Mid-Track (Text Version)

On September 27, 2010, Jeffrey L. Margulies, made this presentation at the 2010 Annual Conference. Select to access the PowerPoint® presentation (1.2 MB). 

---

Slide 1

Mid-Track

AHRQ Annual Conference
September 27, 2010
Jeffrey Margulies, MD, FACEP

Slide 2

Why: Collateral damage

A cartoon showing the emergency room is shown.

Slide 3

What: Identifying the Initiative

• 2.4% LWBS (left without being seen)
• Drill Down reveals ESI 3 issue

A pie chart is shown of the data above.

Slide 4

Who: ESI 3 Conundrum

• Patients are too complex for typical fast track visit.
• Not ill enough to be brought back immediately at times of high census.
• Result: highest LWBS rate for this subgroup of patients.
• Significant potential for morbidity

Slide 5

 

Who: Identify your target!

Chief Complaint	LWBS Rate
Abdominal pain	4.6%
Flank pain	3.5%
Headache	5.5%
Pregnancy complication	5.3%
Vaginal Bleeding	6.1%
Vomiting	2.5%

Slide 6

  I make 

When: Do the math

An image of a bar chart showing the Avg number of Mid-Track Patients arriving by hour of day is shown. The peak is at 1700 hours (5 pm).

Slide 7

 

Where: Enter the Mid-Track

• Create a solution to address the needs of the ESI 3 patients.
• Insufficient space in current ED.
• ASU located above ED and available after-hours.
• Challenge: find a process that works and uses ASU space.

Slide 8

 

How: Mid-Track Evolves

• Concept: frontload patient visit.
• Nurse categorizes patient as ESI 3:
  • Refers to physician sitting in triage.
• Physician in triage, but not triaging:
  • Only sees ESI 3 pts with 1 of 6 CC.
  • Phlebotomy station set up near triage.
  • After initial evaluation pts go up to ASU.
  • Care coordinated with NP for entire shift.

Slide 9

and... 

An image of the Good Samaritan Hospital Medical Center Mid-Track Process Flow Chart is shown.

Slide 10

 

Lessons Learned/Challenges

• Process design quite challenging.
• Start time critical to front loading:
  • Bolus of patients when MT starts at 4p
  • Pts 'triaged' to MT before 4pm
• Cost
• Staffing

Slide 11

 

LWBS rates pre and post Mid-Track

	All Patients Pre Mid-Track	All patients post Mid-Track	ESI Level 3 pre Mid-Track	ESI level 3 post Mid-Track	6 Chief Complaints pre Mid-Track ESI Level 3	6 Chief Complaints post Mid-Track ESI level 3
LWBS%	2.56%	1.93%	4.90%	3.08%	6.96%	3.90%

Slide 12

 

Collateral benefits

• Positive response from patients.
• Favored by staff.
• Reduced stress levels in the ED.
• NP role better defined than previously.
• Hospital renewed focus on throughput.
• Mitigated our natural tendency towards procrastination.

Slide 13

 

Future of Mid-Track

• Successful initiative to date.
• Expand hours and days of operation.
• Expand ESI 3 patient complaints.
• Included in new ED redesign.

Slide 14

 

Modern Healthcare

An image of the evolution of the wheels is shown.

Slide 15

 

Thanks to the team!

• Charles Bové
• Carol Butler
• Curt Cicotte
• Susan Dries
• Mike Gewirtz
• Kathleen Lock
• Tom Nolan
• Rob Sharma
• Many others

On the right side of the slide is a photo of the team.