Hospital Off-Load ProcessImprovement Team

February 23, 2007

Project Team Team Members

Jennifer Higgins Traci Acton Benjamin Abes Mariellen Shields Janet Quinn Paul Hellriegel

Team Leader Shared responsibility

Team Facilitators Eileen Briscoe John Norton

Sponsor Deputy Director H. C. Hansen

Define Phase Problem statement Lee County hospitals are not off-loading EMS patients in a timely

manner. This results in fewer ambulances available for response at any given time. It also results in more available units having to move around the County to provide coverage.

Justification for project Lee County EMS and hospital partners are losing opportunities for

faster return to available status of ambulances and more timely processing of patients to admission or release. The effort to better manage these resources will pay monetary benefits to both.

Project Impact County objective Project will prove a savings in unit availability hours and

manpower. Quicker off-loads will allow ambulances to turn around quicker and be available for calls, thus potentially reducing response times allowing LCEMS to meet the benchmark response time of < 8min 59sec. To become more knowledgeable about hospital processes and assist hospital partners in streamlining the ED intake process. The estimated savings is ≈$350,000; using $140/hr of unit utilization hour.

Project goal EMS patients should be off-loaded 90% of time within 15 minutes

of arrival at the hospital and within 30 minutes 100 percent of the time.

Project Scope In scope All Lee County EMS ambulances.

Out of scope All other transport agencies in Lee County. Hospitals in other counties.

Process Flow Chart

Please see hand-out.

OFF-LOAD PROCESS MAP FROM PIT MEETING 12-14-2006

TRANSPORT DESTINATION

COORDINATION DECISION

HOSPITAL CONTACT

YESNO

TRANSPORTING

ARRIVAL

HOSPITAL TRIAGE AND ASSIGNMENT

ACCEPTS

HOSPITAL WILL OFF-

LOAD

OFF-LOAD

UNIT CALLS EXTENDED AFTER 30 MINUTES

YES

NO

MULTIPLE UNITS WAITING

OFF-LOAD TO

SUPERVISOR

ARRANGEMENTS MADE

YES YES

UNIT 10-8

SIPOC DiagramSuppliers Inputs Process Outputs Customers

MedicsEMS AdminHospital AdminERBOCC

Medics:Return 10-8Record trip detailContinue pt. careEMS Admin:Political issuesReturn units 10-8ResourcesHospital Admin:Political issuesGenerate revenueFoster good relationsER:StaffingBedsEquipmentBOCC:ResourcesBudget/taxes

