S

Efficiency in the Emergency Room

By: Jessica Comerford, Roberto Ayala,Kyle Meissner

Have you ever?

Gone to the ER and had to sit and wait for hours before being seen?

Left an emergency room with unsatisfied treatment?

Felt rushed or ignored in an emergency room ?

PROBLEMIn-Efficiency in the Emergency Room

Over the last decade, more and more Emergency departments are suffering from “overcrowding “

CONTRIBUTING FACTORSThere are many factors that contribute to this ongoing problem, among some of the more prevalent issues are:

Non emergency patients receiving “care “ at the emergency room causing overcrowding and poor utilization of resources. Especially over the last few years, with the changes occurring in the health care industry,

The high flow of uninsured patients

Utilization of the ER for prescription fills and pain management

Uneducated discharged patients after shortened shortened hospital stays.

WHY IS THIS SUCH A PROBLEM?

The in-efficiency of today’s emergency rooms has an impact on all areas of patient care, including quality of care, access of care and wait time for care which all greatly affect customer satisfaction.

0 to 1 1 to 2 2 to 3 3 to 4 4 to 5 5 to 6 6 >65%70%75%80%85%90%95%

Patient Satisfaction by Time Spent in ED

HoursOve

rall

Pat

ien

t S

atis

fact

ion

Annual ED visits have increased in the past 10 years from 90.3 to 119.2 million (32% increase). With the new healthcare bill it is expected that the average ED will have increased volume of 6,500 patient visits.

Number of ED’s have decreased 4019 to 3833, a 7% loss.

Less ED’s and more ED visits have resulted in ED overcrowding.

Pain has been deemed the “fifth vital sign” that should be routinely monitored. It is one of the leading complaints for patients in the emergency department. Knox, T. MD, MPH, Medscape Emergency Medicine. 2009 Mount Sinai School of Medicine reported a study of ED overcrowding and pain management.

The authors showed at peak census, that on average, patients waited 55 minutes longer for pain assessments and 43 minutes longer to receive analgesics. Hwang, U. Acad. Emergency Medicine 2008; 15: 1248 –1255

OBSERVATIONAL RESEARCH

OBSERVATIONAL RESEARCH

Patients admitted during high ED crowding have 5% greater risk of dying December 6, 2012 | By Alicia Caramenico

High emergency department crowding is associated with increased inpatient mortality, as well as moderate rises in length of stay and costs, concludes a new study in the Annals of Emergency Medicine.

Patients admitted to the hospital during high ED crowding times had 5 percent greater risk of inpatient death than similar patients admitted to the same hospital when the ED was less crowded.

The researchers looked at almost 1 million ED visits resulting in admission to 187 hospitals and used daily ambulance diversion to measure ED crowding, according to a research announcement today.

They found that on days with a median of seven ambulance diversion hours, admitted patients had a 0.8 percent longer hospital length of stay and 1 percent higher costs.

Strategy

Improve ED efficiency by improving patient flow, maximizing resources, developing community based patient education, and implementing a change management culture.

Questions that need to be ask?

Is there enough capacity?

What is the resource utilization rate?

What causes patients wait times?

What is the throughput rate and time?

What is the best possible solution(s)?

Action Plan Assess ED visits by acuity and wait times for use when structuring a

patient flow process. Develop educational programs with the hospital discharge department

and the community health leaders. Create and promote ambulatory programs for patients who require

non emergent care. Establish a SOP- standard operating procedure to assist in

streamlining patient flow incorporating innovative ideas and creative solutions including an electronic tracking system.

Establish a Performance Improvement program that monitors and reports out monthly metrics addressing wait time, expected outcomes, admissions, mortality and customer satisfaction

Develop a culture where Change management , metric review and customer satisfaction is the focus.

Designate Triage areas for patient based on acuity. Develop and implement customer satisfaction surveys for patients to

provide feedback for the ED. Have staff meetings once a month to asses progress, and identify new

ideas.

Facilitating Change, Anticipating Challenges

Facilitating change often involves anticipating common challenges and taking steps to forestall them. We recommend several strategies for addressing those: challenges

Challenge Recommended Approach

Rationale

Culture change

Constant reinforcement of the strategy by leaders

Signals to staff that the improvement strategy will become standard procedure

Staff resistance

Staff education Provides staff with the capabilities andknowledge to carry out the strategy

Staff resistance

Post-implementation adjustmentsreflecting user recommendations

Signals responsiveness to staff concerns

Staff resistance, culture change, and lack of staffing resources

Use of Lean quality improvement methods

Fosters a team environment

Lack of staffing resources Staff resistance

Robust data collection Provides concrete evidence of need for action; demonstrates success to hospital leaders and frontline staff; is crucial in securing an executive champion

Production VS Quality

When it comes to being productive hospitals are at the bottom of the list. They do try but the patient numbers are always increasing at a random rate

After the input of some strategies we want to make sure we utilize them to the best of our abilities.

We want patients to be satisfied and cared for in a timely fashion.

But we also want each and every single patient to be treated in the right manner with 100% quality.

Hospitals need a good balance of excellent patient treatment but also getting it done in a timely fashion. Dr.’s shouldn’t just rush a patient out of the room because they feel their problem isn’t a life threatening issue

Productivity vs. Quality

Resource Utilization will be more tightly monitored due decreasing reimbursements.

A decrease in un-necessary testing , Unnecessary testing will be monitored and will decrease.

Health Care reforms has structured a “pay for performance” reimbursement model.

Quality outcomes will be reimbursed higher.

Readmissions to the hospital will not be reimbursed.