Critical Path Network: LOS project drops ED stay for low-risk chest pain patients
Critical Path Network
LOS project drops ED stay for low-risk chest pain patients
Team focused on delays in testing
At the end of a project to improve throughput in the emergency department, the length of stay for patients with low-risk chest pain dropped from an average of more than 30 hours to an average of between 20 and 24 hours at two hospitals in the Sharp HealthCare system.
Chula Vista Hospital and Sharp Grossmont Hospital chose the low-risk chest pain patients for a Lean Six Sigma project because they represented a high volume of patients in the ED, says Patricia Atkins, MS, RN, CNS, director of Lean Six Sigma for the San Diego-based hospital system and a certified ASQ Six Sigma Black Belt.
Case managers in the emergency department were part of the multidisciplinary team that took on the project, which involved the entire cardiac service line.
Before beginning the project, the team analyzed the patient throughput process and chose a segment on which to concentrate.
"Tackling the entire process from admission to discharge is not always the ideal way to run a project. It's almost too big. It's better to do what we call a business process map and break it down into segments and to develop a project depending on what the data show is an opportunity for improvement," she says.
The chest pain project concentrated on patients with a low risk, who presented with a normal EKG, indicating that they were not having an active myocardial infarction.
"These are observation patients and they often tie up the emergency department waiting for a bed," Atkins says.
Patients were excluded from the study if they had diabetes, were older than 65 years old, or had other comorbid conditions.
"We looked at the entire cycle time from admission to discharge and did a value stream map to determine the roadblocks to a speedy examination and discharge," Atkins says.
The team researched evidence-based medicine and standard practices of the American College of Cardiology, using the information they found to set realistic goals on how long the patients should be in the hospital.
"Our low-risk patients were staying an average of 30 hours or more. Some studies showed that they could be in and out in between 12 and 18 hours. This meant we had to get the labs done faster and adjust the laboratory tests so they are drawn more frequently. We had to influence physician behavior to shift from traditional to more evidence-based," she says.
Tracking stress test orders
The team discovered that the patients spent a significant amount of time waiting for orders for a stress test and that there were a lot of variations and delays in the scheduling and forming of stress tests.
"Our analysis showed that this was where the project should focus as opposed to the discharge portion of the emergency department visit," she says.
The team observed the processes during the emergency department stay of low-risk chest pain patients and talked to the stress test scheduler and other staff members to get a good understanding of how the system works.
"Every hospital has a different system and structure. Our key role on this committee was to observe what was going on and ask questions about why the staff were doing what they were doing," she says.
The team discovered that the process of issuing orders for the stress test was a two-step process that sometimes caused delays.
At the time, physicians would issue the orders for a stress test and then the emergency department staff had to fill out a separate form and fax it to the stress test scheduler.
"We were able to eliminate unnecessary complexities in the project simply through developing standard orders. We merged the two forms so now the order set is faxed to the scheduler. It eliminated an extra step and extra paperwork," she says.
The team worked with the physicians in the noninvasive cardiology department to determine which patients really need a stress test and whether they need a walking treadmill test or a nuclear medicine study.
"We worked on a protocol with the physicians to determine who could have just a walking treadmill. The nuclear medicine study is more expensive and takes a lot longer and not everybody needs that," she says.
While the project was going on, the team continued to look at patients who were positive for a myocardial infarction, making sure that the new procedures didn't eliminate patients who needed to be admitted.
"We wanted to make sure that we didn't miss anyone because we were being too aggressive," she says.
The team was able to collect data to show that moving the patients through quickly did not result in detrimental outcomes.
"Monitoring outcomes is critical to making sure that people don't revert back to their old practices," she says.
Selecting QI projects
Atkins recommends tackling quality improvement projects for high-volume conditions in which patients are fairly homogeneous, making it easier to develop standard protocols.
"It's pretty easy to influence physician behavior with low-risk chest pain patients as opposed to a condition with a lot of variations and not a lot of evidence, such as managing acute acidosis, which occurs in patients with a wide variety in their disease patterns," she says.
It's best to develop a project that can be completed in four to six months, she suggests.
"If people don't see results in a fairly short period of time, they tend to lose interest," she says.
Pick an area on which to focus, rather than tackling a huge project all at once, she recommends. For instance, if your goal is to improve length of stay, you might start with the admission process and then move to the next step.
Put as much effort into sustaining the improvement as you did into developing the improvement strategy, she adds. "If you take a piece of it and improve it, you have to allow enough time to sustain it. It almost always takes longer and more effort to sustain than to improve," she says.
Traditional process improvement projects that involve only creating improvements in one area and then moving on, never hit the mark, she points out.
"If you don't dedicate effort to sustaining the change, people will go back to their old ways. You must show the staff you're serious by attention, enthusiasm, and data," she says.
(Editor's note: For more information contact Patricia Atkins, director of Lean Six Sigma, Sharp Healthcare, e-mail: [email protected].)
At the end of a project to improve throughput in the emergency department, the length of stay for patients with low-risk chest pain dropped from an average of more than 30 hours to an average of between 20 and 24 hours at two hospitals in the Sharp HealthCare system.Subscribe Now for Access
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