Six hospitals, three states, one goal: to eliminate the long-standing problem of emergency department overcrowding in hospitals.
Going with the flow
Six hospitals collaborate on ED overcrowding strategies
Thats the objective of Urgent Matters: Learning Network II, an 18-month collaborative hospital effort funded by the Robert Wood Johnson Foundation in partnership with the Agency for Healthcare Research and Quality, which is also providing additional financial support.
On May 1, the six participating hospitals will send representatives to Washington to present their strategies for improving patient flow in their busy emergency departments. The project builds on the work of the first Urgent Matters learning network, which was established in 2002 and evaluated strategies at 10 hospitals, according to Marcia Wilson, the former deputy director for that program.
The original Urgent Matters was funded by the Robert Wood Johnson Foundation and the foundation recognized that emergency department crowding was a nationwide problem, said Wilson, who is currently the assistant director for regional support at the Center for Health Care Quality at the George Washington University Medical Center in Washington. While ED visits were increasing, hospital EDs were decreasing.
As with the first program, George Washington University Medical Center will oversee and administer the program for the Robert Wood Johnson Foundation and provide technical assistance to the program participants. The six hospitals are: 431-bed Good Samaritan Hospital, West Islip, N.Y.; 536-bed Stony Brook (N.Y.) University Medical Center; 483-bed Hahnemann University Hospital, Philadelphia, a Tenet Healthcare Corp.-owned hospital; 933-bed Thomas Jefferson University Hospital, also in Philadelphia; 274-bed Excela Westmoreland Regional Hospital in Greensburg, Pa.; and 238-bed St. Francis Hospital, Indianapolis.
Since the original program, the emergency department crowding problem has worsened, according to an August 2008 report from the Centers for Disease Control and Preventions National Center for Health Statistics. From 1996 through 2006, the report said, the annual number of emergency department visits increased by 32% to 119.2 million visits from 90.3 million visits for an average increase of 3.9 million visits, or about 3.2%, each year. Meanwhile, the number of hospital emergency departments decreased 4.6% to 3,833 from 4,019 during the same period, which inflated the annual number of visits per emergency department.
In the new project, the six hospitals are required to submit data each month to George Washington University Medical Center, which, in turn, will give that information to the Health Research and Educational Trust to evaluate and analyze, said Vickie Sears, assistant director for quality improvement at the Center for Health Care Quality. HRET is the research affiliate of the American Hospital Association.
Being involved in this collaborative requires that within your institution, you have a collaborative approach, said Adhi Sharma, chairman of emergency medicine at Good Samaritan. They call Urgent Matters a collaborative, and it really is. Not only the ED, but admitting, radiology, lab, nursing.
In May, Good Samaritan will present its so-called Mid-Track plan to improve patient flow in its emergency department, which Sharma said is the busiest of Long Islands 22 hospitals, averaging about 100,000 visits each year. The hospital currently follows the Emergency Severity Index, which assigns numbers to ER patients based on their conditions. For example, patients in cardiac arrest would receive a 1, those who are extremely sick would be assigned a 2, and less-acute patients would receive a 4 or 5, both of which fall under the Fast Track category that allows patients with nonthreatening conditions to be treated and released quickly.
Good Samaritan determined the hospital needed to develop a system in which those patients receiving a 3that is, those not sick enough for the most severe categories but too sick to fall under Fast Trackcould be seen urgently. To do this, the hospital will hire a physician to work in the triage room. After the patient has been triaged as a 3 by the emergency department nurse, that patient will be seen by the physician in the hospitals ambulatory surgery unit, which is adjacent to the ED. The physician would then be responsible for that patients care.
We felt this was a model to marry the triage component and ongoing-care component, Sharma said.
At Hahnemann University Hospital, the emergency department will focus on a
strategy to improve its Fast Track time, said Mary Kay Silverman, a registered nurse who is director of emergency services. Currently, the waiting time for Fast Track patients is about four hours, and Silverman said the hospital wants it to be one to two hours. The hospital recently hired a nurse practitioner who has emergency department experience to help with this strategy, which Silverman said is going very well.
After the hospitals have implemented their strategies, the HRET will evaluate them by choosing appropriate performance measures that apply to each individual strategy, according to Kevin Van Dyke, research manager at HRET. Some, not all, of those performance measures include: the time from ED arrival to departure for admitted patients, the time from ED arrival to departure for discharged patients and the time from the decision to admit a patient until the patient leaves the ED. Funding for the evaluation process, as well as a $10,000 stipend to each hospital, comes from the AHRQ, Van Dyke said.
These practices will change performance in these hospitals and make an improvement in care and throughput, said Sears of George Washington University Medical Center. And once theyre tested, they would be strategies that other hospitals could implement, she added. These hospitals are really laboratories for change.
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