Bay Medical improves ED throughput via ICU

Frustrated patients, core measures that require timely intervention, and optimizing house beds. Those are the issues Bay Medical Center in Panama City, FL, decided it was going to deal when it hired a consultant in 2008. Since then, patient satisfaction in the emergency department has increased by 14 points, throughput has improved, and mortality has dropped from 3.4 at the end of 2007 to 2.1 at the beginning of 2010.

Robert Campbell, PharmD, director of performance improvement, patient safety, regulatory compliance, and director of pharmacy services, attributes that drop to all the successes of each intervention, not just one.

The hospital's work began with developing a steering committee comprising staff up to the VPs and the CEO. Then subgroups were devised around issues such as core measures, patient satisfaction, and patient placement. Teams present their goals and subsequent barriers or hurdles, and with senior leadership involvement, "you have all the players at the table that could make the decision and move forward without having to have all the time it takes to go through a system in a hospital," Campbell says.

One of the main areas of review was wait times in the emergency department. Campbell says the team began by investigating the answer to two questions: How fast are staff moving patients who can be treated and released, and if patients are admitted, how long are they staying?

They found there was a direct correlation between the ICU transfer time and the hold time in the ED. So "if the ICU transfer time went up (and that is patients being transferred from the ICU not to the ICU), then there would be a longer wait time in the ER," Campbell says.

Campbell shared with staff an important statistic and a motivator for ramping up ED throughput: Patients who sit in the ED for longer than six hours have a 27% increase in mortality. "We explained to our staff if you have a family member who comes in here and they're right there at the 50/50 chance of making it and they have to sit in the ER for six hours, the odds are against them," he says.

He says the overriding goal became "pulling" patients out of the ICU rather than "pushing" them. "So the idea is that the med/surg floor will pull that patient from the ICU so ICU can pull patients from the ER instead of the ICU calling and saying, 'I'm sending this patient. I hope you're ready for them.' Or the ICU calling the med/surg floor and saying the same thing. The idea is we create an environment where we're working together to pull the patients through the system and get them out the door. And as efficiently as they need to be."

Campbell closely tracks the ICU transfer times — tracking from the time the request is made to the time the bed is ready on the floor and from the time that bed is ready to the time it takes for the patient to be transferred. The total time is recorded and then that can be broken down to bed request to bed ready and bed ready to patient transfer.

The goal, Campbell says, is that patients are transferred and in a bed on another floor within 60 minutes. On initiation, Campbell says some barriers were uncovered. For example, nurses would wait to transfer a patient at shift change so they wouldn't get a new patient. The other thing is that there is a button in the rooms to alert environmental services when patients are discharged or transferred from a room, and compliance on pushing that button was low. "[T]hat stopped the whole process. Environmental services' point is, 'If I don't know it's dirty, I don't know to clean it.' So we had an issue there." So a process fix was implemented. Now, when transport comes to get a patient, they are responsible for pushing that button. If a patient is leaving the hospital, he or she is given a piece of paper, which specifies whether that button was pushed, and told to carry the paper to the front desk at check out. When front desk staff see that, they can confirm the button was pushed. As another check, when environmental services comes to the room, they're equipped with a check-off list where they record whether the button was pushed. They also mark the current shift, and nursing managers check compliance by floor and shift.

In making the ED more efficient and making patients happier, Campbell says scripting was created for physicians and nurses to communicate to patients what was going on and, if there was a hold-up, why that was. So patients are told, for example, "Yes you're going to be admitted. These are the steps we've got to do just so you know what's going on behind the scenes and expect to be up there within this time frame."

Campbell says for busy staff members, 30 minutes may seem like nothing, but to patients, those 30 minutes could turn into two or three hours waiting for a bed or the frustrating realization that they don't know exactly how long it could take. "When you continue to say, 'I don't know, I don't know' it builds on people's frustration. And their tension," he says. Communicating with patients about what's going on and when they can expect to be put in a room has made a huge difference in patient satisfaction, he says.

Bay Medical, beyond its traditional ED, has a rapid response department for lower-acuity patients. The ED staff, he says, are responsible for monitoring the utilization of that department. "Our goal is that 30% of all patients who go through the department go through the rapid response department. And the way we determined it was we took historical data for a year, looked at the triage levels for the patients, and determined that this percentage could easily go through the department and not create any issues and actually improve throughput and improve patient care and outcomes," he says. "So we monitor that. Plus, we say, 'OK, given the acuity of these patients and given what we normally see based on our data, the turnaround time should be 90 minutes for this room.'"

In a spreadsheet program, he tracks how many times a room was used in a day, how many times a room was left empty, and how many times a room could have been used but wasn't. "We found that they were meeting their 90 minutes but they were not meeting their goal for volume. Well, what we found was they were only using five of the eight rooms. And they were using the rooms closest together to save footsteps. So we actually started monitoring utilization of each of the rooms in rapid and making sure that it was plateaued out. And it made a difference," he says.

Another process helped meet the core measure on 90 minutes to percutaneous coronary intervention. All of the hospital's ambulances are equipped with 12-lead EKGs. So when the team responds to a call they can do the EKG in the patient's home and send the information via cell phone to a physician in the ED, who can notify the cath lab to prepare for a patient. Oftentimes, Campbell says, the team is ready before the patient even gets there.

"The other thing that was interesting was we had some issues with the 90-minute window core measure for PCI, and what was interesting was that part of it had to with simply differences in times on clocks," he says. So atomic clocks were put in the ED and cath labs.

"When the cath lab gets a patient who's going to qualify for the core measure, we have a worksheet they fill out that has time stamps on it where they fill in the times. So they know when that case ends if that patient passed or failed automatically. And then we get that information and then we review that with the staff the following week to go over what we could have done differently and then the physician-related stuff we give to the appropriate physicians," he says.

The hospital also added a discharge lobby, so patients don't have to wait in their rooms to be discharged and thus opening more beds for other patients. The lobby has places for patients to read or watch television and a coffee shop. The hospital also is using its old ED to move patients when they are ready to be discharged and then can leave from there.