-3 yrs) Best Practice Patient Satisfaction Door to Doc (30 mins / 90%) Increased volume and capacity 8
9 Patient Flow Project System Project Teams Cambridge Health Alliance
10 10 Patient Flow is a Hospital-Wide Concern Every hospital unit has a part to play the ED cannot solve the flow problem alone.
11 Patient Flow Project Goals 11 Improve patient flow on all 3 campuses Do so in a timely, safe, effective, efficient, and patient-centered manner Implement best practices Utilize improvement methodologies, tools, and measures Utilize a multi-disciplinary, multi-campus single solution approach Engage hospital staff
12 Focus is Across the Continuum 12 12
13 Fundamental Mission of Teams 13 Team ED Patient Flow Laboratory Turnaround Time No Delay Nurse Report Physician Admitting Orders Inpatient Discharges Mission Minimize time patients spend in the ED through the application of best practices Manage the ordering, collecting, testing, and verification of lab work through improved and standardized procedures Transport admitted patients to inpatient unit within 30 minutes of ED nurse giving report Expedite completion of admitting orders for admitted ED patients Decrease length of stay through effective discharge planning activities
14 Project Methodology 14
15 Recommendations Input Reengineering / Rapid Assessment Patient partner Establish Mini Registration 100 % Bedside Registration Elimination of triage Maximization of bed utilization Engage patients in the improvement project (Press- Ganey comments reviewed monthly with staff and posted in ED) 15
16 Input Reengineering 16
17 ED Patient Partner 17 ED Patient Access Representative Ambassador to patients in the waiting area Mini registration to facilitate patient flow Part of a response to deficiencies in Press Ganey patient satisfaction scores related to arrival and personal issues Press Ganey Percentile Rank All MA Hosp DB 20K-30K State N=961 N=205 N=33 Cambridge Hospital 7/1/06-9/30/06 Waiting time before noticed arrival Helpfulness of first person Personal/Insurance Info Somerville Hospital 7/1/06-9/30/06 Waiting time before noticed arrival Helpfulness of first person Personal/Insurance Info
18 Rapid Assessment Overview The purpose of the unit is to facilitate rapid assessment and treatment at the point of arrival in the Emergency Department Eliminate traditional Express Care, Triage and Registration and utilize the space for Rapid Assessment (RA) Combine nursing resources from Express Care and Triage offers the ability to care for multiple patients at once Physician Assistant in RA. The role of the PA is to rapidly assess and when applicable, treat and release the patient without entering the Acute ED. May also play a role in the initial assessment and ordering of diagnostics for acute patients. 18
19 Space Utilization A room is a room is a room : Eliminate specialty rooms Avoid pooling Centrally locate high-risk patients 19
20 Recommendations Redefining roles of staff RNs and PAR IIs draw labs Charge Nurse Role RN s discharging patients Create MD Order Sets This has streamlined order entry Create RN Order Sets (MD Standing Orders) 20
21 Recommendations 21 IT: EPIC / ASAP PACS MUSE System Integration: PCP Initial notification Heads up from PCP and EMS Medical record access Access to ED workup Referral Standardization of: P &P, Guidelines ED documents Equipment Material
22 Recommendations Process to improve quality of care Throughput: Early identification of admissions Maximize utilization of all inpatient capacity Early assignment of inpatient beds Early handoff to the admitting service Passive nursing report for admitted patients Early transport to the floors Escalation process Back up Code Help 22
