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OUTPATIENT METRICS

Start the Clock!

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The MBQIP quality measures discussed in the next section are time sensitive. To provide the highest standard of quality care for your patients, the care staff must formulate processes that allow for timely and appropriate responses to patient’s needs. Evaluating your ED practices before making changes is helpful and can prove to be less disruptive to staff. The Studer Group www.studergroup.com has created a document to help you diagnose areas for improvement. Multiple resources and tools are available in the appendices of this document and on the Stratis Health website www.stratishealth.org

The document below is divided into three distinct segments relevant to the phases of ED throughput. The questions listed for process evaluation in each area can help you and your ED Performance Improvement team focus on the key areas where improvement is needed. When initiating improvement, it is often useful to divide areas into: people, processes, environment and equipment. The team can examine how each of these areas impact the improvement effort as well as divide opportunities or best practices into these 3 areas. This focus may help you diagnose issues related to time-sensitive patient care.

Taking Your ED to Next Level-Understanding Flow Issues
The next time-sensitive measures will have their focus in the ED. To perform well on these measures, it is essential to examine the processes impacting your ED. Remember, when evaluating areas of opportunity, it is always helpful to examine areas impacting your ED: types of patients received, ambulance service contracts, ED physician/provider contracts, admission offices, and inpatient units. Broken or dysfunctional processes in any of these areas can impact your ED services. You will see in the table below that by dividing up your ED throughput into 3 categories or distinct functions, you can develop insight into flow issues.

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OP- 18, 20, and 22
ED throughput can be a complex and complicated process to improve. Detecting the time from arrival to departure can have an indirect impact on the number of patients leaving without being seen and patient satisfaction scores in the ED population. Evaluating metrics in this measure may help you to determine staffing levels and/or needs for throughput improvement. Below are some examples of best practices.

These measures are best managed when concurrent review (closest to the point of delivery) is used. The best way to build in concurrent review in these processes is to use checklists, prompts in the EHR, and/or teamwork. Having these redundant barriers in place can help prevent an error or omission in care from reaching the patient.

OP-18 MEDIAN TIME FROM ED ARRIVAL TO ED DEPARTURE FOR DISCHARGED PATIENTS
OP-20 DOOR TO DIAGNOSTIC EVALUATION BY QUALIFIED MEDICAL PROFESSIONAL
OP-22 PATIENTS LEFT WITHOUT BEING SEEN

Overall Best Practice Tactics

Equipment

• Synchronize all clocks and equipment in the ED
• Develop a process for plant operations and/or ED leadership for ongoing “clock checks”

Processes

• Work with a team to track a patient from arrival to discharge. Track incremental time and look for delays and bottlenecks in processes.
• Consider Open Bed Policy-allowing patients to advance to open bed upon after initial triage screening (AHRQ Improving Patient Flow and Reducing Department Overcrowding) www.ahrq.gov/research/findings/final-reports/ptflow/index.html
• Have low acuity patients evaluated by provider upon arrival and discharged as soon as full registration is completed

People

• Consider RN triage and preliminary registration
• Provider/RN team evaluations or “provider in triage” to assess patients immediately upon arrival
• Bedside registration can be especially effective for EDs with low-acuity patients
• Build prompts in the EHR or paper forms to track timeframes.

Data

• Partner with your registration staff and IT departments on data collection. Many software packages that capture patient entry into the ED also have mechanisms to capture several of these data points. At the end of the week or month, reports can be run to establish the data points.
• Share data on time before physician evaluation and total time in ED
• Set realistic goals to reduce times

OP-22 PATIENTS LEFT WITHOUT BEING SEEN (LWBS)

Detecting the number of patients who are leaving your ED without being seen can be beneficial on several levels. Primarily, it can be harmful not only to patients returning to the community or home without receiving care, but also to the health of the patient’s family and significant others. Secondly, knowing the number and types of patients (diagnoses, age) who are leaving the ED without being seen can provide information needed to drive the QI process.

Best Practice Tactics

People

• Establish and implement staff education about improving patient experiences, e.g., frequent updates on wait time (see Resource Section below for a variety of tactics)
• Use trained volunteers/staff in the ED to provide updates to patients
• Use nurse or mid-level practitioner in the ED triage

Equipment

• Provide electronic boards with wait times
• Improved time-tracking in the EHR, e.g., seen by provider time

Processes

• Develop detailed tracking of arrival time
• Reduce door to evaluation time
• Use nurse or mid-level practitioner in ED triage
• Capture and visit with patients before they leave without being seen
• Conduct regular patient analyses for trends
• Utilize the knowledge that literature supports the key reason for LWBS is wait times and that communication about wait times is a key driver to prevent LWBS
AHRQ Patient Flow Guide

Data

• Work with registration, IT or data vendor as data may be easily collected from electronic or manual registration logs
• Conduct regular patient record analyses to identify and understand trends, such as a diagnosis-related delays
• The best practices to reduce door to evaluation by qualified medical provider (OP-20) are likely to reduce the number of patients who leave without being seen

Questions?

Karen Kendrick, director of clinical initiatives and quality, 512/465-1091

Ann Shepherd, senior specialist, clinical initiatives and quality, 512/465-1003


The resources included in the toolkits are offered as examples and do not constitute expressed or implied endorsement by the Texas Hospital Association Foundation.

