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Emergency Room Of The Future Leveraging IT At WellStar Health System: Kennestone Emergency Department. September 18, 2008. Jon Morris, MD, FACEP, MBA WellStar Health Systems. Agenda. Introduction Kennestone Emergency Department Metrics More Metrics- Exit Phase - PowerPoint PPT Presentation
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EMERGENCY ROOM OF THE FUTURELEVERAGING IT AT WELLSTAR HEALTH SYSTEM:KENNESTONE EMERGENCY DEPARTMENT
Jon Morris, MD, FACEP, MBAWellStar Health Systems
September 18, 2008
Agenda
Introduction Kennestone Emergency Department Metrics More Metrics- Exit Phase Even More Metrics- Non-ED Physicians So far…
To Err Is Human
Patient Safety Issues: IOM report Nov. 1999
> 44,000 – 96,000 deaths related to preventable medical errors/year
$17B - $29B cost
2000 – Leapfrog Group
Example: 2007 Adverse Drug Events
The Need For Change
“The definition of insanity is to continue to do the same thing over and over again
and expect different results”
Albert Einstein
Kennestone ED
Kennestone Emergency Department
Adult Fast Track PediatricHours 24/7 11A-11P 24/7Levels 4 1 1Beds 61 8 9
Hall beds 9 0 2Total 70 8 11
>102,000 Annual patient volume
40% of Kennestone admissions
24.38% admit rate (July 08)
October 2007: ED Online
ED Flow “Before”
Paper ED Record
Completed ED Evaluation - Waiting For MD
October 2007: Kennestone ED Live Online Documentation and Order Entry
“Sole Source” strategy- McKesson 18 month build
ED Tracking Board Online Clinical Documentation (Horizon
Emergency Care – HEC) Online Order Entry (Horizon Expert
Orders - HEO)
ED Flow “After”
WSKH ED Applications
ED Tracking Board
Patients Waiting For MD
ED Patients: Status & Tasks
WSKH ED Applications
Documentation
Online Documentation
Always Available Real-time Legible Automated Date & Time All Clinical Documentation In One Place More Complete
ED MD Charting
Paper vs. HEC- MD Note
WSKH ED Applications
Order Entry
Definition: CPOE
Provider Enters Orders
Clinical Decision Support Easier to do the right thing Harder to do the wrong thing
Immediate Order Transmission
Tools: I-Forms
Tools: Order Outlines
“Easier To Do The Right Thing:” Weight-based Dosing
“Easier To Do The Right Thing:” Weight-based Dosing
Leveraging CPOE: Automation
“Harder To Do The Wrong Thing”
Allergy Checking
Allergy Alert
CPOE: A Process
Multiple applications Provider Nursing Pharmacy Ancillary Services, i.e., Laboratory, Medical Imaging
Global process - multiple stakeholders
KLAS: 17.5% US Hospitals > 200 beds in 2007
CPOE- Financial Gains
CPOE in Community Hospitals: ADE cost Renal dosing errors Unnecessary / Redundant diagnostic
studies IV to PO conversion
$2.7M Reduction in Cost, 26 month payback*
* Feb 08 MA CPOE Initiative Report
The Competition
Goals- WellStar Health System
Improve Care
Lower Costs
CPOE Using HEO
Two Years To First Facility Go-live
100% Physician Adoption Two Years Post-
live
WSKH ED
Implementation
Challenges in Implementing HEC-HEO
Development
Training
Deployment
Adoption
Reporting
Implementing HEC-HEO
The Good-
The Bad-
And the Ugly Truth.
One solution…
“In the middle of every difficulty lies opportunity”- Albert Einstein
A Better Way: Metrics
Throughput Analysis
Neglected value of ED applications Acquire data from HEC & TB. Quarantine invalid data Report data compliance, i.e., reporting
efficacy and accuracy. Select and study throughput intervals. Identify high-yield opportunities.
