FLOW. fl ] [ your role in emergency

FLOW. fl ] [ your role in emergency

FLOW. fl ] [ your role in emergency wait times Brendan Munn Calgary Emergency Medicine Grand Rounds October 29 2009 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Disclosure Other than being a total control freak I have no conflicts of interest to declare. Disclaimer Too much to be boring, too little to do the subject justice. Eternal Thanks Dr. Grant Innes Dr. Lester Mercuur

Dongmei Wang Edith Lundrigan Jodi Gibson CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Objectives (Overt) 1. discuss a conceptual model of flow 2. define crowding and metrics 3. review the literature on flow (

causes effects solutions ) 4. relevance to calgary and the individual CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Objectives (Covert) 1. crowding is a (the) major ED issue

2. crowding mostly due to hospital factors, but the ED definitely has room for improvement 3. you are a unique and special flower, and have a role to play CALGARY EMERGENCY MEDICINE TEACHING ROUNDS CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Crowding

[krad] debated, unclear and variable Boarding [brd] the process of holding patients in the ED for extended periods of time Access Block

[kss blk] the prolonged wait for an inpatient hospital bed after ED treatment Priapism [pr'-pz'm ] bad news

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Conceptual Model Of Flow Asplin, Ann Emerg Med 2003 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Conceptual Model Of Overflow long term care ward ED

waiting room CALGARY EMERGENCY MEDICINE TEACHING ROUNDS contention #1 crowding is easy to define How Crowded is Crowded? Hwang, Acad Emerg Med 2004 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS A situation in which the identified need for emergency services outstrips available resources

in the ED. This situation occurs in hospital EDs when there are more patients than staffed ED treatment beds, and wait times exceed a reasonable period. Crowding typically involves patients being monitored in non-treatment areas (eg hallways) awaiting ED treatment beds or inpatient beds. Crowding may also involve and inability to appropriately triage patients, with large numbers of patients in the ED waiting area of any triage assessment category ACEP Crowding Task Force 2002 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

hard to define, but I know it when I see it Potter Stewart, Supreme Court Justice, 1964 the number of hours in which patient census exceeds designated patient care areas Welch, Acad Emerg Med 2006 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS contention #2 ED backlog is NOT a safety valve

ED waiting room CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Negative Effects of Crowding Mortality Miro 1999 (VOL) Sprivulus 2006 (OCC) Richardson 2006 Wait Times

Medical Errors Delays to Treatment Hip # Pain - Hwang 2006 (VOL) Hip # Surg - Richardson 2009 (BT) ABx Pneumonia - Fee 2007 (VOL) ACS Chest Pain - Pines 2009 (OCC) NSTEMI - Diercks 2007 (LOS) High Acuity - McCarthy 2009 Abdo Pain - Mills 2009 Pain Tx - Pines 2008 Lytics - Schull 2004 (DIV)

The effect of emergency department crowding on clinically oriented outcomes. Bernstein, Acad Emerg Med 2009 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Ambulance Diversion Burt 2005 (DIV) Redelmeier 1994 Ambulance Availability Eckstein 2004 (OOS) Schull 2003 (DIV)

Patient Elopement Hobbs 2000 (VOL) Polevoi 2005 (OCC) Provider Satisfaction Rondeau 2005 (BT) Williams 2007 (OPIN) Violence Jenkins 1998 (WT)

Financial Bayley 2005 (LOS) Falvo 2007 (OCC) Patient Satisfaction Pines 2008 (LOS, BT, WT) Vieth 2006 (OPIN) Less Teaching Shayne 2009 (VOL)

Hospital Length of Stay Krochmal 1994 (BT) Liew 2003 (LOS) Richardson 2002 (LOS) CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Waiting Room Stats Calgary CALGARY EMERGENCY MEDICINE TEACHING ROUNDS LOS Calgary

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS LWBS Calgary CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Causes and Solutions Emergency department crowding: old problem, new solutions. Bernstein, Emerg Med Clin North Am 2006. Improving access to emergency care: addressing system issues. Govt of Canada, Physician Hospital Care Committee, 2006

Hospital-based emergency care: at the breaking point. Committee on the Future of Emergency Care in the United States Health System, 2006 Ten solutions for emergency department crowding. Derlet, West J Emerg Med 2008. Systematic review of emergency department crowding: causes, effects and solutions. Hoot, Ann Emerg Med 2008. CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Input increasing volume increasing acuity

lack of alternatives surge CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Volume Acuity Tracking emergency 2000 Tracking emergency department crowding in a tertiary care

academic institution. Bullard, Healthcare Quarterly 2009. CALGARY EMERGENCY MEDICINE TEACHING ROUNDS 2007 contention #3 it is not the input itself, but what we do with it that counts inappropriate patients surge capacity CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Low Acuity Patients CTAS 4/5 represented 30% of visits but only 5% of stretchers Vertesi, CJEM 2004 10 low complexity patients per 8 hours increased mean LOS by 5 mins for others Schull, Ann Emerg Med 2007 Khane, Ann Emerg Med 2009 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

contention #4 we have the beds, they have the diseases -- why are they apart? dynamic logistical surge CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Hour of Day

