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Using ED Overcrowding Assessment Tools to Improve Care and Throughput Webinar

May 29, 2014

CHA Webinar

Welcome

Liz Mekjavich

California Hospital Association

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Continuing Education Offered for this Program

Health Care Executives — CHA is authorized to award 2 hours of pre-approved ACHE Qualified Education Credit (non-ACHE) for this program.

Nursing — Provider approved by the California Board of Registered Nursing, Provider Number CEP 11924 for 2.2 contact hours.

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Continuing Education Requirements

Full attendance, completion of online survey, and attestation of attendance is required to receive CEs for this webinar. CEs are complimentary for registrant. If additional participants under the same registration would like to be awarded CEs, a fee of $20 per person, will apply. Post-event survey will be sent to registrant and provide information on how to apply online for additional CEs.

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Program Overview

BJ Bartleson

California Hospital Association

Faculty: Dr. Steven Weiss

Steven Weiss, MD, is an experienced clinician, educator and researcher in the field of Emergency Medicine. With more than 100 publications to his name, he is well known for his work in ED crowding, injury prevention and emergency medical services. In 2002, Dr. Weiss coordinated and designed the National Emergency Department Overcrowding Scale (NEDOCS) study which represented eight major academic institutions nationwide. Since that time he has been involved in numerous ED crowding studies including, most recently, the Community Emergency Department Overcrowding Scale (CEDOCS) study in California.

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The Community Emergency Department Overcrowding Scale

Steven Weiss, MDUniversity of New Mexico Health Sciences Center

Understand the development of the NEDOCS scale

Be aware of the partnership between us and CHA and understand the development of the CEDOCS scoring tool

Objectives

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Introduction

EDs provide an important public service mission

Overcrowding diminishes the capability of the ED to manage emergencies effectively

Institute of Medicine now concludes that ED crowding constitutes a national crisis

Increased Volumes

Hospital Ambulatory Medical Care Survey, 9/.06 CDC.gov

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Solutions

A. EMS Practices=input

B. ED Practices=throughput

C. Hospital Practices=output

Real-Time Throughput Monitoring

NEDOCS EDWIN READI EDCS ED Occupancy

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Study Progression

1. NEDOCS derivation study

2. NEDOCS vs. EDWIN and prospective validation

3. Comparing NECOCS to LWBS

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Introduction

No gold standard

No standardized scale or definition

“We do not know what overcrowding is but we know it when we see it!”

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Methods – Sample

Hospitals included UC Davis, CA Jackson Memorial, FL SUNY Stonybrook, NY Temple U, PA Sinai-Grace Hospital, MI Brigham Womens, MA Harbor UCLA, CA

Methods – Outcome Variable

Each scored on a six-point Likert scale 1=Not busy 2=busy 3=extremely busy but not overcrowded 4=overcrowded 5=Severely overcrowded 6=Dangerously overcrowded

Compared for consistency Averaged equally into an Outcome Variable

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Methods — Objective Data Criteria

Reflects various portions in ED patient management (i.e., triage, treatment, and disposition)

Is readily available and easily quantifiable

The results are reproducible between observers, and

Represent a “snapshot” of the ED

Variables Collected

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Fixed variables Descriptors Time variables Count variables Ratio variables

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NEDOCS score

The reduced model of overcrowding

Number of ED patients

Number of respirators in use in the ED

Total admits in the ED

Waiting room time for last patient called

Longest admit time

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Comparison with EDWIN

EDWIN is defined as

Σniti/Na(BT-BA), ni = number of patients in the ED in triage category

ti ti = triage category based on ESI categories(1-5, 5

being most acute)

Na = number of attending physicians on duty

BT = number of treatment bays

BA = number of admitted/Obs patients in the ED

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LWBS

Overcrowding was found in 44% of our sampling times

There was a significant correlation between LWBS and the NEDOCS score

Correlation was best for LWBS and overcrowding scale two hours after patient registration

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Limitations

Lack of a true gold standard definition

Differences in definition of terms such as “diversion” and “critical care patients”

Pediatric EDs not specifically addressed

Generalizable only to other academic EDs

Community hospitals not specifically addressed

Prospective Validation ofscale

Stage 3B

Academic EDOvercrowding Scale

Community EDOvercrowding scale

Development of Full scale (Site Evaluation form)

Stage 1A

Development of Full scale (Site Evaluation form)

Stage 1B

Evaluation of Full scale andReduced scale development

Stage 2A

Evaluation of Full scale andReduced scale development

Stage 2B

Prospective Validation ofscale

Stage 3A

Fusion of the scales for evaluation of entirecommunity ED overcrowding issues.

Stage 4

Application of scale to complex issues 1. Patients leaving prior to full medical care. 2. Medical Errors 3. Diversion 4. Patient ED Acuity levels. 5. Patient Satisfaction Stage 5

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CHA

Community hospitals not specifically addressed

We need a scale that is specific to the issues in California

How do we do this?

