12/30/2015

1

Nurse Manager Education Day

March 13th 2014 Emergency Department

BRAT/Greeter Nurse

Vital Signs

Customer Service (PITCH IN)

Current ED Initiatives

BRAT (Bypass Rapid

Assessment Triage)

Emergency Department (ED) waiting rooms are a high risk and high liability area for patient safety.

In our department, patients were being greeted by non clinical personnel. Patients were waiting to be seen by the triage nurse. After being triaged by the nurse, patients waited again despite bed availability

NOTE: In looking at our triage times, arrival to physician assigned averaged 27-29 minutes. We wanted to improve our to Door to Physician times.

Original Triage Process

Bypass Rapid Assessment Triage

Greeter Nurse stationed at Registration Desk

BRAT Process includes: Visual Assessment,Chief Complaint, Minimal Screening Questions to determine placement

Patient taken directly to room

NOTE: Improved our arrival to physician assigned times from 27 to 18 minutes by initiating this new process for our patients.

Formed multidisciplinary triage taskforce

Researched best practice initiatives relating to triage

Created BRAT/Greeter Nurse Role

Focused education for night shift - October 2011

started new process during 0300-0700

rolled out education and initiative in stages to other shifts

BRAT utilized all shifts March 2012

Process continually evaluated and modified to meet the needs of the department

Action Steps

12/30/2015

2

BRAT

Improved through-put, safety and customer service for patients

Magnet Poster presented at Lehigh Valley and at National Conference in Orlando

Article recently submitted to JEN

Time from Arrival to Roomed

2421

15

10

15 15 1411

0

5

10

15

20

25

30

FY 12 FY13 Jul.13 Aug .13 Sept.13 Oct.13 Nov.13 Dec.13

Average Time -Arrival to Roomed ALL ED Patients

FY 12- 13- 14 (YTD)

FY 12 FY13 Jul.13 Aug .13 Sept.13 Oct.13 Nov.13 Dec.13

Minutes

Customer Satisfaction

0%

10%

20%

30%

40%

50%

60%

70%

FY 12 FY 13 FY14(YTD)

46.8%53.9%

64.9%

Press Ganey Top Box ScoreWaiting Time to Treatment Area

0%

10%

20%

30%

40%

50%

60%

70%

FY 12 FY 13 FY14(YTD)

