ED Overcrowding VHA Template

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Information about ED Overcrowding VHA Template
Science-Technology

Published on January 12, 2009

Author: aSGuest10189

Source: authorstream.com

ED Overcrowding : ED Overcrowding What can we do about it? Type in your name here Your Title Organization name Overcrowding in the ED ... : Created by Delaney / Palomba, UMMHC-HealthAlliance 2005 2 Overcrowding in the ED ... … the problem lies not in the Emergency Department, rather it is a hospital-wide concern. The Emergency Department : Created by Delaney / Palomba, UMMHC-HealthAlliance 2005 3 The Emergency Department America’s Healthcare Safety Net Open 24 / 7 / 365 Highly trained Physicians and Nurses Open to all-comers EMTALA Major and minor treatment “Front door to the hospital” : Created by Delaney / Palomba, UMMHC-HealthAlliance 2005 4 “Front door to the hospital” Emergency Department Insert a picture of your hospital here Who visits us? : Created by Delaney / Palomba, UMMHC-HealthAlliance 2005 5 Who visits us? ED patients = --- / day (plus at least 1) --- / day through those doors Nearly --- K “ED visitors” per year For the majority, this is their only impression of “the hospital” Approx. -- % LH admission rate Only ---- get the “inpatient experience” : Created by Delaney / Palomba, UMMHC-HealthAlliance 2005 6 Where should we focus of our efforts to improve patient’s perception? Inpatient or ED ------ guests see the ED vs ---- guests go “upstairs” $$$ and the ED ?? : Created by Delaney / Palomba, UMMHC-HealthAlliance 2005 7 $$$ and the ED ?? Approx. -- % of hospital admissions Indirect revenue Ancillary services Procedures Billable supplies Approximately --- % of lab and radiology volume (and revenue) Emergency Medicine What’s our business? : Created by Delaney / Palomba, UMMHC-HealthAlliance 2005 8 Emergency Medicine What’s our business? Get em in … Get em treated … … Get em out … Move on … Keep the tub full, but don’t clog the drain Simply, if no Output, then Overflow : Created by Delaney / Palomba, UMMHC-HealthAlliance 2005 9 How do we handle the ED Overcrowding Crisis? ED Overcrowding : Created by Delaney / Palomba, UMMHC-HealthAlliance 2005 10 ED Overcrowding To Decompress the ED you must either; close the front door Ambulance diversion Wait till they give up (LWBS) or Open the back door Allow the crowd that’s present to leave Left Without Being Seen (LWBS) : Created by Delaney / Palomba, UMMHC-HealthAlliance 2005 11 Left Without Being Seen (LWBS) Patients register, and are triaged, and leave before being seen by a physician 1991 study: 46% of LWBS needed medical attention 11% were admitted to hospital within a week Major source of patient dissatisfaction Nobody cared about me “I had an emergency” but they made me wait Overall a Negative Experience Cost of LWBS ??? : Created by Delaney / Palomba, UMMHC-HealthAlliance 2005 12 Cost of LWBS ??? At least $ --- each patient Your Organization’s ED Average = -- a day LWBS cost? $ ------/year Plus cost of follow up Research Complaints Return later / need more care Don’t return is worse!! Overcrowding Myths : Created by Delaney / Palomba, UMMHC-HealthAlliance 2005 13 Overcrowding Myths Inappropriate Patients Diversion Transfer Out Board Patients in the ED Inappropriate patients : Created by Delaney / Palomba, UMMHC-HealthAlliance 2005 14 Inappropriate patients Who are they? Poor, Uninsured, Unnecessary, Imprudent What are the myths? They don’t belong - shouldn’t have come Waste our resources Sore throats don’t delay MI care Myth #1 Diversion : Created by Delaney / Palomba, UMMHC-HealthAlliance 2005 15 Diversion If the ED is full divert to another? Not a Healthy Option ! Myth #2 Transfer Out : Created by Delaney / Palomba, UMMHC-HealthAlliance 2005 16 Transfer Out No room at the inn? Just call another hospital to admit! No Good !! Labor intensive / ED staff needed elsewhere ED staff time to make the transfer: Phone calls, Paper work, Different procedures at each site Increased Risk Transfer to where? If our house is full, whose isn’t? and WHY? Cost? Myth #3 Transfer Out Costs? : Created by Delaney / Palomba, UMMHC-HealthAlliance 2005 17 Transfer Out Costs? Average $ ---- per patient per day Transfer just 1 patient per day = $ --- K / year