Hello, everyone, and welcome to the 2022 ACC Quality Summit. Hello, I'm Mary Jane Ayers. I'm the Clinical Director of Cardiac Programs at York Hospital in York, Pennsylvania. York Hospital is a 596-bed community hospital that serves as a tertiary care center for our eight-hospital healthcare system. Today I'm going to discuss some of the initiatives that we implemented at our hospital that helped us manage our observation length of stay for our acute coronary syndrome population. The objective of this presentation is to identify two things that could help reduce the length of stay for acute coronary syndrome observation patients, to also understand the importance and cost-effectiveness of observation services, and then also to identify obstacles to meeting the goal of a 16-hour acute coronary syndrome observation length of stay. So before we talk about reducing the observation length of stay, I think it's really important to review what an observation patient is. Many times patients come in through the ED, and we're just not quite sure through the ED assessment and treatment whether the patient is able to safely go home from the ED or if they really need that inpatient admission. And so patients are placed in an observation status when we have ongoing testing that can help make that decision, and then also we can also provide some short-term medical treatment to these patients until we decide whether they can safely be discharged home and followed up in the ambulatory setting or if these patients really need to be admitted to an inpatient status. For our acute coronary syndrome population, we would really like to get these patients either assessed and safely discharged on their way home or get their assessment complete that we know that maybe they're sicker and they need to be a full-blown inpatient. These observation patients can either be placed in an observation unit, which a lot of hospitals have. We have a dedicated observation unit here, or a lot of times if the observation unit is full or if you're at a hospital that does not have a dedicated observation unit, those patients can be admitted on the inpatient floor. And they're mixed in the general population with inpatients. So when you are on an inpatient floor that may have observation patients mixed in with them, it's very important to know which patients are observation and which patients are inpatient status because those observation patients, you really want to keep their testing moving forward and their assessments moving forward so we can get to the point where we're going to make a decision if this patient really needs admitted or if this patient can safely be discharged. The goal for observation status is a minimum of eight hours. So to be able to bill for observation services, a patient must be in observation status for at least eight hours. And then really for these acute coronary syndrome patients that we send to observation, we want to make sure that we're getting them out within 16 hours is our goal. The time, the clock kind of starts ticking when that initial observation order is placed. So if that observation order is placed in the ED and the patient doesn't move out of the ED to their bed until two or three hours later, that two and three hours, the clock was still running. And so that counts. It's really from the time that the observation status was initiated regardless of the location of the patient at the time. Some of the things that we implemented here that really worked for us other than the couple initiatives that we're going to dive a little deeper into during this presentation. One was in our EMR. We were able to identify on the nursing patient list which patients are of an inpatient status and which patient are on an observation status. And that was for nursing and providers within our EMR. So it was very easy for them to identify which patients were inpatient status and which patients are observation status. And then also there is a running on that patient list. There's also a running clock of how long that patient has been here. And then we have thresholds. So once they hit a certain number of hours, they'll turn yellow. And then once they hit that 16-hour point, they will turn red. This is a really useful tool, especially when trying to identify those patients quickly and have access right in front of you of who is in observation status and who is on inpatient status on those mixed floors. So a couple of the initiatives that we implemented here that seemed to work for us that we're going to dive into during this presentation. One was that we developed very strict inclusion and exclusion criteria for observation patients. And then along with that criteria, we really had a double and triple, you could almost say a triple screening process for proper placement of these patients, especially the patients who were going to be assigned a bed in our observation unit. And the second thing that we have begun to look at here is how we can break down the barriers to patient discharge during what we call off hours. So evenings and weekends, we found that it was harder to discharge patients even though that clock is still running during those hours. How can we really make this a 24-7 discharge process for our observation patients? We found success with trying to keep the throughput moving through an especially dedicated observation unit is to really pick the right patients for this unit. And so anyone who has a complex social issue or a potential need for a long-term placement, as we all know, these can add hours and sometimes days to try to get them the right social support that