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E.D. – T.V.E.D. – T.V. A Simulation Capacity A Simulation Capacity
AnalysisAnalysis
Jamey KoontzJamey Koontz
Baylor Health Care SystemBaylor Health Care System
OverviewOverviewBaylor Health Care SystemBaylor Health Care SystemThe ModelThe Model
MethodologyMethodologyCurrent State DataCurrent State DataED LayoutED LayoutED FiguresED Figures
ResultsResultsOther Information - StaffingOther Information - Staffing
Baylor Health Care SystemBaylor Health Care SystemNon-Profit Health Care Non-Profit Health Care System in North TexasSystem in North Texas
14 Owned, Leased and 14 Owned, Leased and Affiliated HospitalsAffiliated Hospitals
1111thth Consecutive Year in Consecutive Year in U.S. News & World U.S. News & World Report’sReport’s “America’s Best “America’s Best Hospitals”Hospitals”
Celebrated 100Celebrated 100thth Anniversary Oct. 2003Anniversary Oct. 2003
Baylor Research InstituteBaylor Research Institute
93,324 Admissions93,324 Admissions
245,558 ED Visits245,558 ED Visits
495,645 OP Visits495,645 OP Visits
13,249 Babies Born13,249 Babies Born
2,587 Licensed Beds2,587 Licensed Beds
15,000 Employees15,000 Employees
3,300 Physicians3,300 Physicians
Baylor All Saints Baylor City View BUMC
Baylor Heart/Vascular Baylor Garland Baylor Grapevine
Baylor Irving Baylor Plano Baylor Waxahachie
Our Children’s House BSH BIR
MethodologyMethodologyA Process Flow Diagram was Developed with the Current A Process Flow Diagram was Developed with the Current ProcessProcess
Data was Obtained from the 2005 MedHost DatabaseData was Obtained from the 2005 MedHost DatabaseSeptember – October 2005September – October 2005
A 2005 Model was Developed as a Base ModelA 2005 Model was Developed as a Base Model
Scenarios Tested were Based off of Volume Projections and Scenarios Tested were Based off of Volume Projections and Future Assumptions and RenovationsFuture Assumptions and Renovations
Current State DataCurrent State Data20052005
BedsBedsMain ED: 15Main ED: 15
Trauma: 1Trauma: 1
Treatment Area 2: 6Treatment Area 2: 6
LWOT – 5% =LWOT – 5% =5 patients/day5 patients/day
Admits – 16.5% =Admits – 16.5% =18 patient/day 18 patient/day
Test Mix
60%
80%
27%
5%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Xray Lab CT Sono
Current State DataCurrent State Data20052005
Volume/Day
115
108105 106
99
103
115
90
95
100
105
110
115
120
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Arrival by Hour
1%
2%
1%1% 1% 1% 1%
1%1% 1%
1%1%
1%1% 1%
1%
1%
2%
2%3%3%
3%
3%
3%3%3%
3%3%
3%3%3%
3%3%
2%3%
3%3%
2%
3%3%
3%
3%
3%
3%3%
2%2%
2%
1%
0.0%
0.5%
1.0%
1.5%
2.0%
2.5%
3.0%
3.5%
4.0%
0.0 1.5 3.0 4.5 6.0 7.5 9.0 10.5
12.0
13.5
15.0
16.5
18.0
19.5
21.0
22.5
24.0
Hour of Day
Current State DataCurrent State Data20052005
Semi-Urgent
34.9%
Urgent
49.7%
Emergent
8.2% Imminent
0.3%
Non-Urgent
6.9%
LOS
3.32.8
2.3
4.34.4
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
5.0
Emergent Imminent Urgent Semi-Urgent Non-Urgent
Average LOS is 3.7
Hours
ED LayoutED Layout
ED FiguresED Figures
Patient
LWOT Patient
Emergent & Imminent
Patients
New Changes & New Changes & AssumptionsAssumptions
7.0 New Beds7.0 New Beds1.0 Trauma Bed1.0 Trauma Bed6.0 Main Beds6.0 Main Beds
Improve Triage Process Improve Triage Process Old Time – 5 minOld Time – 5 min New Time – 4 minNew Time – 4 min
