MID-TRACK

AHRQ Annual ConferenceSeptember 27, 2010 Jeffrey Margulies, MD, FACEP

Why: Collateral damage

What: Identifying the Initiative

• 2.4% LWBS (left without being seen)

• Drill Down reveals ESI 3 issue

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

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%

When: Do the math

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

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

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

LWBS rates pre and post Mid-Track

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

Future of Mid-Track

• Successful initiative to date

• Expand hours and days of operation

• Expand ESI 3 patient complaints

• Included in new ED redesign

Modern Healthcare

Thanks to the team!

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