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Patient Care

Conn. EMS, Hospitals Coordinate Patient Transport with New Technology

New Haven Register, Conn.

Aug. 27—When the K2 overdoses hit the Green and other parts of the city the evening of Aug. 14, ambulances rushed to bring the victims to Yale New Haven Hospital's two campuses.

As the overdoses turned into a crisis the next day, with ambulances answering 114 calls through midday Aug. 16, American Medical Response drivers were directed to either the York Street or St. Raphael emergency departments.

It was the job of the Capacity Coordination Center, situated on the fifth floor of the Smilow Cancer Hospital, to make sure both hospitals shared the rush of incoming patients—some of whom had overdosed, been discharged and overdosed again—so that neither emergency department was overloaded.

Fewer than 10 of the overdosing patients were admitted. If there had been a large need for beds, however, the coordination center's job would have become much more important.

The center "clearly was a huge asset as we transported 114 (cases) that were spread out over both hospitals as a part of the coordination and capacity of our new system," said Rick Fontana, director of emergency operations for the city. "I think everybody agreed that we were able to split the individuals based on their signs and symptoms to both hospitals and not to overburden either hospital at one time."

"We were quite busy," said Tim Craven, operations manager for AMR of New Haven, which serves seven cities and towns. "We deal with overdoses on a daily basis but the numbers were overwhelming."

The center, led by Maribeth Cabie, is the place that makes patients' trips to Yale New Haven, their stays in either of the two main hospitals and their discharges as efficient and comfortable as possible, according to those who work there and those who interact with the hospitals.

"There's a lot of factors that go into that perfect bed selection for that patient," said Cabie, who has a background in pharmacy. "What makes this work is the communication and collaboration within this room."

After patients arrive at the Emergency Department, if they are admitted to the hospital, other parts of the coordination center are linked in, from the pool of nurses and other staff who are not attached to a unit and who can be assigned where needed, to doctors who can discuss the care the patients need, to the staff who transport patients to their bed, to the people who clean and prepare the room.

The two elements that make the coordination center succeed are technology and increased communication among all the departments within the hospital, as well as the city's Department of Emergency Operations and AMR.

"It's about improving the processes," Cabie said. "If I can get you from the ED to your bed in a more timely and efficient manner, your care starts earlier and on the back end you're able to leave earlier. If I can even save 10 minutes in the ED ... over the course of a year that becomes a significant amount of time."

The technology is represented by a dashboard, run by the Epic medical records system that is used by all of the Yale New Haven Health System, including doctors' practices in the community. The computer screens give detailed information about patient population, available beds, bed-cleaning time, transport time and quality and safety indicators. The left side shows patients on their way to the hospitals, the center describes those who have been admitted and the right side shows discharges and ambulances on their way out, according to Dr. Victor Morris, administrative director of physician and patient access services.

"We are the first institution to create these dashboards," Cabie said. "They are built in and part of our electronic medical record, which is Epic. They update automatically with live feed because they're in the medical record and are able to update us with that situational awareness.

"The setup of using Epic for our dashboards has led a lot of academic medical institutions and health systems to come and visit us here," Cabie said, including the University of Pennsylvania.

But all the data would be useless if staff stayed in their departments, not in proximity to each other. "What makes this work is the communication and collaboration within this room," Cabie said.

While other hospitals track the number of patients coming into their emergency departments, "The way that we've approached the coordination center concept is different from what other places have," said Dr. Robert Fogerty, who is Cabie's "physician partner" in the center. "We spend more time thinking about patients that are here, as well as patients that are going home from here."

Not everyone involved is located in the coordination center, but meetings four times a day involve people who "dock in" from other departments: pharmacy, food and nutrition, TeleHealth, laboratories and quality and safety among them.

At the morning meeting, they may discuss "how many operating room cases we're expecting to have admitted into the hospital" as well as how many discharges are expected, Cabie said. "AMR will tell us how many ambulances have come to the hospital. It creates a picture of what the day looks like."

"It's very structured" so everyone who needs to know is aware "if an MRI scanner goes down or if there's an electronic medical record update," Fogerty said.

"It's a time where we can provide any critical updates that will impact the operations of the hospital," Cabie said.

From a practical perspective, because "we have two points of entries here in town," it helps everyone to have the "ability to help direct where they're able to go to so we can handle that patient better and quicker," said Dr. Andrew Ulrich, operations director for the Emergency Department.

By communicating with AMR as the ambulance is heading to the hospital, "Essentially, what they're doing is load balancing," Cabie said. "Having a good view [of] where beds are more or less available helps them to know where best to send that patient."

"I think the important thing is when you have multiple fire departments and ambulances out in the field transporting people to the hospital ... as you bring patients in, those patients get tied up in triage," said Fontana.

While a patient wouldn't be refused if he or she wanted to go to the main campus on York Street, they might be told "it's going to be an extended wait time" there and that they'd be better off going to St. Raphael, Fontana said. "I think the best thing is patient outcome is much better" by evening out the numbers, he said. "Our personnel are out on the street quicker."

Where to direct the ambulance "is one small part of what goes on in here," Ulrich said. "It was the realization of how many different services and groups are involved" in patient care and "integrating all those services together in one area. There were a lot of sequential activities that would occur. Here, what they've done is make everything work in parallel."

"One of the largest groups we have in here is our bed-management group," Cabie said. "Once it's decided that a patient is ready for admission, they're finding the right bed at the right time for the right patient.

"If we have a critical patient that needs an ICU-level bed, there may be collaboration within the room to identify the bed, make sure it's cleaned and to make sure that we get the patient to that bed as soon as possible."

The center also works with AMR when it comes to discharging patients. "We work on who do we need to get out, where do they [have] to go," whether it's a rehabilitation center or home, Craven said. "It's up to my employees to get the discharges out of the hospital."

By efficiently managing discharges, "My crew coming in is not delayed with a patient because there's now a bed in the emergency room," Craven said. If an emergency department patient is admitted, it frees up space in the ED, and "now the patient doesn't have to wait on my stretcher, waiting for a bed to become available," he said.

Another major component the coordination center relies on is the Nursing Resource Operations Center. "Our department is essentially the 'float pool,'" said Laura Jansen, interim clinical program director. "We have nurses, we have PCAs [patient care assistants], we have sitters," who will stay with a patient who might endanger himself or try to leave the hospital.

Jansen said the Capacity Coordination Center has improved her employees' ability to do their jobs. "Number one, it's created awareness within our group of how our department affects other departments within the hospital in regards to patient flow," she said. "Hopefully, it's streamlined and ... you're going to get your nurse assigned to you."

There are 400 members of the pool, including staffing associates "who actually live up here in the coordination center," Jansen said, communicating with others in the nursing resource center.

The nurses are "very vital to us, especially at times when we're at surge ... to potentially open additional beds for use," Cabie said.

The pool "is important to everything that we try to do, but I could say that about everybody that's in here," Fogerty said. "If the bed isn't clean or the room isn't clean, it doesn't matter. You could have the world's greatest surgeon.

"All the fancy IT and data stuff that we have ... sets the discussion," he said. "It reminds us that it's not about a job or a task. It's about the patient in the bed."

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