Clinical Safety & Effectiveness Session # 11 Emergency Center Observation Unit DATE

Project Team Patrick Chaftari, MD Assistant Professor, GIM, AT & EC Jean H Tayar, MD Assistant Professor, GIM, AT & EC Ashutosh Gupta Clinical Business Manager, EC Richard A. Ivey Quality Engineer, Office of Performance Improvement Cindy Segal Clinical Quality Improvement Consultant, Office of Performance Improvement Cylette R. Willis, PhD Associate Director, Quality Education and Evaluation, Office of Performance Improvement Project Sponsor: Carmen E. Gonzalez, MD Associate Professor, GIM, AT and EC Section Chief, EC

Improving Patient Care in the EC

EC Situation National benchmark ER Length of Stay (LOS) is 4 hours MDACC EC LOS averages 9.5 hours (up to 24 hrs ) Current situation affects patient care and safety

Can We Improve This Picture? Patient safety Patient care Patient satisfaction Bed utilization

00-05 Hrs, N=4,734 42% Hrs, N=3,879 34% Hrs, N=1,328 12% Hrs, N=642 6% 20+ Hrs, N= 675 6% Pts Treated while in The EC (No Inpt Admission) Patients Treated While in EC (No Admission) % of Visits by Hours in EC from Lobby Sign-In to Leave Time April 1, 2008 to March 31, year Data Prepared by: Linda DeFord OPI Clinical Informatics Data Source: EC Tracking Data

16-20 Hrs N=642 6% 20+ Hrs N= 675 6% Snapshot of Patients Discharged from EC After a LOS > 16 hrs (March 2009, 119 pts) (14) 12% (74) 62% (4) 3% (27) 23% One year data

EC Patient Process

OBS Unit  Better Care Opportunity to improve patient safety and patient care Literature review: Placement on OBS will improve quality of care and revenue Improve disposition→ clinical outcome→ decrease liability Decrease patient and caregiver frustrations Free up EC bed →Decrease some of the EC congestion →Shortens LOS Decrease cost by efficient usage of EC and inpatient bed Avoid unnecessary admissions and decrease un-reimbursed readmissions

Observation Unit Observation unit could be →a safe →effective →cost-saving way of ensuring that patients who are considered to be intermediate category receives appropriate care. 10

Project

AIM Statement The aim of this project is to increase the percentage of EC patients placed on Observation by 50% from the baseline of 1.95% to 2.93% during the pilot period, July 1 - July 22, Baseline period: May April 2009 Process begins when provider evaluates patient in EC and ends when provider places patient on Observation Value to the organization – improve patient care and safety, potential financial advantage

How Will We Know That a Change is an Improvement? Outcome measure:Percentage of EC patients placed on Observation Data collection:Whiteboard activity report Technical charges Specific target:2.93%

Project Milestones Team createdApril 2009 AIM statement createdApril 2009 Weekly team meetingsMay - August PlanningApril - June Interventions implementedJuly 1 – 22 PresentationAugust 7

Fishbone Diagram LOW NUMBER OF PATIENTS PLACED ON OBSERVATION Order sets Physicians Lack of education Lack criteria to place on Observation Don’t think about it Nurses Technology Processes Facilities Clerks Do not check observation box on charge sheet Do not notify clerks that patient placed on Observation Training Data entry Whiteboard does not visually identify current Observation patients Unclear processes Lack of space Tracking LOS countdown Identifying Observation patients Budget to staff space Do not understand billing Guidelines for disposition decision Tracking patient progression Appropriate forms Confirm access to CARE system Staffing Paperwork Physician hand-off Training

PLAN: The Intervention Plan project Develop presentation materials for providers Design new EC physician order set and forms Start general guidelines for placing patients on Observation Gain leadership buy-in Raise awareness of OBS availability

Observation Placement Form Placeholder for Obs form and/or physician order set visual

DO: Implement the Changes April – June: Build awareness (soft implementation) July 1: Implement interventions July 1 – 22: Measure outcomes July 1July 2July 3July 4July 5July 6July 7July 8 Conduct kickoff Implement order sets Post order sets online Place poster in EC

EC Observation start date: July 1 st,09 Consider Observation placement Patient is not ready to be discharged home Patient do not meet admission criteria And you expect improvement within the next 23h to the point where the patient could be discharged home Upon completion of the patient’s work-up

Implementation Issues Stakeholder identification was incomplete (Clinical Effectiveness) →Delay in posting physician order set Implementation period was too short to address EC meeting schedule, introduce language and new forms Non-EC faculty working in the EC not familiar with the process

Results 21

Baseline (May 1, 2008 – April 30, 2009) Project Intervention Period (July 2009) OBS Patients 1.95 %5.20 % Total Number of patients CHECK: Results and Impact Test of proportions p-value < 0.001