Bedside Registration – allows for process to occur simultaneouslyBedside Registration – allows for process to occur simultaneously
CPOE/EMR – Reduce Patient Treatment TimeCPOE/EMR – Reduce Patient Treatment Time 2007 – 4.5%2007 – 4.5% 2008 – 10.0%2008 – 10.0% 2011 – 12.5%2011 – 12.5%
New Changes & New Changes & AssumptionsAssumptions
Lab POC TestingLab POC Testing Reduce TAT by 75%Reduce TAT by 75%
1.0 Additional Radiology Unit1.0 Additional Radiology Unit Reduce TAT by 75%Reduce TAT by 75%
1.0 Additional CT1.0 Additional CT Reduce TAT by 60%Reduce TAT by 60%
New Changes & New Changes & AssumptionsAssumptions
Will Gain 120 Inpatient Beds by FY10Will Gain 120 Inpatient Beds by FY10Reduce Admit Length of Stay up to 2 Reduce Admit Length of Stay up to 2 HoursHours Admit
LOS (hrs)IP Beds
2005 5.5 105
FY06 5.2 121
FY07 4.7 145
FY08 4.4 161
FY09 3.8 193
FY10 3.2 225
New Changes & New Changes & AssumptionsAssumptions
Future Fiscal YearFuture Fiscal Year
Volume Projections Volume Projections were Calculated as were Calculated as Follows:Follows:
2006 – 0%2006 – 0%
2007 – 2%2007 – 2%
2008 – 1%2008 – 1%
2009 – 4%2009 – 4%
2010 – 5%2010 – 5%
2011 – 5%2011 – 5%
2012 – 5%2012 – 5%
2013 – 5%2013 – 5%
2014 – 5%2014 – 5%
2015 – 5%2015 – 5%
2005
110
2007 2009 2015
154
107
115
Average Daily Volumes
2011
126
2013
139
ResultsResultsTrauma
Beds
Main
BedsHall Beds TA2 Beds
2005 Current 4.0 75% 80% 44% 35% 38% 5
FY 2007
All Changes,
4.5% CPOE
Reduction
3.8 55% 61% 5% 32% 37% 5
FY 2009
All Changes,
10% CPOE
Reduction
3.3 52% 56% 3% 32% 38% 4
FY 2011
All Changes,
12.5% CPOE
Reduction
3.0 51% 57% 4% 33% 40% 4
FY 2013
All Changes,
12.5% CPOE
Reduction
3.1 58% 62% 9% 37% 44% 4
FY 2015
All Changes,
12.5% CPOE
Reduction
3.1 62% 67% 18% 41% 49% 4
CT
Util.%
LWOT
(pts./day)Year Improvements LOS
Bed Utilization%
Other InformationOther Information
What Else Can You Do What Else Can You Do with All this Data??with All this Data??
BUMC Avg. Pt. Flow / NursingBUMC Avg. Pt. Flow / NursingBUMC Average Patient Flow by Hour June 2005
5.8
4.4
3.6
3.7
3.2
3.4 4.1 5.6 9
11.8
12.8
13.3
12.2
12.4
11.4
10.6
11.1
10.5
10.1
10.8
9.7
9 8.2
6.9
80
73
67
62
56 58 60
58
55
62
70
77
82
87
92 9
5 98
102
109
109
101
96
92
86
11.8
11.4
9.6
8.7
9.2
1.4 2.1
7.6
12
4.8
4.8 6.3 7.2
7.4
6.4 7.6 8.1
6.5
3.1
10.8
17.7
14
12.2
12.9
18
18
16
14
14
14
14
14
14
14
17
17
19
19
21
23
23
23
23
23
23
23
20
20
0
20
40
60
80
100
120
Hour
Avera
ge C
ou
nt
0
4
8
12
16
20
24
28
Arrivals
Census
Departures
Nurse Count
Nurse to Patient Ratio 1:4.3
Total Staff to Patient Ratio 1:2.7
GARLAND Avg. Pt. Flow / NursingGARLAND Avg. Pt. Flow / Nursing
0.0
10.0
20.0
30.0
40.0
50.0
60.0
0
2
4
6
8
10
12
14
16
5.2
3.7
3.7
3.2
2.2 3.2
3.3 4.2
7.5 8.2 9.1 1
0.9
9.6 1
0.8
9.8
8.4 9
.7 10
.1
9.9 10
.9
11
.3
8.9
7.2 8
.3
39
.0
33
.3
29
.6
25
.1
21
.5
19
.3
18
.6
19
.1
24
.8
30
.7
34
.5
39
.8 42
.6
47
.3 49
.9
49
.7
50
.8
52
.1
52
.1 53
.4
54
.2
51
.6
45
.9
42
.6
9.4
7.4 7.7
5.8
5.4
4.1
3.7
1.7 2.3 4
.2 5.7 6
.7
6.1 7
.2 8.6
8.6
8.8 9
.9
9.5 1
0.6
11
.5 12
.8
11
.7
10
.4
11
.6
11
.8
10
.4
9.2
7.7
7.4
10
.5
9.7
8.5 8.8
8.7 9
.2
10
.0 10
.5 11
.0 11
.6
12
.7 13
.1
14
.7
15
.8
13
.7
12
.4
11
.1
12
.0
ArrivalCensusDepartureNurse Count
Hour
Av
era
ge
Co
un
t
Nurse to Patient Ratio 1:3.5
Total Staff to Patient Ratio 1:2.9
