Published on August 9, 2012
Ambulance Diversion Aversion at a Suburban Hospital’s Emergency Department : Ambulance Diversion Aversion at a Suburban Hospital’s Emergency Department Lindsay J. Houck RN, BSN, CEN, CPEN, PHRN California University of Pennsylvania Overview of Project : Overview of Project The need for ambulance diversion is cyclical. Over the past seven years, there has been varying amounts of ambulance diversion by the Emergency Department. The necessity for diversion was completely eliminated during this period after an expansion of both the emergency department as well as of the inpatient units. Unfortunately, the need for diversion has once again presented itself. Problems : Problems It is supposed that the increasing need for ambulance diversion in the Emergency Department is a “back door” problem. It is not felt like it is a sheer lack of Emergency Department space, but instead, lack of available Emergency Department space due to a delay in transitioning patients out of the Emergency Department to inpatient units. It is expected that a delay in admission orders from the admitting teams as well as inpatient beds being at capacity are the two main causes of this problem. Objectives : Objectives Identify the status of the Emergency Department environment at times of diversion through a data collection tool. Tool may also be used during high volume of admissions being held in the emergency department when diversion is not yet necessary. Educate on use of data collection tool and institute it’s use during times of diversion. Analyze data that is collected in order to indentify patterns and other consistencies that compare to diversion. Propose possible solutions to decrease Emergency Department diversion hours. The Diversion Aversion Team : The Diversion Aversion Team The interdisciplinary team included members of nursing leadership, physician leadership, and staff members. The core members of this team include: Patient care services administrator functioning as sponsor on this project Emergency department patient care coordinator (student) functioning as clinical leader Emergency department directors of three emergency department sites Administrative secretaries Bed management analyst Core charge nurses from the emergency departments. Why are we doing this? : Why are we doing this? The major goal of this project is to improve the delivery of patient care and improve patient satisfaction. By eliminating the back log in the ED, more patients are able to be cared for. Also, a more expedited ED visit immensely improves patient satisfaction. We are striving to ever improve and advance our culture of patient care, and to provide excellent patient care. The best way to do this is to ensure that we are meeting our mission and enhancing our reputation (Studer, 2010) by upholding our slogan “A Passion for Better Medicine”. Theoretical Framework : Theoretical Framework Our ambulance diversion aversion project affects the ED in numerous ways. The goal of the project is to identify and correct the issues that lead to need for ambulance diversion. These issues affect the patients primarily. It prevents ambulance patients from coming to the ED of their choice. It is usually as a result of a large number of “ED HOLDS” (admissions that are holding in the ED because there is not a bed available for them in the inpatient units). Emergency patients may suffer because of the large volume of admissions in the ED, and the admitted patients may not get care to the extent that they would on the inpatient units. All of these dilemmas can be related to Kathy Kolcaba’s Comfort Theory. The Comfort Theory focuses on patient centered experiences which impacts the patient experience ratings on the HCAHPS surveys. With the recent changes in healthcare reimbursements, creating positive improvement on the HCAHPS survey is important. Some of the specific areas that are addressed through the comfort theory are: “communication by nurses and doctors responsiveness, (quick help) of hospital staff, pain control, explanation about medications, cleanliness, night time quiet, and discharge planning” (Kolcaba’s, 2010, http://www.thecomfortline.com). Developing the Data Collection ToolPLAN : Developing the Data Collection ToolPLAN The interdisciplinary team met on multiple occasions to develop the goals and the tools of this project. The team developed the data collection tool (see next slide, following the tool are the definitions for each field). This data collection tool includes all of the areas that the team felt were necessary to track in order to document the problem. Expected values were established for all fields and the data collection tool indicates when the functional values are exceeded. ImplementationDO : ImplementationDO The Core Charge nurses in all three emergency departments were educated on the data collection tool. Criteria was established as to when the form should be implemented. The implementation of this project/tool has given the Core Charge nurses more autonomy to place the department on ambulance diversion then with the previous process. Implementation cont’dDO : Implementation cont’dDO All of the yellow fields in the collection tool are the responsibility of the charge nurse to complete – either at the time of diversion, or in the case of 15 or more admissions being held in the emergency department. In order to make this tool user friendly, these fields are completed by the charge nurse using a survey located on the intranet. The data from the completed surveys are received by the administrative secretaries and entered into the official spreadsheet of the collection tool. Implementation cont’dDO : Implementation cont’dDO Once submitted by the Charge RN, the form is received by an administrative secretary. After a 24 hour period has passed, she will enter remaining data about the diversion. The 24 hour delay allows charts to be locked so that accurate data can be received. An administrative secretary will then forward the forms to the respective directors, who will fill data in such as # of patients who left without being seen Daily ED Census Director Executive Summary Paints a picture of what was occurring and why we needed to go on divert Implementation cont’dDO : Implementation cont’dDO The data, including the executive summary, will be analyzed to find opportunities in the network that prevent diversion. This data will be presented to the EDs, senior