Our transfer average = -- / dayAs a result, we sent away over a million dollars ($ --------- ) ICU Transfers average $ ----- / ptTransfer just 1 a week = loss of over -- million dollars per year. Transfer Out : Created by Delaney / Palomba, UMMHC-HealthAlliance 2005 18 Transfer Out ICU Utilization “holding an ICU bed for crashes” ? Revenue lost per empty bed ? # of times utilized vs. # transfers out -- bed ICU staffed for -- ??? -- % utilization ??? “91% of ED Directors report overcrowding as a major problem” - American College of Emergency Physicians Study : Created by Delaney / Palomba, UMMHC-HealthAlliance 2005 19 “91% of ED Directors report overcrowding as a major problem” - American College of Emergency Physicians Study Contributing to this were the following: High volume/acuity Radiology delays Laboratory delays Consultant delays Insufficient space Yet, the #1 reason sited for Overcrowding in the ED:Caring for already Admitted patients ... … a.k.a BOARDERS! Boarders : Created by Delaney / Palomba, UMMHC-HealthAlliance 2005 20 Boarders Patients who remain in the ED after decision has been made to admit. Reasons? lack of inpatient beds staffing levels patient complexity Problem: Boarders still require care and staff time while in ED, and most importantly they occupy a bed that other ED patients need. Myth #4 Got Boarders?So … just call in more ED staff : Created by Delaney / Palomba, UMMHC-HealthAlliance 2005 21 Got Boarders?So … just call in more ED staff NO Good !!! Staffing to “regular” is already difficult Where do the “extra” staff come from? Still need to care for the 50K ED pts. ED staff are specially trained in ED care Call in appropriate staff for INPATIENTS Admitted patients must “board” until room is ready : Created by Delaney / Palomba, UMMHC-HealthAlliance 2005 22 Admitted patients must “board” until room is ready NO Good !!! More square footage in inpatient areas than ED - bigger hallways too! Specialty staff trained for that area Use conference rooms/sun rooms/ waiting rooms upstairs EVERY objection to placing a patient in inpatient hallways also applies in to the ED. Cancel “elective” Surgery : Created by Delaney / Palomba, UMMHC-HealthAlliance 2005 23 Cancel “elective” Surgery NO Good !!! Minor surgery already taking care of “electives” outpatient/same day “Elective” not done today becomes “emergency” tomorrow Potentially would eliminate all elective procedures Impact of rescheduling on patient ! All surgery must be considered “emergent” What is the Response to the ED when a patient needs an admission? : Created by Delaney / Palomba, UMMHC-HealthAlliance 2005 24 What is the Response to the ED when a patient needs an admission? Surgical Patient - OR & PACU notified and and mobilize staff ASAP OB Patient (in labor) – “Send them up” M/S, Tele, or ICU Patient - ??? Inpatient Responses: : Created by Delaney / Palomba, UMMHC-HealthAlliance 2005 25 Inpatient Responses: “No beds” “Not my problem” “Discharges can’t leave yet” “MDs didn’t round” “Hold till change of shift when we have more staff” “Bed’s not clean yet” (M/S, Tele, ICU) ED - Current flow : Created by Delaney / Palomba, UMMHC-HealthAlliance 2005 26 ED - Current flow ED Treatment Rooms:21 available Flow: One patient out = another one in National Benchmark: 1 treatment bed per 2,000 annual visits WaitingRoom ED Treatment Rooms Overcrowding… : Created by Delaney / Palomba, UMMHC-HealthAlliance 2005 27 Overcrowding… As the 21 available slots fill up, the waiting room begins to “back up” Increased wait time = decreased satisfaction = increased LWBS = decreased revenue WaitingRoom ED Treatment Rooms ED with “Boarders” : Created by Delaney / Palomba, UMMHC-HealthAlliance 2005 28 ED with “Boarders” Same incoming patients Less “slots” available Longer delay from waiting room And the beat goes on ……….. ED Treatment Rooms Boarders WaitingRoom Slide 29: Now we’re drowning!! “Boarders” are Admissions. : Created by Delaney / Palomba, UMMHC-HealthAlliance 2005 30 “Boarders” are Admissions. According to JCAHO!! All admitted patients must receive the same standard of care regardless of their physical location It is simply not possible in the ED Same standard of care? : Created by Delaney / Palomba, UMMHC-HealthAlliance 2005 31 Same standard of care? ED staff