AMI AND CHEST PAIN MEASURE SETS

OP-1: MEDIAN TIME TO FIBRINOLYSIS
OP-2: FIBRINOLYTIC THERAPY RECEIVED WITHIN 30 MINUTES
OP-3: MEDIAN TIME TO TRANSFER TO ANOTHER FACILITY FOR ACUTE CORONARY INTERVENTION
OP-4: ASPIRIN AT ARRIVAL
OP-5: MEDIAN TIME TO ECG

When dealing with patients with known or suspected cardiac arrest, effective time management is essential. Time is muscle! Once again, the best practice tactics identified below have been divided into areas for processes, people and equipment.

Best Practice Tactics

• Establish local guidelines or care pathways for AMI patients with EMS
• Ensure the emergency physician on duty activates the reperfusion plan according to established local guidelines and care pathways
• Treat registration for patients with AMI similar to trauma patients with the ability to fast-track critical labs, such as creatinine and Prothrombin Time (PT)/International Normalized Ratio (INR) test
• Nurse Driven Protocol for aspirin upon arrival
• Develop a process with receiving hospitals for feedback on how to improve patient care and transfer processes. A process or care pathway that:

o diagnoses the patient early
o contains a reperfusion plan
o treats registration of these patients like trauma
o identifies patients needing ECG through registration and nurse interview
o works with local EMS, helicopter and regional care center
o contains a transfer plan for these patients

People

• Develop a comprehensive educational program for staff, using the SBAR (format explained earlier in the document) and the AMI CareMap Appendix A for staff education and training
• Reinforce education through daily huddles and routine staff meetings
• Teach the importance of teamwork and the concept of “wingman” to help reinforce team ownership

Data

• Present data in increments to detect variation in processes
o Door to EKG
o Door to aspirin
o Door to fibrinolytics

• Display data on units
• Present data in board and leadership meetings

Equipment/Supplies

• Provide or arrange for dedicated EKG machine in ED
• Place EKG on auto-read and respond to + for STEMI
• Identify the management of fibrolytic agent in ED. Some hospitals have arranged to transfer fibrolytics near expiration dates to avoid the drugs from expiring.

The Chest Pain AMI Quality CareMap can serve as a Care Pathway for the patient presenting to the ED with chest pain or other symptoms that may indicate an AMI. (See Appendix A, Chest Pain AMI Quality Care Map). This form is most useful if it is used concurrently with any patient with chest pain. Tracking times as the patient is progressing through the ED can help keep all staff aware of providing quality evidence-based care and thereby meeting time-sensitive metrics.

ChestPainAMIQualityCareMap

OP-21 CARE OF THE PATIENT WITH A LONG-BONE FRACTURE (LBF)

Addressing pain management in the ED can be difficult. Many providers are skeptical about prescribing and often seem to doubt the credibility of a patient’s self-assessment of pain. In evaluating and treating pain in the presence of long-bone fractures there should be little doubt to the significance of the pain. Assessment and appropriate medication administered in a timely manner is essential in providing quality care.

Best Practice Tactics:

People

• Provide ongoing staff education on the requirements for LBF pain management
• Give frequent feedback on performance

Processes

• Consider implementing a nurse-driven pain protocol for LBF or suspected LBF
• Triage patients with suspected or known LBF as Emergency Severity Index (ESI) level-2, or equivalent prioritization
• Examine the Emergency Nurses Association Position Statement at www.ena.org for best care practices for pain management
• Document time of arrival in ED and time of 1st physician assessment

Look for best practices such as the one noted in the diagram below:

WithinSixtyIsNifty

Appendices:

Appendix A: Chest Pain AMI Quality CareMap Tool

Resources:

OP-21 Long Bone Fracture - Pain Management
OP-21 Long Bone Fracture - ICD-10 codes
hest Pain (CP) CART Paper Abstraction Tool
Chest Pain AMI Quality CareMap Tool
Regional STEMI Plan, Panhandle RAC
STEMI Thrombolytic Checklist, Big County RAC
21 Steps for Optimizing your ED, HealthStream
A Pragmatic Approach to Improving Patient Efficiency Throughput, IHI
Emergency Department Flow and Operations, HealthStream
Emergency Department Success, Leave Without Being Seen, Studer Group
Emergency Department Hourly Patient Flow Analysis, IHI
Emergency Department Operations in Top-Performing Safety-Net Hospitals, Commonwealth Fund
Florida Hospital Tampa ED Workflow, diagram
7 Tips for Improving ED Patient Flow, Florida Hospital Tampa, HFMA
Improving Inpatient and Emergency Department Flow for Veterans, IHI
Improving Patient Flow and Reducing Emergency Department Crowding, AHRQ
OP 21, Documenting Pain Medication given to Patient, QualityNet
Patient-Centered Excellence in the ED, HealthStream
TNKase® (Tenecteplase) Dosing and Administration

Templates, Policies, Processes:

Little River, QA, PI Loop Enclosure
Average Minutes to Milestones Report, Memorial Medical Center
Chest Pain Tracking Template, Otto Kaiser Memorial Hospital

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