TITRE - CHU de Toulouse

TITRE - CHU de Toulouse

Quality Improvement in the Emergency Department Creating the culture so its second nature Jonathan A. Edlow, MD Associate Professor of Medicine Harvard Medical School Function of the ED Clinical care of patients Teaching Research Primary mission: to give the best possible clinical care for every patient To do this, one must continually improve Creating the Culture Must be a priority for departmental leadership It must be easy to come forward with a problem NE TIREZ PAS

DE DataCONCLUSIONS should be easy to gather Problem-solving must be done as a group, with appropriateHTIVES representatives from various groups All providers must feel empowered to do so Nothing punitive and no blame assigned (unless the process ultimately finds that) Emergency Department (ED) Basic statistics 53,000 patients per year 30% arrive by ambulance (or helicopter) 33% admitted 5% admitted to an ICU 8% admitted to an ED-based observation unit Clinical Laboratory

Radiology Obstetrics-Gynecology Surgery Pre-hospital Psychiatry ED Hospital Administration Cardiology Neurology Internal Medicine

Structure of QA in the ED Patient complaints Patient complaint committee ED Management Team Doctor or nurse complaints Automatic QA trigger Regulatory mandated metric Emergency Department

QA Committee Chief of Emergency Medicine Hospital QA committee Hospital Legal Insurance company Patient Care Advisory Committee Hospital Board of Directors Massachusetts Board of Registration of Medicine

Try to simplify data collection Collecting data QA flags over time 140 120 100 80 Series1 60 Linear (Series1) 40 20 0

STEMI process improvement Percutaneous Coronary Intervention (PCI) Received Within 90 Minutes of Hospital Arrival The Problem Percentage under 90 minutes 80.00% BIDMC 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00%

0.00% Pre Guideline National Goals Multi-disciplinary review the cause of delay for patients with Acute Myocardial Infarctions requiring primary angioplasty Implement a standard treatment protocol utilizing current evidence-based medicine and AHA Guidelines . Increase percentage of AMI patients who receive primary angioplasty within 90 minutes of hospital presentation to 75% Key Metrics Analysis of delay points in the workflow from ED to Cardiac Catheterization Lab

Door to initial ECG (Goal: 8 minutes) Door to Cath team notified (Goal: 15 minutes) Door to Departure to Cath Lab (Goal: 45 minutes) Door to PCI (Goal: 90 minutes) Who does the ECG and when? Who reads the ECG and when? Cardiology notified of STEMI: 617- CARDIAC CODE STEMI TIME:__________ Admitting Interventional Cardiology Attending Interventional Cardiology

Fellow Cath lab technician Cath lab nurse Security CCU resource nurse Simplify the Process Simplify and Standardize the Process All medications listed on a pre-printed single order sheet with dosages, and potential contra-indications The medications are all grouped together in PYXIS; just enter STEMI to automatically be prompted to pull out all the meds. Bolus only; no drips

Analyze the Data Data (time windows) collected and analyzed by health care quality All cases reviewed within 24 hours Case conference for all cases > 90 min (also within 24 hours) Monthly STEMI team meeting Emergency physician Cardiologist ED nursing Success BIDMC Percentage under 90 minutes 90.00% 80.00% 70.00% 60.00%

50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Pre Post Guideline National Stroke process improvement Reduce the time for door to administration of tPA for acute ischemic stroke Code Stroke activations Monthly Code Stroke Volume (n=130)

30 26 # Codes 25 20 19 21 15 13 14 Dec

Jan 19 18 Feb Mar 10 5 0 Oct Nov FY'09 The problem getting the work done faster

Apr The Magic Hour: Door to ... Time of onset last time known to be normal 60 min 10 Emergency MD min Stroke Neurologist 15 45 min min

CT/MRI started CT/MRI interpreted tPA started 25 min Recommended Time Intervals No routine delays for: Blood testing (most) Chest x-ray Vascular imaging Composite data average Registration to Code Stroke activation Tim e from ED Registration to Code Stroke Called 30 27

Minutes 25 20 27 23 24 Jan Feb 22 22 Apr

Overall 18 14 15 10 5 0 Oct Nov Dec FY'09 Mar MRN

ED Reg ED Registration Time Code Stroke Call Reg to Code Stroke 0482278 5/15/2009 15:09 17:39 2:30

2381088 5/15/2009 17:40 18:03 0:23 2217000 5/12/2009 11:21 11:33 0:12

2313439 5/6/2009 11:04 11:25 0:21 2379062 5/6/2009 23:07 23:13 0:06 2381050

5/6/2009 15:58 16:11 0:13 1167444 5/4/2009 22:29 22:41 0:12 1533121

5/3/2009 5:23 5:33 0:10 2380271 5/1/2009 21:45 22:16 0:31 5/19/2009 22:13

22:53 0:40 1259747 5/20/2009 23:20 0:01 0:41 0602301 5/20/2009 15:10

15:34 0:24 2384292 5/23/2009 10:00 10:04 0:04 1517892 5/24/2009 9:42 9:43

0:01 0958724 Data by doctor and clinical symptoms at onset ED Doctor Clinical Syndrome DC Bilateral leg weakness and old deficit DC TIA DC

Acute speech deficit, s/p recent stroke (? old versus new) ST Altered mental status, ? seizure DC TIA RF Time of onset was ambiguous TK Recurrent speech changes Tentative Conclusions One doctor needs some education

Staff needs better education about patients presenting with TIA Some of the longer times were associated with significant clinical ambiguity about the diagnosis of stroke 7 of the 8 problems were on the evening shift (when the ED is busier) - ? Bottleneck at triage issue This project is still a work in progress Conclusions Create the culture of improvement Promote this from the top Create clear metrics; gather them accurately Involve all parties in the process Break down processes into component parts Reduce variation Above all, avoid jumping to conclusions !!

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