Before/After Intervention Test of Means, p-value = Source: EC Whiteboard Prepared By: Ash Gupta & Richard Ivey

Before/After Intervention Test of Means, p-value = Source: EC Whiteboard Prepared By: Ash Gupta & Richard Ivey

Potential Financial Impact What is the financial impact of these results on the organization? Decrease waste by more efficient use of EC bed and inpatients beds Capture of uncharged technical and professional fees Bed utilization and resources

Technical Charges for Observation

$650,000 Source: EC Whiteboard Prepared By: Ash Gupta & Richard Ivey

Professional Charges EC Visit: rvuObservation: – (0.56) $179DD – (1.1) $ (1.73) $240 – (1.68) $ (2.86) $325 – (3.18) $ (3.99) $437 – (4.71) $ (1.84) $192 – Level 4: (3.18)$ V/S---(4.7)$517 – Level 5: (4.71) $657---V/S---(5.83) $634 EC charges are distinct from Observation Financial incentive to use non-EC provider …

Professional Reimbursement (CIGNA Health Care) EC Visit: rvuObservation: – (0.56) $DD – (1.1) $ (1.73) $65.62 – (1.68) $ (2.86) $ – (3.18) $ (3.99) $ – (4.71) $ (1.84) $69.39 – Level 4: (3.18)$ V/S (4.7)$ – Level 5: (4.71) $ V/S (5.83) $221.84

Assuming 62% of patients with EC stay > 16 hours and discharged home were placed on obs, this represents a potential benefit of approximately $428,000 Data source: EC Whiteboard (May '08 - Apr '09) To estimate the charges for patients with EC stay > 16 hours, an average approach was used using Levels 4 and 5 charge amounts ‘Obs – 1 provider’ assumes that the EC provider is caring for the obs patient ‘Obs – 2 providers’ assumes that a non-EC provider is caring for the obs patient Source: EC Whiteboard Prepared By: Ash Gupta & Richard Ivey

Annual Cost Requirement for UnitAnnual Cost Physician provider (1)$250,000 Nurse (4.2 FTE)$267,260 Medical supplies (4% of Annual EC Medical Supplies) $ 17,129 TOTAL Cost$543,389 FTE is based on the assumption that the Observation unit will be operational 24/7 Personnel Cost is based on new staff with less than 1 year at M.D. Anderson Medical supplies/expense = 4% of Total EC Medical supplies Deduction % = 48.67

Estimated Annual Net Financial Impact Revenue Cost Profit $1,078,000 $(543,389) $534,611

Estimated Number of Observation Beds

Source: EC Whiteboard Prepared By: Richard Ivey

The Avg Number in Queue is the avg number of patients waiting for an obs bed across the entire year The choice of number of obsn beds should be balanced with the desired utilization rate Source: EC Whiteboard Prepared By: Richard Ivey

The 'Utilization of Obs Beds' is calculated as the average amount of time occupied divided by the total time available (24-7). This is done by looking at each of the dedicated beds over the entire year. The choice of number of obs beds should be balanced with the number of patients waiting for a bed Source: EC Whiteboard Prepared By: Richard Ivey

Next Steps

Lessons Learned during Implementation Communicate with impacted groups sooner and more often Allow sufficient time for education Familiarize all providers working in EC with OBS process Familiarize RNs and Clerks to apply appropriate charges

ACT: Expansion of Implementation Maintain and expand awareness of available OBS services in the EC Improve identification of OBS patients in the EC Review appropriate use of OBS placement Track progress of revenue realization

Conclusions OBS unit could be a viable solution to improve patient safety and quality of care in the EC By decreasing waste and capturing uncharged services OBS unit may provide net revenue to organization

Recommendations Designated OBS Unit (Closed unit) –Access limited to EC provider and/or observation provider –“Virtual” or “Shared” OBS unit within Pod A Designated non-EC provider coverage –Improve safety and quality of patient care –Cost of additional provider offset by fee structure

What have we accomplished so far? Increased number of observation patients to 5.57% Improved patient safety  Medication reconciliation  Diet, activity, fluid infusion Improved quality of care  Better oversight by having an APN following these patients on OBS Increased RN satisfaction and confidence  Improving communication about plan of care 42

43 Source: EC Whiteboard Prepared By: Ash Gupta & Richard Ivey

Questions Thank you

Patients Discharged with LOS > 16 hrs, Not Waiting on a Test (March 2009, 74 pts)

Overnight Observation Patients in EC

Prepared by: Patrick Chaftari, MD Source: White Board Snapshot of Hospital Admissions with LOS< 30 hrs (Sep 2008, 92 pts)