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Information about ENA2-final

Published on January 12, 2009

Author: aSGuest10195

Source: authorstream.com

ED Overcrowding & Throughput : ED Overcrowding & Throughput By Deb Delaney Massachusetts Emergency Nurses Association June 21,2006 Objectives : January 09 Delaney UMMHC-HealthAlliance 2 Objectives Acknowledge current situation of overcrowding Identify factors causing overcrowding Learn strategies to improve ED throughput time Understand common terminology Utilize consistent data for comparison & benchmarking Ultimate Objective : January 09 Delaney UMMHC-HealthAlliance 3 Ultimate Objective Realize ED overcrowding is a symptom of a greater problem and the ED is NOT the problem It’s so simple!! : January 09 Delaney UMMHC-HealthAlliance 4 It’s so simple!! Dave Eitel MD MBA ( ESI 5 Level triage) Factors affecting ED Length of Stay (ED LOS) : January 09 Delaney UMMHC-HealthAlliance 5 Factors affecting ED Length of Stay (ED LOS) Input Throughput Output Input = Arrivals : January 09 Delaney UMMHC-HealthAlliance 6 Input = Arrivals Who’s coming ? Emergencies & “other” Why do people present to ED Insurance Status Sicker people discharged from hospital Unavailable Primary Care Perception of quality of care Input (cont) : January 09 Delaney UMMHC-HealthAlliance 7 Input (cont) Growing number of uninsured 44+ million and growing Have no alternative Under insured Cost of insurance premiums increasing Wait longer due to $$ Saturated primary care offices Only game in town for nights & weekends Throughput : January 09 Delaney UMMHC-HealthAlliance 8 Throughput Actual ED operations Design of ED processes Registration, triage, treatment areas Staffing (type, skill, and number) Availability Specialists Diagnostic information Increased use of images Access to critical info (ie. med records, old EKGs,etc.) Throughput= ED start to finish : January 09 Delaney UMMHC-HealthAlliance 9 Throughput= ED start to finish Output : January 09 Delaney UMMHC-HealthAlliance 10 Output Hospital Admission Available beds?Staff? Transport/housekeeping Community Discharge Detox? Mental health beds? Rehab? SNF Morgue ME case? Prisoner? Religious issues? Etc. Back to OTHER Nursing home transfer Prison Urgent Matters Input / Throughput / Output Model : January 09 Delaney UMMHC-HealthAlliance 11 Urgent Matters Input / Throughput / Output Model ED overcrowding : January 09 Delaney UMMHC-HealthAlliance 12 ED overcrowding 91% of EDs in USA report “at” or “over” capacity American College of Emergency Physicians Study Contributing to this were the following: High volume/acuity Radiology delays Laboratory delays Consultant delays Insufficient space Delays threaten patient safety Delays in diagnosis & treatment decreased quality of care & poorer pt outcomes r/t delays Factors Contributing to Waiting/Overcrowding : January 09 Delaney UMMHC-HealthAlliance 13 Factors Contributing to Waiting/Overcrowding Over capacity by region : January 09 Delaney UMMHC-HealthAlliance 14 Over capacity by region Where we are…. : January 09 Delaney UMMHC-HealthAlliance 15 Where we are…. BUT… The good news is….. it’s on everyone’s radar Slide 16: January 09 Delaney UMMHC-HealthAlliance 16 Slide 17: January 09 Delaney UMMHC-HealthAlliance 17 ED “unique”ities : January 09 Delaney UMMHC-HealthAlliance 18 ED “unique”ities Open 24 / 7 / 365 Highly trained Physicians and Nurses Open to all-no referrals needed EMTALA-COBRA America’s Healthcare Safety Net Medicaid / uninsured / vulnerable populations Mix of care provided Major and minor treatment welcome here GAO Report (General Accounting Office) March 2003 : January 09 Delaney UMMHC-HealthAlliance 19 GAO Report (General Accounting Office) March 2003 commissioned by the US Senate to evaluate extent of overcrowding Data collected from July /01 thru Feb /03 Survey 2000+ hospitals (74% response rate!) Indicators for comparison Diversion Boarding Left before medical evaluation (LWBS) Findings : January 09 Delaney UMMHC-HealthAlliance 20 Findings