UPMC Mercy is a 492-bed hospital located in Pittsburgh, PA, with a level I trauma and burn center and primary stroke program. UPMC Mercy was acquired by UPMC Health System in January 2008 from the Pittsburgh Mercy Health System. At the time of acquisition, UPMC Mercy was serving roughly 45,000 patients per year in their ED. The 25-bed ED was functioning to serve the needs of the patients that presented to the hospital, but there was much opportunity to improve to become a more efficient operation.
In June 2008, UPMC Health System made the logical operational decision to close UPMC South Side, which was located less than two miles away and across the river from UPMC Mercy. UPMC South Side was running a low medical and surgical census that could easily be absorbed by UPMC Mercy. The plan was to integrate UPMC South Side into UPMC Mercy to consolidate services and reduce the financial overhead required to run UPMC South Side.
One of the fundamental questions that needed to be answered in preparation for the consolidation was: how many ED visits would UPMC Mercy inherit from UPMC South Side? UPMC South Side was seeing approximately 20,000 ED visits per year. A market analysis was completed to arrive at an estimated retention of 15,000 ED visits per year. This would increase the yearly ED visits at UPMC Mercy to around 60,000.
As part of the preparation for the influx of volume, several iterations of renovation and expansion designs were created. The team from UPMC Mercy visited Mary Washington Hospital in August 2008 to understand the Super Track concept and look for ways to improve operational efficiency. Two things were evident: UPMC Mercy had 10 months to do something and a renovation or expansion was not going to solve operational inefficiencies. What UPMC Mercy had to do was evaluate and solve flow-related problems and then design a new department based on the specific flow demands for the population they serve.
Historically, the ED at UPMC Mercy reported to the Chief Nursing Officer. Given the size of UPMC Mercy and the complex needs of the ED, the President decided to add an executive position to oversee emergency and trauma services. This position would also have oversight for operational improvement. This position was filled in June 2009, one month prior to the closure and integration of UPMC South Side.
On July 1, 2009, the ED at UPMC Mercy encountered a 25% increase in volume with the closure of UPMC South Side.
Figure 1 – UPMC Mercy ED Volume May 2009 to June 2010
This trend continued through the month of July and the hospital set a record for the number of ED visits it saw that month. With a decline in operational performance for this period, UPMC Mercy’s ED leadership team decided to implement some process changes to improve flow.
Focusing and Fixing Flow:
Operational metrics revealed that there was opportunity on the front and back-end flow in the department. This especially seemed to be true for patients being admitted from the ED to the hospital. In August 2009, the ED team began to tackle issues related to both ends of flow, but the major focus was to fix the back end first.
As the team met to brainstorm about opportunities, one of the things that came to mind to improve flow was to improve radiology and laboratory turn-around times to get results back quicker. A quicker disposition would result in a shorter length of stay. In particular, this might help discharged patients move through the department at a faster pace if diagnostic tests could be performed more rapidly. However, as the team thought this through, they realized that this would not be a big win for admitted patients. The ED might be able to get to a disposition faster, but if there was not a bed available for a patient to land in, then they would still be sitting in the ED waiting.
Working on the Back End:
Instead, the team decided to work on partnering with the inpatient units to help them predict their demand and capacity throughout the day. The ED went through historical data and utilized queuing theory to determine the arrival rates of admitted patients by hour of day. UPMC Mercy started by looking at the total number of bed requests by 2 p.m. from the ED. This was around 20 patients each day. The inpatient units then used a real-time, demand and capacity management process to create capacity for patients in the ED. This would ensure that patients that needed to be admitted from the ED would have a bed available.
As the ED worked through the admission process, another opportunity was discovered. The ED had traditionally requested a bed once the patient was ready to move to the unit. The bed search process typically took 30 minutes to complete, which was non-value added time since the patient was ready to go. The ED worked with patient placement to develop a process such that a bed would be requested 30 minutes prior to the patient being ready to move. This would allow patient placement to begin looking for a bed to assign while the ED was finishing up necessary tasks to ensure the patient was ready to move once the bed was assigned. This transitioned a serial process into a parallel one to eliminate a wasted wait for the patient.
In addition to these changes, the ED realized that it didn’t always have the necessary resources when there were volume surges. It was evident that a surge plan needed to be created so that the ED would get the necessary help to promote patient flow. The ED at UPMC Mercy decided to utilize the National Emergency Department Over-Crowding Scale (NEDOCS), which was developed by the University of New Mexico. This 6-point, objective scale is a measure to show how busy an ED is based on capacity, known waits, and acuity. Once the two highest levels are reached (level 5 and level 6), key departments must respond to the ED to ensure the appropriate resources are in place. Patient placement, environmental services, patient transport, and inpatient units all have an active role in responding to the alert. Most notably, inpatient units are required to come down to the ED to pick up their admitted patients as a means to decompress the department and to keep the key resources in the ED to take care of their patients. With these changes in place, the admit length-of-stay for the ED continued to decrease through December 2009 while volume continued to increase (Figure 2).
