emergency room study
TRANSCRIPT
Ms. Venus A. Bolivar
Mr. Siegfredo L. Lopez
Dr. Raymundo B. Ibarrientos
Ms. Wilhelmina C. de Castro
Improving Patient Waiting Time at the Emergency Room of
Bicol Medical Center, Naga City
2
E.R.
ER-QI Team Mission
Provide a responsive quality health care system for patients admitted at the Emergency Room of
Bicol Medical Center, Naga City
Quality Improvement Team
FMTP Team – Medical Svc. : Dr. Raymundo IbarrientosFMTP Team – Finance Svc. : Mrs. Venus A. BolivarFMTP Team – Admin. Svc. : Mr. Siegfredo L. LopezFMTP Team – Nursing Svc. : Mrs. Wilhelmina C. de CastroER Head : Dr. Elvin Panliboton ER Supervising Nurse : Mrs. Bernadette Betito ER Senior Nurse : Mr. Marlon CloresChief Resident of Medicine : Dr. Molave TabanaoAdmitting Unit : Mrs. Cyril TolledoRadiology Department : Mr. Marlon VillamoraPharmacy Section : Mrs. Maria Reina LagramadaSocial Service Section : Mrs. Agnes TabiosCentral Supply Room : Mrs. Marivic FrancoCash Section : Mrs. Ma. Dinia FortunoDepartment of Laboratories : Mr. Rexy Alvarez, Mrs. Evangelina Ramos
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FMTP Team with Dr. Edgar O. Esplana, Medical Center Chief
FMTP Team with Management Committee
Members
Quality Improvement Process
Step 1: Reason for Improvement
Theme Selection Matrix Theme Customer Impact
on Custome
r
Need to improv
e
Total Rank
Internal External
Waiting time of patients at ER
Doctors, nurses, lab., x-ray, pharmacy, social service, admitting unit
PatientsRelativesReferring agencies
5 5 25 1
Accomplishment of job requests
BMC management and employees
Patients, Relatives, Other Stakeholders
4 5 20 2
Hospital in-patient days
Doctors nurses Records Section, Dietary Service, Billing Unit
PatientsRelatives
4 4 16 3
Absconding of patients
Doctors Nurses Security Billing Cash Section
PatientsRelatives
3 4 12 4
Income generation
BMC Management & employees
Patients, Relatives, Other stakeholders
3 3 9 5
Theme
Indicator
Waiting time of medical patients admitted at the Emergency Room of Bicol Medical Center, Naga City
Average waiting time of medical patients admitted at the Emergency Room of Bicol Medical Center, Naga City
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N = 40
Step 2: Current Situation
Average Waiting Time of ER Patients by DepartmentOctober 2006
Med OBPediaSurg
Time
ER Department
0
0.5
1
1.5
2
2.5
N = 1969
Step 2: Current Situation
Emergency Cases by DepartmentBicol Medical Center, Naga City
December 2006
patients admitted < 2 hrs
patients admitted > 2 hrs
17%
83%
OB Gyne32%
n=640
Medical27%
n=525Pedia24%
n=463
Surgery17%
n=341
Problem Statement
In December 2006, the average waiting time of medical patients admitted at the Emergency Room was 3 hours and 55 minutes
resulting in delayed treatment thereby causing patients’ dissatisfaction.
By the end of August 2007, the average waiting time of medical patients admitted at the Emergency Room will be reduced to < 2 hours.