WS KH ED - Throughput Intervals
•Arrival to Triage
•Arrival to Bed
•Arrival to EDMD Assigned
•Arrival to EDMD At Bedside
•Bed to EDMD at Bedside
•EDMD at Bedside to EDMD Decision to Disposition
•EDMD Decision to Disposition to RN Disposition
•RN Disposition to Exit
•LOS
ED Metrics
The Good: Reliable ED Metrics
ERK - July 2008
The Bad: Delays in Seeing EDMD
Admitted Patients:
Patient Arrival to MD At Bedside: 61 minutesPatient in Bed to MD At Bedside: 42 minutes
The Ugly: Delays in Exit From ED
July 2008 EDMD Decision to Admit to Exit from ED:
Exit Phase = EDMD Decision to Admit → Patient Exit From ED
162 + 10 = 172 minutes
39-47% Average ED Patient LOS (Jan – July 2008)
Progress: Bed to MDATBEDJul 08: Additional 1P EDMD shift present on 12/31 (38.7%) days
90% August dates have 1P ED MD Coverage
Exit Phase Delays
Admitted ED Patients: 3 Steps
1. Get Into An ED Bed
2. Receive ED Treatment &/Or Evaluation
3. Move to Next Level of Care
Getting Into An ED Bed:
Available ED Bed and Resources Clinical Staff, i.e., RN, tech, etc. Open Beds Patients Must Be Able To Leave
ED MD Must Be Available Appropriate ED MD Staffing
Treatment &/Or Evaluation:
Treatment Laboratory Tests Medical Imaging Studies Consultation for Admitted Patients
ED Process Improvement Committee
Moving to the Next Level:
Receive Admitting Orders, then…
Additional ED Orders Call For Bed (Next Level Of Care) Bed Assignment Inpatient RN Staff Available to Receive
Report ED Staff Available to Move Patient
Moving to the Next Level:
Exit Phase: Begins With EDMD Decision To Admit Ends With Patient Exit From ED
158-251 minutes January – August 2008
39-47% of LOS
Exit Phase: Study Intervals
How long did it take to receive orders? Consult Interval [EDMD Decision to Disposition] to Admit
Orders Received (AOR)
Exit Phase: Study Intervals
How long after AOR did patient leave EDTB? ED Inpatient Admit Interval AOR to Exit (ED bed available)
Exit Phase Study: May – September 2008
May 2008 June 2008 July 2008 Sep 2008Total #
Admissions1531 1348 1613 1578
Admission Rate
23.05% 23.41% 24.42% 23.54%
Admit Record Compliance
51.67% 54.15% 53.81% 55.32%
Total # Compliant Records
791 730 868 873
Average Consult
Interval (min.)86 (1-1360) 90 (0-1376) 92 (0-2391) 110 (0-1467)
Averaged 86-110 minutes just to get admit orders Haven’t even called for a bed.
(Practice & provider-specific data available)
Results- Consult Interval
Results- Inpatient Admit Interval(additional studies in progress)
ED Metrics
Admitting (Non-ED) physicians
Average ED Consult Intervals May-July 2008
Practice
# Admits
A 696
B 245
C 202
D 105
E 92
F 72
G 63
H 50
I 49
J 41
Selected Average Consult IntervalMay – July 2008(EDMD Decision to Disposition to AOR*)
*AOR = Admit Orders Received
But…
Admitting Strategies
Cardiology- Average Consult IntervalMay – July 2008(EDMD Decision to Disposition to AOR)
Cardiology Admissions
Significant variation in consult intervals exists between cardiology practices.
• Two of three cardiology practices, Practices “A” and “C,” account for 22.7% of all ED admissions. These practices almost exclusively admit only following consultation and evaluation in the ED.
• Practice “B” routinely phones in orders and evaluates the patient on the floor if they left the ED by the time they arrive.
• This is reflected in patients’ consult intervals and LOS:
Cardiology- Average ED LOSMay – July 2008(EDMD Decision to Disposition to AOR)
In Progress:
Medical Staff Admit Strategies
Staffing Changes and Allied Health
Professionals
EDMD Calls For Bed
Admit Holding Area
Summary
Introduction Kennestone Emergency Department Metrics More Metrics- Exit Phase Even More Metrics- Non-ED Physicians So far…
