SUPERTRACK SWARM TAMPA GENERAL HOSPITAL

Publication Year: 2014

SUPERTRACK SWARM TAMPA GENERAL HOSPITAL

SUMMARY: Design and implementation of a split flow ED with a mid-track, including leadership "swarm" meeting for rapid improvement and sustainability.

SUBMISSION CATEGORY: Flow and Efficiency

HOSPITAL: Tampa General Hospital

LOCATION: Tampa, FL

CONTACT: Melissa D. Cole MSN, ARNP, ANP-BC Director of Emergency & Trauma Services, mcole@

CATEGORY: A: Arrival C: Clinician Initial Evaluation & Throughput

KEY WORDS:

Door-to-Doc ESI Fast Track Lean Left-

Without-

Being-Seen Queuing Rapid Intake

Registration Triage Wait Times

HOSPITAL METRICS: Annual ED Volume: 85,000 Hospital Beds: 1018 Ownership: Private, Not-For-Profit Trauma Level: 1 Teaching Status: Yes, Primary Affiliate USF

College of Medicine

TOOLS PROVIDED:

Prescriptive Plan Flow Progress ED Punch List Results and Images

CLINICAL AREAS AFFECTED: Ancillary Departments ED EMS Environmental Services Inpatient Units Laboratory Radiology Registration Triage

Copyright ? 2002-2014 Urgent Matters

STAFF INVOLVED:

Administrators Ancillary

Departments Case Management Clerks Clinic Registration

ED staff IT staff Nurses Pharmacists

physicians Registration

Staff Technicians

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Innovation To address long arrival to provider times and high-left-without-being-seen rates we developed a split flow emergency department. As part of this split flow model, separating vertical patients from horizontal patients, we created a combined low acuity/mid-track area which we called "Supertrack" for vertical patients. We converted our 4 triage rooms into patient exam spaces and converted a specified portion of the waiting room into a results pending lounge. Additionally, we converted a dedicated area of 10 private rooms, into a flexible treatment space for those vertical patients who needed to be temporarily horizontal, for procedures or other needs. We utilized projected arrival patterns to flexibly staff this area using attending physicians, advanced practice clinicians, residents and scribes. We built a real time data dashboard in our EMR to help charge nurses and managers better identify and respond to flow challenges rapidly.

Background Patients presenting to our ED suffered from long wait times and they frequently left prior to seeing a health care provider. We had tried using LEAN methodology and split flow solutions in the past but with only moderate improvement and frequently suffered from a lack of sustainability. The process we designed works by reducing triage times while still accurately placing patients into the correct track. The Supertrack area was able to reduce waiting times for all patients by effectively utilizing virtual capacity for vertical patients. Previous change attempts had been derailed by too much variability in flow decisions; in order to combat this we created a prescriptive guideline to provide parameters for our nurses and physicians to make smart and reliable decisions. We selected this solution because it allowed for maximum flexibility in patient movement and creation of virtual capacity. Triage was a process that took nearly 15 minutes; we truncated the process and focused on obtaining information relevant to appropriate placement of the patient.

Innovation Implementation Triage is now a sorting process that consists of 5 questions taking approximately 3 minutes which we call pivot. While we continued to use traditional ESI levels we split level 3 patients into vertical and horizontal calling them "3V" and "3H". We also made some minor modifications to our existing triage rooms placing slim computers for nursing as well as exam tables in order to use them as patient evaluation rooms. Additionally, we purchased new recliners to convert a part of our waiting room into a results pending lounge. SuperTrack sees ESI level 5,4 and "3V" patients, while the main ED sees ESI levels "3H",2 and 1. The Supertrack process involved simultaneous evaluation by nurse and provider of a patient in their single exam room. We implemented the use of scribes in Supertrack to allow for improved concurrent assessments. The provider writes orders while a scribe documents the note. The nurse completes their documentation and the patient transitions out of the room to the next phase of their care. We created a dedicated space for phlebotomy, a 10 bed procedure area, and an area to complete registration. By limiting the patient's time in the evaluation room the next patient could be evaluated in that space sooner. After initial testing, the patient is moved to the result pending recliners to await results or for further testing. As much as possible IV utilization was limited in favor of oral and IM medications. Once results were back the patient was returned to the exam room for reevaluation and disposition. We reserved 10 private rooms in one ED pod for patients who required procedures, privacy or brief monitoring so as to keep the front rooms free. There were multiple providers utilizing these 4 exam rooms with a maximum of 5 providers at peak hours. We changed our staffing matrix for physicians and nurses to better align with arrival patterns and stressed direct bedding. By caring for vertical patients in Supertrack rather than in a bed we created more bed spaces for the horizontal patients who required them.

