San Diego County 4 th Annual Overcrowding Summit Roneet Lev, MD, FACEP
Agenda Purpose of this conference Improve ED Care in San Diego County Inspire Ideas Learn from each others to improve care Collegiality in working together throughout the year Speakers CEO Panel Lunch ED Director Panel Speakers
EMOC Accomplishments Bypass getting right patient to right hospital Police and Psychiatric community right psych patient to right place Capacity Alert System to County Work with clinics for follow up care SART team guidelines Collaboration
About the Data Questions from EMOC members Voluntary Blinded by hospital To be used to promote self improvements rather than promoting competition 100% participation!!
San Diego EDs Census Monthly Volume June 2008 - June 2009 with comparison of last year s data 2009 2008 1145 870 2985 2621 2208 2400 2000 Fallbrook Coronado Thornton Alvarado Pomerado 9 hospitals increased volume 10 remained stable or reduced volume County average 513 patients less per month 3100 3274 3125 La Jolla Encinitas UCSD PVH Scripps CV 5793 5100 5379 5419 4481 4800 4299 6954 8031 Sharp CV Mercy Memorial Palomar Balboa Childrens TriCity Grossmont Kaiser
ED Patient Impact Annual Visits/Beds (not include halls) Annual Visits/ ED Beds: should not exceed 1600 ED solutions Benchmark tool: www.emaedsolutions.com Can increase bed availability by decreasing LOS admission 50,000 visits x 0.2 (%admission) x 1 hour = 10,000 hr/yr = 27.4 hrs/day 2579 2689 2305 1600 1711171817661800 197419902097 2110 1200126813041305 14791550 15711600 Memorial Kaiser Grossmont Fallbrook TriCity UCSD Scripps CV Thornton National Average Childrens Coronado Alvarado Pomerado PVH Encinitas La Jolla Palomar Balboa Sharp CV Mercy
Overall Throughput Over Past Year 9 8 7 6 5 4 3 2 1 0 8 7 4 Improved Same Declined
%LWOT + AMA Range 0.5% - 8% range Median 2.4% (2.9% last year, 3.0% yr before) Correlation with LOS and ED beds National Average 1.9% LWOT 8 6 6.5 7 0.5 1 1 1.5 1.5 1.9 2 2 2 2.4 2.6 2.8 2.93 3 3.3
LOS Admitted Patients Admit LOS in Hours 2.8-8.2 hours; 5.9 average Highest number correlates with inpatient bed problem Discharge LOS in Hours 1.7 4. 5 hours; 3.4 average Highest number correlated with ED beds and ancillary services 3.2 hours overall national average 7.0 6.9 7.0 8.7 7.6 8.3 8.0 8.0 8.2 6.0 2.8 3.3 5.1 5.1 4.4 4.6 4.5 4.0 3.6 3 2.8 2.8 3.2 3.6 3.3 3.6 2.6 2.4 4.5 3.2 4 5 4.1 4.3 4.5 3.5 Admit Discharge 1.7 2.1
3 Year Summary 2.88 10 8.9 8 8 8 8.2 6.4 6 5.9 3.38 5 3 2.8 3.34 4.5 4 3.5 3.32 2.4 0.68 2.8 1.78 1.7 1 1 1.7 2007 2008 2009 LWOT + AMA LWOT HIGH LWOT LOW LOS ADMISSION LOS Admit HIGH LOS Admit LOW LOS DISCHARGE LOS Discharge HIGH LOS Discharge LOW
Percent of Admissions San Diego Average Admissions 18.6% National Average: 11.7% (2001 CDC data); ED Solutions: 17% Correlation with acuity 27 16 16 16.6 17 16.1 13.5 14.315.1 20 18 18.318.9 22.6 23 23 23.8 24 10
Correlations Acuity = % Admission (10-27%) LOS Admit = LOS Discharge = LWOT = Beds = % Admission 30 25 20 15 10 %LWOT Volume/Beds LOS Admit LOS D/C %Admission 5 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
Is Impact governed by Payor Mix? Impact = Volume/Beds No association with payor mix Payor Mix: 0% - 35% self pay 40 35 30 25 20 15 %Self Pay Volume/Beds 10 5 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
Holds > 2 Hours 9/19 hospitals reporting Not uniformly measured % Admission in ED > 2 hours 3.4 hours extra average 50,000 hours 7252 patients LOS Admission better measure 120 100 80 60 40 20 0 Percent of ED Admission Waiting for Bed > 2 Hours 1 2 3 4 5 6
