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From Access to Success in the Emergency
Department

Improving Access to the Emergency
Department at Penticton Regional
Hos...
Penticton and Area
∗ 32,000 residents in the
City of Penticton
∗ In the summer the
population doubles to
60,000
∗ Penticto...
Penticton Regional Hospital

∗ 137 beds
∗ Services: Orthopedic and General Surgery, Intensive
Care, Medical, Obstetrics, P...
PRH Emergency
∗ 13 bed Emergency
Department
∗ 24 hour physician coverage
∗ 32,500 visits per year
∗ 80-100 patients per da...
What is the problem?
Emergency Physicians brought concerns forward:
1. Department congested with admitted patients
2. Phys...
What to do?
∗ Decision by the Director of Acute Care Services to
enter into a Continuous Quality Improvement project
∗ Sep...
What Did We Find?
Time From Registration to Initial Physician
Assessment
2011/2012
150
100
50
0
CTAS 2

CTAS 3
Time (Minut...
Are the Admitted Patients Really The Problem?
ED Activity Profile – CTAS distribution

60%
50%
40%
30%
20%
10%
0%
2009/10
...
Let’s focus!
To improve the acute care patient flow through the Emergency
Department while maintaining quality of care, de...
Streaming: Project Objective

“Implement a streaming model of care

delineating 4 distinct care areas that patients
may be...
Streaming: How it works
Initial Triage




Trauma/

Resuscitation

• CTAS Level 1s
and 2s

Quick triage
Patient demogra...
Streaming - How it Works
∗ 14 chairs and 4 exam spaces available for
Streaming and Minor treatment
∗ Patients triaged to t...
Why Stream?
∗ More efficient use of minimal space 14 patients can be seen out of
three stretcher spaces
∗ Decreased time w...
Streaming as a care area
Program Design
∗
∗
∗
∗
∗

Inclusion/exclusion criteria
Physical space allocation
Patient flow
Sta...
Creating Buy In
One Month Education Blitz
∗ Mandatory one hour education sessions for all ED staff
∗ Education sessions fo...
Go Live!
APRIL 15th, 2013 Went live with Streaming Trial
∗ Daily Evaluations
∗ Daily communication reports and status upda...
Challenge: Culture Shift
How do we go from this….

Footer

To this?

17

2/24/2014
Challenge: Concerns About Patient Dignity
Challenge: Who will change the sheets?

Footer

19

2/24/2014
Challenge: Staffing Model
∗ Need to remove one RN
on days to dedicate to
streaming
∗ Team nursing model
cherished
∗ How to...
How Did We Do??
140

Pre and Post Streaming Time to Physician Assessment
120

100

80

Pre Project
Benchmark
Post Project
...
Wait times CTAS 2, 3, 4, 5
Pre Streaming
Average wait to see the
physician

65

42

Minutes

Footer

Post Streaming
Averag...
Staff Satisfaction!
∗ “ As a PCC I don’t feel that constant worry about
where I am going to put the next chest pain”
∗ “I ...
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Improving Emergency Department Access at Penticton Regional Hospital

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This presentation was delivered in session D3 of Quality Forum 2014 by:

Anne Morgenstern
Manager, Emergency Department, Penticton Regional Hospital
Interior Health

Published in: Health & Medicine
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Improving Emergency Department Access at Penticton Regional Hospital

