GETTING ADMITTED PATIENTS OUT OF THE EMERGENCY DEPARTMENT

(EXPRESS ADMISSION CONCEPT)

Dr. Norm Schneiderman, MD, FACEP

 

1. INTRODUCTION – MIAMI VALLEY HOSPITAL (MVH) – LEVEL 1 TRAUMA CENTER

76,000 ED PATIENTS-VIRTUALLY ALL ADULTS-OVER 40 ADMISSIONS PER DAY OUT OF ED

827 BED HOSPITAL – RUNS OVER 60% OCCUPANCY

1200 PHYSICIAN MEDICAL STAFF

RENAL DIALYSIS CENTER/BURN CENTER

2. OVERCROWDING (GRIDLOCK)

1. Reasons (Negative)

1. Uninsured Americans (47,000,000)

2. Very few private practitioners or clinics will see patients same day

(or even same week). For patients without means-the access is even worse

3. Private offices and clinics not set up to do same day testing; results

take even longer.

4. Yes-virtually everyone dumps on us and we can’t say no.

5. No appointments in ED – patients arrive all at once, overwhelming our resources.

SUMMARY OF WHY WE ARE OVERCROWDED:

More patients coming to us each year

We get dumped on, We can’t say no, and WE ARE GOOD!!!

And that is why Emergency Departments are seeing over 100,000,000 visits per year and still growing!!!

3. Example of growth of an ED (The MVH experience).

4. HOW DO WE AMELIORATE THIS OVERCROWDING?

1. Start doing a terrible job – volume will go elsewhere (Easy)

2. Build a bigger ED adding beds (Relatively easy) Many are doing this including MVH (It only takes money)

3. IMPROVE YOUR EFFICIENCY! (Hard to do)

5. IMPROVING YOUR FLOW

1. We see 11 new patients every hour (24 hours a day). If we don’t discharge 11 patients every hour, we get backlogged.

1. Leads to patient dissatisfaction, increased LWT, increased risk management problems, staff frustration

2. Solutions? Are any easy?

1. Hire more doctors (Not to easy to find and harder to pay for)

2. Hire more nurses/ancillaries (Not so easy to find in the year 2000)

3. Create more inpatient beds (Not so easy considering hospital finances)

4. Shorten LOS in ED (Very hard)

6. WHAT ARE NON-VOLUME FACTORS THAT TEND TO INCREASE OUR LOS

1. Nurse triage times-can cause mild delays

2. Registration procedure – moderate contributor (Bedside registration)?

3. Time till sees doctor-can be an issue particularly in single coverage with no PAs

4. Lab is probably the major time delay in most ED’s

5. With increased diagnostic technology (new diagnostic tools) LOS has been increasing even without additional volumes. (Trend to do more testing and not admit patient)

1. CT’s (especially Abdomen)

2. VQ’s

3. Ultrasounds if not done by ED physicians

6. Waiting for consultants/admitting doctor to be contacted and give orders

7. Discharge procedure – moderate contributor

8. Waiting for a bed "upstairs" – Increasingly becoming a major problem (particularly monitored beds)

7. ADMITTING A PATIENT THROUGH THE ED

1. Decision to admit often dependent upon testing results

2. Time to decide if admission required very operator dependent (some ED doctors can do it much quicker than others)

3. Private attending vs residents – usually a big difference

4. Time from decision to admit till patient actually goes upstairs can be lengthy (hours)

5. Bed Flow Task Force – our two year experience

1. Multidisciplinary group of people

2. Monthly meetings

3. Totally dissected each step of the admission process

4. Conclusions after 2 years of work

1. Admission process is complicated

2. Any one inefficiency can derail efficiency

3. The "floors" have very sophisticated protectionist techniques especially around change of shift time, mealtime, breaktime, etc.

4. Improvements achieved

1. Have nursing team in admission office now

2. Bed report (hospital wide) each shift-attempts to uncover empty beds

3. Improved housekeeping responsiveness-phone report and bed ahead concept

4. Results – modest so far

5. Needed to study this process so administration would even listen to suggestions for improvement

8. EXPRESS ADMISSION CONCEPT – Express Admission Unit (EAU)

1. Time it takes to get patient to the floor after decision to admit ED patient can be well over 60 minutes

2. This time increases dramatically if the hospital is quite full, especially if monitored bed or CCU/ICU is required

3. (EAU) is a separate (new site) which acts as an intermediate location where the patient waits till bed upstairs is ready

4. As soon as admission orders written or verbally transcribed by ED nurse, patient transported to (EAU)

5. Time isn’t wasted because all admission orders are done in (EAU) (more quickly, more efficiently)

6. Within 1-2 hours, everything done and patient ready to go to floor

7. Floors are ready for patient much more quickly than before because all the admission work is done for them – (magically, hidden beds appear)

9. WHAT GETS ACCOMPLISHED IN (EAU)?

Initial assessments and care plans, lab work, EKG, x-rays, social work referral, specimen collections, first doses of medications, IV’s, respiratory treatments and urinary catheterizations

10. WHO’S A CANDIDATE FOR THE (EAU)?

1. All non CCU/ICU ED admissions

2. All direct admissions from private attending offices

3. Outpatients requiring minor procedures e.g. central lines, transfusions, etc. – (if hospital doesn’t have alternate place to do these)

11. DESIGNING THE (EAU)

1. Assemble a multidisciplinary team

1. Nursing

2. Medical Staff

3. Administration

4. Radiology/Lab

5. Pharmacy

6. Information Systems

7. Plant operations/Maintenance

2. Find the location – Proximity to x-ray important (1^st floor near ED)

3. Decide hours of operation – Must be open at least 2-3 hours on either side of peak ED volumes – 10:00 a.m. – 2:00 a.m. at minimum

4. Staffing requirements – Somewhere between ED and floors. Heavy use of techs to supplement RN’s and emphasis on cross training all individuals

5. Size/# of beds – Plan on 2 hour occupancy per patient. Calculate current # of ED admissions and plan on extra patients as direct admits and procedures.

12. MAKING THE SALE TO ADMINISTRATION

1. Need to show them results of your Bed Flow Task Force – Must first get the cheap easy stuff done first

2. Get stats like % of admitted patients who wait over 60 minutes to go to floor

3. After initial construction expenditures, can be revenue neutral considering decrease of inpatient LOS and relative FTE neutrality.

13. BENEFITS OF THE (EAU)

1. Increase patient satisfaction

1. Less fragmentation

2. Few people coming into room

2. Increase nursing and physician satisfaction

3. Decrease LOS

1. Decrease IV antibiotic times

2. Early social service involvement

4. Improve overall hospital efficiency

14. MVH PLANS FOR (EAU)

1. 3-6 months after new ED opens, old ED will be converted

2. Currently, making plans to open our EAU 1^st quarter 2001

3. Hopefully, next year at this time I will be able to report about our successes!

 

CONTACT INFORMATION

Norman Schneiderman, M. D. FACEP

Director, Emergency & Trauma Center

Miami Valley Hospital

1 Wyoming St.

Dayton, OH 45409

Phone: (937) 208-2662