MeasureTarget Baseline 5/1/15 Current 5/29/15 % change or improved ED length of stay for patients presenting with low acuity chest pain (a fit for outpatient, regular exercise stress test) 5 hours 20 hours with Obs stay 8 hours60% % of outpatient regular exercise treadmill test (ETT) orders with turnaround time from ED order to appointment scheduled and call back to ED provider, of less than 15 minutes 100%n/a100% % of ED chest pain patients needing a regular, exercise stress test, who get a scheduled, outpatient test rather than an Observation stay (as of 5/29) 40% 0 39% % of outpatient, regular exercise stress tests canceled by patient, or no show 0n/a0%100% Patient satisfaction (13 patients as of 5/29)100%n/a100% Clinical Integration IMPROVEMENT BULLETIN Chest Pain – Outpatient Stress testing from the ED Start Date: Sept 1, 2014 Sponsors: Jeff Johnson, MD; HPSO Team: Peter Grape, MD (Harbor); Vinny Mangili, MD (HPSO); Chris Dindy, RN (Cardiovascular Clinic); Jody Clergy, RN (Cardiovascular Clinic); Cheryl Coveney (Patient Access); Kathleen Sheehan (Patient Access); Laura Hickey (IS); Ruth Dzialo (IS); Joshua Forgue (IS); Tom Gormley, Lean Facilitator Background: Patients arriving to the ED with symptoms of chest pain can spend 20 hours in the Observation unit (at an average cost of $3,000) undergoing standard diagnostics (labs, enzymes, and stress test) to rule out acute coronary syndrome (ACS). According to an SSH ED provider survey, approximately 40% of ED patients with chest pain are low risk for ACS and would be candidates for outpatient stress testing at much lower total expense (as little as $500) and with less waiting. Problem: ED providers do not have an easy, reliable way to offer the outpatient option. Goals: Create an easy, reliable process to increase the use of outpatient, regular, exercise stress testing for ED patients presenting with low acuity chest pain, from 0 to 40% (based on SSH ED provider estimates). Improve the patient experience and satisfaction of ED patients with low acuity chest pain. Progress: Implemented and tested first on May 7 th. ED providers report it’s easy to use and average turnaround time is well under the 15-minute expectation. ED LOS for these patients reduced to an average of 8 hours. All patients completed their outpatient tests and were 100% satisfied according to exit surveys in the Cardiovascular Clinic. Total expense savings including patient and insurance payer costs to date (5/29) are approximately $32,500. Next Steps: Continue study to confirm results and standardize the process; Extend outpatient appointment scheduling to 24/7. METRICS/DATA Health Provider Services Organization Questions? Contact Jeff Johnson, MD at See page 2 for information on the process improvements that were made. Next Steps TaskImpactWhenStatus Track usage of outpatient regular ETT & compare with prior expectations. Break down data by provider. Facilitate adoption by ED providers June 15In process Expand appointment scheduling from weekdays 7am – 8:30pm, to nights and weekends too Increase access (Decrease waiting) TBD Planning in process

Clinical Integration IMPROVEMENT BULLETIN The table below is a summary of the challenges or barriers encountered, and the process improvements made to enable the outpatient option. ProblemCausesCountermeasuresResultsNext Steps Options for management of patients deemed to be at low risk for myocardial ischemia as a cause of their chest pain are too limited, resulting in some patients being unnecessarily placed on observation. Change in process had not been considered or requested until now, in part because there was no way to offer patients an outpatient option. Survey ED providers regarding their potential to utilize an expedited outpatient stress test process if it were developed and made available. Develop, share, and standardize a method for risk stratification based on American Heart Association guidelines ED providers informed of new outpatient option. 5 out of 65 ED providers (8%) have chosen the outpatient option for one or more patients Reminders to ED providers as needed. Track usage of the outpatient regular exercise treadmill test option by provider. No easy, reliable method for ED providers to order an outpatient stress test Order is not available in hospital EMR (Meditech) Requires complex, multi- disciplinary collaboration with IS, Patient Access, and the Cardiovascular Clinic Work with ED, Patient Access, IS, and Cardiovascular Clinic staff to develop an easy, reliable process from ED order request to outpatient stress test completion Educate staff in the ED, Patient Access, and Cardiovascular Clinic Meditech system built by IS, has been well received by ED providers (easy to use) Patient Access team notifying ED providers within 4.5 min (below target of 15 minutes) ED provider entry of appointment time into the discharge instruction packet is inefficient 100% patient satisfaction; One patient suggested improving directions to CV Clinic Sustain and spread use to all ED providers Pursue easier ways to capture appointment times Update directions to CV clinic in patient instructions Scheduling (Patient Access) is only available 7am to 8:30 pm, M-F Existing staffing model. Need for off hours is not prioritized To be determined, based on analysis and prioritization None yet No ability to schedule the outpatient test at an ambulatory office in the community Ambulatory office scheduling staff are not 24x7 No access to ambulatory office scheduling systems To be determined, based on analysis of alternatives None yet Health Provider Services Organization Find more bulletins on the Clinical Improvement Corner on the Medical Staff website. us at: internal distribution Last rev