ALL SAINTS Avg. Pt. Flow / NursingALL SAINTS Avg. Pt. Flow / NursingBASMC Average Patient Flow By Hour of Day Dec. 2005
2.6
1.9
1.7
1.7
0.8 1.1 1.6 2
.4
3.6 4.2
5.6
5.7 6.0
4.8
4.3
3.7
5.1
4.6
4.0 4.4
4.3
3.7
3.7
2.6
19.6
15.4
11.2
10.5
9.4
7.4
6.7 7
.7
10.4
13.1
16.6
20.8
23.2
25.7
25.8
25.4
24.9
24.4
27.2
26.5 2
7.8
26.1
26.0
22.8
2.3 2.9
2.5
2.1
1.8
1.4
1.5
0.9 1.1 1.3 2
.2
2.0
3.2
2.8 3.2
3.2 3.4 3.7 3.9
2.3
3.9
4.0
3.1 3.7
6 6 6
5 5 5 5
6 6
7 7 7
8 8 8
9 9 9 9 9 9
8 8
7
0.0
10.0
20.0
30.0
Hour
Avera
ge C
ou
nt
0
2
4
6
8
10
Arrivials
Census
Departures
Nurse Count
Nurse to Patient Ratio 1:2.6
Total Staff to Patient Ratio 1:2.1
Service AuditsService Audits
The Service Audit is used to assist in The Service Audit is used to assist in evaluating the level of service and evaluating the level of service and performance of the area. performance of the area.
It provides a standard of measurement It provides a standard of measurement and a means of determining areas and a means of determining areas where service needs to be improved.where service needs to be improved.
Service AuditsService AuditsExample QuestionsExample Questions
Do personnel report on duty to Do personnel report on duty to receive daily assignments? receive daily assignments?
Each shift routinely resolves Each shift routinely resolves discrepancies before leaving?discrepancies before leaving?
Is the chart signed by the nurse Is the chart signed by the nurse after completion?after completion?
Are test results placed with the Are test results placed with the E.D. record prior to discharge?E.D. record prior to discharge?
Have the vital signs been Have the vital signs been charted on ALL patients’ charted on ALL patients’ records with time?records with time?
I. ADMINISTRATIVE AND MANAGERIAL SERVICES YES NO N/A 1. Do personnel report on duty to receive daily assignments? ___ ___ ___ 2. Do personnel report off duty to nurses station? ___ ___ ___ 3. Is personnel appearance in accordance with uniform code? ___ ___ ___ 4. Do all personnel wear the hospital ID? ___ ___ ___ ADMINISTRATIVE & MANAGERIAL SERVICES TOTALS ___ ___ ___ %SCORE ____ II. MEDICATIONS 1. Is the narcotic control properly maintained with Pyxis? ___ ___ ___ 2. Each shift routinely resolves discrepancies before leaving. ___ ___ ___ MEDICATIONS TOTALS ___ ___ ___ %SCORE ____ III. CHARTING AND FORMS 1. Is the chart signed by the nurse after completion? ___ ___ ___
2. Is the "release of responsibility" form signed and on the chart of all patients refusing treatment? ___ ___ ___
3. Are all test results placed with the E.D. record prior to discharge? ___ ___ ___
(If no tests ordered, mark N/A.)
4. Have the vital signs ( WT for peds) been charted on all patients' records with time? ___ ___ ___
5. Is the E.D. record filled out completely and properly? ___ ___ ___
ED Modeling TipsED Modeling TipsWhat is the Problem?What is the Problem?
Capacity vs. StaffingCapacity vs. Staffing
Charge Acuity System vs. Urgency Acuity Charge Acuity System vs. Urgency Acuity ClassificationClassificationSimultaneous ProcessesSimultaneous ProcessesAncillary CapacityAncillary CapacityED Hold IssueED Hold IssueService AuditsService Audits
QuestionsQuestions
Jamey KoontzJamey Koontz
Sr. Management EngineerSr. Management Engineer
Baylor Health Care SystemBaylor Health Care System
[email protected]@baylorhealth.edu
