MYTHS AND BARRIERS TO OPTIMIZING ED PATIENT

FLOW

PART 2

Joseph Twanmoh, MD, MBA Senior Vice President, MS2

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Objectives

• Review the most commonly used strategies to improve ED patient flow.

• Does the evidence support the practice? • Where are they applicable? • Why does it fail?

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Recap Part 1

• Direct to Bed – 1,500 patients/bed

• Bigger ED • Fast Tracks

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Myth vs. Reality?

• Advanced Triage Protocols • Provider Triage • PCOT • Advanced front end flow

model

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Advanced Triage Protocols Survey

• Are you using advanced nursing triage protocols?

• How effective have they been at reducing waiting times and LOS?

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The Role of Triage Nurse Ordering on Mitigating Overcrowding in Emergency Departments: A Systematic Review

Academic Emergency Medicine, Vol.18, Issue 12:1349-57 Dec. 2011

• 14,000 potentially relevant studies • 14 in the systematic review • 37-minute reduction in ED LOS in one

RCT • 51-minute reduction was observed in

non-RCTs

CONCLUSIONS: Overall, TNO appears to be an effective intervention to reduce ED LOS Myths and Barriers to Optimizing ED Patient Flow | Part 1 | 6

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AUTHOR (YEAR) LOCATION SAMPLE STUDY

PERIOD STUDY DESIGN

TRIAGE NURSE INTERVENTION

Bliss 1971 US 100 Unknown Retro cohort Distal limb XR Stiell 1993 Canada 1,180 5 mos. B-A Foot/ankle XR

Lee 1996 Hong Kong 1,633 3 mos. Pro cohort XR

Thurston 1996 UK 1,833 NR RCT XR

Parris 1999 Australia 175 3.25

mos. CCT XR

Ching 1999 Singapore 276 3 mos. C-C Limb/skull XR

Lindley-Jones 2000 UK 675 2 weeks RCT XR Winn 2001 US 40 2 mos. Retro cohort Diagnostic tests Cheung 2002 Canada 250 NR B-A XR/Blood work

Australia 1,806 12 mos. Pro cohort Ext. XR

Fan 2006 Canada 130 3 mos. RCT XR

Pedersen 2009 Denmark 106 NR Pro cohort XR

Rosmulder 2010 Dutch 704 22 days B-A Foot/ankle XR Retezar 2011 US 15,188 2 yrs. Retro C-C Diagnostic tests

An Advanced Triage System Accident and Emergency Nursing, (2002) 10, 10-16

• Centenary Health Center, Toronto, Canada

• 9 Algorithms (6 incl. testing) • 4 hour training sessions • Emergent, Urgent, Non-Urgent

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Results

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Accident and Emergency Nursing, (2002) 10, 10-16

STUDY LIMITATIONS

• 250 random charts one year later • N=43; N=22; • Study period not defined • Hours of operation • Triage methodology not defined • No statistical analysis

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The Effect of Triage Diagnostic Standing Orders on Emergency Department Treatment Time

Annals of Emergency Medicine, Vol. 57 (2) 88:89 Feb. 2011

• Chest Pain – Troponin, INR/PT/PTT

• Shortness of Breath – Troponin, CXR

• Abdominal Pain – UA, Urine Pregnancy, Lipase, Amylase

• Genitourinary – UA, Urine Pregnancy – Did not include OB-Gyn complaints

• Door to Disposition

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“Patients were more likely to receive triage standing orders when a technician was present at triage (75% versus 49%).”

“Diagnostic testing at triage was associated with a substantial reduction in ED treatment time for 4 common

chief complaints.”

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PARTIAL VS. FULL TSO

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Conclusions: Advanced Triage Nurse Protocols

• Useful for extremity x-rays • May be useful for chest pain, SOB,

and GU complaints under a protocol

• Partial protocol adherence negatively impacts patient flow

• Value for other complaints TBD • Should not be a primary strategy

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Provider Triage Survey

• Are you using provider triage? • What type of providers are you

using? – APP (NP or PA) – Physician – Combination of physician and APP

• What has been the impact on ED throughput and LOS?

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Faculty Triage Shortens Emergency Department Length of Stay,

ACADEMIC EMERGENCY MEDICINE October 2001, Volume 8, Number 10

Myths and Barriers to Optimizing ED Patient Flow | Part 1 | 17

Results

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“At our institution, faculty triage appears to improve ED efficiency as demonstrated by a decreased ED length of stay.”

Return on Investment

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Annual Costs

Revenue @

$300/pt.

ROI Revenue @ $400/pt.