Target Indicator
1. Patient arrives at ER with the companion
2. Triage Nurse classifies patient & issues ER slip
Time: 5 mins
2
Companion
Patient
Emergency Room Animated Work Flow
1
Ped
D.Q
D.Q
B. B
O.B
Med ER
Admitting
Triage
Entrance to ER
SA
Medical Annex Ward
3. Admitting clerk issues ER record
4. Nurse monitors/ records vital signs
Time: 20mins Emergency Room Animated Work Flow
3
4
Patient
Med ER
Admitting
Triage
Entrance to ER
Medical Annex Ward
Companion
5. Physician examines patient & issues initial orders
• Nurse carries out orders
Time: 15 min
5
Emergency Room Animated Work Flow
Patient
Ped
D.Q
D.Q
Lab B. B
Hemo
O.B
Sur
O.R
X-ray
Cashier
6
Med ER
Admitting
Triage
Entrance to ER
Medical Annex Ward
Companion
14
(
Time: 40 min
5
Emergency Room Animated Work Flow
Patient
Ped
D.Q
D.Q
Lab B. B
Hemo
O.B
Sur
O.R
X-ray
Cashier
6. If patient requires lab exams:
• Companion brings request to laboratory
• Lab tech performs exams and issues charge slip
6 – A
Companion pay to Cash Section, get the official receipt, present it to the lab tech & obtain the official result
Nurse refer results to Physician
6
6-A
Med ER
Admitting
Triage
Entrance to ER
Medical Annex Ward
Companion
15
7
Emergency Room Animated Work Flow
Patient
Ped
D.Q
D.Q
Lab B. B
Hemo
O.B
Sur
O.R
X-ray
Cashier
7. If patient requires radiologic exam:
• Utility Worker wheel patient to X-ray Dept
Rad tech issues charge slip
7-A Companion pays to
Cash Section, and present official receipt to rad tech
rad tech performs x-ray exam
UW brings back patient with x-ray film to ER
Nurse refers x-ray film to Physician
Time: 40 min
7-A
Med ER
Admitting
Triage
Entrance to ER
Medical Annex Ward
Companion
16
8
Emergency Room Animated Work Flow
Patient
Ped
D.Q
D.Q
Lab B. B
Hemo
O.B
Sur
O.R
X-ray
Cashier
If for admission:
8. Nurse carries out doctor’s orders
Time: 25 min
Med ER
Admitting
Triage
Entrance to ER
Medical Annex Ward
Companion
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Emergency Room Animated Work Flow
Patient
Ped
D.Q
D.Q
Lab B.
B
Hemo
O.B
Sur
O.R
X-ray
Cashier
Time: 1 hr, 20 mins
9. Admitting clerk records admission of patient, informs ward & secures Consent for Admission
10. Social service classifies patient and endorse patient’s chart to nurse
Med ER
Admitting
Triage
Entrance to ER
109
Medical Annex Ward
Companion
18
11
Emergency Room Animated Work Flow
Patient
Ped
D.Q
D.Q
Lab B.
B
Hemo
O.B
Sur
O.R
X-ray
Cashier
Time: 10 mins
11. Nurse checks patient’s condition and chart
12. UW transports patient to ward
Med ER
Admitting
Triage
Entrance to ER
12
Medical Annex WardPatient admitted, Endorse to ward NOD
Companion
Emergency RoomWork Flow Chart
Triage Nurse classifies patients
NoPatient needs ER care?
YES
Patient arrives at the ER
Refer to OPD or instruct patient
to comeback the next day at the OPD
Triage nurse issues ER slip and Admitting Clerk releases ER record
A
5 min.
20 min.
A
ER nurse assesses patient and document initial v/s to ER record and refer to ER
ROD
ER doctor examines patient
Patient needs diagnostic tests?
NO
YES
Admit Patient?
NO
YES
C
D
ER ROD prepares requests for diagnostic procedures
B
15 min.
B
If for X-ray, IW brings patient to radiology
X-ray tech issues charge slip
ER nurse refer results to ER ROD
Lab. tech issues charge slip
Needs confinement?
NO
YESC
D
40 min
Relative brings request to laboratory
Lab tech. performs exam
Relative pays to Cash Section
X-ray tech releases x-ray film
ER nurse refers results to ROD
30 min
Relative pays to Cash Section
X-ray tech performs exams
Lab. tech releases results
30 min
40 min
Disposition of ROD For Consultation
NOD carry out initial order of ROD, administer Txt and meds
NOD issue charge slips and Patient’s Relative settles bill to
cashier
Relatives pay at the cashier and present OR to NOD, who then
signs patients clearance
Discharged
If unable to pay, cashier refers relative to social service who will decides whether to give discount
or to sign a promissory note
Pts/ relatives presents clearance to guard
C D
For Admission
NOD carry out initial orders of ROD
NOD informs Admitting Unit of the admission
Admitting clerk records admission of patient, secure Consent to Care, and informs ward
NOD checks patient’s condition and patient’s chart
UW transports patient to ward
Admitted
Social service classify patients and endorse patients chart to NOD
25 min.
1hr 20 min.
10 min.
Step 3: Analysis
In December, 2006, the average waiting time of medical patients admitted at the Emergency Room was 3 hours and 55 minutes resulting to delayed treatment thereby causing patients’ dissatisfaction.
ManpowerMethod
Materials
People / Manpower
Overcrowding of patients
Insufficient trained ER personnel to attend to patients
Patients are not attended immediately
In December, 2006, the average waiting time of medical patients admitted at the Emergency Room was 3 hours and 55 minutes resulting to delayed treatment thereby causing patients’ dissatisfaction.
