Clinical Safety & Effectiveness
Session # 11
Emergency Center Observation Unit
10.15.09
DATE
Project Team
• Patrick Chaftari, MD
Assistant Professor , GIM, AT & EC
• Jean H Tayar, MD
Assistant Professor, GIM, AT & EC
• Ashutosh Gupta
Clinical Business Manager, EC
Project Sponsor:
• Richard A. Ivey
Quality Engineer, Office of Performance
Improvement
• Cindy Segal
Clinical Quality Improvement Consultant,
Office of Performance Improvement
• Cylette R. Willis, PhD
Associate Director, Quality Education and
Evaluation, Office of Performance
Improvement
Carmen E. Gonzalez, MD
Associate Professor, GIM, AT and EC
Section Chief, EC
Improving Patient Care in the EC
EC Situation
• National benchmark ER Length of Stay (LOS) is 4 hours
• MDACC EC LOS averages 9.5 hours (up to 24 hrs )
• Current situation affects patient care and safety
Can We Improve This Picture?
• Patient safety
• Patient care
• Patient satisfaction
• Bed utilization
Pts Treated while in The EC (No Inpt Admission)
Patients Treated While in EC (No Admission)
16-20 Hrs,
N=642
6%
11-15 Hrs,
N=1,328
12%
20+ Hrs,
N= 675
6%
00-05 Hrs,
N=4,734
42%
06-10 Hrs,
N=3,879
34%
Prepared by:
Linda DeFord OPI Clinical Informatics
Data Source: EC Tracking Data
% of Visits by Hours in EC from Lobby Sign-In to Leave Time
April 1, 2008 to March 31, 2009
1 year Data
Snapshot of Patients Discharged from EC
After a LOS > 16 hrs
(14) 12%
(27) 23%
(74) 62%
16-20 Hrs
N=642
(March 2009, 119 pts)
6%
20+ Hrs
N= 675
One year data
6%
EC Patient Process
OBS Unit  Better Care
• Opportunity to improve patient safety and patient care
• Literature review: Placement on OBS will improve quality of care and
revenue
 Improve disposition→ clinical outcome→ decrease liability
 Decrease patient and caregiver frustrations
 Free up EC bed →Decrease some of the EC congestion →Shortens
LOS
 Decrease cost by efficient usage of EC and inpatient bed
 Avoid unnecessary admissions and decrease un-reimbursed
readmissions
Observation Unit
• Observation unit could be
→ a safe
→ effective
→ cost-saving
way of ensuring that patients who are considered to
be intermediate category receives appropriate care.
10
Project
AIM Statement
The aim of this project is to increase the percentage of EC patients placed on
Observation by 50% from the baseline of 1.95% to 2.93% during the pilot
period, July 1 - July 22, 2009.
• Baseline period: May 2008 - April 2009
• Process begins when provider evaluates patient in EC and
ends when provider places patient on Observation
• Value to the organization – improve patient care and safety,
potential financial advantage
How Will We Know
That a Change is an Improvement?