Psychiatric Holds A Concern at 7 Hospitals LOS for psychiatric patients longer than admit LOS for all those reporting 10 9 8 7 6 5 4 3 2 1 0 Number of Psychiatric Holds Overnight 9 5 4 None Not Measured 0.5-3 Average LOS for Psychiatric Patients 12 10 8 7.3 8 10 10 10.5 11 6 4 2 3.25 4.95 0 1 2 3 4 5 6 7 8
What is the greater problem Admission or Discharged Patients? Admitted Patients are Greater Barrier to Throughput Compared to Discharged Patients 16 15 14 12 10 8 6 4 2 3 1 0 Admit Discharge Both
Biggest Obstacle for LOS of Admitted Patients Universal Answer = Inpatient Bed Not Available 19 Additional Concerns Hospital Physician - 1 Consultants - 3 Nursing Staff - 1 Nursing Report - 1 EMR 1 ICU beds 1 CT scan - 2 Inpatient Bed
Biggest Obstacle for LOS of Discharged Patients 7 1 1 1 2 3 3 4 Intoxicated Patient Paperwork RN Free to Do Dc Consults EMR Getting DC Done Ancillary Services Bed 2008 Answers Ancillary - 9 Beds 7 PMD 1 Work Ups 1 Academic 1 Social Issues - 1 2007 Answers ED beds - 6 Tests - 4 Nursing shortage 2 Getting dc done 3 Nursing productivity 1 High census 1 Specialist 1 Physician decision - 1
On Call Problems issues over past year Call Panel Issues Improve Each Year; ENT & Hand # 1 5 5 6 1 1 1 1 1 1 2 2 3 3 3 GI GYN Neurology Opthalmology Orthopedics Vacular Neurology Oral Surgery Neurosurgery Plastic Urology ENT Hand No Problem Number of Hospitals with No On Call Concerns 6 4 3 2009 2008 2007
Triage Do you initiate orders from triage 100% YES How Often? Routine - 4 When Busy - 3 If More than 5 in WR - 1 Rare (8-20%) 3 hospitals
Provider in Triage No 13 hospitals Yes 6 hospitals (down for 9 last year) Occasional Resident NP, PA MD 6 days a week
Pharmacist No Pharmacist 9 Trialed - 1 Pharmacist 9 Available For trauma Scheduled FTE - 4
Medication Reconciliation Manual entries are done by RN or pharmacists 11 8 Electronic Manual
Greeter No 5 hospitals In process 1 hospital Yes 13 hospitals ( last year 10) RN Volunteer, rare 8 Hours / Day Volunteer 24/ 7
How Hospitals Manage Surge Most Hospitals Add Bed Capacity When Surge Occurs 16 12 3 4 Beds On Call Docs On Call Nurses Administration
Clinical Turn Around Times All hospitals have some form EKG- 16 hospitals (13 last year) 5 min or 10 min Antibiotics 19 hospitals (probably all for pneumonia) < 6 hours, 10 hours for pneumonia < 3 hours, < 4 hours for infection < 2 hours for febrile child (Children s) Pain 3 hospitals <1 hours 2 hospitals for sickle cell patients ED bed for sick patient 5 hospitals On arrival, 15 min, 20 min Time for Consultant 2 hospitals measure 1 in EMR 2 hospitals in process
Nursing Report Delays in Getting Patients Upstairs for Admission Fax Report - 5 No Report, Patient taken upstairs 1 30 minute Rule Involve Leadership - 4
Holding Orders No 2 Yes 17 Some minimal Some mandatory Limited for hospital that has computer access for docs to write orders remotely All should have expiration times; minimal orders No change from last year
Do you Repatriate Patients? Yes 14 Kaiser Sharp Scripps Patient requested transfers No, unless requests - 1
Major Work Ups in the ED Yes 13 Try to Avoid 2 Sometimes 2 Only if Admitted - 1
Admit First Time TIA Controversial among neurologist. Neurologist on County Stroke Task Force have recommended admission for first time TIA, but this is unofficial Yes Admit 16 100% - 7 High Risk 1 Frequent - 8 No Admit - 1 (last year 3)
Clinical Protocols/ Guidelines 17 hospital YES Order sets Many on line guidelines Only STEMI, Stroke 2 hospital - NO
THANK YOU ALL FOR MAKING THIS DATA POSSIBLE