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UCSD Medical Center
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1. University of California San Diego TC Chan, J Killeen, GM Vilke, D Kelly, D Guss Department of Emergency Medicine, University of California, San Diego
2. UCSD Medical Center & ED Located in urban corridor of San Diego
Academic teaching hospital
Approximate bed capacity of 300; average daily census of 250-280.
Only state-designated comprehensive ED in San Diego and Imperial Counties
Only Level I Trauma Center and Regional Burn Center
Annual Census ~ 40,000
Total Beds: 24 (4 fast track)
3. Patient Makeup
4. SD region pop growth of 12.3% from 1990-2000
6 hospitals with EDs have closed (3 within UCSD’s catchment)
15.2% decline in hospital beds
19.7% decline in ED beds Hospital / ED Closures
5. UCSD ED
6. The Problem Increasing LOS
Increasing Wait Times
Increasing LWBS
Flat ED Census
7. Process Improvement Approach ED Team
Improve ED Entry
Initiate Care Earlier
Inpatient Team
Overcome barriers to admit process
Improve Admission/Discharge process
8. ED Entry
9. Rapid Entry
Electronic Sign-in
Quick Registration Process (name, dob, sex)
Patient ID Wristband / Barcoding on arrival
Open Bed Policy
Triage-driven Bed Placement
Bedside Registration
ACT (Accelerate Care at Triage)
MD-initiated evaluation, care at triage
10. Major EMR Revisions
Electronic Sign-in
Interface with hospital registration system
Patient identification barcode system
Wireless ED
Mobile laptops for staff, registration
Vocera instant communication system
Staff Changes
Change in Entry Culture (RN, MD, AP)
11. Integration Ability to Initiate Simultaneous Activities
Bar-code system allowing evaluation to proceed without prior registration (tracking, error-reduction)
Integration of multiple computer systems/programs for each of the ancillary services
ED EMR
Hospital Computer System
Registration (ADT)
Radiology (IDX-Rad, PACS)
Laboratory Interface (CCA)
12. ACT Philosophical and cultural change in ED Triage
Initiate evaluation and care at Triage
Change ED patient flow from SERIES of steps to one in which steps occur in PARALLEL
13. Traditional Ambulatory ED Flow
14. “Increased utilization leads to increased numbers of patients waiting in a queue and increased waiting time”
- Queuing Theory
15. Waiting Room Census and Ancillary Lab Studies by Time of Day
16. Patient Flow with ACT
17. ACT Process
18. ED Entry
20. Results
21. Results
22. Results
23. Results
24. Results
25. Findings Improved ED Entry
Decreased wait times, LOS, LWBS even with higher census
No registration errors identified
Mislabeled laboratory specimens reduced by 90%
Initiated Care Earlier
Decreased LOS
Many studies expedited from triage (10-20% of patients) including XR, CT, US, labs
Small but not insignificant #s of patients discharged from triage
26. Lessons Learned Information technology and integration facilitated process improvements, but staff buy-in and culture change on all levels critical to implementation and success
AP – new integrated, wireless registration process
RN – new triage philosophy and ED entry process
MD – initiate evaluation earlier and at triage
