- Email: [email protected]
21 Applying Lean Methodologies Reduces Emergency Department Laboratory Turnaround Times
Research Forum Abstracts patient did not result in the experienced learner reporting a damaging psychological effect; 3) learners who experience a poor outcome with their simulated patient may feel better prepared long-term to manage a similar patients. While these conclusions are not meant to suggest that having every simulated patient die is appropriate, they endorse death in simulation as one valuable tool in the simulation educator’s armament.
21
Applying Lean Methodologies Reduces Emergency Department Laboratory Turnaround Times
White BA, Baron J, Chang Y, Camargo CA, Jr., Brown DFM/Massachusetts General Hospital, Boston, MA
Background: While emergency department (ED) crowding has myriad causes and negative downstream effects, the application of systems engineering science and targeting throughput remains a potential solution to increase functional capacity. The most effective techniques for broad application in the ED remain unclear. Objective: We examined the hypothesis that Lean-based reorganization of Laboratory process flow would improve laboratory turnaround times, specifically median sample collect to result turnaround times (TAT). Methods: This study is a prospective, before/after analysis of laboratory process improvements in a Level 1 tertiary care academic medical center ED with >100,000 annual patients visits. All adult patients seen during the study periods of 9/2012-3/ 2013 and 3/2013-9/2013 were included, and data were collected from a computerized tracking system. The intervention included a reorganization of laboratory sample flow based in systems engineering science and modeling and Lean methodologies, with associated reallocation of resources. No resources were added. The primary outcome was the median TAT from sample collection to result reported for tests previously performed in an ED kiosk. Median TATs were compared using Wilcoxon rank sum tests. Results: Following the intervention, median laboratory TAT decreased across all tests. The greatest decreases were found in reflex tests performed after an initial screening test; troponin T TAT was reduced by 33 minutes (86 to 53 minutes, 95% CI 30-36 minutes) and urine sedimentation TAT by 88 minutes (117 to 29 minutes, 95% CI 86-89 minutes). In addition, troponin I TAT was reduced by 12 minutes (41 to 29 minutes, 95% CI 11-13 minutes), urinalysis TAT by 10 minutes (29 to 19 minutes, 95% CI 9-11 minutes), and urine HCG TAT by 10 minutes (28 to 18 minutes, 95% CI 9-11 minutes). Conclusion: In this single-center intervention, simple reorganization of laboratory process flow reduced laboratory TATs for ED patients. Broad, multi-centered application of systems engineering science might further improve ancillary testing efficiency, and overall ED throughput and capacity.
Results Total Patient Volume Troponin T Quant Urine Sediment Troponin I Screen Urinalysis Urine HCG
9/12-3/13
3/13-9/13
25,538 86 (71-106) 117 (89-153) 41 (29-58) 29 (17-49) 28 (18-46)
26,495 53 (46-65) 29 (21-40) 29 (24-36) 19 (14-28) 18 (13-25)
TAT reduction, min (95% CI) 33 88 12 10 10
(30-36) (86-89) (11-13) (9-11) (9-11)
P value <0.001 <0.001 <0.001 <0.001 <0.001
min, minutes; TAT, turnaround time.