Diversions 2/3 of the nations hospitals were forced to divert ambulances to other facilities Boarding Major cause of ED overcrowding r/t holding of admitted patients LWBS Average between 3-5% Worse in teaching hospital Increased risk and decreased satisfaction ED volume (2000) : January 09 Delaney UMMHC-HealthAlliance 21 ED volume (2000) NHAMCS 2000-National Center for Health Statistics CDC NHAMCS (2003)(National Hospital Ambulatory Medical Care Survey) : January 09 Delaney UMMHC-HealthAlliance 22 CDC NHAMCS (2003)(National Hospital Ambulatory Medical Care Survey) Updated totals… 113.9 million ED visits (another 6% increase since 2000 report) # of Emergency Departments = 4079 Another 98 EDs have closed 2003 NHAMCS stats (cont) : January 09 Delaney UMMHC-HealthAlliance 23 2003 NHAMCS stats (cont) 15.8 million patients were admitted to the hospital via the ED (14%) 2 million transfers (1.9%) 16 million arrived by ambulance (14.2%) Majority ambulance = over 65 years old Only 9% of visits nationwide were “clinic level” (or triage level 5) Slide 24: January 09 Delaney UMMHC-HealthAlliance 24 # of Hospital Beds per 1000 residents # of admissions per hospital bed Massachusetts Wait time to MD eval : January 09 Delaney UMMHC-HealthAlliance 25 Wait time to MD eval 46.5 min ave. wait to see a physician 3.2 hours average length of stay Utilization : January 09 Delaney UMMHC-HealthAlliance 26 Utilization 38.9 visits per 100 persons Medicaid enrollees = 64.2 visits per 100 Private insurance= 21.5 visits per 100 Uninsured = 34.2 per 100 # of ED visits per hospital beds : January 09 Delaney UMMHC-HealthAlliance 27 # of ED visits per hospital beds Massachusetts USA ED - Current flow : January 09 Delaney UMMHC-HealthAlliance 28 ED - Current flow ED Treatment Rooms:24 available Flow: One patient out = another one in National Benchmark: 1 treatment bed per 2,000 annual visits ED Overcrowding : January 09 Delaney UMMHC-HealthAlliance 29 ED Overcrowding As the available ED beds fill up, the waiting room begins to “back up” Manager’s office Hall #1 #2 #3 Increased wait time = decreased satisfaction = increased LWBS = decreased revenue JCAHO report : January 09 Delaney UMMHC-HealthAlliance 30 JCAHO report over ½ of all reported “sentinel events” in the “delays in treatment” category occur in hospital EDs JCAHO LD 3.15 (Leadership Standard)effective Jan 2, 2005 : January 09 Delaney UMMHC-HealthAlliance 31 JCAHO LD 3.15 (Leadership Standard)effective Jan 2, 2005 JCAHO recognizes it’s not an ED problem!!! Even changed the name From ED Overcrowding to HOSPITAL Overcrowding Hospital leadership MUST develop and implement plans to identify and mitigate impediments to efficient patient flow throughout the hospital More leadership standards : January 09 Delaney UMMHC-HealthAlliance 32 More leadership standards LD.3.20 Patients with comparable needs receive the same standard of care, treatment and service despite their physical location LD.3.30 Commitment to community by providing essential services in a timely manner So? What can we DO ?? : January 09 Delaney UMMHC-HealthAlliance 33 So? What can we DO ?? 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) : January 09 Delaney UMMHC-HealthAlliance 34 Left Without Being Seen (LWBS) Patients registered & triaged but leave before being seen by a physician Majority (60 %) went back to (or another) ED 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 ? : January 09 Delaney UMMHC-HealthAlliance 35 Cost of LWBS ? Ave $225 per ED patient LWBS average 3-5% LWBS $$ loss? At least $250,000/year Plus cost of follow up Research Complaints Return later / need more care Don’t return is worse!! US Health Care Expenditures 2004 : January 09 Delaney UMMHC-HealthAlliance 36 US Health Care Expenditures 2004 Total 1.8 Trillion Physician Services 23% Hospital care 33% Other 19% Nursing home 7% Prescription drugs 10% Other professional 8% Co$t of keeping up! : January 09 Delaney UMMHC-HealthAlliance 37 Co$t of keeping up! CT Utilization : January 09 Delaney