FLOW. [ flō ] your role in emergency wait times Brendan Munn Calgary Emergency Medicine Grand Rounds October CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Disclosure Disclaimer Eternal Thanks Other than being a total control freak I have no conflicts of interest to declare. Too much to be boring, too little to do the subject justice. Dr. Grant InnesDongmei Wang Dr. Lester Mercuur Edith Lundrigan Jodi Gibson

Objectives (Overt) 1.discuss a conceptual model of flow 2.define crowding and metrics 3.review the literature on flow causes effects solutions 4.relevance to calgary and the individual CALGARY EMERGENCY MEDICINE TEACHING ROUNDS ( )

Objectives (Covert) 1.crowding is a (the) major ED issue 2.crowding mostly due to hospital factors, but the ED definitely has room for improvement 3.you are a unique and special flower, and have a role to play CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Crowding [kra ʊ d ɪ ŋ] Boarding [b ɔ rd ɪ ŋ] Access Block [ ˈ æks ɛ s bl ɒ k] Priapism [prī'ə-pĭz'əm ] debated, unclear and variable “the process of holding patients in the ED for extended periods of time” bad news “the prolonged wait for an inpatient hospital bed after ED treatment”

Conceptual Model Of Flow CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Asplin, Ann Emerg Med 2003

Conceptual Model Of Overflow CALGARY EMERGENCY MEDICINE TEACHING ROUNDS long term care ward waiting room ED

contention #1 “crowding is easy to define” CALGARY EMERGENCY MEDICINE TEACHING ROUNDS How Crowded is Crowded? Hwang, Acad Emerg Med 2004

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS “A situation in which the identified need for emergency services outstrips available resources in the ED. This situation occurs in hospital EDs when there are more patients than staffed ED treatment beds, and wait times exceed a reasonable period. Crowding typically involves patients being monitored in non-treatment areas (eg hallways) awaiting ED treatment beds or inpatient beds. Crowding may also involve and inability to appropriately triage patients, with large numbers of patients in the ED waiting area of any triage assessment category” ACEP Crowding Task Force 2002

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS “the number of hours in which patient census exceeds designated patient care areas” Welch, Acad Emerg Med 2006 “hard to define, but I know it when I see it” Potter Stewart, Supreme Court Justice, 1964

contention #2 “ED backlog is NOT a safety valve” CALGARY EMERGENCY MEDICINE TEACHING ROUNDS waiting room ED

Negative Effects of Crowding CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Delays to Treatment Hip # Pain - Hwang 2006 (VOL) Hip # Surg - Richardson 2009 (BT) ABx Pneumonia - Fee 2007 (VOL) ACS Chest Pain - Pines 2009 (OCC) NSTEMI - Diercks 2007 (LOS) High Acuity - McCarthy 2009 Abdo Pain - Mills 2009 Pain Tx - Pines 2008 Lytics - Schull 2004 (DIV) Mortality Wait Times Medical Errors Miro 1999 (VOL) Sprivulus 2006 (OCC) Richardson 2006 The effect of emergency department crowding on clinically oriented outcomes. Bernstein, Acad Emerg Med 2009

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Ambulance Diversion Ambulance Availability Patient Elopement Patient Satisfaction Less Teaching Provider Satisfaction Violence Financial Hospital Length of Stay Bayley 2005 (LOS) Falvo 2007 (OCC) Burt 2005 (DIV) Redelmeier 1994 Eckstein 2004 (OOS) Schull 2003 (DIV) Hobbs 2000 (VOL) Polevoi 2005 (OCC) Jenkins 1998 (WT) Krochmal 1994 (BT) Liew 2003 (LOS) Richardson 2002 (LOS) Pines 2008 (LOS, BT, WT) Vieth 2006 (OPIN) Rondeau 2005 (BT) Williams 2007 (OPIN) Shayne 2009 (VOL)

Waiting Room Stats Calgary CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

LOS Calgary CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

LWBS Calgary CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Causes and Solutions CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Emergency department crowding: old problem, new solutions. Bernstein, Emerg Med Clin North Am Improving access to emergency care: addressing system issues. Govt of Canada, Physician Hospital Care Committee, 2006 Hospital-based emergency care: at the breaking point. Committee on the Future of Emergency Care in the United States Health System, 2006 Ten solutions for emergency department crowding. Derlet, West J Emerg Med Systematic review of emergency department crowding: causes, effects and solutions. Hoot, Ann Emerg Med 2008.