they need before we would discharge them. So these patients, we would not want to put in an observation unit. Also, patients who will need a lot of nursing care and kind of tie up your nursing resources for periods of time, we also don't want to place those types of patients on this unit just because we really want the focus to be on throughput and making sure that we're getting patients assessed and to testing in an expedited manner so that we can really make an informed decision about which direction this patient's going to take. So if you have patients who are total nursing care or need titratable meds or are on isolation or may end up going through alcohol withdrawal, these are patients that we would not really want to select for a dedicated observation unit just because they are by nature going to need more nursing support, and it will tie up your nursing staff who is really focused on reassessing patients and figuring out if they are safe enough to go home or if they're going to stay in an inpatient status. To help make sure that our exclusion criteria was being followed, we implemented a patient selection screening process. So once the initiate observation status order was placed for a patient in the ED, our patient logistics department or our hospital patient placement nursing team would review the patients for appropriateness to make sure that they met the inclusion criteria and that for any reason they wouldn't have had one of the exclusion criteria before they would give them a bed assignment on our observation unit. Once the bed was assigned, the charge nurse would review the patient for appropriateness. So again, it was more, we called it a double-check process, but it is almost a triple-check process with the physician initially putting in the order, the patient placement team reviewing it, and then also the charge nurse on the unit reviewing the patient for appropriateness to make sure that we met our inclusion and exclusion criteria. If anything was found to be inappropriate in the placement of this patient or something that the patient placement nursing team or the charge nurse found that they were questionable whether this patient was appropriate for placement on the observation unit, we would initiate a three-way call between the patient placement nurse, the charge nurse on the unit, and the admitting physician to go through the patient history and kind of what was found that was questionable and review together as a team if this patient was appropriate for observation placement or not. On this slide, you can see our median length of stay for chest pain observation patients over the period of time of April of last year until February of this year. You can see that our baseline before we implemented a lot of these measures that I just talked about, we were well above 30 hours for our median length of stay for chest pain observation patients. And since then, we have really drastically improved with our lowest month being in November at 16 hours. As I said before, a lot of our patients do go to the dedicated observation unit. However, we also do have a fair number of our patients who are intermixed on the regular inpatient nursing floors. So, as I think our inclusion exclusion criteria process of who we send to our observation unit and who we do not, along with our double check system has really helped. But I also think that that visual cue in our EMR has really helped improve this metric as well, which is why we see such a drastic drop in all of our chest pain observation status patients. So, these patients depicted in this graph are all patients regardless of if they were on the observation unit or not. The next initiative that we're going to discuss is the barriers to 24-7 discharge. Currently, we are in the process of identifying all of these barriers with the goal in mind of eventually being able to discharge patients at 2 o'clock in the morning, the same we would discharge patients at 11 o'clock a.m. or noon. So, really, it's identifying why we can't discharge patients the same in the evening and overnight and on the weekends, the same as we do Monday through Friday during normal business hours. Two of the barriers that we have found are some of our largest barriers are, is one, the physician availability, and then two, the timing of our ancillary testing. Because provider availability was one of the 24-7 discharge barriers that were identified, we have started to develop a discharge by checklist criteria for our observation patients. And what that entails is the development of a checklist for each patient that the provider spells out for nursing of what needs to be completed and what parameters the patient needs to be within to be discharged. So, once the provider enters that checklist of what that specific patient needs and how they should look when they leave, nursing can follow that. And once everything on that checklist has been completed and the patient is within the parameters set by the provider, we can go ahead and discharge that patient without the provider needing to come back and see them again. Another major barrier that we identified was the operating hours of our ancillary departments and kind of the timely testing that needed to be done, especially for these acute coronary syndrome patients who we really want to be able to evaluate and get results back within that 16-hour time frame. And so, as you all know, cardiac patients present themselves all hours of the day, any day of the week. And so, you know, many of those patients may need an echo, or they need a stress test, or they need certain radiology studies where those