Clinical Safety & Effectiveness Session # 11

Emergency Center Observation Unit

10.15.09

DATE

Project Team

• Patrick Chaftari, MDAssistant Professor , GIM, AT & EC

• Jean H Tayar, MD Assistant Professor, GIM, AT & EC

• Ashutosh GuptaClinical Business Manager, EC

• Richard A. IveyQuality Engineer, Office of Performance Improvement

• Cindy SegalClinical Quality Improvement Consultant, Office of Performance Improvement

• Cylette R. Willis, PhDAssociate Director, Quality Education and Evaluation, Office of Performance Improvement

Project Sponsor: Carmen E. Gonzalez, MDAssociate Professor, GIM, AT and ECSection Chief, EC

Improving Patient Care in the EC

EC Situation

• National benchmark ER Length of Stay (LOS) is 4 hours

• MDACC EC LOS averages 9.5 hours (up to 24 hrs )

• Current situation affects patient care and safety

Can We Improve This Picture?

• Patient safety

• Patient care

• Patient satisfaction

• Bed utilization

00-05 Hrs, N=4,734

42%

06-10 Hrs, N=3,879

34%

11-15 Hrs, N=1,328

12%

16-20 Hrs, N=642

6%

20+ Hrs, N= 675

6%

Pts Treated while in The EC (No Inpt Admission)Patients Treated While in EC (No Admission)

% of Visits by Hours in EC from Lobby Sign-In to Leave TimeApril 1, 2008 to March 31, 2009

1 year DataPrepared by: Linda DeFord OPI Clinical Informatics Data Source: EC Tracking Data

16-20 Hrs

N=642

6%

20+ Hrs

N= 675

6%

Snapshot of Patients Discharged from EC After a LOS > 16 hrs

(March 2009, 119 pts)

(14) 12%

(74) 62%

(4) 3%

(27) 23%

One year data

EC Patient Process

OBS Unit Better Care

• Opportunity to improve patient safety and patient care

• Literature review: Placement on OBS will improve quality of care and revenue Improve disposition→ clinical outcome→ decrease liability Decrease patient and caregiver frustrations Free up EC bed →Decrease some of the EC congestion →Shortens

LOS Decrease cost by efficient usage of EC and inpatient bed Avoid unnecessary admissions and decrease un-reimbursed

readmissions

Observation Unit

• Observation unit could be → a safe→ effective→ cost-saving

way of ensuring that patients who are considered to be intermediate category receives appropriate care.

10

Project

AIM Statement

The aim of this project is to increase the percentage of EC patients placed on Observation by 50% from the baseline of 1.95% to 2.93% during the pilot

period, July 1 - July 22, 2009.

• Baseline period: May 2008 - April 2009

• Process begins when provider evaluates patient in EC and ends when provider places patient on Observation

• Value to the organization – improve patient care and safety, potential financial advantage

How Will We Know That a Change is an Improvement?

Outcome measure: Percentage of EC patients placed on Observation

Data collection: Whiteboard activity report Technical charges

Specific target: 2.93%

Project Milestones

• Team created April 2009

• AIM statement created April 2009

• Weekly team meetings May - August

• Planning April - June

• Interventions implemented July 1 – 22

• Presentation August 7

Fishbone Diagram

LOW NUMBER OF PATIENTS PLACED ON

OBSERVATION

Order sets

Physicians

Lack of education

Lack criteria to place on Observation

Don’t think about it

Nurses

Technology Processes Facilities

Clerks

Do not check observation box on charge sheet

Do not notify clerks that patient placed on

Observation

Training

Data entry

Whiteboard does not visually identify current Observation patients

Unclear processes

Lack of space

Tracking LOS countdown

Identifying Observation patientsBudget to staff

space

Do not understand billing

Guidelines for disposition decision

Tracking patient progression

Appropriate forms

Confirm access to CARE system

Staffing

Paperwork

Physician hand-off

Training

PLAN: The Intervention

• Plan project • Develop presentation materials for providers• Design new EC physician order set and forms• Start general guidelines for placing patients on Observation• Gain leadership buy-in• Raise awareness of OBS availability

Observation Placement Form

Placeholder for Obs form and/or physician order set visual

DO: Implement the Changes

April – June: Build awareness (soft implementation)July 1: Implement interventionsJuly 1 – 22: Measure outcomes

July 1 July 2 July 3 July 4 July 5 July 6 July 7 July 8

Conduct kickoff

Implement order sets

Post order sets online

Place poster in EC

EC Observation start date: July 1st,09

Consider

Observation

placement

Patient is not

ready to be

discharged home

Patient do not

meet admission

criteria

And you expect

improvement within the next

23h to the point

where the patient

could be discharged home

Upon completion of the patient’s work-up

Implementation Issues• Stakeholder identification was incomplete (Clinical Effectiveness)

→ Delay in posting physician order set •Implementation period was too short to address EC meeting schedule, introduce language and new forms

• Non-EC faculty working in the EC not familiar with the process

Results

21

Baseline(May 1, 2008 – April 30, 2009)

Project Intervention Period (July 2009)

OBS Patients1.95 % 5.20 %

391 87

Total Number of patients

20086 1674

CHECK: Results and Impact

Test of proportions p-value < 0.001

9.0%

8.0%

7.0%

6.0%

5.0%

4.0%

3.0%

2.0%

1.0%

0.0%

Month

Perc

ent of Patients

Pla

ced o

n O

bs

(%)

_X=4.6%

UCL=8.3%

LCL=0.8%

Apr-09May-08

Percent of Patients Placed on Observation of the Total EC Visits (Monthly)

Before/After Intervention Test of Means, p-value = 0.004

Source: EC WhiteboardPrepared By: Ash Gupta & Richard Ivey

0.18

0.16

0.14

0.12

0.10

0.08

0.06

0.04

0.02

0.00

Day

Perc

ent of Patient Pla

ced o

n O

bs

_P=0.0534

UCL=0.1435

LB=0

9-J un 1-J ul9-J un 1-J ul

11

Tests performed with unequal sample sizes

Percent of Patients Placed on Observation of the Total EC Visits (Daily)

Before/After Intervention Test of Means, p-value = 0.002

Source: EC WhiteboardPrepared By: Ash Gupta & Richard Ivey

Potential Financial Impact

What is the financial impact of these results on the organization?

