Boarding Solutions Increase Profits by Ending Gridlock [Physician Name] [Date of Meeting]

1. Boarding Solutions • Increase Profits by Ending Gridlock • [Physician Name] • [Date of Meeting] Confidential

2. Introduction to Physicians • The Virginia College of Emergency Physicians developed this document to help members talk with their administrators about addressing boarding. • You may customize this document for your hospital’s unique situation. • We included “placeholders” indicated with brackets throughout the document. For example, the cover slide has two placeholders that you should customize: • [Physician Name] • [Date of Meeting] • We also added speaker’s notes for some slides in the “Notes View” to help guide the conversation. • Visit www.vacep.org/boardingtoolkit for more information on boarding, including in-depth presentations and documents you can use to customize this document. Confidential 2

3. Contents • Why Address Boarding • Impact on patients • Impact on bottom line • State guidance • Internal Scan: Our Situation • External Scan: What’s Working in Virginia • Bridge orders • Admission units • Rapid Intervention Treatment Zones and Results Waiting Areas • Special situations: mental health patients • Recommendations • Resources Confidential 3

4. Why Address Boarding • Addressing boarding reduces crowding • ED crowding often occurs because no inpatient beds are available in the hospital, not because we have patients with non-urgent medical conditions • “Boarding” means holding patients who have been admitted to the hospital in the ED, keeping them on gurneys or chairs in hallways and waiting areas • Boarding has a negative effect on patient safety, comfort and satisfaction • Boarding ties up emergency department resources resulting in fewer physicians and staff to care for patients and, ultimately, less revenue Confidential 4

5. Patient Satisfaction Source: Press Ganey Confidential 5

6. Quality & Safety Source: Press Ganey Confidential 6

7. 2010 VDH Boarding Guidelines • The Virginia College of Emergency Physicians helped design state guidelines on boarding with an eye toward making emergency department patients safer by: • Quickly moving patients to inpatient floors • Avoiding ambulance diversion • Freeing up resources for patients who are in critical need of emergency care Confidential 7

8. Internal Scan Note to members: adjust the table below to include the data that will best illustrate the severity of boarding at your hospital. Confidential 8

9. What We Have Done in the ED • Note to physicians: insert examples of changes you have made inside the ED to address the problem. • Physician examples here • [One] • [Two] • [Three] Confidential 9

10. Collaboration is Vital “Emergency department crowding is an institutional problem that goes well beyond the emergency department. Only when all stakeholders agree that the problem is systemic and hospital-wide can solutions be implemented that will improve patient flow from triage to discharge and protect everyone’s access to emergency care.” 2008 Task Force Report on Board American College of Emergency Physicians Confidential 10

11. External Scan: What’s Working in Virginia Confidential 11

12. Solutions for Success • Bridge orders • Admission units • Rapid Intervention Treatment Zones and Results Waiting Areas • Special situations: mental health patients Confidential 12

13. Bridge Orders Confidential 13

14. Bridge Orders: Challenge • HCA Henrico Doctors Hospital, Richmond, VA • Hospitalists visited stabilized patients in the ED before admitting them to the hospital, which meant patients often had long waits for inpatient beds. • Meanwhile, fewer new emergency department patients could be seen because stable patients were using ED beds while waiting for a hospitalist to admit them. Confidential 14

15. Bridge Orders: Solution • Now ED physicians call the hospitalist to discuss the patient’s status, level of care, etc. • If the hospitalist and the ED physician agree that the patient can be sent upstairs, the patient goes upstairs to a room and is admitted by the hospitalists on the appropriate floor. • The ED physicians also complete a one-page bridge order outlining vitals, diet, etc. • Goal: after phone call to hospitalist, patient goes to appropriate floor within one hour. Confidential 15

16. Bridge Orders: Benefits • Minimal cost • Increased patient safety, comfort, satisfaction • Decreased patient wait times • Increased revenue 172.8 69.3 Confidential 16

17. Bridge Orders: Steps for Implementation • ED physicians, hospitalists and administrators meet to discuss. • Set up a cross-functional team to implement. • Develop a hand-off tool to ensure information exchange is thorough for patient. • Establish measures. • Once process is established, hold kick-off dinner to brief all parties on process. • Start during a slow time (e.g., a summer Tuesday). Confidential 17

18. Bridge Orders: Considerations • Trust across teams is critical. • Patients that are typically good candidates for a bridge order include those with pneumonia, pancreatitis, etc. • Patients should have stable vital signs. • This works well in a facility where hospitalists admit the majority of patients. • Avoid bridge orders when patients are unstable or if staff are debating about whether a patient meets the criteria for bridge orders. • Pick one or two measures to focus on initially. Confidential 18

19. Admission Units Confidential 19

20. Admission Units: Challenge • Lynchburg General Hospital, Lynchburg, VA • Staff recognized an opportunity to increase the efficiency of moving patients from the ED Bay to the inpatient unit. • Many floor nurses anticipated long, dedicated periods of time for admission and therefore would wait until that specific period of time passed before theywould report the bed was 'ready’. • Thus, the patient would remain in the ED Bay longer than necessary, cloggingthe system. Confidential 20

21. Admission Units: Solution • We develop the Admission Unit – a unit dedicated solely to the admissions process. • Admission Unit nurses perform admissions duties quickly and efficiently, since their role is focused on admissions. They handle all logistics, checklists and initial orders so the floor nurses are no longer responsible for these tasks. • In short, the Admission Unit nurses “pull” the admitted patients from the ED, then “push” them to the floor. Confidential 21

