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Slash wait times, maximize resources with novel ED protocol
While emergency department (ED) volume is always going to be somewhat unpredictable, ED operations at Ochsner Medical Center in New Orleans, LA, used to hum along so optimally that there was no reason to rethink the way things were done. "We had 99% patient satisfaction for 15 straight quarters, and our door-to-doc time was like 20 minutes. Life was pretty smooth," recalls Joseph Guarisco, MD, chairman of the department of emergency medicine at Ochsner Health System.
But everything changed in 2006 when hurricane Katrina decimated the city, along with 77% of the region's health care resources. "We were one of the few hospitals open, so our volume nearly doubled, and it just destroyed the way we practiced," stresses Guarisco, explaining that all of a sudden, the typical day in the Ochsner ED involved long lines, people waiting, and resource constraints. Patient satisfaction plunged into the 20th percentile.
Guarisco knew he needed to find a way to move patients through the system more efficiently without utilizing more resources, so he reengineered ED operations in a way that preserves precious beds only for the sickest patients and maximizes the use of treatment rooms and waiting areas so that patients who are waiting to undergo tests or procedures aren't keeping new patients from being seen.
It has taken years to fine-tune the process, dubbed QTrack, and obtaining provider buy-in is a never-ending affair as new clinical staff are constantly rotating through the system, says Guarisco, but the results are impressive. Patient satisfaction is now back above the 90th percentile, the left-without-being-seen (LWBS) rate is below 1%, and the average door-to-doc time is in the 30-minute range.
Preserve beds for sickest patients
Guarsico's goal in developing the QTrack approach was to weed inefficiencies out of the system. For example, he felt that the hand-offs from triage to a fast track area involved wasted time and energy, so he re-purposed the fast track function and moved it to the front of the ED so that it is now situated directly behind triage. This eliminates the needless transporting of patients to a more distant area. Secondly, while triage nurses used to have to determine whether a patient was too sick for fast track, the only question they have to answer now is whether a patient requires a bed.
"The bottom-line rule is that patients who don't need a bed don't get a bed. If they need a workup, we can do that in the ambulatory environment just like most people do in the outpatient setting, but they don't get a bed," explains Guarisco. "We have put this superhighway, front-end cueing system in place that preserves beds in the back ... so that we preserve our most valued resource, which is the bed on the acute side."
Instead of being placed in beds, patients who are awaiting tests or procedures are typically sent back to the waiting room where there are chairs and recliners they can use, depending on their level of need. This has effectively doubled the size of the ED, says Guarisco. "We put an LPN in the waiting room who does nothing but monitor patients and make sure that they are kept informed," he says. "She's a safety net ... and I think patients like having a clinical person out there in the waiting room with them to answer questions, so it has been a win/win for everyone."
Match staffing to demand
A second key component of QTrack involves making sure that you resource demand, says Guarisco. "We have as many intake rooms as it takes to see patients on arrival," he says. "We don't always succeed because you can exhaust any system, but we've had significant improvements by getting rid of fast track, implementing an in-line process, and putting rules and resources in place. The end result is that we don't run out of beds most of the time."
Getting the staffing just right to optimally manage QTrack took time to finesse, acknowledges Guarisco. "We actually had some attrition, and then we replaced those [physicians] with mid-level providers, and we replaced some of our RNs with LPNs, so that allowed us to resource the demand at lower cost," he says. "We added people, but we didn't add cost."
Further, once QTrack went online, it was clear that adjustments needed to be made in the staffing levels so that they correlated better with patient demand. "We took the same personnel and the same volume, and deployed them in a different fashion so we did not add people; we just resourced them differently. The result was that right away patients were seen earlier, so the later shifts were over-staffed," says Guarisco. "So we took staff from the later shifts and moved them up earlier."
The core principles behind QTrack are not clinical at all, but rather stem from engineering theory, lean thinking, and demand and capacity matching, explains David Eitel, MD, MBA, a co-inventor of ESI Triage, and co-author of Optimizing Emergency Department Throughput: Operations Management Solutions for Health Care Decision Makers (Productivity Press, 2009). "It's a way of thinking that hasn't come to most of health care just yet," he says.
Further, while Eitel admires the approach that he has reviewed in person, he stresses that it is not necessarily going to work in all settings. "You need to have a volume that can support at least two physician-level providers working at the same time," he says. "And people have to be willing to work together in teams, although I don't find that to be much of a problem in emergency medicine because that is what we try to do." (See: Be prepared to customize when implementing a new ED protocol, below.)
Eitel explains that approaches like QTrack are focused on the delivery side of things, as well as making sure people get the right cluster of resources they need in a series of steps that eliminates all the waiting that typically goes on in most EDs. It's a positive approach, says Eitel, but he cautions ED managers who are interested in implementing this type of system to make sure all personnel understand their roles in the new system before going live. "Learn your roles altogether before the switch goes on so there will be no chaos," he says.
Put teeth in the process
Further, you can't just implement a process like QTrack and assume all the changes will stick, stresses Armando Hevia, MD, the director of emergency medicine at Ochsner Medical Center. He explains that administrators realized relatively quickly that they needed to put more teeth in the process. "Once we launched QTrack, everyone eventually drifted to old patterns or old behaviors, so it was really a matter of maintaining a set of rules that would allow the process to continue to work," he says.