• Decrease waste by more efficient use of EC bed and inpatients beds

• Capture of uncharged technical and professional fees

• Bed utilization and resources

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%$0

$200,000

$400,000

$600,000

$800,000

$1,000,000

$1,200,000

$1,400,000

$1,600,000

$1,800,000

$2,000,000

Annual Technical Charges for Patients with EC Stay > 16 Hours and Discharged Home

Expected Charges Including Obs

Estimated Actual Charges

Percent of Patients Placed on Obs with EC Stay > 16 Hours

Estim

ated

Ann

ual T

echn

ical

Cha

rge

Data source: EC Whiteboard to compute LOS (May '08 - Apr '09)

Note: To estimate the actual tech-nical charges for patient with EC stay > 16 hours, an average ap-proach was used using Levels 4 and 5 charge amounts

Assuming 62% of patients with EC stay > 16 hours and discharged home were placed on obs, this represents a potential benefit of approximately $650,000

$650,000

Source: EC WhiteboardPrepared By: Ash Gupta & Richard Ivey

Assuming 62% of patients with EC stay > 16 hours and discharged home were placed on obs, this represents a potential benefit of approximately $428,000

Data source: EC Whiteboard (May '08 - Apr '09)

To estimate the charges for patients with EC stay > 16 hours, an average approach was used using Levels 4 and 5 charge amounts

‘Obs – 1 provider’ assumes that the EC provider is caring for the obs patient

‘Obs – 2 providers’ assumes that a non-EC provider is caring for the obs patient

0.10.13

0.160.19

0.220.25

0.28

0.3100000000000020.34

0.37 0.40.43

0.460.49

0.520.55

0.58

0.610000000000001

0.640000000000005

0.670000000000005

0.700000000000001

0.730000000000001

0.7600000000000040.79

0.820000000000001

0.8500000000000010.88

0.91

0.940000000000001

0.970000000000001 1$0

$200,000

$400,000

$600,000

$800,000

$1,000,000

$1,200,000

$1,400,000

$1,600,000

Estimated Annual Professional Charges for Patients with EC Stay > 16 Hours and Discharged Home

Standard Recovery

Obs - 1 provider

Obs - 2 providers

Percent of Patients Placed on Obs with EC Stay > 16 Hours

Estim

ated

Ann

ual P

rofe

ssio

nal C

harg

e

$428,000

Source: EC WhiteboardPrepared By: Ash Gupta & Richard Ivey

Annual CostRequirement for Unit Annual CostPhysician provider (1) $250,000Nurse (4.2 FTE) $267,260Medical supplies (4% of Annual EC Medical Supplies)

$ 17,129

TOTAL Cost $543,389

• FTE is based on the assumption that the Observation unit will be operational 24/7

• Personnel Cost is based on new staff with less than 1 year at M.D. Anderson

• Medical supplies/expense = 4% of Total EC Medical supplies

• Deduction % = 48.67

Estimated Number of Observation Beds

3 4 5 6 7 8 9 10 11 120%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Avg Utilization Rate vs Number of Observation Beds in Operation

Utilization of Obs Beds

Number of Dedicated Observation Beds

Util

izati

on R

ate The 'Utilization of Obs Beds'

is calculated as the average amount of time occupied divided by the total time available (24-7). This is done by looking at each of the dedicated beds over the entire year.

The choice of number of obs beds should be balanced with the number of patients waiting for a bed

Source: EC WhiteboardPrepared By: Richard Ivey

Next Steps

ACT: Expansion of Implementation

• Maintain and expand awareness of available OBS services in the EC

• Improve identification of OBS patients in the EC

• Review appropriate use of OBS placement

• Track progress of revenue realization

Conclusions

• OBS unit could be a viable solution to improve patient safety and quality of care in the EC

• By decreasing waste and capturing uncharged services OBS unit may provide net revenue to organization

Recommendations

• Designated OBS Unit (Closed unit)– Access limited to EC provider and/or observation

provider– “Virtual” or “Shared” OBS unit within Pod A

• Designated non-EC provider coverage– Improve safety and quality of patient care – Cost of additional provider offset by fee structure

What have we accomplished so far?• Increased number of observation patients to 5.57%

• Improved patient safety Medication reconciliation Diet, activity, fluid infusion

• Improved quality of careBetter oversight by having an APN following these patients on OBS

• Increased RN satisfaction and confidence Improving communication about plan of care

42

43

8.0%

7.0%

6.0%

5.0%

4.0%

3.0%

2.0%

1.0%

0.0%

Month

Perc

ent of Patients

pla

ced o

n O

bse

rvation

_X=4.8%

UCL=7.8%

LCL=1.7%

May-08 Apr-09

Percent of Patients Placed on Observation of the Total EC Visits (Monthly)

Before/After Intevention Test of Means, p-value < 0.001

Source: EC WhiteboardPrepared By: Ash Gupta & Richard Ivey

Questions

Thank you