22
Making it Work: Correlating Nursing Perception of Physician Productivity to Physician Interpersonal Skills and Actual Productivity
Krzyzaniak S, Dschaak TG, Frederick R, Hafner J, Wang H/OSF-Saint Francis Medical Center, East Peoria, IL; University of Illinois College of Medicine-Peoria, Peoria, IL
Study Objectives: Emergency physicians are required to evaluate and treat acute and complex patients with both skill and efficiency. The importance of teamwork in the busy and unpredictable emergency department (ED) setting has been described
Volume 64, no. 4s : October 2014
23
Effect of a Multi-Diagnosis Diagnostic Treatment Unit on Emergency Department Length of Stay and Inpatient Admissions at Two Canadian Hospitals
Cheng AHY, Barclay NG, Abu-Laban RB/St. Michael’s Hospital, Toronto, ON, Canada; Royal Columbian Hospital, New Westminster, BC, Canada; Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
Table. Median Collect to Result, min (IQR)
previously and various methods have been used to assess non-technical physician skills, such as communication and patient throughput. The purpose of this study is to examine how reliably ED nurses perceive EP efficiency and if there is a correlation between overall physician interpersonal skills and perceived/actual physician clinical productivity. Methods: Emergency nurses at an urban academic tertiary care ED (>85,000 annual visits) were asked to complete an anonymous survey of 34 full and part time attending emergency physicians as part of a 360 feedback evaluation. Surveys were administered using an electronic Internet survey instrument (www.SurveyMonkey. com) and utilized a 1-5 Likert scale (1 low, 5 high) to evaluate the perceived physician clinical productivity as well as interpersonal skills (teamwork, attitude, approachability, and communication). For this study, each physician’s averaged perceived clinical productivity was correlated with the physician’s averaged number of patients evaluated per total hours worked (actual emergency physician clinical productivity), for the same period captured in the survey (2013). Perceived emergency physician clinical productivity and interpersonal skill scores were compared to actual clinical productivity using Spearman’s correlation. Results were further stratified by age, sex, and experience (number of years as an attending). Results: A total of 1,576 responses were received for 34 emergency physicians (28-65 responses per physician). Experience as an emergency physician was stratified into <5 years of experience (n¼12), 5-10 years (n¼3), 10-20 years (n¼9), and >20 years (n¼10). Physician age was stratified as 30-40 years old (n¼16), 40-50 years (n¼6), 50-60 years (n¼10), and >60 years (n¼2). No statistically significant correlation was noted between perceived emergency physician clinical productivity and actual emergency physician clinical productivity (r¼0.27; P>0.12). However, significant correlations occurred between perceived emergency physician clinical productivity and interpersonal skills: communication (r¼0.87; P<0.01), teamwork skills (r ¼ 0.85; P<0.01), approachability (r ¼ 0.77; P<0.01), and overall attitude (r¼0.80; P<0.01). No changes in correlations between perceived and actual clinical emergency physician productivity were noted when groups were stratified by age, sex, and years of clinical experience. Conclusions: Nursing opinion regarding emergency physician clinical productivity does not correlate with actual emergency physician clinical productivity. However, nurses’ perception of emergency physician productivity correlates with other reported emergency physician interpersonal skill measures and does not vary by sex, age, or experience. These results suggest that a better relationship between nurses and physicians leads to perceived increased physician productivity. Further work may be done to explore the impact of this finding on teamwork in the ED and patient care. Limitations include varying survey numbers for each physician, various ages and work experience of each physician, and possible selection or sampling bias.