41.0% 45.1% 56.4%

Press Ganey Top Box ScoreWaiting Time to See Doctor

Vital Signs Initiative for Trauma Service Patients

12/30/2015

3

Reviewed FY 13 data on Trauma patients

Compliance poor for admitted TTT patients

Focus on increasing VS compliance with Code T/Trauma Alert and TTT patients

PDSA created

Established VS taskforce/champions

Education blitz by ANM’s via huddles and Bulletin Boards

Self Audit tool created, doing 100% retrospective reviews for fallouts

Vital Sign Initiative

Emergency Department

Vital Sign (VS) Compliance –

Admitted TTT’s

59%

42%39%

52%

33%

44%

53%

60%

55%58% 58%

607

548567

591

88 9379 78

6785

101

0

100

200

300

400

500

600

0%

20%

40%

60%

80%

100%

To

tal

Main

ED

Pati

en

ts

Perc

en

t C

om

plian

ce

Better

Emergency Department

Vital Sign (VS) Compliance – ALL Code T’s, Trauma Alerts,

TTT’s and ACT Alert Patients

80%76%

73% 74%

69%

69%

74%

79%77% 77%

72%

20502111 2099

1289

221 201 204 164 137186 176

0

500

1000

1500

2000

0%

20%

40%

60%

80%

100%

To

tal

Pati

en

ts

Perc

en

t C

om

plian

ce

Better

Emergency Department

Vital Sign (VS) Compliance –

All Code T’s and Trauma Alerts

95%97% 97%

95% 93%

93%

98%

97%

99%94%

89%

1241

1314

1247

694

131

108124 86

70100

75 0

100

200

300

400

500

600

700

800

900

1000

1100

1200

1300

0%

20%

40%

60%

80%

100%

To

tal

Tra

um

a P

ati

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ts

Perc

en

t C

om

plian

ce

Better

Customer Service Initiative

12/30/2015

4

Assessment of LGH ED historical Press Ganey data

Press Ganey Site Visit March 2013

ED Customer Care multi-disciplinary task force established

Priority Index and ED Correlation Matrix Key Data Points reviewed

Key Words and actions that work expectations developed and implemented

Mandatory Staff Education which included role playing by task force members

Customer Service Education embedded into Orientation Process

ED leadership dedicated to focused Assistant Nurse Manager rounding

Individual ED Nurse report cards and Press Ganey Trending

Customer Service

EMD Patient Experience Improvement Journey

Correlation IndexEmergency Department Customer service project notes:

ED Correlation Chart/Graph= All ED’s are in the PG database, responses received in calendar year

2012=1,500,000 patients treated at 1,974 ED’s.

All questions are listed vertically and horizontally

1 = the highest correlation- So this is helpful for trying to determine what questions are drivers for

Likelihood to recommend (Dept goal for FY 13):

Questions which have highest correlation/drivers to improve: Likelihood to recommend:

1. Degree of which staff cared about you as person (.792)

2. How well kept informed about delays (.723)

3. How well pain controlled (.721)

4. Doctor’s concern for comfort while treating you (.710)

5. Doctors concern to keep you informed about your treatment (.705)

6. Staff concern to keep family/friends informed about your status (.706)

Questions which have highest correlation/drivers to improve: Degree to which staff cared about you

as person:

1. Likelihood to recommend (.792)

2. How well you were informed about delays (.767)

3. Nurses attention to needs (.763)

4. Nurses concern to keep you informed about your treatment (.762)

5. Staff Concern to keep family/friends informed about your status (.756)

6. How well pain controlled (.750)

Questions which have highest correlation/drivers to improve: Nurses concern to keep you informed

about your treatment:

1. Nurses attention to your needs (.866)

2. Degree which nurse took time to listen to you (.830)

3. Nurses concern for privacy (.782)

4. Courtesy of nurses (.778)

5. Degree to which staff cared about you as person (.762)

PITCH-IN

P = PRIVACY- Always pause @entrance, knock

I = Always INTRODUCE yourself by name and title

T= Always THANK-”Thank you for allowing us to care for

you.”

C = Demonstrate COMPASSION– tone and body language

H = HELLO-Include family and friends, acknowledge

I = INFORM-patient should be aware of next steps at all times

N = NEEDS MET- offer comfort measures, ask if anything needed

Emergency Department--Nursing OverallFY 14 YTD(July-Dec)

by Discharging Nurse

0

10

20

30

40

50

60

70

80

90

100

88

33

42

51

22

55

29

47

90

19

7 94

49

6 31

2 3 92

50

17

1 16

11

74

15

77

62

65

61

67

35

14

48

70

59

45

60

69

91

87

56

26

73

78

84

18

52

66

57

46

27

86

12

98

30

44

71

41

34

5 68

85

81

38

20

4 10

32

72

58

93

83

37

43

25

97

23

80

21

28

54

9 36

Pe

rce

nti

le R

ank

(>1

00

,00

0 vi

sits

)

Blinded Nurse Number

Needs Improvement Satisfactory Very Good

TOP BOX

Individual Nurse report PG reportcard.

Nurse NancyVP=very poor, P=poor, F=fair Received Date Received Date

G=good, VG=very good 1st Q FY14 2nd Q FY14

n=9 n=9

Question VP P F G VG VP P F G VG

Nurses courtesy 0 0 1 1 7 0 0 0 1 8

Nurse took time to listen 0 0 1 1 7 0 0 0 1 8Nurse attention to your needs 0 0 1 3 5 0 0 0 1 8Nurse informative re treatment 0 0 1 3 4 0 0 0 2 7Nurses concern for privacy 0 0 1 4 4 0 0 0 2 7

Comments Received-Nancy (RN) was great. She was kind & caring & reassured me when I was very scared. The nursing care was excellent.