UMMHC-HealthAlliance 38 CT Utilization Space in the hospital : January 09 Delaney UMMHC-HealthAlliance 39 Space in the hospital Emergency department The rest of the hospital Slide 40: January 09 Delaney UMMHC-HealthAlliance 40 In spite of a gazillion square feet in the rest of the hospital and a zillion more staff who incidentally are actually TRAINED in inpatient care let’s stuff all the overflow into the tiniest Busiest most critical and chaotic space in the hospital. This is Health Care Planning as a Fraternity Stunt. --Peter Viccellio MD Areas of Variability (Competing for resources) : January 09 Delaney UMMHC-HealthAlliance 41 Areas of Variability (Competing for resources) Emergency Department demand Elective procedures (seeking same resources) Discharges (opening up beds) Which factors are more easily controlled? SUNY -Stonybrook : January 09 Delaney UMMHC-HealthAlliance 42 SUNY -Stonybrook Old model New model Share the burden : January 09 Delaney UMMHC-HealthAlliance 43 Share the burden Slide 44: January 09 Delaney UMMHC-HealthAlliance 44 What can we do now? : January 09 Delaney UMMHC-HealthAlliance 45 What can we do now? Plan ahead Data collection is mandatory Feds and others need to keep hearing from us JCAHO requires full administrative support What we should NOT do! : January 09 Delaney UMMHC-HealthAlliance 46 What we should NOT do! More Ambulance Diversion Transfer elsewhere Triage out Ignore the safety net Minimize “unnecessary” visits Stop trying new ideas Give up! STOP BUT…They don’t belong here!!! : January 09 Delaney UMMHC-HealthAlliance 47 BUT…They don’t belong here!!! “Anti- Dumping Laws”- COBRA/EMTALA Patients arriving to EDs are sicker and in need of more services Only 9.1% of visits nationwide were “clinic level” (or triage level 5) (Over 90% needed legitimate ED care) Societal “safety net” : January 09 Delaney UMMHC-HealthAlliance 48 Societal “safety net” It IS what we do!! SHOUT IT OUT!! 24/7 services to all despite ability to pay Who else can say that!!! patient mix includes substantial share of Uninsured >42 million uninsured US residents (Asplin AEM 11/01 vol 8 No 11) Medicaid (36 million) & other vulnerable population Affirmed and mandated by federal legislation Increased ED burden as other social programs have eroded Why not Just build more!!! : January 09 Delaney UMMHC-HealthAlliance 49 Why not Just build more!!! Mass Laws-Department of Public Health 105 CMR 130.834 regarding ED requirements Hospital staffing based on # of staffed beds Decreased utilization and lower reimbursements reduce inpatient beds More beds for specialties ($$) reduce flexibility Reduced SNF and home health care for hospital discharges Insurance reviewers scrutiny Balanced Budget act (BBA) reimbursement changes to Medicare Slide 50: January 09 Delaney UMMHC-HealthAlliance 50 Massachusetts Census 2000 Population = 6,349,097 State Acreage Total: 5,176,255.6 Region 1 Region 2 Region 3 Region 4 Region 5 The Commonwealth of MassachusettsExecutive Office of Health and Human ServicesDepartment of Public Health250 Washington Street, Boston, MA 02108-4619 : January 09 Delaney UMMHC-HealthAlliance 51 The Commonwealth of MassachusettsExecutive Office of Health and Human ServicesDepartment of Public Health250 Washington Street, Boston, MA 02108-4619 Over the past five years The Department of Public Health (Department) has been working collaboratively with the Massachusetts Hospital Association and other stakeholders on initiatives to address problems associated with Emergency Department (ED) overcrowding, patient boarding, and ambulance diversion. This letter is one of an ongoing series that communicates to hospitals the Department’s expectations regarding policies that address these ED issues. Slide 52: January 09 Delaney UMMHC-HealthAlliance 52 The goal of all of these efforts is maintain the hospitals’ capacity to accept and manage new patients presenting for emergency care, which requires that hospitals move admitted patients out of the ED as quickly and safely as possible. This