Patients Registered = Patients Admitted CALGARY EMERGENCY MEDICINE TEACHING ROUNDS FMC total annual ED high acuity bed utilization in hours admitted (output) 13.7

35.3 usable (throughput) CALGARY EMERGENCY MEDICINE TEACHING ROUNDS 49 + 8 MET _______

57 beds Throughput Type of Center Triage Staffing Ancillary Services Information Technology Layout CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

contention #5 it behooves us to develop operational efficiency for ourselves for patients room to move limitations temporize economies of scale the future CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

(minutes) 116 255 28 176 investigations and consultations are important independent predictors of ED length of stay Yoon, CJEM 2003 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

EDs with combinations of low inpatient census, in-room registration, point of care testing and an urgent care area demonstrated increased patient throughput Analysis of the literature on emergency department throughput. Zun, West J Emerg Med 2009. successful strategies to improve patient flow are distinguished by an organization wide commitment to measurement, transparency in data reporting and sustained management

attention Enhancing work flow to reduce crowding. Siegel, Jt Comm J Qual Patient Saf 2007. CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Quality Improvement Applying systems engineering principles in improving health care delivery. Kopach-Konrad, J Gen Intern Med 2007. CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Manufacturing : LEAN and Six Sigma Use of LEAN in the emergency department: a case series of 4 hospitals. Dickson, Ann Emerg Med 2009. _____________________________________________ Modeling Discrete event simulation of emergency department activity: a platform for system-level operations research. Connelly, Acad Emerg Med 2004. Forecasting emergency department crowding: an external, multicenter evaluation. Hoot, Ann Emerg Med 2009.

Queuing Theory CALGARY EMERGENCY MEDICINE TEACHING ROUNDS alternative triage methods can increase efficiency bedside registration triage physician increasing the number of beds in the ED does not decrease patient length of stay Han, Acad Emerg Med 2007

Khare, Ann Emerg Med 2009 special units and even bed closures can increase throughput Kelen, Acad Emerg Med 2001 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Output Boarding Boarding Boarding Outpatient Follow Up

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Occupancy Calgary CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Generally agreed that boarding is the major culprit in ED crowding Emergency department crowding. General Accounting Office of the United States, 2003 Estey, CJEM 2003

Schull, Acad Emerg Med 2003 Fatovich, Emerg Med J 2005 Olshaker, J Emerg Med 2006 Rathlev, Ann Emerg Med 2007 Changes to ED structure and function do not address the underlying causes or major adverse effects of overcrowding [these] lie outside the ED. Richardson, Med J Aust 2006 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS contention #4a

crowding is an ED problem rest of the hospital, 1990-2009 contention #4b crowding is a non-ED problem emergency department, 2003-current CALGARY EMERGENCY MEDICINE TEACHING ROUNDS daily average ED LOS increased 18 minutes per 10% increase in hospital occupancy Forster, Acad Emerg Med 2003

elective surgery volume predicts ED gridlock McManus, Anesthesiology 2003 Litvak, Acad Emerg Med 2001 OR Manager, 2004 ED Wait Times 60 -> 40 mins, ED LOS dec by 45 minutes CALGARY EMERGENCY MEDICINE TEACHING ROUNDS shared boarding has demonstrated safety and the benefits of ownership of the crowding problem

Viccellio, Ann Emerg Med 2009 changes the inpatient units attitude toward flow the result is better flow through the entire hospital Pines, Ann Emerg Med 2009 targeted discharge planning, active bed management and improved follow-up outpatient resources are important CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Review the put 1. flow depends on in/through/output output is the major contributor but the ED has work to do in Calgary 2. crowding difficult to define simplest measures probably the best 3. solutions are multi-pronged, hospitalwide and dynamic in nature 4. intervene and evaluate benchmarks CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Throughput and the Individual In Direct Control Speed Service Use (DI, Lab, Consult) Teaching Out of Direct Control ED Factors Services Themselves Output

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Review You 1. this is our all our THE problem 2. how is your operational efficiency? 3. know your committees you are ideally situated to suggest areas of improvement 4. get involved bugle horns are $7.50 at Wal-Mart

5. patients & providers are beneficiaries CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Questions? CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

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