Ineffective Replenishment system
Materials
Some commonly used medicines and supplies were not available at the ER
ER meds and supplies were not replenished promptly
Patients relatives are asked to buy meds and supplies at the hospital pharmacy / outside hospital
In December, 2006, the average waiting time of medical patients admitted at the Emergency Room was 3 hours and 55 minutes resulting to delayed treatment thereby causing patients’ dissatisfaction.
Methods / Processes
Relatives/ Patients have to undergo circuitiuous process of
payment
Delayed released of Diagnostic test results
Delay in diagnosis and disposition of ER patientIn December, 2006, the average waiting time of medical patients admitted at the Emergency Room was 3 hours and 55 minutes resulting to delayed treatment thereby causing patients’ dissatisfaction.
Methods / Processes
ER patients mixed up with in and out patients
Long queue of ER patients at the ancillary sections Laboratory, Radiology
congestion of ER patients
No protocol for patient case classification
Patients were not classified according to severity of cases
Delayed in carrying out of ancillary procedures
In December, 2006, the average waiting time of medical patients admitted at the Emergency Room was 3 hours and 55 minutes resulting to delayed treatment thereby causing patients’ dissatisfaction.
Countermeasures Practical Methods
Reassign-ment of senior
nurse and clerk to ER
Insufficient trained
personnel to attend to ER
patients
Root Cause
Ensure adequate number of
trained personnel at
ER
E F Overall Axn
5 5 25 yes
Step 4: Countermeasures and Practical Methods
Detailing of PHO staff as
an addtl manpower for
ER
Hiring of additional ER
personnel
4 2 8 no
5 1 5 no
In December, 2006, the average waiting time of medical patients admitted at the Emergency Room was 3 hours and 55 minutes resulting to delayed treatment thereby causing patients’ dissatisfaction.
Countermeasures Practical Methods
Send HC personnel for
training in other specialty hospitals
Root Cause
Capability building of existing ER
staff
E F Overall Axn
5 5 25 yes
5 5 25 yes
Conduct specialty
training for ER staff
Step 4: Countermeasures and Practical Methods
Close supervision of
ER staff by medical
consultants and ER manager
5 4 20 no
Insufficient trained
personnel to attend to ER
patients
In December, 2006, the average waiting time of medical patients admitted at the Emergency Room was 3 hours and 55 minutes resulting to delayed treatment thereby causing patients’ dissatisfaction.
Countermeasures Practical Methods
Ineffective replenishment
system
Root Cause
Ensure an effective
replenishment system
E F Overall Axn
5 1 10 no
Adopt existing Replenishment system of other tertiary hospital
Step 4: Countermeasures and Practical Methods
Review/Revise existing
replenishment system
5 5 25 yes
In December, 2006, the average waiting time of medical patients admitted at the Emergency Room was 3 hours and 55 minutes resulting to delayed treatment thereby causing patients’ dissatisfaction.
Countermeasures Practical Methods
Pt/relative have to undergo circuitiuous process of payment
Root Cause
All charges of ER patients for
admission should be
included in the hospital bill
prior to discharge
E F Overall Axn
5 5 25 yes
Step 4: Countermeasures and Practical Methods
4 2 8 noER patients should not be
charged of diagnostic tests
Simplify process of payment
In December, 2006, the average waiting time of medical patients admitted at the Emergency Room was 3 hours and 55 minutes resulting to delayed treatment thereby causing patients’ dissatisfaction.
Countermeasures Practical Methods
Provide area and personnel to attend to ER
patients
ER patients are mixed up with
in and out patients
at the different ancillary services
Root Cause
Ensure that ER patients
are not mixed with the in and out pts at diff.
ancillary services
E F Overall Axn
5 5 25 yes
5 1 10 no
Step 4: Countermeasures and Practical Methods
Provide one-stop ancillary
services at the ER area
In December, 2006, the average waiting time of medical patients admitted at the Emergency Room was 3 hours and 55 minutes resulting to delayed treatment thereby causing patients’ dissatisfaction.
Countermeasures Practical Methods
Develop procedures for
ER patient case classification
No protocol for patient case classification
Root Cause
Formulate protocol for patient case classification
E F Overall Axn
5 5 25 yes
Adopt patient case
classification from other hospitals
Step 4: Countermeasures and Practical Methods
3 2 6 no
In December, 2006, the average waiting time of medical patients admitted at the Emergency Room was 3 hours and 55 minutes resulting to delayed treatment thereby causing patients’ dissatisfaction.
