Webinar: Testing Emergency Department Improvements with Simulation

Testing Emergency Department Improvements with Simulation – A Quality Improvement Perspective

Amanda Peterson, MS, RDN, LDN, Vidant Duplin Hospital

I. Vidant Duplin Hospital

Thank you for the introduction, Claire. We want to start off with a bit of background about where we are located. Vidant Duplin Hospital is part of the Vidant Health System. We are located in eastern North Carolina. Our health system [2.30] is composed of a large academic medical centre, seven community hospitals and a medical group. We are located in south-eastern North Carolina. Vidant Duplin Hospital is in a rural, low income and low resource area. It is highly characterised by an agricultural focus.

We are licensed for 81 beds. 25 of the beds are for an adult psychiatric unit and 25 are for a medical/surgical floor. We have a nine bed ICU [3.00] and a maternity ward. The majority of the work that we are going to talk about is focused in the ED. Our ED consists of 12 beds.

Implementing a Pharmacy Technician into the Emergency Department (ED) for Collecting Medication Histories

II. Current Problem

The motivation for this project emerged from our systems [3.30] pharmacy work group. The goal was to standardise practices for collecting medication histories, and the reconciliation process, across the hospital and our system. As hospitals in our system range from small and rural hospitals to the large academic teaching centre, the pharmacists knew that the solution would not be one size fits all. We would need to consider the context and the local constraints. The Lean department was brought in to assist and collect observations and data. [4.00]

III. Process Details

Emergency department nurses are responsible for obtaining patients’ medication history. Our observations on the ED and the unit indicated a variation in medication history collection, which is something that is also seen in the literature. There is not yet a standardised process or a best practice.

Research suggests that greater than 40% of medication errors [4.30] are the consequence of inconsistent medication history process, and 20% of which are considered serious safety concerns. We therefore wanted to investigate the feasibility of integrating a pharmacy technician into the ED to collect the history. The thought was that if we implemented a pharmacy technician and conducted scripted patient interviews then we would get a more accurate account of a patient’s medication history. [5.00]

IV. Scripted Interviews

The process involved scripted patient interviews for collecting comprehensive medication history, which would come either from the patient, if they were able to do so, or the family. Patients are not good historians. We knew that having a scripted interview would be better, as we could help to jog their memories in certain things. The interviews covered everything from prescription medication to over the counter medication, including dietary supplements and ointments.

The interview generally [5.30] takes 15 to 30 minutes with the patient, depending on their medical history and how accurate the records have been up to that point.

[Simulation demonstrated]

IV. Scripted Interviews

Amanda Peterson

As you can see, this is the model that we built. We had a pharmacy technician in the ED for seven days a week. We implemented them for an eight hour shift during the busiest time of day, which for us is between 3.00 p.m. and 11.00 p.m. We prioritised the patients that the pharmacy technician would see based on the order to consult. [6.30] If we were looking to admit the patient then the pharmacy technician would know that that patient would come first. However, because the process takes about 15 to 30 minutes then there are other constraints. We built in a time to expire. If the pharmacy test was wrapped up collecting histories, then it would default to the emergency department nurse.

I will show you a still of the screen. There is one slight typo in here [7.00] that I want to clarify. Where it says: ‘Without order to consult’ and then it says: ‘RN patient interview’ is a typo. The pharmacy technician would do that as well. If they did not have any orders to consult, then they would start to collect medication histories on patients as well.

VI. Key Findings

We found that they collected about 14 medication histories a day. The process was quite lengthy, because they had to call the pharmacies and, as I said, the busiest hours for us are between [7.30] 3.00 p.m. and 11.00 p.m. Given that we are in a small, rural area a lot of our patients get their medications from small pharmacies which do not have 24 hour services for collecting their histories. The pharmacy technician could start the interview, but if it was late and the pharmacy was closed then they would not be able to complete it. That was something the nurses also had trouble with.

They would call the pharmacies [8.00] and if the patient was on any high risk medication then the pharmacy technician would go back and verify the order with the patient.

VII. Simulation Model

This process was completely new for us, so we did not have any baseline data. We therefore worked with the research. As I said earlier in the presentation, about 40% of medication histories collected have errors, which, in turn, [8.30] really affect the medication reconciliation process.

This is where there is the typo that I mentioned. This is also the pharmacy technician here. On the simulation it says RN. It would default to down here.

VIII. Results

The peak hours were between 3.00 p.m. and 11.00 p.m., so the working hours for the pharmacy technician were [9.00] about 2.30 p.m. to 11.00 p.m., which we ran seven days a week. There were about 14 medication histories a day. Based on our numbers we were doing about 10 consults a day per admission at the time. The pharmacy technician would only see about four patients without an order to consult.