Unit arrives at hospital

Patient is offloaded

Unit becomes available

Offload timeUnit is available for calls

PatientsEMSHospital AdminBOCC

Measure Phase

Jan 2006-August 2006 Hospital Offloads

11.8

16.1

11.213.7

17.6

11.7

15.515.6

8.5 7.8

0

5

10

15

20

Lee SWFRMC Cape Gulfcoast Healthpark

Hospital

Tim

e in

Min

ute

s

AVG

StDev

Measure Phase Jan 2006- August 2006 Offloads

142

200 215

78

155

0

50

100

150

200

250

Lee

SWFRM

CCap

e

Gulfco

ast

Health

park

Hospital

Tim

e in

Min

ute

s

Range

Analyze Phase Destination Coordination

Effect

Delayed Offloads

Machinery

Measurement

Methods Materials

Manpower

Radio failure

unable to make

contact

Allowing patient choice

Physician/ facility request

Communication with triage or

charge nurse for beds

EMS overloading one facility

Lack of specialty services

Lack of specialty services

Shift Command schedule

inconsistency

No standardized coding system for ER

status

Lack of bed availability communication

Not taking patients to appropriate

facility

Analyze Phase Turn Around Times in ER

Effect

Delayed Offloads

Machinery

Manpower

Methods Materials

Mother Nature

Equipment Failure

Non-emergency transport back to

nursing home

Work pace

Boarding patients

Lack of specialty services

Waiting for test results

Non-acute ER

patients arriving

Boarding patients

Staffing in ER

Lack of mental health services

Analyze Phase Available Beds in ER

Effect

Delayed Offloads

Machinery

Measurement

Methods Materials

Manpower

Lack of stretchers

Equipment Limitations

Patients waiting for discharge in

ER rooms Multiple

patients backed up in triage

Communication with triage nurse for triage or beds

Boarding patients

Space limitations

Shift change

Staffing to support beds

Field

personnel unable to see

ER bed status in real time

Communication back to EMS on

bed status

Analyze Phase Root Causes Found

Destination Coordination: Ambulance clumping at ERs

Available beds at ERs Hospital Turn Around Time: Hospital boarding

patients in ER

Improve Phase Solution Prioritization Matrix

SOLUTION RANK

Mandatory Transportation Officer Contact

1

Standardize ER Status Codes 6

ER Update With Bed Status Via EMSystems

2

Hospital Assigns Off-Load RN 5

No Patient Choice 4

Room Assignment When EMS Calls 2

Improve Phase Solutions Implemented

Transportation Destination Coordinator

contact prior to transport. Transportation

Officer must be a paramedic

EMSystems update by hospitals.

Lee Memorial Hospital ER nurse finding

bed space prior to EMS arrival.

Improve Phase

Pilot ran from February 1st to February 14th

The only facility implementing all three

solutions was Lee Memorial Hospital

Shift Command took on the role of

Transportation Officer

Improve Phase

Results: Pilot proved a statistically significant

reduction in the average off-load times for Lee Memorial Hospital.

A decrease in the variation (range).

Improve Phase

Average Offload Times In Season 2006 & 2007

13.21883657

44.2

0

10

20

30

40

50

Feb-07 Feb-Mar 2006

Month

Tim

e In

Min

utes

Improve Phaset-Test: Two-Sample Assuming Unequal Variances

  Feb-07 Feb-Mar 2006

Mean 13.21883657 44.2

Variance 107.5936442 441.1714286

Observations 361 15

Hypothesized Mean Difference 0

df 14

t Stat 5.683950102

P(T<=t) one-tail 2.82155E-05

t Critical one-tail 1.761310115

P(T<=t) two-tail 5.64309E-05

t Critical two-tail 2.144786681  

Improve Phase

Pilot Results Offloads 2/1-2/14 2007

86

124

92

119

151

101

0

20

40

60

80

100

120

140

160

d1 d2 d3 d4 d5 d7

Hospital

Tim

e In

Min

ute

s

Range

Improve Phase

Offload Fractile <30 Minutes Pilot Results

94%

71%

88%77%

83% 81%

0%

20%

40%

60%

80%

100%

d1 d2 d3 d4 d5 d7

Hospital

<30

Improve Phase

Offload Fractiles Pilot Results

75%

50%

69%59%

64%

21%27% 24%

50%

19% 19% 17%16%23%

17%

19%29%

12%

0%10%20%30%40%50%60%70%80%

d1 d2 d3 d4 d5 d7

Hospitals

0-15

16-30

>30

Improve Phase Recommendations:

Team to review results with Process Owners and hand off (2nd week in March).

Pilot demonstrated significant reduction in range.

Recommend that process used in pilot be continued with Lee Memorial as normal part of operation.

Recommend that process used in pilot be implemented on an incremental basis in all other hospitals within county.

Control Phase Process owners:

EMS Shift Commanders EMS Transportation Officer

Control Phase Process data to be reported via weekly

reports from Public Safety Information Resources.

Data will be in Microsoft Excel format.

Reports will be input to worksheets which are formatted to calculate timelines.

Control PhasePercent Offloads <16mn Goal 90%

80 76 7367

61

50

60

70

80

90

100

O N D J F-12 M A M J J

Months 06-07

Perc

enta

ge

Control Phase

Percent Offloads >16 <31

16 18 2023 23

0

5

1015

20

25

O N D J F-12 M A M J J

Months 06-07

Perc

enta

ge

Control Phase

Percent Offloads >30

4 6 710

16

05

101520

O N D J F-12 M A M J J

Months 06-07

Perc

enta

ge

Hand-off Issues (Parking Lot Issues) Hand off should not present any unforeseen

difficulty.

Following recommendations will require workload adjustment for Shift Commanders or addition of an EMS Transportation Officer.

Future projects will be decided by management with recommendations from Six Sigma Steering Committee.

Questions?