Our leadership team for the ED process consisted of a medical director, associate medical director, nursing director, and nurse manager in addition to 7 nurse clinicians to cover charge responsibilities for each shift. The leadership team was especially visible throughout the first 6 weeks of implementation to answer questions and trouble-shoot the new process with staff.

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We began planning for the change in July of 2013 to create/improve data reports in anticipation of a large 2 day Comprehensive Process Redesign meeting in September. That meeting was focused on redesigning the process and had representatives, both leadership and frontline staff, from all stakeholders present. At the conclusion of that meeting we had a sketch of what the plan would look like and began to hold weekly flow meetings with frontline staff to create a prescriptive guideline for flow in the emergency department including the new split flow Supertrack area. We spent time with the newly built reports and data to arrange staffing models to staff both the super track area and acute ED based on patient arrival times. We conducted two Supertrack tests on one day at peak times in late October as a proof of concept for the improvement. We continued to meet weekly with the process improvement team and went live on December 3rd 2013. After going live, we began a daily rapid leadership meeting (ED executive swarm) which included hospital and physician executive leaders from multiple involved disciplines to actively trouble shoot issues. These disciplines included supply management, information technology, facilities, housekeeping, and transport. The meetings were no more than 30 minutes in length. The previous day's performance was reviewed for underlying causes potential solutions. As we moved away from go-live we continued these swarms but moving to twice weekly and then weekly times. We also continued the weekly flow meeting with frontline staff to modify the prescriptive guideline and ensure accountability from all team members.

In order to implement the change the resources were minimal. The resources included 20 recliners, 2 phlebotomy chairs, 4 exam tables, 8 computers and minimal construction of the triage space. Staffing was essentially reallocated and not added. In order to sustain the updated workflow, construction was recommended and started to optimize patient flow.

ARRIVAL TO PROVIDER TIME

90 80 70 62.62 60 50 40 35.07

78.89

56 46.66 42.5

68.9 51.06

30

20

10

0 December January February March

80.73 53.83

April

58.95 36.82

May

45.62 34.14

June

Median arrival to provider time after change (min)

Median arrival to provider time before change (min)

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DISCHARGE PATIENT TOTAL LENGTH OF STAY

400

350 310

300 250 240

348 251

322 263

343 276

200

150

100

50

0 December January February March

354 280

April

320 255

May

301 254

June

Median total length of stay for discharged adult patients after change (min)

Median total length of stay for discharged adult patients before change (min)

Timeline Medical Director hired February 2013 Nursing Director hired June 2013 Report building and data verification started in June 2013 and completed by October 2013 Preparation meeting for Comprehensive Process Redesign (CPR) workshop began in July 2013 Provider in triage trial started in July with modification in August 2013 CPR workshop September 2013 that included multiple disciplines and front line staff Weekly flow meetings began October 2013 to implement the action plan for preparation of go-live New work flow trial November 2013 Triage room construction end of November 2013 Staff and provider education the last weeks of November Go live of new front end process December 3, 2013 Daily swarms with executive leaders began December 7, 2013 Weekly flow meeting continue to present time

Cost/Benefit Analysis The cost of the new flow design was minimal. There were some costs to convert the existing triage rooms and some IT equipment which was approximately $10,000. There was no increase in nurse staffing matrix as part of the plan, we simply redistributed resources. Scribes were introduced at a cost of approximately $175,000 for the year. There was an increase in provider hours, both physicians and advanced practice clinicians which was offset by increase in arrival volume. In fact there was a slight increase in adjusted patients per hour but within expected parameters of productivity. The reduction in left without treatment yielded a significant financial benefit estimated at $1.4 million annually.

