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CMIOJune 2011 CMIO.net

One o the challenges to driving [ED] throughput down is it can bedi cult to dissect the processes and determine which interventionsare making a di erence, says Neal Sikka, MD, emergency physicianat the George Washington University Hospital in Washington, D.C.Un ortunately, individual components o the throughput processare not [taking place] in a vacuum, and something thats out o yourcontrol can and might change.

In 2005, to help improve care or the rising number o patients inthe ED and to begin collecting data on patient throughput, GW Hos-pital, whose 36-bed ED receives 65,000 patients annually, imple-mented an ED in ormation system/EMR (Picis ED Pulsecheck).

Be ore then, ew data or metrics were gathered, says Sikka. Butonce the ED data spigot was turned on, clinicians started gettingreal-time data, which enabled them to examine work ows and makea variety o changes to expedite care. For example, EMR data analy-sis showed that the peak ED arrivals began at 9:00 a.m., not 11:00a.m., as had previously been thought. We now plan to sta or triageearlier and we reduce the risk o getting behind, he says.

As part o the hospitals initiative to leverage EMR data to improveED throughput, a variety o time intervals were examined. Insightgained rom tracking greet arrival patterns and intervals such as

greet to triage, triage to bed, and bed to disposition have lead to pro-cess modi cations. In addition to matching nurse sta ng in triageto the highest arrival rates, the hospital has shifed to electroniccommunication between greeting ED technicians and triage nurses,and now uses nurse-initiated triage protocols to start workups.

Over the past ew years since we began collecting data, our greet-to-triage times have improved nearly 50 percent, Sikka notes, and thetotal length o stay in the ER has dropped by more than 15 percent.

GW Hospital plans to migrate to a Cerner EMR plat orm this all.Like many other medical centers, the acility is moving to an inte-grated system or the entire hospital as compared to the current, dis-

parate I environment, according to Sikka. ED sta at al l levels havebeen a part o the development and implementation team in plan-ning or the changeover to the EMR. Every e ort is being made toensure that there is no loss o unctionality and that the ED can takeadvantage o the bene ts that come with an integrated hospitalwideEMR, he says.

Managing the patientTroughput issues arent limited to large urban hospitals. Great PlainsRegional Medical Center (GPRMC), a 116-bed ull-service medical

Swi t, e ective care and smart economics rest on getting patients through the emergency roomas soon as possible. IT that delivers patient ow data plays a major role in maximizing efciencies

within the emergency department (ED).

By Jef Byers

Throughput Is Key

More in ormation, aster: The emergencydepartment in ormation system at GreatPlains Regional Medical Center in NorthPlatte, Neb., automatically uploads nurseand clinician documents rom a patients ERencounter into the EMR.Source: Great Plains Regional Medical Cent

Department ITEmergency

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center in North Platte, Neb., went live with a system developed by -System in 2004 to document patient throughput within the ED.One o the big concerns was whether the new system would actu-

ally slow care, says GPRMC CIO Jim Anderson. As CIO, I worriedthat the implementation o a computer system in a high-volume,

ast-paced environment might slowdown total ED throughput.By uploading patient throughput data, the system assists with

clinical decision support. Because decisions must be made quickly inthe ED, GPRMC needed a system to quickly access a patients symp-toms and record, Anderson reports. Te -System EDIS automati-cally uploads nurse and clinician documents rom a patients EDencounter into the EMR. Te EDIS matches ED ow in terms o thesymptoms the patient presents with when he or she enters into tr iage.Tose are ollowed up with nurses and the initial visit rom the phy-sician through to the ordering o labs or exams, says Anderson.

Te acility was so pleased with the EDIS capabilities that whenGPRMC implemented its EMR system (Eclipsys) in 2009, the hos-pital opted to integrate the ED documentation sofware into theEMR because the unctionality was richer in the EDIS environ-ment, Anderson says. Clinicians can see t he integrated EDIS dataas part o the patients EMR, which enables them to quickly makedecisions based on a more complete view o the patients history,according to Anderson.

