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ED was well prepared for no-diversion law
Keys: triage doc, 'in-house' lab, radiology
When the Massachusetts legislature outlawed ambulance diversions effective Jan. 1, 2009, dire predictions were made about how overwhelmed the busy EDs would be. However, although volume has increased by about 13% at Massachusetts General Hospital in Boston, it has continued making improvements on its door-to-doc times, left-without-treatment averages, and lengths of stay, thanks to several processes that it had put in place prior to the announcement.
One of the most effective changes, and one which just became fully implemented shortly before the diversion ban was put in place, was a change in the triage process. "We reinvented our triage system and have made it physician-led," says Alasdair Conn, MD, FACEP, FACS, the chief of emergency services. The preparation for the shift began about three years ago when a team from IBM was contracted to perform computer modeling of the ED.
"The conclusion was that [a physician-led triage is] pretty expensive, but it does decrease flow time," says Conn. The existing length of stay (LOS) for treated and discharged patients was 5.6 hours. IBM staff said that the ED could reduce it to 3.5 hours.
"I couldn't find any place that had done this until I found Corey Slovis [chairman of emergency medicine] at Vanderbilt," he recalls. "He said it was the best thing he had done for his department in 20 years." Conn sent physicians, nurses, and a representative of administration to visit Vanderbilt and come back with a plan.
The protocols and policies were first implemented in 2007, "but not very effectively," admits Conn, noting that the department's physical plant was inadequate. "About 1½ years ago, we reconfigured the department to have four screening rooms. Without that and the new triage process, we would not have able to survive."
The timing couldn't have been more favorable, notes David Brown, MD, the ED's vice chairman. "The screening process really ramped up then, so we were able to keep up with the increase in volume," he says. The new process includes having an attending out front 12 hours a day, a resident in screening eight to 10 hours a day, and a nurse practitioner there 12 hours a day — in addition to ample ED nursing support, he says. "That enabled us to increase efficiency and throughput so the volume increase last January could be managed," Brown says.
Conn says, "Yes, this is added costs, but the CEO was happy to support it — although he said we had to drop length of stay by two hours and improve the door-to-doc time."
And they've done just that. The IBM LOS target has been met, and door-to-doc time, which had been at about 90 minutes, has dropped considerably. Brown says, "About 75% of the patients are seen within 30 minutes." Adds Conn, "My aim is 20 minutes."
Prior to the new process, says Conn, about 6% of patients left without treatment. "We've gotten that down to 1.5%, and it has stayed there monthly," he reports.
Radiology and lab help improve flow
While a new triage process was instrumental in helping the ED at Massachusetts General Hospital in Boston survive a new state law banning diversions, several other strategies in the past few years helped put the department in a position to handle the added volume, says ED chair Alasdair Conn, MD, FACEP, FACS.
For example, he notes, "We implemented our own satellite lab in the ED 24/7," he says. "Any time any of the day that the labs are done and put into a computer, [the ED's "homegrown" computer system displays] a little flashing icon, so you immediately know there's a new lab value." Just making that change saved 20 minutes of every ED visit," he says.
The department also has an attending radiologist 24/7. "We have a 64-slice and 16-slice CAT scan and our own MRI in the ED," Conn adds, "but more important than that is the fact that these guys can go in at three in the morning if they need to and see a CAT scan." Members of the radiology staff also set their own performance targets, he says. "For example, they wanted results from ordering a plain CT scan back within 90 minutes," says Conn. "Right now, 90% of the time they do it in 60 minutes."
These changes did not occur by accident, says Conn. "The CEO mandated that every chief of other services that interfaced with the ED had to spend four hours in the department seeing what we were doing and how their service could help improve the function of the ED," he says.
The ED worked very closely with lab services and radiology, says David Brown, MD, the ED's vice chairman. "These are divisions of lab services staffed by lab technicians of the department, and emergency radiology is a division of radiology," Brown says. "They staff the area and read all the imaging for us."
The other departments were happy to participate in these changes, he says. "They helped us make the changes because they saw increasing volume and needed additional machines and human capital to get turnaround time down to what we all thought would be appropriate for ED patients," Brown explains.
Don't forget those time-based metrics
No matter how crowded your ED becomes, maintain focus on the time-based metrics you have established for processes involving ST segment elevation myocardial infarction (STEMI), acute stroke, and and other critical conditions, says David Brown, MD, vice chairman of the ED at Massachusetts General Hospital in Boston.
"In increasingly crowded EDs, meeting these metrics is difficult, so you must build in triage and screening processes to identify those patients early," he says. So, for example, when any patient presents in the Mass General ED complaining of chest pain, shortness of breath, or similar symptoms, triage is stopped and patients are given an immediate EKG.
"If you do this, you can rapidly move patients through the process so you will be able to meet your time-based metrics while still taking care of an increasingly large number of patients," says Brown.