Highlights from the
Poster Presentations
Poster Sessions (information presented was from
materials provided and after discussion with presenters at the site)
ED Patients to ICU within 30 Minutes
“Moving ICU admissions out of the ED
in 90 minutes”
Purpose:
Research suggests that delays with ED patients admitted to the ICU
are correlated with increased hospital length of stay, and higher Intensive
Care Unit mortality. Improving throughput for the sickest patients is
central to many quality and safety markers including the Surviving Sepsis
Campaign, decreasing ambulance diversion, reducing ED overcrowding,
improving patient satisfaction, and reducing patients who leave without
being seen. The goal was to decrease the time it took to move ICU patients
out of the ED.
Design:
Quality Improvement Project
Setting:
Urban teaching, non trauma designated Medical Center, with 247 inpatient beds, 50 ED
beds and 16 ICU beds. ED volume
has grown from 40, 474 visits in 2004 to over 52,000 visits in 2010 with the
same number of inpatient beds and a consistent admission rate.
Participants/Subjects:
All patients who were accepted to the ICU service where included in
this quality improvement project. The ED / ICU Quality Improvement Team
included the ED Director, ED Nurse Manager, ED Physician, Nursing
Supervisor, Admitting Manager, ICU Physician Director, ICU Nurse Manager and
Clinical Coordinator, ED Quality Nurse, CNO & CMO.
Method:
The ED Quality RN reviewed all ICU admissions out of the ED in June
of 2009, at which time ICU admits left the ED within 90 minutes 29.7% of the
time. An improvement team assembled in September of 2009 and the data
collection method was established. Using the MedHost®
data base, the time stamp of admit to ICU or “care complete“ and time to
“depart ED” was measured for all ICU admissions. The goal was to have 45% of
ICU admissions depart the ED within 90 minutes. The improvement team
reviewed the process for affecting an admission to the ICU, and there were
clear variables along the process points which we revised and streamlined.
Every step of the process that created variation and delays was
examined and researched for best practice, or evidence to support our
existing policies. One change
that greatly improved our throughput time was a revision to the
intra-hospital transport policy that previously required an ICU resident to
assist in transporting out of the ED.
The revised policy has guidelines by which the ED team determines the
safest transport team, and does not mandate the ICU resident for
transporting these patients.
Results/Outcome:
From October 2009 to September 2010 the quality measure of ED to ICU
admissions that depart the ED within 90 minutes improved from 27.7% to
57.1%. In addition, the average time from ICU decision to admit to departing
the ED dropped from 130.4 minutes in October 2009 to 73.1 minutes in
September 2010.
Implications:
Improving ED throughput, especially for our most resource intense
patients, is central to our ability to care for new patients seeking our
services. Applying what we have
learned to all admitted patients will meet our ED quality objectives.
Summary- Research suggested that
delays with ED patients being admitted to ICU directly correlated with
increased hospital length of stay and higher ICU mortality. The first step
was to collect the data and validate current status. The second step was to
eliminate unnecessary steps in the ED (including extensive work ups and
procedures) and to develop algorithms for all barriers to patients moving to
the ICU. (See attached contact and poster presentation copy.)
Temporal Thermometer Use in the ED
Limit use to lacerations, complaints that do not involve
possible infections. Users must be trained consistently and monitored for
accurate use to assure reliable results.
Nursing Research Internship Program
A month by month listing of how to develop this program
over one year was provided.
Discharge Phone Calls
Information was collected on making calls to the high
risk populations (pediatrics less than 18 and elderly more than 73). The
program clarified discharge instructions which resulted in reduced
misunderstanding of continued care, fewer return visits, increased patient
satisfaction, and continuity of care for the patients and their families.
Improving ED Throughput (more than one poster
presentation was on this topic)
Identified (summaries of all posters)
-
Physical organizational
improvements to increase access to supplies and decrease travel for same
-
Improvement of intra-ED
bed utilization
-
Targeted time for
inpatient admission of 60 minutes
-
Inpatient Charge Nurses
who identified next available bed known as the “Bed Ahead” plan
-
Improved lab turnaround
times
-
Improved teamwork and
communication between staff and staff and management
-
Triage was renamed
“Intake” and was staffed by RNs, tech and providers with this team being
mobile- patients being taken directly to beds when space was available- care
was initiated by the intake team when no beds were available and additional
staff was assigned to intake as needed.
-
The ED float nurse was
renamed the “flow nurse” and was responsible for expediting discharges,
admissions, and (lastly) assisting other nurses
-
Improved
discharge/admission with the designation of a discharge/admission ED nurse
-
Improved triage
strategies and criteria for expediated care
-
Development of an
escalated plan involving departmental directors and senior administration
when bed assignments were not made in a timely manner
-
Additional point of
care testing was added to ED to expedite care
The results of these improvements were positive in
decreased ED LOS, improved patient satisfaction scores and improved ED
throughput.
Catheter-Associated Urinary Tract Infections
Audit was done of all Foleys placed in the ED to
determine if infection rate was due to techniques and procedures used in ED
and it was determined that techniques were not compromised and that 1/3 of
the patients presenting to the ED had UTIs that may have been exacerbated by
the use of catheters.
Walk-Out Patients
Since these numbers are clinical indicators of patient
satisfaction and ED quality, it is imperative that a plan to reduce these
numbers be developed. A study was done and callbacks were made to determine
how best to provide follow up. Some of the patient care was resolved by
referrals and return advice and staff was reminded to keep patients informed
about wait times.
Reduce Time in Restraints for Agitated Patients
Study included giving medications to reduce restraint
times and increased reassessment for removal of restraints in a timely
fashion.
Airway Management- LMA vs. ET Times
This study was done in the pre-hospital setting but
proved that time to ventilation of the patients were longer for the ET
patients (36.5 seconds) than with the LMA patients.
Pediatric Spinal Immobilization
Most studies done on spinal immobilization are done on
adults. While spinal injuries in children are rare, they contribute to
significant morbidity and mortality.
The dangers in pediatric immobilization are that it
raises their intracranial pressures, restricts respiratory function,
increases risk of aspiration, can lead to potential airway compromise. It is
also not generally tolerated well by children especially when they are
frightened, hypoxic, or combative.
Extended time on the backboards should be limited also
due to false positive clinical exams from sensations experienced by patients
on backboards (altered sensations and pain) and skin breakdown which can
occur within a few hours.
If immobilization is necessary
-
Monitor patients
closely for changes in condition
-
Use pediatric sized
boards and equipment
-
Remove patients from
boards as soon as possible
-
If adult backboards are
used, pad underneath patient and in all the empty spaces to prevent slipping
and sliding and add padding underneath the shoulders to maintain airway
alignment