Study Objectives: Emergency department (ED) crowding is a worldwide problem. Diagnostic Treatment Units (DTUs) are designated areas that manage patients requiring additional observation and/or testing. Single diagnosis DTUs, such as chest pain units, may reduce ED crowding, as they have been shown to reduce both ED length of stay (LOS) and hospital admissions. However, the effect of DTUs that manage patients with multiple diagnoses remains undetermined. Our objective was to assess the effects of a DTU that uses standardized protocols to manage patients with various presenting complaints on the median ED LOS and hospital admission rates at two EDs in British Columbia, Canada. Methods: This was a pre/post study that utilized a prospectively collected administrative database. The DTUs consisted of designated stretchers within the existing EDs at two sites: a tertiary care trauma center with 67,000 annual ED visits and a community hospital with 62,000 annual ED visits. Patients were admitted to the DTU by attending emergency physicians using pre-defined criteria. Once admitted, DTU patients were cared for by the attending emergency physicians and designated DTU nurses using one of 14 standardized treatment algorithms based on the presenting complaint. The DTU protocol mandated that patients were either discharged directly from the DTU or admitted to an in-patient unit within 24 hours of DTU admission. The median ED LOS and rates of in-patient admissions were measured for all ED patients. The pre-DTU cohort included all consecutive adult emergency patients (> 17 years of age) who presented to the study sites between October 11, 2011 and April 10, 2012 at the tertiary site and September 29, 2011 and March 28, 2012 at the
Annals of Emergency Medicine S9
21
Applying Lean Methodologies Reduces Emergency Department Laboratory Turnaround Times
White BA, Baron J, Chang Y, Camargo CA, Jr., Brown DFM/Massachusetts General Hospital, Boston, MA
Background: While emergency department (ED) crowding has myriad causes and negative downstream effects, the application of systems engineering science and targeting throughput remains a potential solution to increase functional capacity. The most effective techniques for broad application in the ED remain unclear. Objective: We examined the hypothesis that Lean-based reorganization of Laboratory process flow would improve laboratory turnaround times, specifically median sample collect to result turnaround times (TAT). Methods: This study is a prospective, before/after analysis of laboratory process improvements in a Level 1 tertiary care academic medical center ED with >100,000 annual patients visits. All adult patients seen during the study periods of 9/2012-3/ 2013 and 3/2013-9/2013 were included, and data were collected from a computerized tracking system. The intervention included a reorganization of laboratory sample flow based in systems engineering science and modeling and Lean methodologies, with associated reallocation of resources. No resources were added. The primary outcome was the median TAT from sample collection to result reported for tests previously performed in an ED kiosk. Median TATs were compared using Wilcoxon rank sum tests. Results: Following the intervention, median laboratory TAT decreased across all tests. The greatest decreases were found in reflex tests performed after an initial screening test; troponin T TAT was reduced by 33 minutes (86 to 53 minutes, 95% CI 30-36 minutes) and urine sedimentation TAT by 88 minutes (117 to 29 minutes, 95% CI 86-89 minutes). In addition, troponin I TAT was reduced by 12 minutes (41 to 29 minutes, 95% CI 11-13 minutes), urinalysis TAT by 10 minutes (29 to 19 minutes, 95% CI 9-11 minutes), and urine HCG TAT by 10 minutes (28 to 18 minutes, 95% CI 9-11 minutes). Conclusion: In this single-center intervention, simple reorganization of laboratory process flow reduced laboratory TATs for ED patients. Broad, multi-centered application of systems engineering science might further improve ancillary testing efficiency, and overall ED throughput and capacity.
Results Total Patient Volume Troponin T Quant Urine Sediment Troponin I Screen Urinalysis Urine HCG
9/12-3/13
3/13-9/13
25,538 86 (71-106) 117 (89-153) 41 (29-58) 29 (17-49) 28 (18-46)
26,495 53 (46-65) 29 (21-40) 29 (24-36) 19 (14-28) 18 (13-25)
TAT reduction, min (95% CI) 33 88 12 10 10
(30-36) (86-89) (11-13) (9-11) (9-11)
P value <0.001 <0.001 <0.001 <0.001 <0.001
min, minutes; TAT, turnaround time.
