MEU Efficiency Gretchen Zsebik, Jonathan Boone, Amy Goss, Erin Wait - - PowerPoint PPT Presentation

MEU Efficiency

Gretchen Zsebik, Jonathan Boone, Amy Goss, Erin Wait

MEU Visits per Year

1000 2000 3000 4000 5000 6000 7000 8000 9000 10000 FY 2004 FY 2005 FY 2006 FY 2007 FY 2008 FY 2009 FY 2010 FY 2011 FY 2012

MEU visits by month/year

100 200 300 400 500 600 700 800 900 2008 2009 2010 2011 2012

Survey

• 1. Please indicate level of training (attending, lower level/upper level resident, nurse)
• 2. What are your responsibilities in the MEU?
• 3. What problems have you seen that make the MEU inefficient?
• 4. What are your suggestions to making the MEU more efficient?
• 5. Do you feel that the MEU pathways are readily accessible to you? Elaborate.
• 6. Do you feel that the MEU pathways are followed consistently? Elaborate.
• 7. Do you feel that the MEU pathways need to be modified/readdressed? Elaborate.
• 8. Any other comments that you have regarding the MEU and its efficiency?

What problems have you seen that make the MEU inefficient?

Attending:

• “Unnecessary labs, radiology and labor rechecks”
• “ Patients are sent to MEU for evaluations that could be better performed

as an outpatient, but because of insurance restrictions they cannot be seen as outpatients”

• “Pts sent from clinic for problems which could be dealt with in clinic—
• “Pts not educated”
• “Too many unnecessary tests ordered”
• “ Resident constantly pulled to multiple other sites. Large volume of

patients who present for issues better handled in a clinic setting”

What problems have you seen that make the MEU inefficient?

Fellow:

• “Volume of patients for number of residents, residents get bogged

down with H&Ps, residents not involving attendings early enough in the evaluation so that too little or too much testing is done”

• “Usually many patients at once, resident is usually trying to do too

many things at one time, all the information is recorded in different places (paper, impact, etc). The most inefficient part is that the notes do not come to the attending prior to checkout. They may sometimes come over after the fact.”

What problems have you seen that make the MEU inefficient?

Residents:

• “being called by upper levels repeatedly while trying to get work done “
• “Lack of appropriate amount of nursing staff. There have been several days in which we've only

had two nurses to see and evaluate patients. This slows down our efficiency if it's a busy day ‐ not

• nly do we need them to be chaperones for pelvic exams, but they also are critical for giving

prescriptions to patients and drawing labs or starting IVs.”

• “All the nurses insisting on seeing one patient at a time instead of someone being available to help

with exams”

• “Multiple checkouts to upper levels (i.e running the board over and over). Time it takes to use the

EMR system (H&Ps are time consuming and the departs/orders).

• “All nurses going into a new patient room leaving no nurses available to aid in other MEU tasks”
• “One thing that I have noticed is when ALL, as in every single RN gets up to help initially check a

patient in, it can limit the LLR's ability to Examine other patients. Just a thought, always have at least one RN who is responsible for being a chaperone”

What problems have you seen that make the MEU inefficient?

Nurse:

• “attending wait time, intern being called to other areas”
• “variation from pathways, pts told to come in by the MD <16 weeks

pregnant, 3rd RN being pulled from the MEU”

• “interns have too many pts that they are responsible for and this contributes to

longer waits for pts”

• “Lack of communication between MDs and RNs”
• “not following the pathways or adding certain labs/tests after the pt has been

here for a while, seeing pts less than 16 weeks”

What are your suggestions to making the MEU more efficient?

Attending:

• “Discussion with Chief resident / Attending prior to ordering labs, US, XRAYs”
• “ Educate pts better, Ensure pts evaluated quickly and discuss any extensive work up

with attd early in stay”

• “Improve patient education in the clinic on most common inappropriate MEU
• presentations. Consider either an NP or PGY‐2 who runs the MEU”
• “Prioritizing patients‐(ie sicker patients/laboring need to be seen first and definitive

plans need to be made prior to seeing nonsense complaints in MEU)

• “ upper levels need to set guidelines on how frequently the MEU board needs to

be run‐‐That way, this will allow upper levels not to frequently interrupt their flow of

patient care (this also often happens when multiple upper levels call despite plans being checked out to a different upper level)”

What are your suggestions to making the MEU more efficient?

Fellow:

• “More upper level resident involvement, make H&Ps brief and problem‐

focused, finish all work with one patient before moving on to next patient”

• “ Streamline the H&P writing. More upper level supervision and no "sink
• r swim" attitude”

What are your suggestions to making the MEU more efficient?

Resident:

• “scheduled calling of ULR to checkout pts”
• “ Always have at least three nurses available for patient care”
• “ systematic form of communication between residents and nurses”
• “NP to filter out bogus complaints”
• “residents should maybe have one designated upper level to check things
• ut to rather than the entire board team”
• “have enough RN staff, having enough MD staff is also an issue at times,

but we would need more residents in our program...”

What are your suggestions to making the MEU more efficient?

Nurse:

• “ have the intern stay put. Have an upper level resident readily available

and actually willing to come over and help”

• “use the white board”
• “if scrub techs aren’t busy they could help with chaperoning”
• “have either 2 interns collaborate to run the MEU or have a 2nd year run

the board”

• “ better communication between nurses and residents”

Do you feel that the MEU pathways are followed consistently?