Advice and Lessons Learned Managing the change with staff and providers proved to be the most challenging aspect of this undertaking. While much of it was handled well, in hindsight there are things that we would have done differently. When we implemented the change, we excused the pediatric section of the ED out of the overall design, as the focus was the adult emergency department. We did include them in the education but underestimated the impact the change would have on their

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model. The pediatric staff felt as though they were ignored and had staffing changes related to the updated flow model. Additionally, we did not include radiology in much of the conversation and found that the new model affected the times and way the radiology department processed patients. In spite of education tying our metric goals to real patient care we underestimated front line staff resistance to feeling as though we only focused on the numbers. As we realized this we altered the content and structure of some of our communications, linking metrics such as arrival to provider to patients and focusing more on some non-metric based outcomes as well.

As mentioned, the flow model consists of separating the "not so sick" from the "very sick" which increased the acuity level in the main ED pods. Although this was a known, we underestimated how challenging the higher acuity pods became to manage. We had a 20% nurse vacancy rate at go-live which exacerbated the stress felt with the changes. It would have been great to wait for staffing to improve but our patients could not wait for us. The strength of the physician and nurse dyad was crucial during this change. Additionally, the support of the executive leadership was essential at times to push the team through difficult stretches.

Sustainability three phases of the throughput project. Since the go-live in December, the ED has partnered with laboratory, radiology, and the admitting units to enhance the efficiency of patient flow. In order to continue to drive success the following continue to occur:

The executive leadership members continue to huddle or "swarm" regularly in the department to continue to problem solve issues.

The weekly flow meetings with staff and leadership with updates to the prescriptive guidelines as needed. These meeting also, at times, include updates from our partners in other departments.

Daily Metric emails to the leadership team Began an executive steering committee meeting where the leaders from the ED, laboratory, radiology,

transport, environmental services, information technology, and the admitting units come together monthly to report progress Nursing and Medical Director with frequent rounding in the department. Frequent joint updates from Nursing and Medical Director regarding improvements and progression of metrics toward goals Celebrate when we achieve the goals that were set from the beginning. We have had a one month gift card for all the staff and ancillary department. Most recently, we are celebrating our six month's achievements with a carnival celebration.

Tools to Download Prescriptive Plan Flow Progress ED Punch List Results and Images

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Prescription for Tampa General Hospital's New ED

Pivot Process ? Splitting the Flow

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I.

Rapid Assessment and assign ESI

a. 6 Items

i. Chief Complaint

ii. Allergies

iii. Immunosuppression

iv. Vitals Signs

v. Primary triage assessment (Airway; Breathing; Circulation; Disability)

vi. Assign ESI level (include v3 and h3)

b. Indication & Communication of next location via ESI level in EPIC

c. Vertical to SuperTrack V3,4,5 Some Chest pain to the front if low risk by pivot

d. Horizontal to back 1,2,H3 DIRECT BED THESE PATIENT WHEN ABLE

e. Please note attached considerations/guidelines for care areas

f. Patients should be directed to appropriate area of the lobby only if the need to wait to

be seen (SuperTrack Lobby or Acute Care Lobby)

g. Pediatric patients will also be sorted at the pivot desk and the pediatrics area will pull

pediatric patients to their care area. See Pediatric Patient section

h. PIVOT NURSE may have patients seen quicker by expressing a desire in the comments

section for patients to be seen in a particular order.

i. Registration should be continuous. No intentional slowing down to wait for PIVOT

NURSE.

j. All Adult and Pediatric Patients shall have the questions asked (be pivoted) up front and all ages

shall have a temperature taken.

II. What to do if pivot is backed up? a. Second area is located behind glass i. Activate second area for pivot if there are more than 4 patients waiting for pivot ii. Use the Flow Nurse as second pivot nurse b. "Protect the Quarterback" ? pivot nurse is the quarterback i. Patients should sorted from visitors and visitors should be kept away from pivot desk ii. Patients waiting for pivot should be directed to the appropriate seating area c. On occasions SuperTrack exam rooms may be filled ahead of pivot can pull clear low acuity visits to exam room and skip pivot

III. EMS Arrivals: Same Process 2 locations a. Pivot triage of EMS traffic done by the Charge nurse i. Same information collected and documented as listed above in part I. ii. Patients arriving by EMS may also go through SuperTrack

* Patients Requiring Procedural Sedation Should Not Be Placed in Pod 2

Prescription for Tampa General Hospital's New ED

Page 2 of 14 12/2/13

IV. Patient identified as needing immediate intervention a. Examples include but not limited to: acute stroke, unstable vital signs, respiratory distress, under 30 days old with fever. b. The pivot nurse will vocera overhead or appropriate unit to notify staff that there is a critical patient being brought to an acute care bed c. The pivot nurse or tech will bring the patient back to the appropriate acute care space

SuperTrack ? Swarm to one of 5 decisions

I.