ROI

Mondays only $124,800 $89,700 ($35,100) $119,600 ($5,200) Mon-Fri

$624,000 $448,500 ($175,500) $598,000 ($26,000)

7 days/week $873,600 $627,900 ($245,700) $837,200 ($36,400)

Assume: 12 hr./day @ $200/hr. = $2,400/day 5.75 pts. discharged per shift Represents new patient charges

Impact of a Triage Liaison Physician on Emergency Department Overcrowding and Throughput:

A Randomized Controlled Trial ACAD EMERG MED August 2007, Vol. 14, No. 8

• Answer all incoming physician calls • Support and assist triage nurses • Evaluate ambulance patients awaiting ED bed • Initiate clinical patient evaluation and

diagnostic studies • Initiate treatment if appropriate • Deal with administrative issues should they

arise. • Not designed with a goal of ‘‘see and treat”

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University of Alberta Hospital 55,000 adult ED

Results

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“…a TLP reduces LOS and, to a lesser degree, the number of patients LWBS in an overcrowded ED.”

Evaluation of a ‘see and treat’ pilot study introduced to an emergency department,

Accident and Emergency Nursing, Vol. 12 Issue 1, 24-27, Jan 2004

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Results

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CONCLUSION: ‘See and Treat’ reduces waiting times for patients with minor injuries and illnesses and has a positive effect on waiting times for patients elsewhere in the department.

CONCLUSIONS FOR PROVIDER TRIAGE

• Many different models exist • Additional provider staffing can be

cost prohibitive • Patient screening models can lead

to over-ordering of tests

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PCOT Survey

• Are you using PCOT in your ED? • Which PCOT do you utilize?

– UA, Urine Preg, or Strep screen – Cardiac Enzymes – Chemistries, Lactate, and others – All of the above

• What has been the effect on ED LOS?

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i-STAT Accelerates Door-to-ResultDecision Times in the ED

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https://www.abbottpointofcare.com

Reducing lab TAT outliers improves ED LOS Holland, LL, et al. Am J Clin Pathology 2005;124:672-674

• ED LOS decreased from 4.1 to 3.2 hours as lab outliers decreased from 14.4% to 4.9%

• Outpatient labs only • Lab TAT not defined

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Implementation of a point-of-care satellite laboratory in the emergency department of an academic medical center. Impact on test turnaround time and patient emergency department length of

stay. Lee-Lewandrowski, et. al., Arch Pathol Lab Med. 2003 Apr;127(4):456-60.

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369 patients pre/post pilot study 162 patients (43.9%) admitted

But did it impact LOS?

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“Our data showed a statistically significant change in the ED LOS for patients having

POCT.”

Use of a Comprehensive Metabolic Panel Point-of Care Test to Reduce Length of Stay in the Emergency Department: A

Randomized Controlled Trial Jang, et. Al. Ann. Emer. Med, Feb. 2013

• 54,000 visits, urban academic ED • Randomized, non-blinded study • Piccolo Xpress Chemistry Analyzer • 5154 test/ 5090 control • CBC and coags sent to central lab

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Results

Lab (min.) PCOT (min.)

Difference Percent Reduction

Lab TAT 55 12 (43) 78%

ED LOS 372 350 (22) 6%

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“No statistical difference in LOS for contrast CT studies”

28,000 visit Peds ED 144 test group 111 control

5 month study using i-STAT cartridges

A Randomized Trial to Assess the Efficacy of Point-of Care Testing in Decreasing Length of Stay in a Pediatric Emergency

Department Hsaio, et. al. Pediatric Emerg Care Jul. 2007

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Results

LAB PCOT Difference Percent Reduction

LAB TAT 70 min. 5 min. (65 min.) 93%

ED LOS 224 min. 185.5 min (38.5 min) 17%

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A Multicenter Randomized Controlled Trial Comparing Central Laboratory and Point-of-Care Cardiac Marker Testing

Strategies: The Disposition Impacted by Serial Point of Care Markers in Acute Coronary Syndromes (DISPO-ACS) Trial

Ryan, et. al., Annals of Emer. Med. March 2009

2,000 pt. 4-center randomized trial Used i-STAT troponin Myths and Barriers to Optimizing ED Patient Flow | Part 1 | 34

DISPO-ACS Results

Lab PCOT Change

Lab TAT 52.8 min. 15 min. (37.8 min.)

Admitted 5.50 hr. 5.35 hr. (9 min.)

Discharged 4.62 hr. 4.50 hr. (7.2 min.)

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“Across all sites, point-of-care testing did not decrease time to disposition for admitted or discharged patients”

PCOT Conclusions

• Time savings from lab do not directly translate to LOS.

• Enormously expensive – Assume $3 for lab vs. $19 for PCOT – 10,000 tests= $160,000 difference

• Use wisely and selectively – UA – Urine pregnancy testing – Strep screen – Rapid Influenza, RSV

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What doesn’t work

Costly Physical Capacity Expansion

Dysfunctional Fast Tracks

Inappropriate Immediate Bedding

Wasteful Advanced Triage Protocols

Inefficient Provider “Triage”

Expensive Point of Care Testing*

*Except Urine HCG, UA, or Rapid Strep

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Advanced Front-end Flow

Lean Intake System

Rapid Clinical Evaluation Unit

Dedicated Processing area

Intermediate Care conversion

Transit (Results Waiting) Area

Exit Registration

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Questions?

Joseph Twanmoh, MD, MBA jrt@ms2group.com

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www. ms2group.com