Research Forum Abstracts

32 A Lean-Based Process Redesign: Resource Utilization Inthe SPEED Trial

Mink J, Werzen A, Wescott JN, Levine B, Reed III JF, Reese IV CL, Sweeney T,Farley H, Jasani N/Christiana Care Health Services, Newark, DE; University ofDelaware, Newark, DE

Background: Lean principles have been used in manufacturing processes for manyyears and have been associated with improved quality and success. Recently Leanprinciples have been applied to health care and, in particular, emergency departments(ED) to identify waste, inefficiencies and over-processing. Health care has adoptedthese processes to improve operations, increase efficiency and reduce waste. We used aLean-based Synchronized Provider Evaluation and Efficient Disposition (SPEED)process to evaluate resource utilization.

Study Objectives: To evaluate resource utilization in a targeted EmergencySeverity Index (ESI)-3 patient population at a large, academic ED center with annualcensus in excess of 100K.

Methods: A prospective study using weekly rapid cycle tests (RCT’s) was conductedfrom January through November 2009. Applying the SPEED process, a synchronizedprovider evaluation, treatment and disposition process was implemented. Utilization oflaboratory, radiographic and consultant resources was analyzed. Results were collected inreal time for 305 ESI-3 SPEED patients and compared to a control group of 294 SPEEDeligible ESI-3 patients when SPEED process was not operational. Statistical analysis wasperformed using Pearson’s chi-square test.

Results: See Table.The application of Lean health care principles through the SPEED redesign

process resulted in fewer laboratory tests and CT scans. On the other hand, there wasan increase in the number of consultants in SPEED. No significant differences werenoted with respect to plain X-ray and ultrasonography utilization.

Conclusion: Although SPEED process appears to decrease some utilization ofresources, this may be offset by an increase in other areas. Larger studies will need tobe undertaken to further explore these variables.

33 Emergency Department Personnel Perception of TheirRole In Patient Experience

Kobayashi L, Sweeney LA, Cousins AC, Bertsch KS, Gardiner FG, Tomaselli NM,Boss III RM, Gibbs FJ, Jay GD/Alpert Medical School of Brown University,Providence, RI; [Consultant], Cranston, RI; Rhode Island Hospital, Providence, RI

Study Objectives: Prior studies have assessed patients’ perceptions of emergencydepartment (ED) care and identified key elements factoring into their experience.Investigators examined ED clinical providers’ perceptions of both individual jobresponsibilities as well as their insight into the key determinants that shape the patientexperience.

Methods: A Web survey was developed by investigators working with ED clinicalleadership and ED communications workgroup. Survey queries assessed howpersonnel in each ED health care discipline (eg, nursing, physicians) and supportiveservice (eg, registration, security) perceived clinical care-related actions (CCA’s) withrespect to a) their job responsibilities and b) importance to their patients’ experience.CCA categories were: communication [eg, self introduction, explanation of EDmedical care]; direct patient care [eg, timely analgesia]; disposition/follow-up [eg,expediting discharge]. Survey elements were used to demarcate discipline- or service-specific areas of ownership and identify any “dead zones” or CCA’s that consistentlyfell outside of perceived individual job responsibility. Quota sampling ensured arepresentative subject population, with an 80:20 distribution between primary ED

care providers (ie, CNA, MD, LNP/PA, RN, ED technicians) and supportive care

S12 Annals of Emergency Medicine

services personnel (eg, interpreter, security) respectively. The study was approved bythe Institutional Review Board.

Results: 153 of 634 active ED personnel were surveyed as targeted betweenDec.2009 and Mar.2010. 117 were primary ED care providers, comprising 7midlevel providers, 63 RN’s, 10 nursing assistants, 18 attending/fellow MD’s, 15resident MD’s, and 4 ED technicians; discipline correlation was 0.85 betweensurveyed and total personnel. There were 36 supportive care staff members from casemanagement, interpreters, registration/secretarial services, security, social work,transport and non-ED technicians. Of 7650 potential survey responses, 41 were“prefer not to answer”; 51 were missing.