Te average ED throughput time be ore implementation o thesystem (2004) was 121 minutes. GPRMC experienced a 10 percent jump in ED volume between 2009 and 2010, and the averagethroughput time last year was 129 minutes. Our ocus was to notincrease length o stay when moving to the electronic system and toimprove care in terms o sharing in ormation, says Anderson, whoreports hes satis ed with the results.

In ra-readyIn 2002, Philadelphias Albert Einstein Medical Center (AEMC) wasexperiencing a host o ailments, including high emergency depart-ment walkout rates and poor ED throughput times. o alleviate the

issues, the hospital began a renovation o the ED to improve through-put and reduce the perception o chaos, says Carl Chudno sky,MD, chair at the department o emergency medicine at AEMC.

AEMC has a high-acuity EDChudnosky estimates that the EDwill see about 90,000 patients in 2011.

Tey wanted an automatic patient tracking system to reduce longwaits. A rst-generation in rared technology (Versus) was deployedin 2004. Te in rared patient badges required a line o sight betweenthe censors, the ceiling and the badges that patients wear. I thebadges ipped or were covered by a gown or sheet, you lost the track-

ing, says Chudno sky. AEMC developed a workaround by puttingthe badges on IV pulls.

Te tracking was better than any tracking screen, since those canlook like an Excel spreadsheet bogged down with icons which becomesless help ul, says Chudno sky.

Five years later, AEMC upgraded to an ultrasound-based trackingsystem or patient tracking. Te sofware never worked. We spentabout a year troubleshooting, he says. AEMC subsequently replacedthe aulty ultrasound system with a second-generation in rared sys-tem (Centrak) earlier this year, which doesnt require the line o sight.

Te long road has paid o or AEMCautomatic tracking o patients has helped drive down the average monthly ED diversion

rom 170 hours in scal year 2004 to less than 20 hours in scal 2010.riage time currently averages nine to 12 minutes: Te average was

nearly twice that time prior to the tracking system being implement-ed, says Chudno sky.

Te in rared system, thanks to badges attached to patients, auto-matically tracks patients on large plasma screens in the ED in ronto physicians and on desktops. In ormation will be integrated intothe hospitals Cerner EMR plat orm when it goes live this month.

In the past, to know what patients were in the waiting room, youhad to physically go there. When admitting in the past, you had tomake phone calls. You dont have to do either now, says Chudno sky.

racking patients has helped AEMC optimize patient prioritizationand distribution, identi y bottlenecks and improve time intervals. Inaddition, the number o ED patients leaving without being seen hasgone rom 4 percent in 2003 to about 2.75 percent in 2010, he says.

Once numbers on physician exam throughput times were avail-able, the clinicians competiveness spurred a cultural change toimprove their personal throughput times: Te goal is 15 minutes inbetween a patient gett ing to the room and being seen by a physician,says Chudno sky. Once physicians times were shown to everyone,no one wanted to be last. Tere was no prodding to get times withinthat 15 minute average. We keep a tight range.

Te total throughput time di ers i a patient is admitted or dis-

charged. It may be much shorter or a low-acuity patient who is dis-charged, or example, notes Chudno sky. At AEMC, 2.5 hours is theaverage time to disposition decision, he says.

Although many initiatives are under way at AEMC and elsewhereto reduce patients dependence on the ED, such a reduction wonthappen overnighti it happens at all. In the meantime, hospitals o all sizes are tapping ED in ormation systems, EMR data integrationtools and other options to reduce the amount o time patients spendin the ED and increase physician e ciency, all the while improvingthe care they provide.

In the past, to know what patients were in the waitingroom, you had to physically go there. When admittingin the past, you had to make phone calls. You donthave to do either now.Carl Chudno sky, MD, Chair, Department o Emergency Medicine, Albert Einstein Medical Center, Philadelphia

Reprinted, with permission, rom the June 2011 issue o CMIO magazine (ISSN 2 151-1659). Copyright 2010 TriMed Media Group. All rights r eserved.