1. EMERGENCY ROOM OF THE FUTURE LEVERAGING IT AT WELLSTAR HEALTH SYSTEM: KENNESTONE EMERGENCY DEPARTMENT Jon Morris, MD, FACEP, MBA WellStar Health Systems September 18, 2008

4. Agenda  Introduction  Kennestone Emergency Department  Metrics  More Metrics- Exit Phase  Even More Metrics- Non-ED Physicians  So far…

5. To Err Is Human  Patient Safety Issues: IOM report Nov. 1999  > 44,000 – 96,000 deaths related to preventable medical errors/year  $17B - $29B cost  2000 – Leapfrog Group

6. Example: 2007 Adverse Drug Events

7. The Need For Change “The definition of insanity is to continue to do the same thing over and over again and expect different results” Albert Einstein

8. Kennestone ED

9. Kennestone Emergency Department AdultFast TrackPediatric Hours24/711A-11P24/7 Levels411 Beds6189 Hall beds902 Total70811 >102,000 Annual patient volume 40% of Kennestone admissions 24.38% admit rate (July 08) October 2007: ED Online

10. ED Flow “Before”

11. Paper ED Record

12. Completed ED Evaluation - Waiting For MD

13. October 2007: Kennestone ED Live Online Documentation and Order Entry  “Sole Source” strategy- McKesson  18 month build  ED Tracking Board  Online Clinical Documentation (Horizon Emergency Care  – HEC)  Online Order Entry (Horizon Expert Orders  - HEO)

14. ED Flow “After”

15. WSKH ED Applications ED Tracking Board

16. Patients Waiting For MD

17. ED Patients: Status & Tasks

18. WSKH ED Applications Documentation

19. Online Documentation  Always Available  Real-time  Legible  Automated Date & Time  All Clinical Documentation In One Place  More Complete

20. ED MD Charting

21. Paper vs. HEC- MD Note

22. WSKH ED Applications Order Entry

23. Definition: CPOE  Provider Enters Orders  Clinical Decision Support  Easier to do the right thing  Harder to do the wrong thing  Immediate Order Transmission

24. Tools: I-Forms

25. Tools: Order Outlines

26. “Easier To Do The Right Thing:” Weight-based Dosing

28. Leveraging CPOE: Automation

29. “Harder To Do The Wrong Thing”

30. Allergy Checking

31. Allergy Alert

32. CPOE: A Process  Multiple applications  Provider  Nursing  Pharmacy  Ancillary Services, i.e., Laboratory, Medical Imaging  Global process - multiple stakeholders  KLAS: 17.5% US Hospitals > 200 beds in 2007

33. CPOE- Financial Gains CPOE in Community Hospitals:  ADE cost  Renal dosing errors  Unnecessary / Redundant diagnostic studies  IV to PO conversion  $2.7M Reduction in Cost, 26 month payback* * Feb 08 MA CPOE Initiative Report

34. The Competition

35. Goals- WellStar Health System  Improve Care  Lower Costs  CPOE Using HEO  Two Years To First Facility Go-live  100% Physician Adoption Two Years Post-live

36. WSKH ED Implementation

37. Challenges in Implementing HEC-HEO  Development  Training  Deployment  Adoption  Reporting

38. Implementing HEC-HEO

39. The Good-

40. The Bad-

41. And the Ugly Truth.

42. One solution… “In the middle of every difficulty lies opportunity” - Albert Einstein

43. A Better Way: Metrics

44. Throughput Analysis  Neglected value of ED applications  Acquire data from HEC & TB.  Quarantine invalid data  Report data compliance, i.e., reporting efficacy and accuracy.  Select and study throughput intervals.  Identify high-yield opportunities.

