As many as 40% of patients in the nations’ emergency departments (ED) require a bedside consultation from a specialist—consults that, depending on time of day and availability, could cause significant wait times for patients.* Many across the country believe these wait times can result in patient and provider dissatisfaction as well as increased lengths of stay. (Pictured left to right: Evalina Burger, MD and Jen Wiler, MD)
This is why the Clinical Leadership Council (CLC) of the University of Colorado School of Medicine introduced a pilot project to improve the effectiveness of requests for consultation. The result was the creation of a novel workflow that allowed for the capture and analysis of data. The workflow was implemented by the emergency and orthopedic departments at University of Colorado Hospital. Since the pilot was launched, 2,000 data points have been analyzed, and the workflow has been demonstrated to be sustainable and adaptable across hospital services.
The project was brought before the CLC in 2013 when variability in consultation responsiveness was identified as a common problem within the system. Using previous initiatives that established a stratified framework of consultation priorities and definitions of timeliness, the project aimed to implement and evaluate the framework as it relates to “level 1” consult requests, which requires the consultant to call back within 10 minutes and provide actionable recommendations in Epic within one hour.
“Our mantra in the ED is ‘patient centered and data driven,’ so the opportunity to measure this part of care delivery has been important,” said Dr. Wiler.
Evalina Burger, MD, is vice chair of the Department of Orthopedics and also sits on the CLC. For her, volunteering the orthopedics department to be part of the pilot project was a no-brainer: She had recently experienced a significant wait for a consult while she was a patient in the emergency department.
“It was a frustrating experience,” she said. “My own personal experience is what made me want to dive into this project in order to do right by our patients.”
Prior to implementing the workflow, project leads agreed that the process needed to remain patient-centered. All care plans needed to be well-documented and actionable, with agreement on the shared expectations for both requestor and consultant. The workflow also needed to provide for alignment across all UCH care settings for priority definitions and ambulatory consultation types.
The workflow implemented in the ED starts with a timestamped Epic consult order. This triggers an automatic page, which identifies the department the request is coming from, the patient’s name, medical record number and location. It identifies the urgency level and provides the consultant with a call back phone number. A second timestamp is created once “actionable recommendations” are entered into the patient record and received by the ED. Once the full consult note is complete, a third timestamp is created for billing purposes.
The timestamps allow for the data to be collected and assessed. Since data collection began in February 2015, the ED and orthopedics teams receive a monthly analysis that allows for ongoing discussion about improving responsiveness.
The workflow has been proven to be sustainable across 100+ ED providers and orthopedic surgeons. The team is confident that this “proof of concept” pilot has been successful.
“I think the collaboration between the ED and orthopedics team has been exciting. It’s been productive, and it helps to show that looking at handoffs of care and co-managing patients is an important area to optimize care delivery,” said Dr. Wiler. “So now we’ve proven the workflow works, we’ve proven we can capture actionable data, and now it’s a question of dissemination across the organization.”
“Above all, documenting these consults and measuring our response time is the right thing to do for our patients,” said Dr. Burger.
This fall, the group will launch a performance improvement initiative to improve gaps and barriers that may cause miscommunication. The group aims to identify a positive correlation between consultation responsiveness and ED length of stay. If a positive correlation is present, the project can be spread across other departments who receive consultation requests from the ED.
* R.S. Lee, R. Woods, M. Bullard, et al. Consultations in the emergency department: a systematic review of the literature. Emerg Med J, 25 (2008), pp. 4–9.
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