year, to facilitate the expeditious movement of patients out of the ED, the Department has reviewed the widely discussed approach of temporarily placing stabilized patients admitted through the ED, onto inpatient floors, where they can be monitored by nursing staff while waiting for a bed to become available. Recognizing that receiving care on an inpatient unit is usually preferable to receiving care while boarding in the ED, the Department will endorse this practice, and expects that hospitals will implement this option as appropriate, as one of many strategies to prevent boarding in the ED. In order to assure the safety of patients, hospitals that adopt this practice must have developed protocols approved by their governing bodies that address issues identified in Addendum A (see attached). So how do we fix it? : January 09 Delaney UMMHC-HealthAlliance 53 So how do we fix it? Understand the problem Need clinical quality measures PI / CQI / QA / TQM etc. AND also ED Benchmark data Dashboard monitors Data for comparison (vs. ourselves & others) Uniform definitions r/t ED operations State the problem clearly : January 09 Delaney UMMHC-HealthAlliance 54 State the problem clearly ED Dashboard Monitors: : January 09 Delaney UMMHC-HealthAlliance 55 ED Dashboard Monitors: Time from arrival to triage Triage time Triage to bed Bed to provider Consultant response time Overall ED length of stay Discharged ED LOS Admit LOS Staff turnover/vacancy Volume/Age/Payer mix Patient satisfaction % of Inpatient admissions originating from ED % of ED admissions Acuity LWBS Diversion hours “Boarder” hours Times from disposition to admit by unit Collect and measure : January 09 Delaney UMMHC-HealthAlliance 56 Collect and measure Choose your dashboard criteria Pick a few that are easily collectable Tracking boards? Timestamps? Daily logs? Establish GOALS Benchmarks available Diversion logsample : January 09 Delaney UMMHC-HealthAlliance 57 Diversion logsample Urgent Matters research : January 09 Delaney UMMHC-HealthAlliance 58 Urgent Matters research 10 safety net hospitals received grant ED bed assigned to ED doc Total throughput time Inpatient bed assignment till pt leaves ED Hours on diversion Disposition by MD to decision made Slide 59: January 09 Delaney UMMHC-HealthAlliance 59 Sample Performance Indicators report form Urgent Matters Benchmarking goals : January 09 Delaney UMMHC-HealthAlliance 60 Benchmarking goals Parallel Processing : January 09 Delaney UMMHC-HealthAlliance 61 Parallel Processing Slide 62: January 09 Delaney UMMHC-HealthAlliance 62 Proven Methods That have worked for others Slide 63: January 09 Delaney UMMHC-HealthAlliance 63 Slide 64: January 09 Delaney UMMHC-HealthAlliance 64 Moving admission upstairs : January 09 Delaney UMMHC-HealthAlliance 65 Moving admission upstairs Easy Cruisin’ ahead ? : January 09 Delaney UMMHC-HealthAlliance 66 Easy Cruisin’ ahead ? Baby boomer effect??? : January 09 Delaney UMMHC-HealthAlliance 67 Baby boomer generation=80 million strong Born 1946-1964 the first turned 60 this year! majority of ambulance arrivals are over 65 years of age (approx 40% are > 65) increase in visits by elderly patients past three years (59%) fastest growing segment of society now reaching retirement age Increased emphasis on cardiac care/home care/innovative treatment modalities/long term care/etc Baby boomer effect??? Don’t add roadblocks.. : January 09 Delaney UMMHC-HealthAlliance 68 Don’t add roadblocks.. But when this happens….. : January 09 Delaney UMMHC-HealthAlliance 69 But when this happens….. Have a plan : January 09 Delaney UMMHC-HealthAlliance 70 Have a plan Final thought : January 09 Delaney UMMHC-HealthAlliance 71 Final thought Our greatest glory is not in never failing but in rising up every time we fail -Ralph Waldo Emerson If we wanted easy…we wouldn’t be in the ED…. If a tree falls in the forestand nobody hears it…. : If a tree falls in the forestand nobody hears it…. Is it still the ER’s fault?

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