45. WS KH ED - Throughput Intervals Arrival to Triage Arrival to Bed Arrival to EDMD Assigned Arrival to EDMD At Bedside Bed to EDMD at Bedside EDMD at Bedside to EDMD Decision to Disposition EDMD Decision to Disposition to RN Disposition RN Disposition to Exit LOS

46. ED Metrics

47. The Good: Reliable ED Metrics ERK - July 2008

48. The Bad: Delays in Seeing EDMD Admitted Patients: Patient Arrival to MD At Bedside: 61 minutes Patient in Bed to MD At Bedside: 42 minutes

49. The Ugly: Delays in Exit From ED July 2008 EDMD Decision to Admit to Exit from ED: Exit Phase = EDMD Decision to Admit → Patient Exit From ED 162 + 10 = 172 minutes 39-47% Average ED Patient LOS (Jan – July 2008)

51. Progress: Bed to MDATBED Jul 08: Additional 1P EDMD shift present on 12/31 (38.7%) days 90% August dates have 1P ED MD Coverage

52. Exit Phase Delays

53. Admitted ED Patients: 3 Steps 1. Get Into An ED Bed 2. Receive ED Treatment &/Or Evaluation 3. Move to Next Level of Care

54. Getting Into An ED Bed:  Available ED Bed and Resources  Clinical Staff, i.e., RN, tech, etc.  Open Beds  Patients Must Be Able To Leave  ED MD Must Be Available  Appropriate ED MD Staffing

55. Treatment &/Or Evaluation:  Treatment  Laboratory Tests  Medical Imaging Studies  Consultation for Admitted Patients ED Process Improvement Committee

56. Moving to the Next Level:  Receive Admitting Orders, then…  Additional ED Orders  Call For Bed (Next Level Of Care)  Bed Assignment  Inpatient RN Staff Available to Receive Report  ED Staff Available to Move Patient

57. Moving to the Next Level:  Exit Phase:  Begins With EDMD Decision To Admit  Ends With Patient Exit From ED  158-251 minutes January – August 2008  39-47% of LOS

58. Exit Phase: Study Intervals How long did it take to receive orders?  Consult Interval  [EDMD Decision to Disposition] to Admit Orders Received (AOR)

59. Exit Phase: Study Intervals How long after AOR did patient leave EDTB?  ED Inpatient Admit Interval  AOR to Exit (ED bed available)

60. Exit Phase Study: May – September 2008 May 2008June 2008 July 2008Sep 2008 Total # Admissions1531134816131578 Admission Rate23.05%23.41%24.42%23.54% Admit Record Compliance 51.67%54.15%53.81%55.32% Total # Compliant Records 791730868873 Average Consult Interval (min.) 86 (1-1360)90 (0-1376)92 (0-2391)110 (0-1467) Averaged 86-110 minutes just to get admit orders Haven’t even called for a bed. (Practice & provider-specific data available)

61. Results- Consult Interval

62. Results- Inpatient Admit Interval (additional studies in progress)

63. ED Metrics Admitting (Non-ED) physicians

64. Average ED Consult Intervals May-July 2008 Practice# Admits A696 B245 C202 D105 E92 F72 G63 H50 I49 J41

65. Selected Average Consult Interval May – July 2008 (EDMD Decision to Disposition to AOR*) *AOR = Admit Orders Received

66. But… Admitting Strategies

67. Cardiology- Average Consult Interval May – July 2008 (EDMD Decision to Disposition to AOR)

68. Cardiology Admissions Significant variation in consult intervals exists between cardiology practices. Two of three cardiology practices, Practices “A” and “C,” account for 22.7% of all ED admissions. These practices almost exclusively admit only following consultation and evaluation in the ED. Practice “B” routinely phones in orders and evaluates the patient on the floor if they left the ED by the time they arrive. This is reflected in patients’ consult intervals and LOS:

69. Cardiology- Average ED LOS May – July 2008 (EDMD Decision to Disposition to AOR)

70. In Progress:  Medical Staff Admit Strategies  Staffing Changes and Allied Health Professionals  EDMD Calls For Bed  Admit Holding Area

71. Summary  Introduction  Kennestone Emergency Department  Metrics  More Metrics- Exit Phase  Even More Metrics- Non-ED Physicians  So far…

72. Questions? Contact Information: Jon Morris, MD, FACEP, MBA WellStar Health Systems Jon.morris@wellstar.org