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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 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 FutureLeveraging IT At WellStar Health System:Kennestone Emergency Department

September 18, 2008

Jon Morris, MD, FACEP, MBA

WellStar Health Systems

  • Introduction
  • Kennestone Emergency Department
  • Metrics
  • More Metrics- Exit Phase
  • Even More Metrics- Non-ED Physicians
  • So far…
to err is human
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
the need for change
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 emergency department
Kennestone Emergency Department

>102,000 Annual patient volume

40% of Kennestone admissions

24.38% admit rate (July 08)

October 2007: ED Online

october 2007 kennestone ed live online documentation and order entry
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 tracking board
ED Tracking Board

WSKH ED Applications


WSKH ED Applications

online documentation
Online Documentation
  • Always Available
  • Real-time
  • Legible
  • Automated Date & Time
  • All Clinical Documentation In One Place
  • More Complete
order entry
Order Entry

WSKH ED Applications

definition cpoe
Definition: CPOE
  • Provider Enters Orders
  • Clinical Decision Support
    • Easier to do the right thing
    • Harder to do the wrong thing
  • Immediate Order Transmission
cpoe a process
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- 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

goals wellstar health system
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
challenges in implementing hec heo
Challenges in Implementing HEC-HEO
  • Development
  • Training
  • Deployment
  • Adoption
  • Reporting
one solution
One solution…

“In the middle of every difficulty lies opportunity”

- Albert Einstein

throughput analysis
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
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
the bad delays in seeing edmd
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
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
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

admitted ed patients 3 steps
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
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 &/Or Evaluation:
  • Treatment
  • Laboratory Tests
  • Medical Imaging Studies
  • Consultation for Admitted Patients

ED Process Improvement Committee

moving to the next level
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 level57
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
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 intervals59
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
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)

selected average consult interval may july 2008 edmd decision to disposition to aor
Selected Average Consult IntervalMay – July 2008(EDMD Decision to Disposition to AOR*)

*AOR = Admit Orders Received

cardiology admissions
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:
in progress
In Progress:
  • Medical Staff Admit Strategies
  • Staffing Changes and Allied Health Professionals
  • EDMD Calls For Bed
  • Admit Holding Area
  • Introduction
  • Kennestone Emergency Department
  • Metrics
  • More Metrics- Exit Phase
  • Even More Metrics- Non-ED Physicians
  • So far…

Contact Information:

Jon Morris, MD, FACEP, MBA

WellStar Health Systems

[email protected]