  1. 1. From Access to Success in the Emergency Department Improving Access to the Emergency Department at Penticton Regional Hospital
  2. 2. Penticton and Area ∗ 32,000 residents in the City of Penticton ∗ In the summer the population doubles to 60,000 ∗ Penticton Regional Hospital serves 79,000 people in the Okanagan Similkameen Hospital District Footer 2 2/24/2014
  3. 3. Penticton Regional Hospital ∗ 137 beds ∗ Services: Orthopedic and General Surgery, Intensive Care, Medical, Obstetrics, Pediatrics, Neurology, Rehab ∗ Regularly107-116% over capacity Footer 3 2/24/2014
  4. 4. PRH Emergency ∗ 13 bed Emergency Department ∗ 24 hour physician coverage ∗ 32,500 visits per year ∗ 80-100 patients per day ∗ 100-130 patients per day in the summer ∗ Average wait time to see physician for CTAS 2, 3, 4 and 5’s: 65 minutes Footer 4 2/24/2014
  5. 5. What is the problem? Emergency Physicians brought concerns forward: 1. Department congested with admitted patients 2. Physicians ready to see waiting patients but no space to assess them Footer 5 2/24/2014
  6. 6. What to do? ∗ Decision by the Director of Acute Care Services to enter into a Continuous Quality Improvement project ∗ September 2012: Initial Access and Flow committee brought together ∗ Early 2013: Emergency Department working group brought together to process map the patients journey. ∗ Data was captured around time to physician assessment
  7. 7. What Did We Find? Time From Registration to Initial Physician Assessment 2011/2012 150 100 50 0 CTAS 2 CTAS 3 Time (Minutes) CTAS 4 CTAS Guideline CTAS 5
  8. 8. Are the Admitted Patients Really The Problem? ED Activity Profile – CTAS distribution 60% 50% 40% 30% 20% 10% 0% 2009/10 CTAS 2 CTAS 3 2010/11 CTAS 4 CTAS 5 2011/12 LWBS/Unspec 84% of patients that come through PRH ED are not admitted!
  9. 9. Let’s focus! To improve the acute care patient flow through the Emergency Department while maintaining quality of care, despite competing demands and constrained resources. BY Creating a care area designed to meet the needs of the lower acuity ambulatory patients that don’t need a bed, utilizing existing physical and staffing resources
  10. 10. Streaming: Project Objective “Implement a streaming model of care delineating 4 distinct care areas that patients may be assigned to immediately following triage with the goal of improving the time from registration to Emergency Physician assessment by December 2013”
  11. 11. Streaming: How it works Initial Triage    Trauma/ Resuscitation • CTAS Level 1s and 2s Quick triage Patient demographics Brief and focused history    Patient assessment Assign triage score Assign Patient Care Area Minor Treatment Acute ED Stretchers • CTAS Level 2s and 3s • Patients that are not independently mobile • CTAS Level 4s and 5s • Lacerations • Cut fingers • Sprained ankles 11 Streaming • CTAS Level 3, 4 5 medical • Patients that are independently mobile
  12. 12. Streaming - How it Works ∗ 14 chairs and 4 exam spaces available for Streaming and Minor treatment ∗ Patients triaged to the chair area must independently mobile ∗ Patients who are too ill or too frail to sit in a chair are not appropriate for Streaming ∗ Streaming runs similar to a Physicians office or clinic ∗ Patients on stretcher only when receiving care from RN or MD ∗ Patients may walk to diagnostic imaging and back once studies have been ordered 12
  13. 13. Why Stream? ∗ More efficient use of minimal space 14 patients can be seen out of three stretcher spaces ∗ Decreased time waiting for a stretcher bay decreases wait to see the physician increasing patient satisfaction: Patients come to see the Dr. ∗ Improved time to diagnostic/treatment orders ∗ Patients are more willing to come back if condition worsens due to decreased wait time ∗ Number of people Leaving Without Being Seen decreases ∗ Mitigates the worries of leaving a sick person in the waiting room out of sight and un-assessed, increasing staff satisfaction ∗ Recruitment and retention is enhanced
  14. 14. Streaming as a care area Program Design ∗ ∗ ∗ ∗ ∗ Inclusion/exclusion criteria Physical space allocation Patient flow Staffing Model Equipment needs 14 24/02/2014
  15. 15. Creating Buy In One Month Education Blitz ∗ Mandatory one hour education sessions for all ED staff ∗ Education sessions for physicians ∗ Presentations to support services DI, Lab, Nursing Supervisors, Registration 15 24/02/2014
  16. 16. Go Live! APRIL 15th, 2013 Went live with Streaming Trial ∗ Daily Evaluations ∗ Daily communication reports and status updates ∗ Revisions, revisions, revisions!!!! Footer 16 2/24/2014
  17. 17. Challenge: Culture Shift How do we go from this…. Footer To this? 17 2/24/2014
  18. 18. Challenge: Concerns About Patient Dignity
  19. 19. Challenge: Who will change the sheets? Footer 19 2/24/2014
  20. 20. Challenge: Staffing Model ∗ Need to remove one RN on days to dedicate to streaming ∗ Team nursing model cherished ∗ How to cover breaks ∗ Staff mix Footer 20 2/24/2014
  21. 21. How Did We Do?? 140 Pre and Post Streaming Time to Physician Assessment 120 100 80 Pre Project Benchmark Post Project 60 Time saved 40 20 0 CTAS 2 Footer CTAS 3 CTAS 4 21 CTAS 5 2/24/2014
  22. 22. Wait times CTAS 2, 3, 4, 5 Pre Streaming Average wait to see the physician 65 42 Minutes Footer Post Streaming Average wait to see the physician Minutes 22 2/24/2014
  23. 23. Staff Satisfaction! ∗ “ As a PCC I don’t feel that constant worry about where I am going to put the next chest pain” ∗ “I love streaming…they’re in, they’re out, just like that!” ∗ “I can’t see how we would be functioning now if it was not for streaming.” When the team was asked recently by an administrator what they were most proud of as a team they said: STREAMING!!! Footer 23 2/24/2014

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