cannot provide needed emergent care when worried about where to put the next incoming! Admissions to appropriate areas : Created by Delaney / Palomba, UMMHC-HealthAlliance 2005 32 Admissions to appropriate areas Increases patient’s level of appropriate care Decreases inpatient length of stay (LOS) Increases hospital discharges Improves discharge times (out faster to get these patients in that room) x X X x Opens ED rooms to more ED patients In the hall upstairs ??? Yes !!! Because… : Created by Delaney / Palomba, UMMHC-HealthAlliance 2005 33 In the hall upstairs ??? Yes !!! Because… Inpatient units are LESS Crowded LESS chaotic LESS noisy Provide appropriate clinical expertise Inpatient hallway placement will result in closer AND faster access to room Who’s the winner here ????? the PATIENT Priority of Hallway placement : Created by Delaney / Palomba, UMMHC-HealthAlliance 2005 34 Priority of Hallway placement Medical/Surgical Admissions 30 minutes to floor Patient with little or no co-morbidity Patient with minimal or moderate co-morbidity Telemetry Admissions Little or no co-morbidity Low index of suspicion for cardiac event Telemetry box available (portable OK) Exclusions to Hall Placement : Created by Delaney / Palomba, UMMHC-HealthAlliance 2005 35 Exclusions to Hall Placement ICU Admissions (Provided ALL ICU beds are full) Rule-in MI or at high risk for cardiac event Ventilator dependent patients Patients requiring negative pressure or Isolation rooms Patients requiring > 4 liters O2 via n/c Key points : Created by Delaney / Palomba, UMMHC-HealthAlliance 2005 36 Key points Admitted patients are a hospital systems problem The ED is essential, and it is not a replacement for everything The ED is NOT an effective back-up unit Place the admitted patients in the appropriate hospital treatment locations that can handle it. Do the right thing for the patient. Take home message … : Created by Delaney / Palomba, UMMHC-HealthAlliance 2005 37 Take home message … … it is really the acutely ill patient who is waiting in the ED for a hospital bed who creates the bottleneck that leads to overcrowding, diversions, and essentially a breakdown in the entire system. Our Mission : Created by Delaney / Palomba, UMMHC-HealthAlliance 2005 38 Our Mission Get every patient to the best resources in the right place and in the shortest time. Where do we go from here?Immediate changes: : Created by Delaney / Palomba, UMMHC-HealthAlliance 2005 39 Where do we go from here?Immediate changes: Bring this information to PI Flow team Require full representation Admission Criteria Potential discharges given at at 09:30 bed meeting Floor assignment given upon admission - not phone tag 30 minute transfer to room once assigned … period SMT support !! Pt flow team Goal- 3 months : Created by Delaney / Palomba, UMMHC-HealthAlliance 2005 40 Pt flow team Goal- 3 months Encourage “ownership” of admitted patients Invite OB to share strategies with other inpatient units Create environment of “Pull up” vs. “Push out” of ED Mandatory training for all staff? Incentives for inpatient staff? (contests?) Identify discharge goals to open beds Care pathways for most common diagnosis i.e. R/O MI = labs at predetermined (0 / 6 / 12) hours then off tele (like UMass), instead of waiting for PCP to round Revise Full bed Protocol PI flow team to review best practice Include provisions for “Adopt a boarder” Goal- 6 months : Created by Delaney / Palomba, UMMHC-HealthAlliance 2005 41 Goal- 6 months Fill all FTEs on inpatient units Staff beds to current census Increase telemetry capability on FW Institute Realistic Full capacity protocol Real life / not just on paper Include “adopt a boarder” placement as strategy Consider discharge nurse Identify D/C early Review plan of care Make arrangements and follow up Frees up the RN Ultimate goal : Created by Delaney / Palomba, UMMHC-HealthAlliance 2005 42 And Your Organization's Name will be a model for others to follow Ultimate goal Safe appropriate patient care provided at Your Organization’s Name Increased revenue Improved patients’ perceptions and ED morale Inpatient Units / ED Partnership Hospital wide Environment of Cooperation and Respect Insert a picture of your hospital here

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