22. Admission Units: Benefits • The Admission Unit improves flow in the emergency department. ED LOS is decreased significantly and the patient vacates the ED bay as soon as the doctor decides admission is warranted. • Admission Unit staffers process admissions efficiently, since their it primary responsibility. • The Admission Unit enhances patient safety. • Admission Unit staffers take pride in their role. Confidential 22

23. Admission Units: Steps for Implementation • Find a location for the admission unit. • Learn from others – we visited two hospitals to see their processes and tailored them for our needs. • Determine goals for the admission unit (e.g., time goals, etc.). • Open the Admissions Unit with limited hours. Initially, we opened 12 hours/7 days, but later opened 24/7. • Add staff as needed. For example, we added a medical records nurse who is solely responsible for obtaining accurate medical records. We also added a floating nurse who can capture admission histories. Confidential 23

24. Admission Units: Considerations • Location can be a challenge – think carefully about where to put the unit. • Dedicate a specific manager to the unit’s success. • Strict criteria are important when deciding whether to send patients to the admissions unit; criteria may vary by hospital. • Sample Inclusion Criteria • Medical/surgical patients • OB patients (medical reasons) • Telemetry patients • Neurologic Intermediate Care Unit • Sample Exclusion Criteria • Pediatrics • ICU patients • Seizure patients • Titratable drips • Mother/baby patients • Mental health • 23-hour observation patients Confidential 24

25. Rapid Intervention Treatment Zones and Results Waiting Area Confidential 25

26. RITZ and Results Waiting Area: Challenge • Sentara Potomac Hospital, Woodbridge, Virginia • High incidence of ED boarding (hours and number of patients) and High LWOT • No metrics • Poor customer service scores • Previous attempts focused on front end • Needed to improve performance as new owners implemented key metrics including: • The agreed upon metric in which the door to discharge time for • level 2s and 3s is < 180 minutes is met 39% of the time • levels 4s and 5s is <75 minutes is met 25% of the time • Percentage of patients to triage < 15 min is met 95% of the time 26

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28. RITZ and Results Waiting Area: Solution • The staff created a “Rapid Intervention Treatment Zone.” They also created a “results waiting area” for patients who can stay vertical. This allows another patient to be seen in the bed. 28

29. Name of Initiative: Benefits • Minimal ED boarding • Improvements involve front, middle and back end • Clearly defined metrics • Gains in customer service scores Confidential 29

30. RITZ and Results Waiting Area: Steps for Implementation • Use the right tool for the right job. Look at the resources you have: • Human resources / staffing • Physical space • Determine the best way to allocate the right people for the right jobs. • Determine whether you have space for a results waiting area. • Develop a plan in collaboration with administrators, nursing and support services. • Rapid Cycle Test and Refine. Confidential 30

31. RITZ and Results Waiting Area: Considerations • As you evaluate your situation, look for ways to keep horizontal patients horizontal and vertical patients vertical. In other words, if your patients don’t need beds, don’t leave them in beds (results waiting area helps with this). • Focus on metrics and share the data. Transparency is critical for improvement. • Celebrate successes and learn from failures. • Share with and update administration and medical staff. Confidential 31

32. Special Situations: Mental Health Patients Confidential 32

33. Mental Health Patients: Challenge • Carilion Clinic Roanoke Memorial Hospital, Roanoke • Excessive length of stay for mental health patients and boarding of mental health admissions in the ED. Confidential 33

34. Mental Health Patients: Solution • Improve intake: • All mental health patients = Level 1 triage • Standardized patient intake • Created of dedicated ED Mental Health Unit • Improve throughput and care in the ED: • Dedicated ED Psych Nursing Staff + 1 fte RN, 1 fte ED psych unit med tech • Psych RN coordinators (Connect Team) • Parallel evaluations (med clearance and Connect Team) • ED Physician rounder on boarders (2hrs/day) • Improve disposition and placement: • “One Call” for all Mental Health Patients • Expanded weekend bed capacity • 1-to-1 communication with ED physician and psychiatric team • County/City Mental Health Coordination with Connect Team • Automatic Psychiatry Consult for ED >24 hrs • Direct Facility Protocol Placement for Unique Patients Confidential 34

35. Mental Health Patients: Benefits Confidential 35

36. Mental Health Patients: Benefits Confidential 36

37. Mental Health Patients: Steps for Implementation • Quantify the problem and map the process. • Improve care and maximize efficiency within the ED first. • Engage and collaborate across three key areas: • Law enforcement • City and county services • Inpatient and outpatient psychiatry • Expand resources and eliminate redundancy • Training, staffing, bed availability Confidential 37

38. Mental Health Patients: Considerations • Expand the narrative: make it a community issue and not an ED issue. • Flow diagrams are critical to keeping everyone on the same page. • Variations in practice must be eliminated. • Relatively small upfront expenditures can have dramatic effects in LOS. Confidential 38

39. Recommendations Confidential 39

40. Opportunities • Note to physicians: insert examples of changes that you want to make in collaboration with people outside the hospital. • Physician examples here • One • Two • Three Confidential 40

41. Resources Dr. Tamera Barnes Henrico Doctors Hospital 804-379-0444 804-432-0416 tcbarnes1@verizon.net Dr. Luis Eljaiek Sentara Potomac Hospital 703-670-1283 703-670-1782 LFELJAIE@sentara.com Dr. Damon Kuehl Carilion Clinic Department of Emergency Medicine 540-597-9153 drkuehl@carilionclinic.org Dr. Chris Thomson Lynchburg General Hospital 434-200-6858 434-401-7827 chris.thomson@centrahealth.com The Virginia College of Emergency Physicians 757-220-4911 gwen@vacep.org Confidential 41