Consultation Phase for Me

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Methods used in NEDOCS explained

Starting independent variables suggested

Methods of collecting the outcome variable were described

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Variables Collected

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Fixed Variables 4Descriptors 2Time variables 3Count Variables 9Ratio Variables 2

Total Variables considered 20

Fixed Variables Collected (4)

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Hospital size/ED visits per year

Number of ED beds

Number of hospital beds

Percent occupancy of inpatient beds routinely used (recorded once daily)

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Day of the week Time of the day

Descriptors Collected (2)

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Time Variables Collected (3)

Longest time psychiatric patient is waiting in ED

Longest time patient is waiting to be seen in the ED

Longest time an admitted patient is still waiting in the ED

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Count Variables Collected (9)

Number of pts in waiting room

Number of pts in the triage area (“Tweeners”)

Number of pts in the ED

Number of admitted and transfer pts in the ED

Number of psych pts in the ED

Number of nurses with direct care responsibilities

Total number of licensed nurses in the ED

Number of admitted critical care pts in the ED

Number of patients on ventilators in the ED

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Ratio Variables (2)

ED pts-to-ED bed ratio Admitted pts to hospital bed

ratio

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13 Total Hospital (Red=lowest, Bold=Highest)

Hospnum

Annual ER Visits(1000s)

Licensed Beds

Licensed ED Beds

Acute Routinely-

Used Inpatient

BedsTrauma center

(level)Base

Hospital

Annual Admissions

(1000s)1 31 64 26 62 - Yes 52 56 320 27 194 2 Yes 163 66 290 28 286 2 No 114 19 100 7 69 - Yes 55 41 460 36 423 - Yes 186 47 220 36 221 2 Yes 127 30 170 12 118 2 No 108 46 350 34 304 2 Yes 189 44 270 20 140 - Yes 11

10 43 200 19 114 - Yes 911 52 640 49 407 2 Yes 1812 49 380 36 316 - Yes 1713 67 310 34 313 2 Yes 16_

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Methods

Each hospital had a data collector who ensured completion of this form every four hours for a two week period

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Analysis Phase for Me

De-identified dataset sent to me for evaluation

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What is R2

R2 is the coefficient of variability If the correlation coefficient is 0.5

the coefficient of variability is 0.25 If the correlation coefficient is 0.7

the coefficient of variability is 0.49 It means the variable explains 25%

and 49% of the final variable in the outcome

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Variables

CorrelationED Numbers

Percent hospital occupancy (%) -0.01Total ED patients 0.55In waiting room 0.50Admitted and transfer patients 0.34Critical care patients 0.27Psychiatric pts 0.08In the triage area (Tweeners) 0.23On ventilators 0.08

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Variables

Correlation

ED Times (hours-nearest 0.25 hr)

Longest admit time 0.23

Longest admit time for a psychiatric patient 0.00

Longest waiting room wait time 0.35

ED Staffing

# of staffed licensed nurses 0.20

# of direct care nurses 0.20

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35% of sampling times had at least 1 psychiatric patient on hold

Median of 2 patients (1, 2)

Median time was 8 hrs (4, 14hrs)

Maximum was 27 patients and 109 hours waiting in the ED

The Psychiatric Patients

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5-Variable Model

P R2

Critical care ED patients 0 0.463

ED visits per year 0 0.444

Longest wait time for admitted pt

0 0.409

Number of waiting room patients

0 0.361

ED patient-to-ED bed ratio 0 0.000

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Determination of ER Visits/Year in the Model

3 degrees of Freedom -R2=0.474

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5-Variable Final Model

Final Model r2 = 0.474 Full Model r2 = 0.501 Final model accounts for

0.474/0.501 = 95% of the full model

NEDOCS Number of ED beds

Number of hosp beds

ED patients

Respirators

Admits in the ED

Admitted patient wait time

Waiting room wait time

NEDOCS vs CEDOCS

CEDOCS Number of ED beds

Number of ED visits/year

ED patients

Critical care patients

Waiting room patients

Admitted patient wait time44

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Correlation Values

VAS OUTCOMER2

CEDOCS 0.47

NEDOCS 0.39

Full Model 0.50R2 comparison to Overcrowding

NEDOCS – 78%CEDOCS – 95%

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Website

http://hsc.unm.edu/emermed/ CEDOCS NEDOCS

Thank you

Steven Weiss, MD(505) 514-5087 Sweiss@aol.com

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Faculty: Aaron Wolff, RN

Aaron Wolff, RN, is the Trauma Service Line and Pre-Hospital Care manager for Dignity Health at the Mercy Medical Center in Redding. Mr. Wolff has held several positions for Dignity Health including corporate manager of Performance Improvement and director of Emergency and Trauma Service at Mercy Medical Center and director of Emergency Services and Endoscopy at the Redding Medical Center in Redding. Mr. Wolff is a registered nurse, public health nurse and a board certified emergency nurse.