Nurse, Provider and Scribe (when available) see patients as much as possible as a team

utilizing on room at the front (triage room) as their exam room

II. One nurse/provider team will be team lead 7am shift start and 5pm attending start

a. Nurse or Provider may pull next patient into their exam room

i. Focus on the patients that are "pivoted" to SuperTrack (Vertical Patients)

ii. Horizontal patients to be seen/care initiated if no Vertical patients are waiting

1. more details in load balancing

iii. Call patients from lobby by their last name

iv. LOCK AND LOAD: PCT's in the LOBBY/WAITING ROOM will place patients in

chairs located outside the active Triage/Exam Rooms. That patient will be "on-

deck" and may then be pulled into the room by the provider/nurse team

quicker.

b. Team will enter the room together as much as possible and obtain the history and

perform necessary physical exam including GU exams as required

c. Computer Use

i. Wall mount ? Nurse (Exam 4 nurse will also utilize rover no wall mount)

ii. Full size rover ? Provider

iii. Laptop on wheels ? Scribe

d. Provider will enter orders; scribe documents medical record; nurse documents

e. The provider will make a choice for 1 of 5 destinations for the patient

More details of the process for each of these 5 groups follow (sections III-VII)

i. Home ? no testing required patient can be discharged

1. Essential to be sure they are registered before leaving ED

ii. Results pending area in the lobby

iii. Pod-2

1. Patients going to the Results pending lobby or Pod 2 will continue to be

cared for by the original provider

iv. Acute care ED (Pods 3-5)

1. This is an opportunity for secondary triage not for second guessing!

PLEASE REMEMBER THAT THE PIVOT NURSE MADE THE BEST DECISION

WITH THE INFORMATION AVAILABLE

2. These patients must be moved to the acute care area as a priority

options for beds must include trauma, halls, moving other patients to

* Patients Requiring Procedural Sedation Should Not Be Placed in Pod 2

Prescription for Tampa General Hospital's New ED

Page 3 of 14 12/2/13

hall spaces. The flow/charge nurse should make these placements. SuperTrack nurse will flag in EPIC by changing ESI. v. Admit from SuperTrack

III. Destination Home a. Documentation completed by scribe; attested and signed by Provider b. Provider enters disposition Rx and AVS (D/C instructions) c. Rx and AVS printed provided to patient d. Nursing finishes documentation to include medications e. Nurse completes disposition documentation and charges making sure that registration is completed f. Patient is provided with Rx (if not e-prescribed) & IF NOT REGISTERED YET ESCORTED TO REGISTRATION OFFICE TO COMPLETE REGISTRATION

IV. Destination Lobby Results Waiting a. Orders entered by provider i. Try to limit IV orders when straight stick lab draw is appropriate ii. If blood is ordered patient will be moved to a chair just behind sub-triage along wall between Pod-2 and Pod-3 to have blood drawn by PCT 1. Specimens labeled and sent to Lab 2. POC labs completed including obtaining urine iii. Radiology 1. Patient will be located by radiology in the lobby results pending area and brought for imaging 2. Patient may drink PO contrast in the lobby results pending area 3. Radiology process for a. Dressing/undressing b. MRI screening c. Call backs for + results b. Patient will be given a sticker before being returning to the lobby to indicate that they are a patient who has been seen by a provider. c. SuperTrack exam rooms 1-4 are denoted 2000T1, 2000T2, 2000T3, 2000T4 respectively.

Team using exam room 1 should use SuperTrack results pending areas 2001W1-2001W9 Team using exam room 2 should use SuperTrack results pending areas 2002W1-2002W9 Team using exam room 3 should use SuperTrack results pending areas 2003W1-2003W9 Team using exam room 4 should use SuperTrack results pending areas 2004W1-2004W9

d. Each of the groups of chairs corresponding to an exam room will have a color assigned i. Exam room 1 team ? Red ii. Exam room 2 team ? Blue

* Patients Requiring Procedural Sedation Should Not Be Placed in Pod 2

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