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Emergency Room Of The Future Leveraging IT At WellStar Health System: Kennestone Emergency Department PowerPoint PPT Presentation


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Emergency Room Of The Future Leveraging IT At WellStar Health System: Kennestone Emergency Department. September 18, 2008. Jon Morris, MD, FACEP, MBA WellStar Health Systems. Agenda. Introduction Kennestone Emergency Department Metrics More Metrics- Exit Phase

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Emergency Room Of The Future Leveraging IT At WellStar Health System: Kennestone Emergency Department

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Emergency Room Of The FutureLeveraging IT At WellStar Health System:Kennestone Emergency Department

September 18, 2008

Jon Morris, MD, FACEP, MBA

WellStar Health Systems


Agenda

  • Introduction

  • Kennestone Emergency Department

  • Metrics

  • More Metrics- Exit Phase

  • Even More Metrics- Non-ED Physicians

  • So far…


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


Example: 2007 Adverse Drug Events


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


Kennestone ED


Kennestone Emergency Department

>102,000 Annual patient volume

40% of Kennestone admissions

24.38% admit rate (July 08)

October 2007: ED Online


ED Flow “Before”


Paper ED Record


Completed ED Evaluation - Waiting For MD


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)


ED Flow “After”


ED Tracking Board

WSKH ED Applications


Patients Waiting For MD


ED Patients: Status & Tasks


Documentation

WSKH ED Applications


Online Documentation

  • Always Available

  • Real-time

  • Legible

  • Automated Date & Time

  • All Clinical Documentation In One Place

  • More Complete


ED MD Charting


Paper vs. HEC- MD Note


Order Entry

WSKH ED Applications


Definition: CPOE

  • Provider Enters Orders

  • Clinical Decision Support

    • Easier to do the right thing

    • Harder to do the wrong thing

  • Immediate Order Transmission


Tools: I-Forms


Tools: Order Outlines


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


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


Leveraging CPOE: Automation


“Harder To Do The Wrong Thing”


Allergy Checking


Allergy Alert


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


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


The Competition


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


Implementation

WSKH ED


Challenges in Implementing HEC-HEO

  • Development

  • Training

  • Deployment

  • Adoption

  • Reporting


Implementing HEC-HEO


The Good-


The Bad-


And the Ugly Truth.


One solution…

“In the middle of every difficulty lies opportunity”

- Albert Einstein


A Better Way: Metrics


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.


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


ED Metrics


The Good: Reliable ED Metrics

ERK - July 2008


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


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)


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


Exit Phase Delays


Admitted ED Patients: 3 Steps

  • Get Into An ED Bed

  • Receive ED Treatment &/Or Evaluation

  • Move to Next Level of Care


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


Treatment &/Or Evaluation:

  • Treatment

  • Laboratory Tests

  • Medical Imaging Studies

  • Consultation for Admitted Patients

    ED Process Improvement Committee


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


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


Exit Phase: Study Intervals

How long did it take to receive orders?

  • Consult Interval

  • [EDMD Decision to Disposition] to Admit Orders Received (AOR)


Exit Phase: Study Intervals

How long after AOR did patient leave EDTB?

  • ED Inpatient Admit Interval

  • AOR to Exit (ED bed available)


Exit Phase Study: May – September 2008

Averaged 86-110 minutes just to get admit orders

Haven’t even called for a bed.

(Practice & provider-specific data available)


Results- Consult Interval


Results- Inpatient Admit Interval(additional studies in progress)


Admitting (Non-ED) physicians

ED Metrics


Average ED Consult Intervals May-July 2008


Selected Average Consult IntervalMay – July 2008(EDMD Decision to Disposition to AOR*)

*AOR = Admit Orders Received


Admitting Strategies

But…


Cardiology- Average Consult IntervalMay – July 2008(EDMD Decision to Disposition to AOR)


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:


Cardiology- Average ED LOSMay – July 2008(EDMD Decision to Disposition to AOR)


In Progress:

  • Medical Staff Admit Strategies

  • Staffing Changes and Allied Health Professionals

  • EDMD Calls For Bed

  • Admit Holding Area


Summary

  • Introduction

  • Kennestone Emergency Department

  • Metrics

  • More Metrics- Exit Phase

  • Even More Metrics- Non-ED Physicians

  • So far…


Questions?

Contact Information:

Jon Morris, MD, FACEP, MBA

WellStar Health Systems

[email protected]


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