April 24, 2007
May 1, 2007
May 1, 2007
Chief Nurse
Chief AO Medical
Center Chief
ER QI Team
Conduct Meeting with the Nursing Service Management Team and Medical Records Section
Assign senior nurse per shift as a triage nurse and as a "bed site manager“
Assign job order clerk to list patients for consultation at the triage area
Reassignment of senior nurse and clerk to ER
Date DoneStart DateWho DoesTasksPractical Method
Countermeasures: Assign additional personnel to attend to ER patients
April 24, 2007
May 1, 2007
May 1, 2007
Action Plan
May 4, 2007
May 15, 2007
June, 2007
Training Office ER Head ER doctors and
nurses ER QI Team
Determine training needs of ER personnel
Coordinate with other agencies regarding training programs
Schedule training program of ER personnel
• Send healthcare personnel for training in other specialty hospitals
Date DoneStart DateWho DoesTasksPractical Method
May 14, 2007
May 31, 2007
August, 2007
Countermeasures: Assign additional personnel to attend to ER patients
Action Plan
September 4, 2006
Oct. 30, 2006
September 25, 2006
October, 2006
Training Office ER Head ER doctors and
nurses ER QI Team
Develop Specialty program for nurses
Train staff nurses for the specialty program.
Accept volunteer nurses for the specialty program
Monitor implementation of program
Evaluate effectiveness of the implementation of the program
• Conduct specialty training
for ER staff
Date DoneStart DateWho DoesTasksPractical Method
Countermeasures: Conduct special training for ER personnel
September 18, 2006
Ongoing
Ongoing
Monthly
Action Plan
April 25, 2007
May 7, 2007
May 10, 2007
August, 2007
April 25, 2007
May 7, 2007
May 8, 2007
May 15, 2007
ER QI Team
ER QI Team
CAO
ER QI Team
Conduct Meeting with the pharmacy, CSR and the ER staff to review/ revise existing replenishment system
Present reviewed and revised replenishment system to MANCOM for approval
Issuance of hospital order to implement revised replenishment system
Monitor and evaluate effectiveness of the replenishment system
Review / revise existing replenishment system
Date DoneStart DateWho DoesTasksPractical Method
Countermeasures: Ensure an effective replenishment system
Action Plan
Action Plan
May 21, 2007
May 21, 2007
May 28, 2007
August, 2007
May 7, 2007
May 21, 2007
May 28, 2007
May 29, 2007
Review / Revise of policy requiring payment before issuance of result
Present to MANCOM for approval of revised policy
Issuance of hospital order to revise the policy
Monitor/ evaluate effectiveness of the replenishment system
Date DoneStart DateWho DoesTasksPractical Method
Countermeasures: Simplify process of payment
All charges of ER patients for admission should be included in the hospital bill prior to discharge
ER QI Team
ER QI Team
CAO
ER QI Team
April 24, 2007
May 1, 2007
May 1, 2007
Chief Nurse
Chief AO Medical
Center Chief
ER QI Team
Conduct Meeting with the different ancillary services to provide an area and personnel to attend to ER patients
Provision of separate window/ area for ER patients
Assign personnel to attend to ER patients
Provide area and personnel to attend to ER
patients
Date Done
Start Date
Who DoesTasksPractical Method
Countermeasures: Prioritize ER patients at the different ancillary services
April 24, 2007
May 1, 2007
May 1, 2007
Action Plan
May 7, 2007
May 28, 2007
May 29, 2007
June4, 2007
CMPS Departme
nt Head Chief
Nurse Nurse
Supervisor
Senior Nurse
ER QI Team
CAO
ER QI Team
Conduct Meeting with the medical and nursing service to formulate patient case classification
Present to MANCOM for approval of patient case classification
Issuance of hospital order to implement patient case classification
Monitor effectiveness of implementation
Develop procedures for ER patient case classification
Date Done
Start Date
Who DoesTasksPractical Method
Countermeasures: Observe protocol for patient case classification
May 7, 2007
May 28, 2007
May 31, 2007
August 30, 2007
Action Plan
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The Canadian Triage and Acuity Scale ( CTAS)
The CTAS was designed to help ensure that patients who need immediate care get seen first.
The CTAS system group patients into 5 categories.
CTAS I – Resuscitation - immediately CTAS II – Emergent - within 15minutes CTAS III – Urgent - within 30 minutes CTAS IV – Less Urgent - within 60 minutes CTAS V – Non-urgent -within 120 minutes
The CTAS classified under I-III were the only patients included in the study since CTAS IV – V were under observation.