Outcome measure:
Percentage of EC patients placed on
Observation
Data collection:
Whiteboard activity report
Technical charges
Specific target:
2.93%
Project Milestones
• Team created
April 2009
• AIM statement created
April 2009
• Weekly team meetings
May - August
• Planning
April - June
• Interventions implemented
July 1 – 22
• Presentation
August 7
Fishbone Diagram
Physicians
Don’t think about it
Lack of education
Do not understand billing
Guidelines for
disposition decision
Lack criteria to place on
Observation
Nurses
Training
Clerks
Training
Staffing
Paperwork
Do not check observation
box on charge sheet
Do not notify clerks that
patient placed on
Observation
Data entry
Confirm access to
CARE system
LOW NUMBER
OF PATIENTS
PLACED ON
OBSERVATION
Unclear processes
Whiteboard does not visually
identify current Observation patients
Order sets
Identifying Observation patients
Tracking LOS
countdown
Tracking patient progression
Lack of space
Budget to staff
space
Physician hand-off
Appropriate forms
Technology
Processes
Facilities
PLAN: The Intervention
•
•
•
•
•
•
Plan project
Develop presentation materials for providers
Design new EC physician order set and forms
Start general guidelines for placing patients on Observation
Gain leadership buy-in
Raise awareness of OBS availability
Observation Placement Form
Placeholder for Obs form
and/or physician order set
visual
DO: Implement the Changes
April – June:
July 1:
July 1 – 22:
July 1
Conduct
kickoff
Place poster
in EC
July 2
Implement
order sets
Build awareness (soft implementation)
Implement interventions
Measure outcomes
July 3
July 4
July 5
July 6
July 7
Post order
sets online
July 8
EC Observation start date: July 1st,09
Upon completion of the patient’s work-up
Patient is not ready to
be discharged home
Patient do not meet
admission criteria
And you expect
improvement within the
next 23h to the point
where the patient could
be discharged home
Consider
Observation
placement
Implementation Issues
• Stakeholder identification was incomplete (Clinical
Effectiveness)
→ Delay in posting physician order set
•Implementation period was too short to address EC
meeting schedule, introduce language and new forms
• Non-EC faculty working in the EC not familiar with the
process
Results
21
CHECK: Results and Impact
Baseline
(May 1, 2008 – April 30, 2009)
Project Intervention
Period (July 2009)
1.95 %
5.20 %
391
87
20086
1674
OBS Patients
Total Number of
patients
Test of proportions p-value < 0.001
Percent of Patients Placed on Observation of the Total EC Visits (Monthly)
May-08
Percent of Patients Placed on Obs (%)
9.0%
Apr-09
UC L=8.3%
8.0%
7.0%
6.0%
_
X=4.6%
5.0%
4.0%
3.0%
2.0%
1.0%
LCL=0.8%
0.0%
ay
M
08
8
8
8
8
8
8
8
9
9
9
9
9
9
9
-0
-0
-0
-0
-0
-0
-0
-0
-0
-0
-0
-0
l-0
l-0
t
c
r
r
n
g
p
v
n
b
y
n
u
u
c
a
J
J
Ju
Se
O
De
Ja
Fe
Ma
Ap
Ju
Au
No
M
Before/After Intervention Test of Means, p-value = 0.004
Source: EC Whiteboard
Prepared By: Ash Gupta & Richard Ivey
Month
Percent of Patients Placed on Observation of the Total EC Visits (Daily)
Percent of Patient Placed on Obs
0.18
9-Jun
1-Jul
0.16
UC L=0.1435
0.14
0.12
1
0.10
0.08
_
P=0.0534
0.06
0.04
0.02
0.00
n
n
n
n
n
n
n
n
Ju
Ju
Ju
Ju
Ju
Ju
Ju
Ju
9
12
15
18
21
24
27
30
Before/After Intervention Test of Means, p-value = 0.002
Tests performed w ith unequal sample sizes
Source: EC Whiteboard
Prepared By: Ash Gupta & Richard Ivey
LB=0
J
3-
ul
Day
l
Ju
6
l
l
l
l
l
Ju
Ju
Ju
Ju
Ju
9
12
15
18
21
Potential Financial Impact
What is the financial impact of these results on the organization?
