Coordination of Multiple Departments to Improve ED Throughput February 2011 Chad Faiella RN, Terri Martin RN 1
Agenda OhioHealth information Grant Medical Center facts Bed assignment process Key takeaways Discharge by noon Key takeaways Census Alert / Code Expedite Key takeaways Questions
OhioHealth Fact Sheet Total Operating Revenue: $2.1 billion in FY 09 18 Hospitals serving a 46 county region 8 Owned 10 Affiliate Hospitals 20+ Ambulatory Locations Net Income: $128M 6th largest employer in Central Ohio Profile: 93,000 inpatient admissions 15,000 Employees 59,000 surgical procedures 2,300 Physicians 346,000 emergency room visits 5,500 Volunteers 1.8 million outpatient visits 182,000 adjusted admissions $5 billion gross revenue 3
Grant Hospital Columbus, OH Level 1 Trauma Center Average Daily Census in FY10 233 307 Total Beds 30 Critical Care 51 intermediate Care Beds 226 Medical Beds
Importance of a Solid Process An efficient bed assignment process for patients contributes to the success of ED throughput and patient satisfaction. A Astandard d Census Alert process provided d a clear understanding of each disciplines role.
Grant Throughput Timeline Nov 2007 Bed Assignment Sept 09 Process D/C by noon Revision Conclusion Aug 08 Discharge by noon Nov 09 Census Alert/ Code Expedite Revision i
Grant Throughput Timeline Nov 2007 BdA Bed Assignment Process
Before & After - Bed Assignment Process Before X X X 16 STEPS REMOVED X X X
Before & After - Bed Assignment Process Before Default process was to STOP - asked for permission to place patient Inefficient communication, inaccurate bed board, phone tag Floors periodically asking that patient assignment be held until bed on my unit is available Small percentage of patient moves out of ED being done by Transport Assigned dirty beds (not yet available) No defined d plan for shift change
Before & After - Bed Assignment Process After 25% REDUCTION IN PROCESS STEPS
Before & After - Bed Assignment Process After Default process is to GO (bed is assigned and floor is paged) Simpler communication, page is primary means of signaling Only clean beds assigned (available now for occupancy) Bed ahead process allows the charge RN remains in control of where Bed Management is to place their next patient Maximized use of Transport to move patients, Leading to more accurate bdb bed board Default plan for shift change; existing placements continue to move, no new bed assignments between 6:45 7:30 AM and PM; thereafter, assignments continue
Bed Assignment Process Year to Year Throughput Comparison Patient Throughput Times - Admit Orders Written to Patient Discharge 300 250 Started new Process FY 07 FY 08 Linear (FY07) Linear (FY08) 200 tient Minutes/Pat 150 100 50 0 July August September October November December January February March April May June
Bed Assignment Process Admission Times - Orders Written to ED Discharge 240 200 Bed Assigned to Patient In Bed Orders Written to Bed Assigned Average Daily Census 300 270 240 Minu utes/patient 160 120 80 New Process Started 210 180 150 120 90 40 60 30 0 0 Oct 07 Nov 07 Dec 07 Jan 08 Feb 08 Mar 08 Apr 08 May 08 Jun 08 Jul 08
Bed Assignment Process Key takeaways Entire management team was unified to achieve a common goal and support was achieved at the highest levels of the hospital. Momentum was created during this project that enabled the remaining projections to build upon the original gains. Weekly results to all managers and directors individualized to their area. Weekly meeting with all directors and managers to discuss results and lessons learned.