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17%
83%
Waiting time of medical patients admitted at the Emergency Room before and after the quality improvement project
23%
77%
Before QI (n=525)
December1-31, 2006 August 10 to September 7, 2007
After QI (n=235)
patients admitted > 2 hrs
patients admitted < 2 hrs
Step 5: Result
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Emergency Room Slip
Name of Patient: __________________Age: ______ CTAS :______Chief Complain : __________________Date:
Time Arrived : _____ __Time seen NOD :_______Time seen ROD:_______
For X-Ray:Time Requested: _______ Time left the ER : ______ Time left the X-ray: ___
For Laboratory :Time Requested : _______Time Req. forwarded:_ _Time specimen was taken: Time result was released:
Time Admitted by ROD: __________
Time Top sheet was obtain: _______Time classified by social service: Time wheeled to ward: ___________Time endorsed by ER NOD to ward NOD:
Time seen by ward NOD: ______________________________
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To ensure sustainability of the Revised Emergency Room Workflow :
1. Utilization of ER slip to continuously monitor the patients’ waiting time.
2. Utilization of the CTAS as basis for the patient case classification.
3. Regular conduct of the Specialty training program.
Step 6: Standardization
45
Revised Emergency Room Work Flow
46
Revised Emergency Room Work Flow
STEP 1: Initial Triaging of PatientNurse II –Triage Nurse5 minutes
47
Revised Emergency Room Work Flow
STEP 2: Issuance of ER Record / ER Slip ER clerk10 minutes
48
Revised Emergency Room Work Flow
STEP 3: Initial assessment of PatientNurse assigned on Medicine ER 10 minutes
49
Revised Emergency Room Work Flow
STEP 4: Physicians Initial AssessmentConfirm CTAS Classification of PatientER Medical Resident 10 minutes
50
Revised Emergency Room Work Flow
STEP 5: If for diagnostic work –up Perform laboratory examination Perform radiological examination Med. Tech on duty / X – ray tech on duty
30 minutes
51
Revised Emergency Room Work Flow
STEP 6: If for admission, Med ROD issues admitting orders
Med NOD carries out initial doctors orders.Resident On Duty/ Nurse On Duty10 minutes 10 minutes
52
Revised Emergency Room Work Flow
STEP 7: Issuance of Top sheetAdmitting clerk10 minutes
53
Revised Emergency Room Work Flow
STEP 8: Classifies patientsSocial Worker5 minutes
54
Revised Emergency Room Work Flow
STEP 9: Wheel patient to wardUtility worker10 minutes
55
Revised Emergency Room Work Flow
STEP 10: Endorse patient to wardER Nurse on duty5 minutes
56
Revised Emergency Room Work Flow Chart
Triage Nurse classifies patients according to CTAS
>10 min
Patient arrives at the ER
Clerk issues ER record
>5 min.
Nurse assesses patient and document initial v/s to ER
record and refer to ER ROD
Physician examines patient and confirm CTAS
classification
Patient needs diagnostic tests?
NO
YES
ER ROD prepares requests for diagnostic procedures
> 10 min
> 10 min
Radiology performs examination
Lab Tech performs examination
> 30 min
Admitting Clerk issues top sheet
Physician admits patient
Nurse carry out doctors order > 10 min
> 10 min
> 10 min
Social Worker classifies patient
> 10 min
Wheeled to ward and endorse to ward NOD
> 10 min
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Step 7: Future Plans
1. Issue hospital order for the institutionalization of the revised workflow for medical patients at the ER.
2. Issue hospital order to institutionalize the new Replenishment system.
3. Issue hospital order for the full implementation of the simplified payment process.
4. Conduct similar studies in other ER clinical departments
5. Formulate and institutionalize a Manual of Operations for Emergency Case Management for the Bicol Medical Center.
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Step 7: Future Plans
6. Systematize Records Management by separating new and old patients thereby facilitating issuance of ER Records.
7. Post signages of revised ER workflow on strategic places.
8. Reactivate the Satellite Laboratory Room for chemistry examinations at the Out Patients Department
9. Put up a Satellite X-ray Room adjacent to the ER.
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If we bond together and support each other..If we make true the spirit of teamwork..
Regardless of our differences, we can rise to meet our challenges.
If we understand the real value of CARING
If we are aware of the feeling of SHARING..
LIFE WILL BE EASIER
AND THE
PASSING OF YEARS MORE FULFILLING ..
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