Scripted patient interviews were more comprehensive. They required more time with the patient for accuracy. [9.30] The RN would step in to collect the history depending on how many admissions were placed.

IX. Next Steps

1. Sharing the Results

We were really pleased with our simulation. We got a lot out of it because it was a new process. Our role was to share the findings with our hospital executives and senior leadership in Lean Steering, which is a group of Lean practitioners [10.00] all working together. We also shared this with our emergency department and pharmacy work groups in our system.

We also planned to share the results with the community hospitals in our area both within and outside of our system, because rural hospitals face a lot of the same constraints. We were using the results to support a proposal for which we were seeking grant funding for. We already had a jump start on this project when we met Claire and her team, and started [10.30] the simulation. It just aligned perfectly. It helped to smooth the process and help us to organise our thoughts for the proposal, especially because we did not have the baseline data.

As we were investigating a new process, we had to pair it with current research. That piece was really interesting to me, because I thought it would be a barrier for us but it actually ended up really helping in terms of painting a picture. [11.00]

1. Sharing the Results

We were really pleased with our simulation. We got a lot out of it because it was a new process. Our role was to share the findings with our hospital executives and senior leadership in Lean Steering, which is a group of Lean practitioners [10.00] all working together. We also shared this with our emergency department and pharmacy work groups in our system.

We also planned to share the results with the community hospitals in our area both within and outside of our system, because rural hospitals face a lot of the same constraints. We were using the results to support a proposal for which we were seeking grant funding for. We already had a jump start on this project when we met Claire and her team, and started [10.30] the simulation. It just aligned perfectly. It helped to smooth the process and help us to organise our thoughts for the proposal, especially because we did not have the baseline data.

As we were investigating a new process, we had to pair it with current research. That piece was really interesting to me, because I thought it would be a barrier for us but it actually ended up really helping in terms of painting a picture. [11.00]

2. Using Simulation Going Forwards

We would like to investigate using simulation to better understand resource utilisation in our area. As Duplin is a lower income, low resource area patients and communities face challenges such as access to care or a limited number of primary care providers, we believe that simulation can help us to understand what resources are needed. That could include health interventions or prevention efforts. Simulation can also help us to understand how patients are interacting [11.30] with our system and other social service systems.

We also felt that simulation would be great for co-ordinating effort with the intervention and prevention. Claire and I had a great discussion about how simulation could be used in research. It is therefore something that we are also interested in.

X. Lessons Learned

1. Positives

There are a lot of things that we really liked about the simulation process. [12.00] I personally like the fact that it mirrored research processes such that it was an iterative process. It also really offered us the flexibility to tailor it to our community. Going in, I had not been sure whether simulation would appropriate for our community, because we are small and I thought that simulation would be more geared towards larger, more urban centres.

2. Surprising Features

I was pleasantly surprised that you could model your simulation to be as simple [12.30] or as complex as you want. My colleague’s case is more complex, but, in my case, because we did not really know too much about what was going on, we kept it fairly simple. Even with that simplicity, it still worked and it mirrored what we are seeing now. I was very surprised at how simple the model was to build. When I had been sitting through the presentation I had been concerned that there would be a very steep [13.00] learning curve, but it was very helpful having an onsite trainer and also having a colleague that was also working on simulation, as we could check things with each other, error check and learn simultaneously. We both felt that that was very helpful.

3. Ease of Use

I felt that Simul8 was pretty easy to use. I like the ability to access the resources. [13.30] We had regular check-ins with Britney, our instructor at that time. We would have phone calls with her as well as meetings in person if she was local. As I said before, it was very helpful having a colleague to pass ideas to and to help solve problems outside of our SIMUL8 meetings. If anybody listening is considering it, you should try to bring more team members on as that is a big help.

4. Duration

Overall, it only took me about [14.00] 60 minutes for me to develop the model. It was easier to initially draw it on paper, as I knew what I wanted to do. I had help from Britney and Raul. Building the model only took about 20 to 30 minutes, which I was quite surprised by. The things that took a bit longer included the data input, investigating errors to uncover why things did not work. That probably took about [14.30] one to two hours. Again, it was quite simple. That wraps it up for my presentation.

