1. Impact of Process Flow Tool on Wait Times from Emergency Department to ICU. Presenter: Pratik Doshi, MD Assistant Professor, Director of Emergency Critical Care Department of Emergency Medicine Division of Critical Care Medicine, Department of Internal Medicine University of Texas Health Science Center, Houston, Texas

2. Conflict of interest None

3. Overview ● 65,000 Emergency Department visits per year ▪ 37% admitted to hospital ▪ 10% of admitted patients admitted to ICU ● Delayed ICU transfer (>4 hours from care complete to ICU arrival) ▪ Increased hospital mortality ▪ Increased hospital LOS ▪ Increased ICU LOS Chalfin et al. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit care med 2007; 35: 1477-83.

4. Overview

5. Baseline Data March 08- February 09 <4 hours>4 hours Patients 345314 % of total patients 52%48% Mortalty Rate 14%17% Hospital LOS 9.1010.30 CMI 2.332.60 Age 5558 % Male52%48% % Female48%52% 30 day readmits 4032 30 day readmits-- Same DRG127 Care Complete to Depart MICU Admits Mortality 18% higher Length of stay 11% higher

6. Overview Largest Variation : Care complete to departure

7. Overview

9. Methods Prospective case Controlled Trial from 2/2008- 9/2010 In Phase 1:Compare the outcomes of medical ICU admissions between those with ED to ICU wait times 4 hours In phase2: compare similar outcomes after introducing a qualifying admissions tool designed to reduce wait times to admission An admission pre-qualifying checklist, standardized nurse documentation, and accelerated bed management process redesign was introduced

10. Actions Creation of standard operating procedure with an admission algorithm Checklist of contraindications for MICU admission to be filled out on all patients admitted to MICU by EM faculty Standardization of nursing documentation of times of departure Defect log in MICU Educated Faculty, residents, and nursing staff to highlight problems and clarify processes

11. Flow chart for MICU admission

12. Contraindications to MICU Admission 1) Does the patient have an ICH/CVA?Yes □ No □ 2) Does the patient have extensive burns or Stevens-Johnson syndrome (BSA > 15%, 2 nd and 3 rd degree) {Please examine the patient’s entire body} Yes □ No □ 3) Does the patient have severe Heart Failure potentially requiring Intra-aortic balloon pump(IABP) Yes □ No □ 4) Is the patient s/p Cardiac Arrest requiring therapeutic hypothermia Yes □ No □ 5) Has the patient been evaluated by another service for ICU admission and rejected for admission? Yes □ No □

13. Results Mean time from Emergency room care complete to MICU admission decreased by 2.04 hours(37 %), from 5.53 hours to 3.49 hours

14. Results Mean time for Emergency department arrival to departure decreased by 1.98 hours(22%) from 8.81 hours to 6.83 hours.

15. Results CC to Depar Baseline Feb 08-Mar 09 Sept 09-Apr 10 Total Change P- Value CC to Depart xx.xx hrs5.53 (±5.16)3.49(±3.49) 0.0001 CC to Departhh:mm5:32 (+5:10)3:29 (+3.29) CC to Departmin33220912337% CC to Depart<4 hrs346 (52%)474 (74%)22% CC to Depart>4 hrs314 (48%)169 (26%)

16. Results Feb 08 to Mar 09 (Baseline) Sept 09- Apr 10 Total Δ % Δp value Total 660643 Arrival to Departxx.xx hrs 8.81 (± 5.77)6.83 (±4.20) 0.0001 Arrival to Depart mean (hh:mm)8 hrs 49 min6 hrs 50min 1 hr 59 min-22% Arrival to DepartSD (hh:mm)5 hrs 46 min4 hrs 12 min Arrival to Departmin529410119-22%

17. Results

18. BeforeAfterp-Value MICU bed Avail9 hrs 21 min6 hrs 34 min0.0001 MICU bed not Avail7 hrs 45 min8 hrs 43 min0.2352

19. Results

20. Before After Total Δ %Δ %Δ p-Value Length of staymean days9.678.131.54-16%0.0035 Length of staySD(+11.33)(+7.25) Mortality Rate 15% DRG wt (CMI) 2.45 (+2.68)2.38 (+2.37) 0.5836 AgeMean56.455.7 AgeSD(+18.4)(+18.6)

21. Conclusions Boarding of critically ill patients in the Emergency department has an association with worse outcomes Emergency room based process flow tool can be effective in reducing the wait times for patients admitted to the ICU This decrease in boarding times seems to be associated with decreased hospital length of stay

22. Conclusions Mortality rates remained stable More patients in the lower mortality and LOS group translates into potential lives saved and definite hospital days saved The hospital days saved total a potential of 990 days, at a rate of 1.54 days for the 643 admissions after the process was instituted, which results in a conservative estimate of $1,039,500 of cost avoidance over the year.

23. Key Learning No Magic Bullet Walk the process Solution should be the result of process, not pre-conceived Solution may just be “leaning” the process

24. Team Members Brent King, MD: Chair, Department of Emergency Medicine James McCarthy, MD: Medical Director, Department of Emergency Medicine Bela Patel, MD: Medical Director, Medical ICU Yashwant Chathampally, MD: Department of Emergency Medicine Ruth Siska, RN and Tammy Campos, MSN: Medical ICU Sylvia Reimer, RN and Janice Hughes, RN: Emergency Department Katharine Luther

25. Questions?