Input CALGARY EMERGENCY MEDICINE TEACHING ROUNDS increasing volume increasing acuity lack of alternatives surge

Tracking emergency CALGARY EMERGENCY MEDICINE TEACHING ROUNDS “Tracking emergency department crowding in a tertiary care academic institution”. Bullard, Healthcare Quarterly Volume Acuity

contention #3 “it is not the input itself, but what we do with it that counts” CALGARY EMERGENCY MEDICINE TEACHING ROUNDS inappropriate patients surge capacity

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Schull, Ann Emerg Med 2007 Khane, Ann Emerg Med 2009 CTAS 4/5 represented 30% of visits but only 5% of stretchers 10 low complexity patients per 8 hours increased mean LOS by 5 mins for others Vertesi, CJEM 2004 Low Acuity Patients

contention #4 “we have the beds, they have the diseases -- why are they apart?” dynamic logistical surge CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Patients Registered Patients Admitted = Hour of Day

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS usable (throughput) admitted (output) MET FMC total annual ED high acuity bed utilization in hours 57 beds 49 _______

Throughput CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Type of Center Triage Staffing Ancillary Services Information Technology Layout

contention #5 “it behooves us to develop operational efficiency” CALGARY EMERGENCY MEDICINE TEACHING ROUNDS for ourselves for patients room to move limitations temporize economies of scale the future

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS “investigations and consultations are important independent predictors of ED length of stay” Yoon, CJEM (minutes)

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS “EDs with combinations of low inpatient census, in-room registration, point of care testing and an urgent care area demonstrated increased patient throughput” Analysis of the literature on emergency department throughput. Zun, West J Emerg Med “successful strategies to improve patient flow are distinguished by an organization wide commitment to measurement, transparency in data reporting and sustained management attention” Enhancing work flow to reduce crowding. Siegel, Jt Comm J Qual Patient Saf 2007.

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Quality Improvement Applying systems engineering principles in improving health care delivery. Kopach-Konrad, J Gen Intern Med 2007.

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Manufacturing : LEAN and Six Sigma Modeling Use of LEAN in the emergency department: a case series of 4 hospitals. Dickson, Ann Emerg Med Discrete event simulation of emergency department activity: a platform for system-level operations research. Connelly, Acad Emerg Med Forecasting emergency department crowding: an external, multicenter evaluation. Hoot, Ann Emerg Med _____________________________________________ Queuing Theory

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Han, Acad Emerg Med 2007 Khare, Ann Emerg Med 2009 increasing the number of beds in the ED does not decrease patient length of stay alternative triage methods can increase efficiency special units and even bed closures can increase throughput Kelen, Acad Emerg Med 2001 bedside registration triage physician

Output CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Boarding Outpatient Follow Up

Occupancy Calgary CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Generally agreed that boarding is the major culprit in ED crowding CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Emergency department crowding. General Accounting Office of the United States, 2003 Estey, CJEM 2003 Schull, Acad Emerg Med 2003 Fatovich, Emerg Med J 2005 Olshaker, J Emerg Med 2006 Rathlev, Ann Emerg Med 2007 “Changes to ED structure and function do not address the underlying causes or major adverse effects of overcrowding… [these] lie outside the ED.” Richardson, Med J Aust 2006

contention #4a “crowding is an ED problem” contention #4b “crowding is a non-ED problem” CALGARY EMERGENCY MEDICINE TEACHING ROUNDS rest of the hospital, emergency department, 2003-current

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS daily average ED LOS increased 18 minutes per 10% increase in hospital occupancy elective surgery volume predicts ED gridlock Forster, Acad Emerg Med 2003 McManus, Anesthesiology 2003 Litvak, Acad Emerg Med 2001 OR Manager, 2004 ED Wait Times 60 -> 40 mins, ED LOS dec by 45 minutes

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS shared boarding has demonstrated safety and the benefits of ownership of the crowding problem “changes the inpatient units’ attitude toward flow… the result is better flow through the entire hospital” targeted discharge planning, active bed management and improved follow-up outpatient resources are important Pines, Ann Emerg Med 2009 Viccellio, Ann Emerg Med 2009

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Review the ‘put 1.flow depends on in/through/output output is the major contributor but the ED has work to do in Calgary 2.crowding difficult to define simplest measures probably the best 3.solutions are multi-pronged, hospital- wide and dynamic in nature 4.intervene and evaluate benchmarks

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Throughput and the Individual In Direct ControlOut of Direct Control Speed ED Factors Service Use (DI, Lab, Consult) Services Themselves Teaching Output

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Review You 1.this is our… all our… THE problem 2.how is your operational efficiency? 3.know your committees you are ideally situated to suggest areas of improvement 4.get involved bugle horns are $7.50 at Wal-Mart 5.patients & providers are beneficiaries

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Questions?