22
Making it Work: Correlating Nursing Perception of Physician Productivity to Physician Interpersonal Skills and Actual Productivity
Krzyzaniak S, Dschaak TG, Frederick R, Hafner J, Wang H/OSF-Saint Francis Medical Center, East Peoria, IL; University of Illinois College of Medicine-Peoria, Peoria, IL
Study Objectives: Emergency physicians are required to evaluate and treat acute and complex patients with both skill and efficiency. The importance of teamwork in the busy and unpredictable emergency department (ED) setting has been described
Volume 64, no. 4s : October 2014
23
Effect of a Multi-Diagnosis Diagnostic Treatment Unit on Emergency Department Length of Stay and Inpatient Admissions at Two Canadian Hospitals
Cheng AHY, Barclay NG, Abu-Laban RB/St. Michael’s Hospital, Toronto, ON, Canada; Royal Columbian Hospital, New Westminster, BC, Canada; Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
Table. Median Collect to Result, min (IQR)
previously and various methods have been used to assess non-technical physician skills, such as communication and patient throughput. The purpose of this study is to examine how reliably ED nurses perceive EP efficiency and if there is a correlation between overall physician interpersonal skills and perceived/actual physician clinical productivity. Methods: Emergency nurses at an urban academic tertiary care ED (>85,000 annual visits) were asked to complete an anonymous survey of 34 full and part time attending emergency physicians as part of a 360 feedback evaluation. Surveys were administered using an electronic Internet survey instrument (www.SurveyMonkey. com) and utilized a 1-5 Likert scale (1 low, 5 high) to evaluate the perceived physician clinical productivity as well as interpersonal skills (teamwork, attitude, approachability, and communication). For this study, each physician’s averaged perceived clinical productivity was correlated with the physician’s averaged number of patients evaluated per total hours worked (actual emergency physician clinical productivity), for the same period captured in the survey (2013). Perceived emergency physician clinical productivity and interpersonal skill scores were compared to actual clinical productivity using Spearman’s correlation. Results were further stratified by age, sex, and experience (number of years as an attending). Results: A total of 1,576 responses were received for 34 emergency physicians (28-65 responses per physician). Experience as an emergency physician was stratified into <5 years of experience (n¼12), 5-10 years (n¼3), 10-20 years (n¼9), and >20 years (n¼10). Physician age was stratified as 30-40 years old (n¼16), 40-50 years (n¼6), 50-60 years (n¼10), and >60 years (n¼2). No statistically significant correlation was noted between perceived emergency physician clinical productivity and actual emergency physician clinical productivity (r¼0.27; P>0.12). However, significant correlations occurred between perceived emergency physician clinical productivity and interpersonal skills: communication (r¼0.87; P<0.01), teamwork skills (r ¼ 0.85; P<0.01), approachability (r ¼ 0.77; P<0.01), and overall attitude (r¼0.80; P<0.01). No changes in correlations between perceived and actual clinical emergency physician productivity were noted when groups were stratified by age, sex, and years of clinical experience. Conclusions: Nursing opinion regarding emergency physician clinical productivity does not correlate with actual emergency physician clinical productivity. However, nurses’ perception of emergency physician productivity correlates with other reported emergency physician interpersonal skill measures and does not vary by sex, age, or experience. These results suggest that a better relationship between nurses and physicians leads to perceived increased physician productivity. Further work may be done to explore the impact of this finding on teamwork in the ED and patient care. Limitations include varying survey numbers for each physician, various ages and work experience of each physician, and possible selection or sampling bias.
Study Objectives: Emergency department (ED) crowding is a worldwide problem. Diagnostic Treatment Units (DTUs) are designated areas that manage patients requiring additional observation and/or testing. Single diagnosis DTUs, such as chest pain units, may reduce ED crowding, as they have been shown to reduce both ED length of stay (LOS) and hospital admissions. However, the effect of DTUs that manage patients with multiple diagnoses remains undetermined. Our objective was to assess the effects of a DTU that uses standardized protocols to manage patients with various presenting complaints on the median ED LOS and hospital admission rates at two EDs in British Columbia, Canada. Methods: This was a pre/post study that utilized a prospectively collected administrative database. The DTUs consisted of designated stretchers within the existing EDs at two sites: a tertiary care trauma center with 67,000 annual ED visits and a community hospital with 62,000 annual ED visits. Patients were admitted to the DTU by attending emergency physicians using pre-defined criteria. Once admitted, DTU patients were cared for by the attending emergency physicians and designated DTU nurses using one of 14 standardized treatment algorithms based on the presenting complaint. The DTU protocol mandated that patients were either discharged directly from the DTU or admitted to an in-patient unit within 24 hours of DTU admission. The median ED LOS and rates of in-patient admissions were measured for all ED patients. The pre-DTU cohort included all consecutive adult emergency patients (> 17 years of age) who presented to the study sites between October 11, 2011 and April 10, 2012 at the tertiary site and September 29, 2011 and March 28, 2012 at the
Annals of Emergency Medicine S9