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P R E S E N T E D B Y:

Version 8.0 (June 2011)

Dignity Health

Emergency

Department

Over-

Crowding

Score

Aaron Wolff

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What is DEDOCS: An analytic tool for assessing Emergency Department Saturation

• DEDOCS uses a mathematical formula to objectively determine the level of saturation of Emergency Department resources

• Standardizes the assessment and communication of “We are too busy”

• Links the assessment to evidence-based actions that will improve operational efficiency, care quality and capacity to accommodate business growth

• Tracks patterns of saturation and mitigation actions to support forecasting and action planning

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Clinical purpose for using DEDOCS tool

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Emergency Department Saturation and boarding is identified by The Joint

Commission, IHI, ENA and ACEP as a leading cause of

errors and negative outcomesfor Emergency Department patients

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Regulatory Indications: Joint Commission Flow LD.04.03.11

Elements of Performance

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• EP1: a process that supports the flow of patients throughout the hospital

• EP4: criteria guide to initiate ambulance diversion• EP5: measure and set goals for the components of

the patient flow process– Hospital leaders will need to use data and metrics in

a more systematic process. It is imperative for hospital leaders to monitor and manage the patient flow process throughout the entire organization

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EP 6 (goes into effect January 1, 2014) measure and set goals for mitigating and managing the boarding of emergency department patients

EP 7 require the staffs or individuals who manage the patient flow processes to review the measurement results

EP 8 leaders (include, medical staff ,governing body, CNE, senior managers…) take action to improvepatient flow processes when goals are not achieved

Joint Commission Flow LD.04.03.11Elements of Performance

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Calculating Saturation

When entering data the calculation is automated to produce a final score and level.

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1. Click the Debrief Add2. Click Browse and

locate document3. Click Add and put in a

brief description

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• Debrief Form Example: Must be completed for all Levels 4, 5 & 6

• May be in Word, Adobe or Excel

• Each site should create and include whatever is relevant based on their ED Decompression / Patient Throughput processes

Follow up debrief required for Levels 4, 5 & 6

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To Review or Update a Debrief

1. Search, Open Entry and Click on View

2. Click on Open to see document

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Daily Review – ED Manager and/or Director

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Go to the Search Screen for a Quick Snapshot of the last 24 – 28 hours. Most recent Original Entry is first.

Could have multiple pages, so be certain to click Next to see more entries

You can click on any Entry and see the details or make updates

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Automated Email Messages

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# Template Recipient Description

1 Missing Entry ED Manager(s) for facility E-mail sent 120 minutes after expected entry has not been entered

2 Missing Debrief ED Manager(s) for facility E-mail sent 24 hours after saturation event with level >=4 and no debrief attached

3 No Assigned ED Manager Site Administrator(s) for facility E-mail sent when facility has no configured ED Manager(s). Only one e-mail is sent per week.

4 No Assigned Administrator System Administrator E-mail sent when facility has no configured ED Manager(s) or Site Administrator(s). Only one e-mail is sent per week.

• 1 & 2 sent to individuals designated as ED Managers• 3 to site process directors• 4 to system administrators

Example of Email Notification for Missed Entry

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Example of Email Notification for Missed Debrief

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Running a Report1. Click on reports in the

Menu Bar2. Select the date range and

the type of Report and click Generate.

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When Dialog Box appears choose to Open or Save

Once the Report is Generated you can use in Excel like any other report file

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Sample Reports and Reacting to Trends

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Adding a User to your Facility

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Navigate to the Facility Administration Page

Click on the Add Row link

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Other Facility Administrator Functions

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You will need to enter the following information for your facility:

• Total number of Functional Inpatient Beds in your facility. This should never be more than the total licensed beds

• Total number of beds designated for Emergency Services (could include trauma, psych, etc.) not including “hallway beds”

• Total number (if any) of Critical Care Beds allocated in ED from the Total in previous field. Recommendation from NEDOCS and in California pending legislation is not greater than 4

Defining the User Role

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Select the role

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Linking ASSESSMENT to ACTIONS

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Summary of Value

Indicated for care quality management

Highlights growth opportunity Efficiency in “Load Leveling” Objective analysis of service promise probability

Fulfills regulatory requirements

Guides decisions related to InQuicker opportunity and service promises

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Demonstration

Thank you

Aaron Wolff, RNAaron.Wolff@DignityHealth.org

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Questions

Online questions:Type your question in the Q & A box, hit enter

Phone questions:To ask a question hit 14 To remove a question hit 13

Upcoming Programs

• Hospital Finance and Reimbursement SeminarsJune 5 – June 11, three programs

• Hospital Presumptive Eligibility WebinarJune 19, Sacramento

• Disaster Planning for California HospitalsSeptember 22 – 24, Sacramento

• Physician Leadership ProgramSeptember – April 2015, seven programs

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Thank You and Evaluation

Thank you for participating in today’s program. An online evaluation will be sent to you shortly.

Reminder: evaluation completion is required to receive continuing education credits.

For education questions, contact Liz Mekjavich at (916) 552-7500 or lmekjavich@calhospital.org.

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