LOUISIANA ED RAPIDLY IMPLEMENTS NEW SPLIT-FLOW MODEL TO REDUCE LWBS RATES AND IMPROVE PATIENT EXPERIENCE DURING DELTA SURGE

EXECUTIVE SUMMARY

During Summer 2021, the Delta variant of COVID-19 caused patient volumes to surge by more than 30% at St. Francis Medical Center in Monroe, Louisiana. The surge—lasting from July 2021 to September 2021—required innovative collaboration between Core and the hospital’s onsite leadership and clinical teams. Together, we implemented innovative rapid cycle improvement processes that addressed surging volume, ensured patient safety and care quality, and mitigated spiking Left without Being Seen (LWBS) rates.

THE SITUATION

Core began managing St. Francis Medical Center’s emergency department in May 2020. The staffing model in place accounted for 125 ED patients/day. Over time, volume fluctuated to about 150 ED patients/day, and Core re-adjusted, hiring advanced practice providers (APPs) and two new board-certified emergency medicine physicians to serve the Monroe community. In July 2021, these adjustments were challenged by the Delta variant of COVID-19. Among Monroe’s community of just under 50,000, only 36% of the population were vaccinated. As a result, many community members impacted by Delta required medical attention at the hospital. This demand had a direct impact on emergency department operations.

The first impact was record-setting ED volume that strained staff and existing processes. The surge sent patient volumes climbing from 150, to 175, to 200, to 250—and on the busiest day in August 2021—to 264 patients in one day. This rapid surge caused LWBS rates to spike and patient experience to suffer. One day in mid-July, 20 patients left without being treated. Fortunately, Core had a surge management process prepared that nearly immediately righted LWBS percentages, positively impacted patient experience, and earned St. Francis a reputation in the community for outstanding COVID-19 care.

STRATEGIES TO ADDRESS THE SURGE

Core’s Vice President of Operations, Mark Canada immediately recognized a challenge of this magnitude would require his onsite presence. Addressing the jump in LWBS scores could not be ignored or handled over a phone call or monthly department meeting. Mark spent the next month regularly traveling to Monroe and worked in close partnership with the local leadership and onsite team at St. Francis to implement the following solutions to address the surge:

RAPID-CYCLE IMPROVEMENT TO IMPROVE ED FLOW

Typical Lean methodology takes 8-12 months. That timeline would not work to address the urgent implications of this surge. Rapid-cycle improvements (flow improvements made in 3 months or less) were required. Rapid-cycle improvements call for a four-step approach: plan, do, study, act. In the case of St. Francis, we implemented this approach in a hyper-accelerated manner, within a matter of days and weeks.

ADDRESSING THE REGISTRATION AND TRIAGE BOTTLENECK WITH A SPLIT-FLOW MODEL

The primary pain point causing LWBS rates to climb and patient experience to suffer was registration and triage. Mark collaborated with St. Francis’ nursing leader to address the bottleneck with a split-flow model. Within two days, they developed and implemented the process. Any patient who arrived at the ED with a COVID-related request (a COVID test, a desire to receive a monoclonal antibody, or had COVID-related symptoms) received a Medical Screening Exam (MSE) from a triage nurse, a registration clerk, and an APP. All other patients were directed to a separate registration and triage area, also staffed by a triage nurse, registration clerk, and an APP.

CONTINUALLY COLLABORATING TO REFINE PROCESS

After implementing the split flow model, Mark remained onsite to observe its effectiveness with an outsider’s eye. Each day, he debriefed with nursing leaders to discuss how the new process was going. Based on these discussions, the process was continually refined. In one revision, we re-arranged and added seating for a hallway in the ED that was being repurposed for visitor overflow. In another, iteration, we made the transfer process from the ED to the infusion area clearer by adding a color-coded visual queue to alert the nurses in the clinic when a patient had received their MSE and was ready to go upstairs.

REPURPOSING SPACE TO IMPROVE FLOW

Once the registration and triage bottleneck was resolved, the volume surge grew and another choke point revealed itself: the infusion area where patients received monoclonal antibodies on an IV drip was not large enough to accommodate demand. It was a priority at St. Francis Medical Center to make sure patients who needed this potentially life-saving treatment could walk in and get it, fast, rather than scheduling an appointment. The hospital identified a large conference room on the hospital campus to convert into an ER clinic area during the surge to address the space challenge.

Mark again traveled onsite to help set the space up as a dedicated infusion area that could see 30 patients at a time. The infusion area had an elevated command center to keep tabs on patient status. The NPs, PAs, and nurses staffing the area calmed patient nerves by educating patients and their families on expectations about this treatment, which is a relatively new therapy. The split-flow registration process was modified again to transport patients either by van or golf cart shuttle to the new clinic. This new, larger treatment area lifted a huge burden from the existing ED and hospital spaces and had a significant positive impact on patient experience and community perception.

THE RESULTS

By working hand-in-hand with the hospital to implement a rapid cycle improvement process to address the surge in patient volume due to Delta, we were able to design, implement, and refine clinical processes to meet patient demand. These efforts helped alleviate provider burnout and burden and ensured patient care remained high quality and efficient, despite the challenge surge.

• 90th percentile+ patient satisfaction scores in height of surge

• Maintained 0.5% LWBS rate after rapid cycle improvements

• 100% Sepsis bundle compliance during the surge

• 5,000+ doses monoclonal antibody infusion treatments administered