ED Growth and Left Without Treatment

Raul Medina, MLS (ASCP)cm, CSSBB, Vidant Duplin Hospital

I. Overview

I am one of the Lean co-ordinators. I am certified Six Sigma [15.00] black belt. I am not going to go into all of the detail that Amanda has gone into, as I think she has fairly well covered issues of the type of hospital we are, where we are located and all of the background that she gave. I am going to go right into what I wanted to do. As we are a rural hospital, a lot of our patients come to our ED for services. We are quickly expanding our ED. We are basically increasing, by 10% a year, [15.30] the average number of patients that we see on a daily basis.

We wanted to see how well we would be able to maintain our less than 2% left without treat (LWOT) rate if we continued to increase at 10% a year. That rate is a gold standard that we like to follow and is very important to us. We like to stay below that number. [16.00]

II. Process Details

Our process basically goes into the pre-registration, the triage, the treatment of the patient, the final registration and departure. It therefore covered from when the patient arrives, all the way through the whole function of the ED and to when they are either admitted or go home.

[Simulation demonstrated]

Here you can see [16.30] the simulation running with people coming in. This was done with a two week period. We were concerned about the LWOT rate, which you can see there next to the beds. You can see the acuity levels one through five here. Acuity one is the highest acuity patient that we will see. Within those times that you see each of the acuity levels, I put in our median time for treatment, everything that needed to be done before final [17.00] registration and the patient heading out of the door. Our big focus was then on all of these patients arriving to the ED and then going home. It was not necessarily focused on the ones who were admitted, but the ones that went home. The low acuities increase our LWOT rate. They are just waiting in lobbies, and because they are not too sick and do not want to wait any more they will go home, and that is a big safety concern [17.30] for us. Our median time from arrival to departure is based on the five acuity levels.

IV. Next Steps

1. Sharing the Results

We presented this to the hospital executives, as Amanda said, as well as the emergency room department. We wanted to share all of the information across rural hospitals.

When we started this, we were seeing 78 patients per day. For the last quarter, from January [19.00] to March, our average patient workload in the ED has been 89 patients per day. We have maintained the same LWOT rate of 1.7%. That is basically due to creating the results pending area. The patients that are acuities four, five and sometimes three, who are just awaiting lab or radiology results, will be moved to the results pending area, [19.30] which frees up room, thereby allowing us to see more patients. We also have providers who are more than happy to use our triage to get very low acuity patients out quickly, meaning there is no increase in the LWOT rate.

2. Lessons Learned

As Amanda said, it did not take very long to set up. I think it was very simple to set up the simulation. There was a steep learning curve in terms of learning all of the resources and what [20.00] they can do. I do not think we fully utilised all of the resources that it is capable of using. We just made some simple models. They are expensive but simple models. One of the big takeaways from this was to combine what Amanda was doing with what I was doing to make one big simulation model. There are patients coming in and need their medication reconciliation, because they are being admitted, and there are the low acuity patients who go through the process and then leave the hospital. That was [20.30] what we wanted to do.

We did a lot of error-checking. We worked well together. Amanda and I both asked questions and we helped each other out throughout the process. We were very impressed with the SIMUL8 program, what we were able to do with and what we could do with it in the future. That is the end of the presentation.

V. Benefits of Simulation

Amanda Peterson

One of the things that I would like to highlight is [21.00] that with Lean we work a lot in teams. We really want to hear what the team has to say. We come up with ideas that we want to test. I think that simulation provides a really unique opportunity to allow us to test those experiments. The team may suggest adding another provider or more beds. I like the idea that simulation could allow us to demonstrate that. [21.30] We could not actually run an experiment on those things, but we could use simulation to see if it would work. That is one of the things we really like from the Lean perspective. There is quite a lot of opportunity.

Raul Medina

We have been doing Lean Six Sigma process improvement at our hospital for the last seven years. The ED was our first area of focus. They have been working with Lean [22.00] for a very long time. To give you some more background, at the last quarter we saw 89 patients per day and the average length of stay for those patients that were going home was 132 minutes. This is just the dedication of the process owner or the manager in the ED, as well as their staff, and how well they have taken to Lean and Six Sigma. SIMUL8 showed them that we could show a picture of what was going on, that we could run a model and they could see what was happening and all of the hard work that they were doing. [22.30] A picture is worth 1,000 words. They are very engaged in this process. They have been engaged for the longest time at our hospital. If anything, we are very proud of our ED. I think everybody in our area knows of our ED. Everybody comes to our ED because of that. They know that they are not going to wait a long time. It is a credit to the staff who are there and their manager how well this is working in our ED. We are very proud of them.