3047 (80.1%) responses to 3802 queries as to whether subjects believed aspecified CCA was within their job responsibility were “always my responsibility”(2214; 58.2%) or “sometimes my responsibility” (833; 21.9%); 72 (18%) of 402“never my responsibility” responses were from primary ED care providers.“Introducing self to the patient” (145 of 153 responses; 94.5%) and “upholding andprotecting the patient’s privacy and dignity” (146 of 153; 95.4%) were almostuniformly considered to be a job-related responsibility, whereas actions related todisposition/follow-up were perceived as such primarily by midlevel providers (97%),nurses (74.0%) and physicians (92.1%). 3645 (96.0%) of 3797 responses as towhether subjects believed a CCA was important to the patient experience were“always important” (84.2%) or “sometimes important” (11.8%); 8 (29%) of 28“never important” responses were from primary ED care providers. “Monitoring formedical errors and correcting them when identified” was reported as not being aconsistent job responsibility by 18 (12%) of 152 subjects, although consideredimportant to patient experience by 146 (96.1%) of the same respondents.

Conclusion: A Web survey assessed ED personnel perception on ownership ofselect clinical care-related actions and of their relative importance to the patientexperience.

34 A Tool for Emergency Department Throughput: UsingMaximum Emergency Department Bed Time to ReduceWait Times and the Number of Left Without Being SeenPatients

Joshua A, Chan T, Castillo E/University of California San Diego, San Diego, CA

Background: Improving emergency department (ED) throughput (EDT) is vitalto improving patient satisfaction, reducing wait time (WT) and the number of leftwithout being seen (LWBS) patients. By utilizing a tool to help optimize throughput,ED providers may have greater control in decreasing WT and the number of LWBSpatients. Maximum ED Bed Time may provide a time frame for individual EDpractitioners to work up and get an appropriate disposition for patients in order tomeet optimal ED throughput.

Study Objectives: To calculate a maximum ED Bed Time (MBT) that wouldoptimize flow based on capacity. To determine if decreasing ED Bed Time (BT) leadsto decreasing WT and LWBS patients.

Methods: A retrospective study was conducted from Jan. 1- Dec. 31, 2008 in anurban tertiary care teaching ED with an annual census of 37,000 patients with35,558 patients registered. A total of 1221 patients were excluded due to incompleterecords. For each specified time period (total of 366 12-hr intervals(10:00-21:59) and366 12-hr intervals (22:00-9:59) an average BT, WT, and LWBS patients wascalculated. The sum of LWBS was placed into each time interval based on the timesigned into triage. The BT was defined as the time interval from when the patient wasplaced in an ED bed till they physically left the ED (discharge, admission, transfer).BT was further divided into 30min intervals with the average WT, LWBS, census(based on time interval patient signed into triage), and number of intervals calculated.The MBT was calculated using: MBT� [(# of ED Beds available) x (# of hours theED bed available)] / (Census for time interval measured)

MBT was calculated based on available ED beds for the respective time periodmultiplied by hours available divided by average census during each 12hr time period.This provides a maximum time a patient should spend in an ED bed to optimizethroughput (Bed hours/patient). An adjusted MBT was calculated to account for lostED Bed Hours as a result of bed occupancy at time interval turnover. However, theadjusted MBT was unable to be tested due to lack of bed occupancy data at thebeginning of each interval.

Results: During the time period 10:00-21:59(MBT� 3hr 50m), as BT decreased,the number of LWBS patients and WT decreased except BT 7:30-8:00. There wasgreater than a 50% decrease in LWBS patients and WT if the average BT fell belowthe MBT. During the time period 22:00-9:59(MBT�9hr 36m), as BT decreased,

WT decreased except BT 7:30-8:00. The average WT in this time interval was

Volume , . : September