Grant Throughput Timeline Nov 2007 Bed Assignment Process Aug 08 Discharge by noon
Discharge By Noon Discharge Before Noon Flow Chart 8:30 AM 8:45 AM 2:30 PM 3:00PM 3:30 PM Charge Nurse Case Manager Meet to discuss: Potential discharges for day Review list of discharges for before noon today from previous days 3:00 meeting Assisting RN staff with patient D/C's Approaching RN staff to assist with coordinating patients discharge before noon. Meet to discuss: Review today's potential D/C's before noon that did not take place and why? Review potential discharges before noon for next day and document on Discharge Tracking Tool Approaches individual RN's taking care of patients on the potential discharge list before noon for the next day to review what needs followed up on that evening to insure D/C before noon the next day
Discharge By Noon D/C before Noon Process Started Sept 16 th 2009 Management Support Needed: To confirm that Case Management and Charge RN are meeting in the Am and PM PEx and Case Management manager will round on floors and participate i t in meetings daily Weekly discussions around percent of D/C before noon and review why D/C s did not take place before noon Discussions i start t Sept 30 th 2009
Discharge By Noon DATE DISCHARGE TRACKING TOOL UNIT Name/Room DC by noon Today's Discharges Reason DC after noon Name/Room Tomorrow's Discharges What needs to be done to facilitate discharge Charge RN Case Manager
30% 25% 20% 15% 10% Discharge By Noon Percent of Discharges Before Noon Jan 08 Jan 10 Mar 10 Mar 08 May 08 Jul 08 Sep 08 Nov 08 Jan 09 Mar 09 May 09 Jul 09 Sep 09 Nov 09
15:30 15:15 15:00 14:45 14:30 14:15 14:00 Discharge By Noon Median DischargeTime Jan 08 Mar 08 May 08 Jul 08 Sep 08 Nov 08 Jan 09 Mar 09 May 09 Jul 09 Sep 09 Nov 09 Jan 10 Mar 10
40% 35% 30% 25% 20% 15% 10% 5% 0% Discharge By Noon 7th Floor %D/C Before Noon Percent_Before_Noon Median D/C Time 16:10 15:50 15:30 15:10 14:50 14:30 14:10 13:50 13:30 6 Dec 13 Dec 20 Dec 27 Dec 3 Jan 10 Jan 17 Jan 24 Jan 31 Jan 7 Feb 14 Feb 21 Feb 28 Feb 7 Mar 14 Mar
Discharge By Noon Key takeaways Utilized existing management forum established during Bed Assignment Process by splitting the agenda evenly between throughput reviews and discharge by noon performance. Leadership support and associate level by-in to ensure process is followed and managed Physician understanding of the process and the impact on throughput for the hospital
Grant Throughput Timeline Nov 2007 Bed Assignment Process Sept 09 D/C by noon Revision Aug 08 Discharge by noon Nov 09 Census Alert/ Code Expedite Revision
Census Alert / Code Expedite Code Expedite Evaluation Reviewed current process and didentified dgaps. Established specific criteria to call a census alert and code expedite. Collected data for an 18 day timeframe to evaluate sensitivity of criteria. Identified root causes of frequent code expedite situations during the data collection timeframe. Modified dcode expedite flow to achieve an effective and meaningful process.
Census Alert / Code Expedite ED Hold Opportunities from 6/29-7/16 23% Delay in filling staffed beds 22% 10% 45% Not staffed to current capacity Not staffed to stretch capacity Beyond stretch capacity
Census Alert / Code Expedite Changes from Current State: Added a preliminary warning to nursing. Added criteria with plan to decompress within 2 hours Case Management should look at both potential discharges and Observation and Outpatients in a Bed Every physician will not be contacted, CM / Charge RN to contact c physicians s as appropriate. Give feedback that Code Expedite is over. Review Code Expedites to ensure standardization
Census Alert / Code Expedite