• Decrease waste by more efficient use of EC bed and inpatients beds
• Capture of uncharged technical and professional fees
• Bed utilization and resources
Annual Technical Charges for Patients with EC Stay > 16 Hours and Discharged
Home
$2,000,000
$1,800,000
Expected Charges Including Obs
Estimated Annual Technical Charge
$1,600,000
Estimated Actual Charges
$1,400,000
Assuming 62% of patients with EC
stay > 16 hours and discharged home
were placed on obs, this represents a
potential benefit of approximately
$650,000
$1,200,000
$650,000
$1,000,000
$800,000
Data source: EC Whiteboard to
compute LOS (May '08 - Apr '09)
$600,000
Note: To estimate the actual
technical charges for patient with EC
stay > 16 hours, an average approach
was used using Levels 4 and 5 charge
amounts
$400,000
$200,000
$0
0%
10%
20%
30%
40%
50%
60%
70%
80%
Percent of Patients Placed on Obs with EC Stay > 16 Hours
Source: EC Whiteboard
Prepared By: Ash Gupta & Richard Ivey
90%
100%
Estimated Annual Professional Charges for Patients with EC Stay > 16 Hours and
Discharged Home
$1,600,000
Standard Recovery
Obs - 1 provider
Obs - 2 providers
Estimated Annual Professional Charge
$1,400,000
Assuming 62% of patients
with EC stay > 16 hours and
discharged home were placed
on obs, this represents a
potential benefit of
approximately $428,000
$1,200,000
$1,000,000
$428,000
Data source: EC Whiteboard
(May '08 - Apr '09)
$800,000
To estimate the charges for
patients with EC stay > 16
hours, an average approach
was used using Levels 4 and 5
charge amounts
$600,000
$400,000
‘Obs – 1 provider’ assumes
that the EC provider is caring
for the obs patient
$200,000
‘Obs – 2 providers’ assumes
that a non-EC provider is
caring for the obs patient
$0
10%
20%
30%
40%
50%
60%
70%
Percent of Patients Placed on Obs with EC Stay > 16 Hours
Source: EC Whiteboard
Prepared By: Ash Gupta & Richard Ivey
80%
90%
100%
Annual Cost
Requirement for Unit
Physician provider (1)
Nurse (4.2 FTE)
Medical supplies (4% of Annual
Annual Cost
$250,000
$267,260
$ 17,129
EC Medical Supplies)
TOTAL Cost
$543,389
•FTE is based on the assumption that the Observation unit will be operational 24/7
•Personnel Cost is based on new staff with less than 1 year at M.D. Anderson
•Medical supplies/expense = 4% of Total EC Medical supplies
•Deduction % = 48.67
Estimated Number of Observation Beds
Avg Utilization Rate vs Number of Observation Beds in Operation
100%
90%
80%
Utilization of Obs Beds
Utilization Rate
70%
60%
The 'Utilization of Obs Beds'
is calculated as the average
amount of time occupied
divided by the total time
available (24-7). This is done
by looking at each of the
dedicated beds over the
entire year.
50%
40%
30%
The choice of number of obs
beds should be balanced
with the number of patients
waiting for a bed
20%
10%
0%
3
4
Source: EC Whiteboard
Prepared By: Richard Ivey
5
6
7
8
9
Number of Dedicated Observation Beds
10
11
12
Next Steps
ACT: Expansion of Implementation
• Maintain and expand awareness of available OBS services in the EC
• Improve identification of OBS patients in the EC
• Review appropriate use of OBS placement
• Track progress of revenue realization
Conclusions
• OBS unit could be a viable solution to improve patient
safety and quality of care in the EC
• By decreasing waste and capturing uncharged services
OBS unit may provide net revenue to organization
Recommendations
•
Designated OBS Unit (Closed unit)
– Access limited to EC provider and/or observation
provider
– “Virtual” or “Shared” OBS unit within Pod A
•
Designated non-EC provider coverage
– Improve safety and quality of patient care
– Cost of additional provider offset by fee structure
What have we accomplished so far?
• Increased number of observation patients to 5.57%
• Improved patient safety
 Medication reconciliation
 Diet, activity, fluid infusion
• Improved quality of care
Better oversight by having an APN following these patients on OBS
• Increased RN satisfaction and confidence
 Improving communication about plan of care
42
Percent of Patients Placed on Observation of the Total EC Visits (Monthly)
Percent of Patients placed on Observation
May -08
A pr-09
8.0%
UC L=7.8%
7.0%
6.0%
_
X=4.8%
5.0%
4.0%
3.0%
2.0%
LC L=1.7%
1.0%
0.0%
8
8
8
8
8
8
8
8
9
9
9
9
9
9
9
9
-0
-0
-0
-0
-0
-0
-0
-0
-0
-0
-0
-0
-0
-0
-0
-0
l
l
t
r
r
y
n
g
p
v
c
n
b
y
n
g
c
a
Ju A u
Ju
Ju
O
Ja
Ap
Ju
Se
De
Fe
M
Ma
No
Ma
Au
Month
Before/A fter Intev ention Test of Means, p-v alue < 0.001
Source: EC Whiteboard
Prepared By: Ash Gupta & Richard Ivey
43
Questions
Thank you