Emergency Department

% of Top Box for Likelihood to Recommend

FY 14 Goal= 68%(Significantly exceeded)

62.2%59.1%

64.0%

75.4%74.0%68.2%69.0%68.0%

72.1%67.4%

0

10

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Pe

rce

nti

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an

k >

10

0 K

vis

its

Pe

rce

nt

Top

Bo

x

Better

12/30/2015

5

Emergency DepartmentQuality Measures

AMI- PCI received within 90 min. of arrival

CAP- Blood Culture in ED prior to initial antibiotic

CAP- Antibiotic Selection

2014 Emergency Department Quality Indicators

Monthly LG Emergency DepartmentPI Indicators – FY2014

Median Time from ED Disposition to ED Departure for

Admitted ED Patients

Observation ED Patients

Discharged ED Patients

2014 Emergency Department Metrics

Monthly LG Emergency DepartmentPI Indicators – FY2014

Push-Pull Transfer & Handoff Kaizen

Currently working on verbal report process

Future opportunities may include:

1. PFC bed assignment process

2. admitting physician process

Critical Care Clinical Effectiveness Team – ED to ICU Handoff Process

Initiatives for Improving Disposition to Departure for Admitted Patients

12/30/2015

6

FacilitiesTotal Sites

Pts Per Day Peds % Admit %

Transfer %

EMS Arrival

Median LOS

Treat & Release

Median LOSFast

Track

Median LOS

Admit LBTC

Door to

BedMin.

Door to

DocMin.

% Hospital Admits thru ED

Visits per Sq.

Foot

Over 100K ED's

2012 results 32 315 22.6% 18.8% 0.8% 21% 196 137 396 3.4% 27 49 68% 4.2

LGH ED 113,214

FY 2014 Q1-2Results 1 301 22.5% 19% 1.3% 25% 111 84 216 0.94% 3 10

53% no

OBS 4.2

Emergency Department Benchmarking Data Analysis

Survey Results

Comparison of LGH ED Results with ED Benchmarking Data Analysis Survey 2012

ED Pain Management Indicators

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13

77% 78% 80% 76% 75% 78%

Comprehensive Pain AssessmentCompleted During ED Visit

% Compliance for FY14 (YTD)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13

72% 74% 75% 80% 78% 73%

Pain Scale within 60 min of Pain Med Administration

% Compliance for FY14 (YTD)

Emergency Department

% of Top Box in How well pain controlled

45.9%43.8%49.6%

63.3%

55.2%54.3%55.8%56.7%59.3%

54.0%

0

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100

0%

10%

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100%

Pe

rce

nti

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an

k >

10

0 K

vis

its

Pe

rce

nt

Top

Bo

x

Better

Next Initiative on the Horizon… Pain Management

Improve compliance to initial pain assessment

Medicate pain scores greater than 5

Improve compliance to follow-up pain score within 60 minutes of pain medication

Implement ED protocol for treatment of moderate to severe pain

ED Adult Guidelines for Moderate to Severe Acute Pain Pain score >4 on a scale of 1-10 and at least 2 points > than acceptable pain level,

consult LEA attending for initiation of Pain Protocol For patients less than 65 years of age Morphine 0.1 mg/kg (maximum dose = 10 mg) IV x 1 Morphine 0.05 mg/kg (maximum dose of 5 mg) IV every 10 minutes as

needed for moderate to severe pain For patients greater than or equal to 65 years of age Morphine 0.07 mg/kg (maximum dose = 7 mg) IV x 1 Morphine 0.03 mg/kg (maximum dose of 3 mg) IV every 10 minutes as needed for moderate to severe pain • Narcan 0.1 mg IV PRN for opioid reversal, respiratory rate less than or

equal to 8 and patient over-sedated. May repeat every 1 minute x 3 doses then notify physician

Call physician if 4 doses of PRN morphine have been given and pain is still uncontrolled

Round to the nearest 1 mg dose

Pain Management Protocol

QUESTIONS?