Team RED: Reducing Emergency Delays

Team RED: Reducing Emergency Delays 2018-01-03T19:38:49+00:00

Project Description

Team RED: Reducing Emergency Delays

Background

  • In July 2016, Hospital A created Team RED (Reducing Emergency Delays) to improve services to patients and the community and to address the percent of patients leaving the Emergency Department (ED) before being seen by a healthcare provider (LWBS), the time from patient arrival to being seen by a provider (Door-to-Doc), and orders not executed timely after seeing a provider.
  • Between July 2015 and June 2016, the percent of patients leaving the ED at Hospital A before being seen by a provider was 4.8% and Door-to-Doc time was an average of 65 minutes, which were above the established facility goals of 4.0% and 50 minutes, respectively, leading to an overall decrease in patient experience.

Aim Statement

By the end of FY2017, Team RED will develop strategies and new processes from ED patient arrival to disposition decision in order to reduce LWBS % from a baseline of 4.8% to 4.0%, and improve Door-to-Doc time from a baseline of 65 minutes to 50 minutes.

This will be accomplished by:

  • Creating standard work for clinical staff in the Intake and Triage areas
  • Proactively queueing patients to be triaged, adding a provider in Triage, and seeing patients with a “team” approach
  • Combining Supertrack (Emergency Severity Index Levels 4 and 5 patients) with ACE (Vertical Emergency Severity Index Level 3 patients) to create a Fast Track area
  • Executing procedural and testing orders more timely after patients have been seen by a provider

Financial Implications

Patient and Family Centeredness Implications

  • ED clinical staff and providers collaborated with other non-clinical members of the care team to utilize the “Quick Setup” Lean tool and create a “team” approach to see patients more timely, as well as execute procedural / testing orders more efficiently, thus ensuring quicker results and treatment
  • Interventions (Team Triage, Fast Track, and Linear Triage Flow) were customized around the patient’s agenda and priority, which is seeing the doctor, getting diagnosed, treated, and sent home
  • A decongestion of the waiting room was accomplished via the interventions, creating a safe environment for patients and family members, and improving the patient experience upon arrival

Metrics/Measures

Process

  • Average Arrival to Provider (Door-to-Doc) time
  • Order to Blood Collect
  • Arrival to EKG Complete

Outcome

  • Average Left Without Being Seen (LWBS) %

Balance

  • Average length of stay from Patient Arrival to Departure for Discharged Patients (Discharge LOS)

Rapid Cycle Improvement: Cycle 1

Plan

  • Team members brainstormed issues that caused the patient to leave before being seen, and decided to focus on decreasing Door-to-Doc

Do

  • Team Triage was developed, which was a new process flow within Triage incorporating a “team” approach (Tech / RN / APP)
  • Standard Work was created for all roles in Triage, as well as creating a new role called Triage Flow Clerk that prioritizes patients to be triaged

Check

  • Door-to-Doc continuously decreased post-intervention, reaching an average low of 42 minutes the week of 8/28; LWBS decreased to goal in August

Act

  • All staff were trained on the standardized process to sustain improvements
  • Although Door-to-Doc & LWBS % improved, patients were still being sent to the waiting room after being seen with no orders being executed, thus keeping the waiting room congested and increasing Discharge LOS

Rapid Cycle Improvement: Cycle 2

Plan

  • Waiting room remain congested due to low acuity patients waiting to be seen, for orders to be executed after being seen, and discharged

Do

  • Team members moved Supertrack from Triage bay 4 (1 bed), as well as ACE from C Pod, and combined them in E Pod to utilize 10 beds and an internal waiting area

Check

  • Door-to-Doc reached a historic low of 30 minutes in November; LWBS also decreased to 1.7% in November

Act

  • Improvements were sustained through January, and the main waiting area was decongested
  • Although Door-to-Doc and LWBS % remained below goal through January, both metrics began increasing in February due to admitted patients being held in E Pod beds, making those beds unavailable for low acuity patients
  • Orders were still not being executed timely, thus increasing Discharge LOS

Rapid Cycle Improvement: Cycle 3

Plan

  • Focus was changed in February to improve Doc-to-Dispo and Discharge LOS (via order execution), while sustaining Door-to-Doc / LWBS improvements
  • Team Triage was modified by placing patients in tasking chairs behind Triage for orders to be executed after being seen by a provider; EKGs would now be reviewed by Advanced Practice Professional in Triage, and patients did not return to the main waiting room until orders were executed, then sent directly to be registered and discharged
  • Team RED Dashboard was created to monitor several process metrics

Do

  • Linear Triage Flow was piloted in February/March, & implemented in April

Check

  • Order to Blood Collect and Arrival to EKG decreased below goal for first time since dashboard creation, thus decreasing Discharge LOS by 37 minutes; Door-to-Doc decreased to 34 minutes, and LWBS remained below goal

Act

  • Team continued to modify the Linear Triage Flow to improve process metrics

Results

  • Door-to-Doc decreased by 35%; below goal for seven straight months (October thru April)
  • LWBS % decreased by 33%; at or below goal for eight months since first intervention (August thru January; March and April)
  • Discharge LOS decreased by 37 minutes since implementation of Linear Triage Flow (279 minutes FYTD March to 242 minutes)
  • Year-to-Date Door-to-Doc and LWBS improvements have met or exceeded FY17 Performance Goal for Hospital A ED

Sustainability

  • Monitor Door-to-Doc, LWBS and other process metrics on a weekly basis utilizing Team RED Dashboard
  • Discuss metric trends at ED Nursing (Tier 1) and ED Multi-Disciplinary Operations (Tier 2) huddles to foster front-line staff ideas
  • Hardwire Linear Triage Flow with front-line staff through consistent communication of the process at daily huddles
  • Focus on decreasing patients leaving without treatment complete (LWTC), which includes patients leaving without being seen (LWBS), as well as patients leaving without treatment (LWOT), and patients leaving against medical advice (AMA)
  • Streamline other Ancillary and Support areas within the ED, such as Respiratory, Pharmacy, and Public Safety to improve efficiency and safety of the ED
  • A team member has been assigned to continue improving processes in the ED as issues arise, sustain intervention improvements already achieved, and recognize / celebrate performance and goal accomplishments with all disciplines

Next Steps

  • Team RED will focus on redesigning the trauma area to be able to do portable imaging for patients in Triage; this will allow for timely execution of imaging orders
  • Add Doc-to-Disposition Decision and Discharge LOS to Team RED Dashboard

Lessons Learned

  • Since the scope of the team was from patient arrival to disposition decision (Door-to-Dispo), team should have had initial focus beyond patient seeing a provider (i.e., Door-to-Doc, LWBS)
  • Radiology metrics increased after Linear Triage Flow, which led to decision to execute imaging orders more timely through portable imaging in the Trauma area for patients in Triage