ancillary departments may not be operational during much of the time frame of the 16 hours for that observation patient. So, to help work through that, we really have focused on looking at extending hours for our ancillary departments, and then also making sure that the ancillary departments are aware of these patients and the test that they need and the status that they're in. And then also making sure that once the test is done, that it's also read within a timely manner so that those results are available for the purpose of the provider to be able to make an informed decision if this patient can indeed go home, or if indeed they do need that higher level of care and to be admitted as an inpatient. We have implemented some of these extension of hours in our ancillary departments, and but primarily, you know, we have a daily huddle with nursing and the ancillary departments. And, you know, this is a chance that specifically by patient, you know, the nursing floors can report out exactly who they have and who is ready for discharge. And we do this early in the day so that those folks who, you know, may have come in later in the evening or overnight are identified by those ancillary departments and so they can get them down and get their test done. And they can get their test read and we can keep the throughput through the observation unit and also all the observation patients who are mixed in on the inpatient units that we can really get a decision of if this patient is going to go home or if we're going to keep them. As I said, we're in the very early phases of implementing some of this. I will say that we have been doing the daily huddle for some time now and so I think we've seen some movement. The checklist is something that we're still working on and we have not implemented here. However, you can see in this depiction of times of the day that patients were discharged in July of 2021 from our observation unit to observation discharge times in July of this year. And so you can see a year ago, we really only had one patient who was discharged kind of outside of the normal operating hours. And then you can see in July of this year, that's kind of spread out a little more. We've had a couple more discharged in the very early hours of the day as opposed to what we saw even a year ago. And so we're hoping that with more of these initiatives and especially with the provider checklist to discharge criteria, that we'll really be able to move the mark on this and see more patients being discharged kind of around the clock instead Any initiative that you want to implement to improve your observation length of stay, it's really good to have a couple different ways to measure your success and also to identify where you can maybe fine-tune some things. So one of the things that we've done is we've fine-tuned some things. So one of the things that we monitor currently for our turnaround time testing, as you can see, we monitor based on service area and type of modality that the test is to be done on. And then we also separated out what our dedicated observation unit turnaround times are as opposed to our overall observation population turnaround times. As you can see on this graph, the patients who are in the observation unit have some better turnaround times than those that are on the general floor. Mixed in, and I think this is primarily because of the focus of the nursing staff on the observation unit. But this will give you some important information as you're working through some of these things. And so maybe there's things that the observation unit is doing that the rest of the hospital is not, and maybe they can learn from some of that and vice versa if you see it the other way around. And also just to know the status on the different modalities and kind of how long it's taking each modality to get these patients their test and their turnaround time for how long it's taking them to read. So maybe you can pinpoint and identify some of those areas and kind of who you might need to get on board to help you improve. And then also you can learn from those who are maybe doing well and maybe learn some tricks of the trade from them. So I just wanted to share this with you so that you can see some of the tools that we have used internally to help track how we implement something. And then just kind of break it out so that you can really focus in on some areas that maybe you have more room to improve on. And then also gather some tricks of the trade or things from folks who maybe are doing a better job than other areas. I just want to end with this is really one of these initiatives where everyone really needs to work together. So providers and nursing as well as your ancillary departments. It really takes the whole team to move your observation length of stay. These patients are here for such a short time and there are very specific things that each one of them needs so that we can make an informed decision about whether to send them home or admit them. And so it really, the earlier you can get senior leadership involved and the earlier that you can really bring everyone to the table and kind of have everyone working together for the same cause and for the benefit of our patients, I think the more successful you'll be. Please feel free to email me with any questions that you may have. Thank you all for taking the time to listen today and I wish you much success at your facility. And again, you can email me with any questions that you may have. Thank you.

ACS patients

observation length of stay

initiatives

electronic medical record system

improvement

teamwork