By Shari J. Welch
With a robust quality improvement program in its emergency department (ED) since 1998, LDS Hospital in Salt Lake City, Utah, USA, has frequently used the routine analysis of operational data to improve its care for subsets of patients. Initiatives have successfully addressed pediatric patients with fever, acute coronary syndrome patients, endotracheal intubations and pain management, to name a few. When routine analysis of turnaround time revealed that the treatment of patients with simple lacerations took an average of more than two hours, the process for treating wounds was fully analyzed and streamlined by a project team.
Wound Care Initiative Using a DMADV Roadmap
LDS Hospital is a tertiary care hospital with the highest case mix index (a measure of acuity) in the state. Lacerations make up between 3 to 4 percent of chief complaints in the emergency department – about 1,400 a year. Knowing that numerous studies have demonstrated the relationship between wait time and patient satisfaction, the team began to build a new process model for treating lacerations by using a DMADV roadmap. It followed this outline:
Define – The problem was the inefficient treatment of lacerations and wounds in the emergency department.
Measure – The throughput time for patients presenting with the chief complaint "laceration" was the measure used before, during and after the initiative to gauge the success of the process model.
Analyze – The work team noted that because the acuity of the patients in the ED was so high, frequently the physicians felt unable to break away from sicker patients to perform simple wound closure. In addition, there were many steps to get a patient ready for the physician to perform wound closure, which confounded the problem of delays.
Devise – An education module, a change in the wound care process model and the development of a suture supplies roster were all solutions developed by the work team to improve the overall process.
Verify – Continued monitoring of turnaround times for lacerations revealed a 37-minute reduction in the time to treat lacerations. The training module has been repeated yearly for the benefit of new staff, and 30 minutes of this initial gain has been maintained.
The work team, comprised of physicians and staff, concluded that patients with wounds frequently experienced delays because other higher acuity patients in the ED kept the physician from breaking away to repair the lacerations. The physicians noted that getting a patient set-up for sutures often required several trips to the patient's bedside, only to find that the supplies and setup were not ready for laceration repair. From the staff side, the nurses and ED technicians noted that there was significant variation in the supplies used by each physician, and that the staff would have to find the physician to ask what size gloves were needed and what suture would be used.
The work team devised three remedies for these delays:
| Table 1: Laceration Processes Before and After |
Before | After |
Bedside Registration | Bedside Registration |
Doctor Evaluates
Requests Setup
Nurse Takes Order
Technician Sets Up
Doctor Anesthetizes
Preps Wound
Irrigates Wound | Staff Sets Up
Anesthetizes
Preps Wound
Irrigates Wound |
Doctor Sutures | Doctor Sutures |
An education module was developed to train staff in how to prepare a laceration for repair and to anticipate the needs of the physician in completing the task. Interestingly, this training module utilizes pig's feet as a human skin analog and the staff has a hands-on experience in wound evaluation, preparation and care. It is a popular education module for the staff.A new wound care process model was designed to eliminate steps in wound treatment based on the education module.
The staff and physicians created a roster indicating the glove sizes and suture preferences for each physician, which could be referenced in lieu of having to contact the physician each time.
The core content of the wound management educational module is:
- Mechanism of Injury/Wound Assessment
- Tetanus Guidelines
- Local Anesthesia
- Wound Preparations
- Risk Factors of Infection
Results of the Three Remedies
The turnaround time for lacerations in the emergency department went from 127 minutes before the initiative to a low of 89 minutes (Table 2). Each year the staff was educated in the principles of wound management and by the third year was 100 percent trained. This period showed the best turnaround times. Though there was slight recidivism noted, most of the gains have been maintained.
| Table 2: Turnaround Times for Lacerations |
Year | 1998
4th Qtr. | Intervention | 1999
1st Qtr. | 2000
1st Qtr. | 2001
1st Qtr. | 2002
1st Qtr. | 2003
1st Qtr. |
Turnaround Time
(Minutes) |
127
|
|
110
|
105
|
89
|
96
|
97
|
The initiative to improve the turnaround time of lacerations in the emergency department was successful. By eliminating steps in the process, educating staff as to expectations and employing a simple data roster regarding suture supplies, LDS Hospital was able to provide more efficient care for patients. An added bonus was an increase in physician satisfaction. When surveyed, 94 percent said they were satisfied or extremely satisfied with the new process model.
About the Author: Shari J. Welch, M.D., is the quality improvement director for the emergency department at LDS Hospital. She writes a monthly column in Emergency Medicine News titled "Quality Matters." Dr. Welch is a quality consultant for Utah Emergency Physicians and a member of the Emergency Department Benchmarking Alliance. She has been using Six Sigma techniques to improve ED operations at LDS Hospital for seven years, even though the hospital does not have a formal Six Sigma program. She can be reached at sjwelch@networld.com.