Claire Cordeaux

Thank you very much for sharing that with us, Amanda and Raul. [23.00] I think they are two very interesting pieces of work. They are particularly interesting because of your quality improvement background. That has given me some food for thought about using simulation. That is not just about using it in the traditional way, but also what you have just said there Raul in terms of validating the team’s work, and being able to show them what they have achieved. That is not something that I have heard [23.30] much about from other people, though I am guessing that they do probably do it. That is very important, because they can see the impact of what is happening.

Raul Medina

Yes, that is very much the case. I think it is very important to them. I think they realise that all of their hard work is really paying off. We show up with the numbers. Our numbers are great, and we are very proud of them, but it took a lot of hard work and dedication. [24.00]

Questions and Answers

Claire Cordeaux

It is very impressive. If anybody has questions they want to ask then please do so. I would like to put one that has come through to both of you. I think it is stunning how little time it took you to build those simulations. Most people spend a lot longer than you did. [24.30] One of the things is that the models were very focused on a particular. I wonder what work you did in advance of the simulation to be so focused on the question that you wanted to solve.

Amanda Peterson

I can say that for mine we had been conducting [25.00] observations right before the simulation. I had also been discussing the issue with our pharmacist, and we had discussed research. I think our observations, paired with what we were seeing in the literature, really helped to focus my perspective. It was something that was new for us, and it was outside of my realm as Lean co-ordinator and a dietician, as this dealt with pharmacy. I think being submerged in observations [25.30] quite close to when we started the simulation was helpful.

Raul Medina

For mine it was just the fact that we are growing. Our ED has done such a great job that more patients are coming to us from other counties, just to come to our ED. We have a lot of different people showing up who we have never had here before. We have just become stroke certified, and that is attracting more attention. We know that we are growing, and we are increasing the numbers. It was very important to find out where that threshold [26.00] is and how high we can go before we had to make a big decision about whether we need to add more beds. As I said, every year for the last four years we have increased our average daily patient arrivals to the ED by 10%. I do not think that is going to change. I think it will continue to increase. We have to look at what else we need to do.

A big thing for the ED is that we have had days when wen have seen [26.30] 125 patients here. The ED would adapt and change its processes on a daily basis sometimes, just based on the acuity of the patients or the number that they saw. They were very adaptable and able to change their processes, open different places up and do more triage or do things in a certain way. They are very strong. I have to give credit to Kim, the way that she operates and the way she has her staff [27.00] focused on the patient. We do whatever we can.

Claire Cordeaux

That is really great to hear. Whilst you have been talking I think one of your colleagues has come back in and said that: ‘The Lean staff are great to work with. We can see real time benefits to our work.’ I think it is mutual there, so well done guys. That sounds great. Another question has come in. Somebody wanted to know whether the model is connected to live patient data. [27.30]

Raul Medina

My model was. I took the actual data of the patients who were coming through the ED. All of the numbers that I put in was actual data, and the median times for their total stay in the ED was actual data from the time.

Amanda’s model was not because we did not have any baseline model, and it was something new that we wanted to create.

Amanda Peterson

Yes, again, ours was just based on observations and knowing that the [28.00] interview took about 15 to 30 minutes. We knew the numbers coming into the ED, and we used the percentages. When we were talking about medication history errors, we were using research to support all of that, given that we did not have any data.

Claire Cordeaux

Thank you very much. The same person wanted to ask whether that was retrospective. [28.30]

Amanda Peterson

I think that brings up a really interesting point. [29.30] Something we thought simulation would be great for was doing some pre/post and looking at the way that processes were several years ago, where we are now and where we want to be. There is quite an opportunity there. Once the model is built it is as simple as changing the data to match. I think it paints an interesting picture to say, ‘These are the resources [30.00] that we have currently. We expect to grow, so this is what we can expect going forward’. As Raul was saying, we are getting busier. I think that simulation has been really advantageous for us as a small, rural hospital.

Raul Medina

You can say, ‘What happens if I increase my person load coming to the ED by 20%’. You can plug that into SIMUL8 and ask what that would do to the resources and how many LWOTs there would be or what the efficiency would be of all the staff [30.30] and whether we would be burning them out. You can really get that information out of the program.

Claire Cordeaux

Thank you very much. I am going to close it there. I want to say a very big thank you to both of you for sharing your experience with everybody. It has been a really interesting discussion, and very helpful to hear about the work that you have been able to do. [31.00] SIMUL8 have a LinkedIn site, and if anybody wants to have further discussions you can post the questions there and we can get some of those answered. Thank you so much to everybody for joining today. Thank you particularly, Amanda and Raul, for the work that you have done. I look forward to hearing what you are going to do in the future. [31.30] I will see you all again at the next webinar.