Figure 2 – Admit LOS at UPMC Mercy May 2009 to June 2010
The discharge length-of-stay also decreased slightly, but there was little focus on this population. This was a natural byproduct of UPMC Mercy’s focus on the admission process. In fact, the only process that was implemented, which impacted both populations, was a “direct-to-room” policy. The ED historically sent every patient through triage before they would be taken back to a treatment room. UPMC Mercy decided that if a patient room was available, triage should be bypassed. However, when the department became busy and rooms seemed to be full, the normal process of triaging all patients continued.
Working on the ED – Applied Queuing Theory and Lean for the Door to Doc and Doc to Dispo:
As 2010 started, UPMC Mercy experienced further increases in admissions and volume as the hospital continued its growth. Despite the increased throughput for admitted patients, the department was still experiencing bottlenecks in the afternoon hours, which led UPMC Mercy to examine staffing patterns in the ED. One thing to note is that the ED is separated into two pods, which are staffed separately. The main pod, which is open 24 hours each day, sees higher acuity and houses the trauma bays. The extension pod, which is open from 9 a.m. until 2 a.m. each day sees lower acuity patients.
Using queuing theory, the ED matched arrival rates into the department with required staffing, based on acuity. What was revealed was inadequate staffing (short two nurses and one physician/extender) for the extension pod from 9 a.m. until 5 p.m. This mismatch in demand and capacity would cause the main pod to become flooded with both high- and low-acuity patients and inevitably slow down flow during peak hours. With this adjustment, staffing was then matched appropriately and a bottleneck was removed.
During the volume growth through March 2010, the ED experienced significant boarding, which affected both admitted and discharged throughputs. UPMC Mercy still had not implemented the Super Track model, despite a few attempts during the prior, which failed because of a lack of engagement from front-line staff. To engage the staff in designing and implementing this model, the leadership team created a department reorientation to talk about the changes from the prior year, develop a standard for behaviors and attitudes through a staff-designed code of conduct, and educate staff on the basics of improvement and flow. This set the stage for improving the front end and throughout for discharged patients.
UPMC Mercy then took a subset of front-line nurses, techs, and physicians to create the ED Operations Committee (EDOC), which met bi-weekly for 2 hours, along with the administrative, physician, and nurse leaders for the department. This group was fundamental in working through processes and design. EDOC was educated more extensively on improvement techniques to promote flow and eliminate waste in the department.
The ED at UPMC Mercy had made progress, but was still faced with the front-end challenges of flow. It seemed that every day around 2 p.m. the waiting area in the department would become filled with lower acuity patients. There was still the belief that triage added some sort of value to a patient presenting with a minor complaint. EDOC decided that something needed to be done, but wasn’t quite sure how to get there.
With the case made for flow, the group decided that Super Track needed to be implemented fully. However, with a needed renovation and expansion starting, it was going to be difficult to find space to make this work. EDOC would not let this challenge stop them since the group realized the importance of dedicating the space and making the process work for low-acuity patients.
Rapid Cycle Testing – Creating the Community of Scientists:
During March 2010, the group developed trials of Super Track that would run for 8 hours on Mondays to test the concept and adapt it for use at UPMC Mercy. Three rooms were carved out of the extension pod and were staffed with a physician, 2 nurses, and tech support to ensure that flow would be maintained through the area. The trials were debriefed immediately after each completion to identify opportunities for improvement and to allow the staff to give direct feedback on changes that needed to be made for the next trial. The trials were extended to Mondays and Tuesdays in April 2010 and the process was finally live in May 2010.
For the 8-hour periods when Super Track was live during April 2010 through June 2010, the ED experienced an overall reduction of discharge length-of-stay by 25 minutes per patient. This further helped to improve the overall flow of the department and reduced the time it takes to be seen by a provider in the ED.
Figure 3 – UPMC Treat and Release LOS trend May 2009 to June 2010
Figure 4 – UPMC Door to Doc trend July 2009 to June 2010
The improvements made in the ED at UPMC Mercy were essential in the planning process for the renovation and expansion of the existing department. The use of queuing theory and operational improvement methods enabled the department to make quantitative decisions in the space planning for the department to ensure that flow would be optimized and there would be enough beds to effectively treat the three distinct acuity populations that are seen in the department. The major lesson learned in this experience is that you should not assume more beds and space are needed until you can quantitatively justify a shortage, only after improvements have been made.