leadership, and the network. KEY DEFINITIONS : KEY DEFINITIONS Number of Patients at time of divert : Number of Patients at time of divert Total number of patients in the ED census at the time when criteria are met to activate the form. Longest wait time to CT : Longest wait time to CT This is the longest time identified for patients who have a CT scan ordered, but have yet to have their CT scans completed. ED HOLD : ED HOLD Anyone that has an admit order, but does not have a clean and ready bed. Unassigned Dirty Occupied Next Suspended Blocked Pending Admissions : Pending Admissions Total number of patients in the ED that are referred for admission but awaiting admitting orders. In the past, when referring a patient to the admitting physician to be admitted into the hospital, “Fast 5” orders were placed by the ED physician to expedite the patients to the admitting units. The admitting team would then see these patients on the inpatient units to finish their orders. “Fast 5” Orders Bed Request Vital Signs Diet Activity Notification ResultsSTUDY : ResultsSTUDY Data collection began June 1, 2012. Data collection is still ongoing as this remains an active initiative at Lehigh Valley Health Network. This data shown in this project reflects eight separate incidents of diversion specifically at Lehigh Valley Health Network – Cedar Crest Campus. This eight instances occurred over four weeks. There are four major areas of interest noted from this study. Results cont’d.STUDY : Results cont’d.STUDY The average daily scorecard census is based on an expected daily volume of 218 patients per day. Every diversion event met or exceeded the expected daily volume of emergency department patients. On one event of diversion, the expected daily volume was exceeded by 70 patients. Census Variations During Diversion : Census Variations During Diversion Diversion Event Number of patients Results cont’d.STUDY : Results cont’d.STUDY Goal is to have average daily capacity in all units be less then 90% to allow for ED admissions, direct admissions, etc. With the exception of pediatrics and low level monitoring, all units were over this capacity during ED diversions. In one instance, ICU capacity was at 110% which means that those extra 10% of ICU patients were holding in the ED or PACU. Overall, the average house capacity surpassed the less then 90% threshold at 91%. In-House Bed Capacity Averages at Times of Diversion : In-House Bed Capacity Averages at Times of Diversion Type of Inpatient Bed Percentage of Capacity Results cont’d.STUDY : Results cont’d.STUDY With the exception of one diversion event, there were admissions holding in the ED during these events. The ED has a capacity of 42 beds in the main department and 12 beds in the children’s ED. This does not include the patients in the hallways, express care, and the waiting room. During slower times of the day (ie: overnight), only 28 beds are staffed (from 0300-0700). Holding multiple admissions has a significant impact on the ability to handle emergency department patients. Number of Patients Holding in the ED Awaiting an Admission Bed : Number of Patients Holding in the ED Awaiting an Admission Bed Pink #’s = number of patients holding in the ED Results cont’d.STUDY : Results cont’d.STUDY Another significant reason for delay is the lack of admission orders. The data has also shown that it is not always a lack of available beds that results in the back log in the ED. The data has shown significant waiting times for admission orders in the ED. The patients waiting in the ED for those admission orders takes up valuable space that could be in use for ED patients. Patients in the ED at the Time of Diversion who have been Referred for Admission, but lack Admission Orders. : Patients in the ED at the Time of Diversion who have been Referred for Admission, but lack Admission Orders. Diversion Event Patients waiting admitting orders SolutionsACT : SolutionsACT Using the data that has been gathered, two major problems have been identified needing solutions: Lack of available space for admitted patients Specifically in the Intensive Care & Medical-Surgical/Telemetry Units Delay in patients receiving admission orders in order to be transitioned out of the ED. Long wait time for patients to be seen by admitting teams and orders placed. Refusal of admitting teams to allow “Fast 5” orders to be placed by ED Physicians. Solutions cont’d.ACT : Solutions cont’d.ACT The thought of opening an additional inpatient unit is a daunting one. The physical space does exist for additional inpatient units (this was planned for during the last major building project). It was expected that the information collected by this project was going to be needed to solidify the necessity of additional inpatient space. Fortunately, we now know that an additional inpatient unit is being budgeted for the next fiscal year with this data providing additional supporting information, but not as a result of this project. Solutions cont’d.ACT : Solutions cont’d.ACT The focus now lies on decreasing the delay for admission orders: The delays of the admission team to the patient bedside in the ED. The refusal of the admitting teams to allow ED physicians to place the “Fast 5” Orders which have previously been successful in increasing patient flow out of the emergency department. Solutions cont’d.ACT : Solutions cont’d.ACT Financial Implications: Thankfully, the financial impact of this project and solutions should be minimal The focus is going to be teaming up with physician leadership to plan and educate with the admission team leadership in order to decrease the delays related to the admission process. The hope is that these delays can be reduced significantly with a return to frequent placement of “Fast 5” orders. The only “cost” at this point should be time of the team members and those being educated. (Since these individuals are most likely salaried, overtime should not ensue, keeping these solutions very cost effective.) Notes : Notes The design and implementation of this data collection tool has exceeded expectations. This project (also called Project 11: Diversion Aversion for Lehigh Valley Health Network) is on going. There may be other variables and/or results that report out through the continuation of this project. Data collection will continue for a minimum of three months and continue once solutions are implemented as well. Slide 34: THANK YOU!!!!