For example, to keep patients moving through the system, one iron-clad rule is that a patient cannot remain in an intake room when his or her initial assessment has been completed, says Hevia. "Once the physician steps out of that room, it must be made available again to another patient," he says. Patients can be moved from the intake room to a procedure room, a treatment room, the waiting room, or they can be discharged, but they must be moved on, adds Hevia. (Also see Management Tip on the importance of including patients in the communications loop, below.)
Another policy involves what Hevia refers to as the "rule of two." This actually pertains to a series of rules that are easily remembered because of their relationship to the number "two." For example:
"These are just policies and procedures that prevent the system from bogging down," explains Hevia. However, he emphasizes that while they may sound simple enough to implement, the change was actually quite difficult.
"The ED mentality was that when a patient comes to a room, one nurse owns that patient and treats that patient throughout the course of his stay," says Hevia. "In this new situation, one nurse focuses on one particular task, and doesn't get torn away to do three other things with three other patients."
While the QTrack approach enables nurses to focus their efforts in one general area, it nonetheless requires an alteration in the way people have always done things, and that can create stress, says Hevia. However, he adds that the benefits of the approach more than counteract the difficulties inherent in changing old patterns and behaviors.
"The stress that is relieved on the ED [physician and nursing staff] when you don't have three or four-hour wait times is enormous," notes Hevia. "There are a lot of benefits to increasing your power and having a better workflow."
While there is likely to be continued tweaking of QTrack, Guarisco maintains the health system has a mature process now, and the approach has been implemented in six Ochsner hospitals. "It has worked out beautifully. We are seeing more patients faster and at lower cost. And that is where health care is going," he says.
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Be prepared to customize when implementing a new ED protocol
While much can be learned from other institutions, ED managers interested in implementing a new patient-flow process will always need to take their own size, culture, and unique circumstances into account in customizing a process that will work optimally in their work settings, according to Julian Springler Jr., RN, the unit director of the ED at Ochsner Baptist Medical Center in New Orleans.
Springler understands the issue firsthand. When he was at Oshner Baptist Medical Center, he took charge of implementing QTrack, an ED protocol that was developed at Ochsner Medical Center, a much larger sister facility. He had to basically start from scratch to figure out how many intake rooms he needed to allocate for the system to work optimally in his 12-bed ED and how to adjust staffing. "I had worked collaterally with QTrack and really believed in the system and the philosophy a great deal ... but how it works in a larger setting does not really equate to how you would do it on a smaller setting," says Springler.
However, despite some significant initial pushback from both physicians and nurses, Springler was able to bring QTrack online at the hospital in the space of six weeks. "I figured we would go through some pitfalls for a little while, but within a month we had significantly increased our patient satisfaction, our discharge LOS went down by about 40 minutes, and then we also decreased door-to-doc time by 11 minutes," he says. "However, we are still going through revisions. I view it as an evolving, rather than a static process."
Critical to the success of the implementation were weeks of actively engaging staff to get their input on the new process, as well as plenty of staff education on how QTrack works, explains Springler. "We met with a lot of the staff members to solicit their ideas, but we also said that this is going to happen, let's make it work for us," he says, noting that he was eager to hear about any concerns staff had so that these could be addressed before going live with new protocol in December of 2010.
One problem that came to light was how much delays in other hospital departments, such as imaging, for example, can cause delays in the ED. For this reason, Springler stresses that it is critical to consult the administrators of these other areas when you plan to implement a new system. "Make sure you involve imaging, med-surge staff, telemetry, and the ICU, and explain what is going to happen and how will impact their patients," he says. "They need to know that they may get called to do a CT scan on someone who is sitting in the lobby with their clothes on because the imaging staff may need to come with an area where they can get someone into a gown."
Springler emphasizes that there were no new costs associated with the implementation, although the education piece takes time. "A lot of pre-work goes into this. It is not something that you can just snap your fingers and pull the trigger on," he says. "We worked on this for about a month and a half before we went live."
While the implementation required significant effort, the impact of the new approach was apparent quickly. Patient satisfaction, which had hovered in the 30% to 50% range in the months leading up to the implementation, shot up to 90%, and the average door-to-doc time went from 38 minutes to 27 minutes within one month. Further, daily ED volume has increased from about 55 patients per day to 63 patients per day at press time.
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When implementing a new process, make sure patients are brought into the loop
Keep in mind that when you re-engineer your patient-flow process, clinicians aren't the only ones who may feel stressed and concerned. Patients who are used to the way things used to be done are likely to have concerns as well especially if they are experiencing a true medical emergency. Joseph Guarisco, MD, chairman of the department of emergency medicine in the Ochsner Health System in New Orleans, LA, advises colleagues to have a communications plan in place for patients whenever you go live with any new system that impacts their ED experience.
That's what Guarisco did when implementing QTrack, a new approach to the health system's patient flow process that involves sending many patients back to the waiting area while awaiting tests and procedures. He made sure that staff were ready to explain the new approach in a positive way.
"We scripted it in the patients' minds as a value-add," says Guarisco, noting that patients received the message that they were being sent back to the waiting area so that they would have the freedom to move around, go to the cafeteria, or watch television while awaiting the next step in their care. "We also created a brochure that we give to patients that explains the process," he says.
The result is that there have been few complaints about the new process, and patient satisfaction is on the rise. "It's just a matter of how you manage the process and communicate it to patients," says Guarisco.