Attending:

• “I think that there may be too much emphasis on following the

pathways—not every patient with preterm cxns needs a wet prep, GC, CT. Also, the lack of attention to detail in making diagnoses leads to over‐treatment (e.g. wet preps should be evaluated with Amsel’s criteria—not every patient with a few clue cells should get metronidazole).”

Do you feel that the MEU pathways are followed consistently?

Resident:

• “yes, may need more flexibility to deviate when appropriate”
• “I think that sometimes they're followed too consistently. Not every

patient is equal, and it's extremely bothersome when our clinical judgment is questioned because we're ‘going against the pathway’”

• “yes. I think educating the nurses about individualization that sometimes

makes you stray from the pathway would be helpful. This is another area that slows the MEU because they ask all the other residents and attendings about path deviations before the task is completed”

Do you feel that the MEU pathways are followed consistently?

Nurse:

• “no..not usually the fault of the intern, but more the upper levels and

attendings”

Do you feel that the MEU pathways need to be modified/readdressed

Attending:

• “If the pathways actually require the 4 hour rechecks that are unnecessary

then yes”

• “Yes, they should be reevaluated periodically”
• “I think that they should be addressed by the MFM Division during their

current effort to revise the OBCC Guidelines.”

Do you feel that the MEU pathways need to be modified/readdressed

Fellow:

• “They should be continuously evaluated. I think they are good guidelines”

Do you feel that the MEU pathways need to be modified/readdressed

Resident:

• “Absolutely. Some of them have not been updated in years and the literature has

changed on particular topics.”

• “if the pathways are treated like guides and not rules they are fine and a good

starting point for pt evaluation”

Do you feel that the MEU pathways need to be modified/readdressed

Nurse:

• “yes..more flexible for certain conditions and we need a dizziness

pathway”

• “no there should be stricter adherence to following them”

Any other comments that you have regarding the MEU and its efficiency?

Attending:

• “Often it’s feast or famine in MEU. Feasts can be difficult to deal with. Not

sure how willing JRs are to contact the attending when the SR is out of touch.”

• “Pts in each health dept and Primecare and MFM should be given office

numbers and be told to come to MEU only for emergencies unless they are told to come by clinic or other health care provider”

Any other comments that you have regarding the MEU and its efficiency?

Fellow:

• “If funding is available for mid‐level provider, this would help efficiency”

Any other comments that you have regarding the MEU and its efficiency?

Resident:

• “I think overall the MEU works well, but there is definitely room for

improvement (see all of the above). It would work even better if we could get a few of the nursing staff to cooperate more with us and help us get the job done”

Any other comments that you have regarding the MEU and its efficiency?

Nurse:

• “ A Nurse Practitioner would be awesome”
• “ Educate clinics for appropriate usage of MEU so that they can inform patients”
• “I feel that an NP would be an asset in triage. Pts could be seen quicker and be

admitted/discharged in a more tiemly manner.

• “There also needs to either be an upper level over here or 2 interns”
• “I think that the clinics need to be informed of WHEN to direct pts here. Better

education for pts through the clinic would be helpful”

• “Add an NP to the MEU to help see uncomplicated pts and have them dc’d more
• quickly. Keep 3 RN’s and a PCT in MEU”

Summary of Problems..

• High volume partly due to inappropriate patients
• Length of patient stay
• Inappropriate testing
• Discharge H&Ps / documentation
• Pathways needing revisiting –i.e. dizziness
• Education of patients in the clinic
• Nursing staff availability for chaperoning, etc.
• Multiple checkouts to upper levels

MEU Visits per Year

1000 2000 3000 4000 5000 6000 7000 8000 9000 10000 FY 2004 FY 2005 FY 2006 FY 2007 FY 2008 FY 2009 FY 2010 FY 2011 FY 2012

Cost

• MEU visit = ~$1500
• Reimbursed = ~$740
• Budgeted for 2.5 hours stay (hospital protocol)
• >4 hrs stay costs above what is budgeted

Statistics

92% of pts are admitted (in the computer, arm band generated) within 10 minutes of presentation

‐( why multiple RNs go in the room initially to facilitate this process)

52% of lab orders occur after the pt has been in the MEU greater than 1 hour

‐ (data from 1 quarter in 2012)

Proposal

In the MEU…

• Nurse Practitioner vs PCT
• Triage pt’s level 1‐5 for level of priority

– Could have PCT take vitals/doppler heart tones in area

• utside MEU
• Have designated upper level (PGY‐3?) call the MEU for

‘updates/checking out pts/plan of care’ whenever time to update the board on L&D (q2 hrs); continue to utilize the tracking board to communicate tests/plan of care/tasks accomplished

• Involve attending sooner rather than later if not

straightforward patient

In the MEU

• Surgical techs could assist in the MEU when

no cases are going

• Update/revisit pathways (i.e. dizziness , 3rd

trimester N/V, etc.)

• System for pathway deviation/ when ok to

deviate

• LOS <4 hrs for pt discharge
• New template for discharge H&Ps to make it

easier for quicker note‐writing

In the Clinic…

– EDUCATION! $1500 / visit!

• Develop a video to be run on repeat in clinic waiting rooms

covering important issues/what to expect in pregnancy

• OBCC‐‐Have medical students give talks at certain times each

day when the most women are in the waiting room (10:30 am and 2:30 pm)

• Have med students pop in and discuss certain issues with

handouts when clinic is getting busy and pt’s are waiting in clinic rooms.

• This must be communicated to outlying health departments,

MFM, Primecare

– This will hopefully cut down on MEU visits for non‐ emergent reasons and will encourage student education

• Questions/Comments