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24 Outcomes Results are overwhelming ED TAT reduced A 70% reduction in the number of patients leaving without being seen Patients have noticed a difference The reception area has remained empty during peak times This was the quickest emergency room visit I've ever had ED Staff feels like the ED is calmer less chaotic 100% of patients are registered at bedside Budget neutral Reallocated existing staff and space Zero up front capital costs 24
25 ED Diversion Hours / % of Time on Diversion
26 ED Turnaround Time 26
27 ED LWBS/Elope Rate (%)
28 FY07 Projected represents the fist 5 months annualized Historical Volume Trends 28 CH Registered ED Visits Annual visit volume has averaged ~28.5k visits per year 30,000 27,500 28,979 28,800 27,983 29,100 28,510 28,155 Through 5 mos, volume is down 2% from the PY 25,000 22,500 20,000 FY02 FY03 FY04 FY05 FY06 FY07 Projected
29 ED Visits & Admissions 34,000 33,000 32,000 5,000 33,392 4,500 31,864 Visits 31,000 30,000 29,000 28,510 28,792 3,123 30,343 3,155 3,687 3,369 4,000 3,500 3,000 ED Admissions 28,000 2,892 27,000 2,500 26,000 FY06 FY07 FY08 FY09 FY10 2,000 Registered Visits ED Admissions
30 Cambridge ED Press Ganey Patient Satisfaction Overall Mean Score Cambridge ED Patient Satisfaction: Overall Quarterly Means & Percentiles Rapid Assessment started 4/1/08 Peer Group Changed 7/1/08 to 30K-40K visits/yr mean score percentile Q4 Q1FY07Q2FY07Q3FY07Q4FY07Q1FY08Q2FY08Q3FY08Q4FY08Q1FY09Q2FY09Q3FY09Q4FY09Q1FY10Q2FY10Q3FY10Q4FY10 Q1FY11Q2FY11 FY06 TCH Mean Score Mean Score Goal 20-30K %ile Rank Q3 FY11 0
31 CHA ED Press Ganey Patient Satisfaction Overall Mean Score CHA Emergency Medicine Patient Satisfaction: Overall Quarterly Means & Percentiles mean score percentile Q4 FY06 Q1FY07 Q2FY07 Q3FY07 Q4FY07 Q1FY08 Q2FY08 Q3FY08 Q4FY08 Q1FY09 Q2FY09 Q3FY09 Q4FY09 Q1FY10 Q2FY10 Q3FY10 Q4FY10 Q1FY11 Q2FY11 Q3 FY11 CHA Mean Score Mean Score Goal All Hospital DB %ile Rank 0
32 Average ED Sensitive Quality Core Measures Indicator Rates AMI ( ASA on arrival, B Blocker on arrival) CAP (Abx within 4 hours, BC prior to Abx)
33 Why a New ED at Whidden? The oldest facility Whidden 1968, Somerville 1987, Cambridge 1998 Small (18 patient care spaces) No privacy/ Open ward ( Same at SH) No Growth ( Same in all three EDs) Most potential for growth
34 Design follows function The New Whidden ED
35 ED Visits & Admissions 50,000 6,000 45,459 45,000 Rapid Assessment 43,010 5,578 5,500 Visits 40,000 35,000 30,000 30,126 New ED Partially Open 31,953 New ED Fully Open 33,530 4,131 Patient Partner 35,644 4,463 38,424 4,270 41,232 4,504 5,243 5,000 4,500 4,000 ED Admissions 3,802 25,000 3,512 3,500 20,000 CY05 CY06 CY07 CY08 CY09 CY10 CY11 CY12 3,000 Registered Visits ED Admissions
36 Median Door to Provider Time (min) New ED Partially Open New ED Fully Open Patient Partner Rapid Assessment Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q4 2012
37 Median Total Length of Stay (min) New ED Fully Open Patient Partner Rapid Assessment New ED Partially Open 100 Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q
38 ED Left Without Being Seen (% of Total Volume) New ED Partially Open New ED Fully Open Patient Partner Rapid Assessment 3 0 Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q
39 Press Ganey Patient Satisfaction Overall Mean Score New ED Fully Open Patient Partner Rapid Assessment mean score New ED Partially Open percentile Q1 05-Q2 05-Q3 05-Q4 06-Q1 06-Q2 06-Q3 06-Q4 07-Q1 07-Q2 07-Q3 07-Q4 08-Q1 08-Q2 08-Q3 08-Q4 09-Q1 09-Q2 09-Q3 09-Q4 10-Q1 10-Q2 10-Q3 10-Q4 11-Q1 11-Q2 11-Q3 11-Q4 12-Q1 12-Q2 12-Q3 12-Q4 0 WH Mean Score 40-50K visits %ile
40 This can be your billboard too! 40
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42 text message "ertime" to 41411
43 Media Coverage
44 Working together to change the culture
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53 Challenges ACO /PCMH collaboration Sustain and continue improvements Keep the staff engaged Output output output. 53
54 Questions Assaad Sayah, MD, FACEP (617) Cambridge Health Alliance
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