Census Alert / Code Expedite Standard Work Specific to each Discipline 7th Floor Job Duties for Charge Nurses during a Census Alert and Code Expedite Urgent bed huddle 30 minutes after Census Alert/ Code Expedite announced Census Alert Code Expedite 1. With Case Manager, identify pts requiring diagnostic testing / treatment before discharge. testing. (Case Management contact depts. 8am-5pm; Chg RN contact depts. 5pm-8am.) 3. With Case Manager, expedite discharges by contacting specific physicians for orders, etc. 4. Work with physician to reschedule non-emergent studies that may delay discharge. 5. Notify Medical Director of patient care unit if any physicians resisting desired plan. 1. With Case Manager, identify pts requiring diagnostic testing / treatment before discharge. 2. Notify key dept at specified phone number(s) to communicate pt priority 2. Notify key dept at specified phone number(s) to communicate pt priority testing. (Case Management contact depts. 8am-5pm; Chg RN contact depts. 5pm-8am.) 3. With Case Manager, expedite discharges by contacting specific physicians for orders, etc. 4. Work with physician to reschedule non-emergent studies that may delay discharge. 5. Notify Medical Director of patient care unit if any physicians resisting desired plan. 6. Assess and adjust staffing levels to be at stretch capacity. 6. Call Bed Management (566-9001) with a male and female bed within 15 mins of code expedite being called. Census Alert and Code Expedite Criteria Chain of Command Criteria Census Alert Code Expedite (for questions or if meeting barriers) ED Admits with orders holding 5 6 Dayshift Nights and Weekends >100 mins PACU pts holding >30 mins after ASA guidelines are met Approaching critical RN/Pt ratios 2 3 Determined by RN Administrator One critical care bed available Determined by RN Administrator No critical care beds available Critical Care Capacity One step down bed No step down Step Down Capacity available beds available Direct Admits/ED Admits 3 Direct Admits / 2 Direct Admits / 2 ED pts holding >100 mins 3 ED pts Ancillary Departments Phone List Ultrasound 566-9516 CT Scan 566-9987 Diagnostics 566-9519 Vir (M-F 0600-1700) 566-9533 MRI (M-F 0600-2300 Sat 0600-1530) 566-8996 MRI & VIR on call hours contact the File Room Laboratory Nuclear Medicine (M-F 0600-1530) Speech Therapy (Paging instructions)* Physical/Occupational Therapy (Paging Instructions)* Transport (614)842-0908 EVS 618-0568 *PT/OT & Speech Paging Instructions: 1. Click on OH Net icon 2. Type usamobility.com in the address bar 3. Click on Send a Message 4. Step 1 screen appears: type the pager number here, must include area code, click continue 5. Step 2 screen appears: type the text message, click send Administrative Nurse Manager Nurse Administrator Nursing Director (Vicki Graymire) Nurse Administrator On-Call Manager On-Call Nursing Director Chief Nursing Officer Chief Nursing Officer (Donna Hanly) (Donna Hanly) Nursing Director Vicki Graymire (cell) 460-9012 Medical Director Dr. Steve Santanello Staffing Levels Per Floor Current Capacity Stretch Capacity 566-9350 Floor Beds Floor Beds 566-8827 7 20 7 24 566-9384 (614)672-0020 (614)618-0011 Negative Air Flow Rooms 737
Census Alert / Code Expedite Measures of Success Throughput Time ED Elopements ED Diversion hours
Census Alert / Code Expedite 22.5% ED Elopement % 300 20.0% 250 17.5% 15.0% 12.5% 10.0% Modifie ed 200 150 Monthly Elopement % Goal Average Daily Census by Month 7.5% 100 Average Daily ED Visits by Month 5.0% 50 2.5% 0.0% 0 May 09 Jun 09 Jul 09 Aug09 Sept 09 Oct 09 Nov 09 Dec 09 Jan 10 Feb 10 Mar 10
Census Alert / Code Expedite GMC ED: DIVERSION HOURS BY MONTH 80 70 60 50 40 30 20 10 0 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 HOURS 0 12 9.39 23.85 72 0 34.21 18.3 24.13 0 0 0 0 MONTH/YEAR
Census Alert / Code Expedite Key takeaways Have a clear understanding of the delay opportunities Leadership support and associate level by-in to ensure process is followed and managed Identify the role of each discipline involved Measure only what you are going to take action on
Summary Oct-07 Feb-10 Admit Time 180 124 ED Elopment 6.70% 3.40% ED Hours of Care 3.4 2.5 Diversion 17.5 0
Questions For further info feel free to e-mail me Chad Faiella RN cfaiella@ohiohealth.com fill@hih lh