A Lifesaving Living Lab

New Emergency Department at Mayo Clinic will be first in nation to embed an engineering lab

By Mayo Clinic Staff

The Emergency Department at Mayo Clinic Hospital, Saint Marys Campus, is opening its doors to health care delivery researchers to improve care.

If the Emergency Department is a busy street intersection, Alesia R. Fratzke, a physician assistant at Mayo Clinic Hospital, Saint Marys Campus, in Rochester, Minn., is one of its traffic controllers, triaging patients and guiding them through waiting room congestion so that they can get the care they need.

For one patient, Fratzke's decision to redirect traffic was the difference between life and possible death.

"I remember this gentleman in his 80s presenting to the intake window, and for some reason he caught my attention," Fratzke recalls. "He didn't look ill. He was sitting in a wheelchair and was very pleasant and upbeat."

An intake nurse checked the patient's vital signs, which all registered normal, and asked questions about his symptoms. He said he experienced extreme abdominal pain at home but was feeling better now — that the pain went away during his hourlong drive to Mayo.

Based on the initial evaluation, the nurse determined the patient's status was less severe than those who needed more immediate access to the evaluation rooms — which were all full at the time — and that he should return to the waiting room.

Fratzke paused to consider the nurse's recommendation.

"His abdominal pain must have been severe enough that he would drive all the way to Mayo. It just didn't make sense, even though his vitals seemed fine."

Fratzke made a judgment call. "I'm concerned about this gentleman," she remembers telling the nurse. With no rooms open, the nurse suggested taking the patient to the critical care unit.

Within minutes of moving from intake to the critical care bay, the patient's aorta ruptured.

A response team immediately placed an IV, gave blood products, performed a bedside ultrasound and lab work, and prepped the patient for surgery.

With the help of Fratzke's quick maneuvering, the patient was at the right place at the right time and survived a usually fatal condition.

But what if?

What if Fratzke's patient had returned to the waiting room instead of entering critical care? What if he crashed without a doctor or nurse nearby? What if the surge in resources to treat Fratzke's patient negatively impacted access to care for other patients?

Not knowing the downstream impacts of such "what if" scenarios is impairing health care in America, say two experts at Mayo Clinic — Jeanne M. Huddleston, M.D., a physician with a master's degree in industrial engineering, and Thomas R. Rohleder, Ph.D., a scientist specializing in operations management. Together, the pair leads the Health Care Systems Engineering program at the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery.

"America's health care system works because of the heroic actions of our providers in spite of the system," says Dr. Huddleston, the program's medical director.

Health care in the U.S. is rife with problems — long wait times, medical errors and fragmented care, to name a few. The problems lead to inefficiency and redundancy, driving up costs while driving down quality. For patients, Dr. Huddleston says the net effect is "churning, back and forth, with no clear endpoints." And patterns like that compound health care spending in the U.S., projected at $4.5 trillion by 2019, or 19.3 percent of the gross domestic product, according to the Centers for Medicare & Medicaid Services.

Drs. Huddleston and Rohleder don't view the stats as a terminal prognosis for health care in America, but a call to action. The solution is applying the same systems engineering principles to health care that other industries employ to deliver better services and products at lower costs, says Dr. Rohleder, the Robert D. and Patricia E. Kern Scientific Director for Health Care Systems Engineering. He believes Mayo Clinic can lead the nation in designing better systems through computer simulations and predictive analytics — scientific ways to use data to make evidence-based decisions.

"Because these ideas from systems engineering are just now being applied in health care, I think there is tremendous hope," Dr. Rohleder says. "There is so much we can do for people everywhere."

A living lab

The Health Care Systems Engineering team, like all medical researchers, needs a laboratory to test hypotheses. But the conventional laboratory environment — controlled and simulated — won't do. In a live emergency department, nurses are interrupted seven to eight times a minute, with staff and equipment always on the move and noise a constant distraction.

It's high flow and high stress. And it can't be replicated in a lab. So the engineering team will observe the real thing: the Emergency Department at Saint Marys campus.

When the team pitched the concept of embedding a clinical engineering laboratory in the Emergency Department, Drs. Huddleston and Rohleder found eager collaborators in Annie T. Sadosty, M.D., chair of the Department of Emergency Medicine at Mayo Clinic, and Eric T. Boie, M.D., chair of the facility redesign project underway at Saint Marys campus.

"Our Emergency Department is one of the highest achieving in the country, but we want to be better," Dr. Sadosty says. "On the days when we have 22 people in the waiting room, we know that it doesn't feel very good to be one of those 22. We want to be there for everyone when they need us."

Mayo's clinical engineering laboratory will be the first in the nation where health care researchers — including clinicians, systems engineers, informaticians and social scientists — collaborate in a live patient care environment. By embedding the lab in the Emergency Department, researchers will have access to real-time data — the raw material for computer simulations and predictive analytics.

As construction crews open the walls to expand the department's footprint, they plan to install radio frequency identification (RFID) technology. These readers track "anything that moves," explains Dr. Huddleston. Researchers will follow providers, patients and equipment throughout the Emergency Department, seeing where bottlenecks form and why.

The information gathered will give researchers hard data to prove which tweaks to the system work and which don't.

"Right now, when we make changes to our practice, our ability to scientifically evaluate whether those were good changes or not is limited," Dr. Boie says. "When we have hard data about where patients spend their time, we can better determine value. We can conclude that a change resulted in the patient spending 30 percent less time in radiology, for example, or no, that change actually extended their visit."

Better care faster

One change Drs. Sadosty and Boie plan for the Emergency Department aims to improve triage so that providers like Fratzke don't need to make last-minute interventions when beds are unavailable.

"Most patients who are upright and walk into the Emergency Department don't need to lie down in a bed," Dr. Boie points out. "How can we evaluate those patients efficiently without taking rooms from the patients who most need them?"

Their answer is a new intake area where providers can perform more-thorough examinations at the time of check-in, take lab samples and better determine a patient's next steps. The goal is to move patients out of the waiting room sooner and connect them with more tailored care.

With the clinical engineering laboratory's data, the Health Care Systems Engineering team can monitor the implementation of the staging model, study the downstream impact to patient flow throughout the Emergency Department and offer strategies for continuous improvement.

"We'll know a patient's time stamps when they arrive and move on to the next step in their care. And for the first time, we'll have time stamps for the providers," Dr. Rohleder says. "We can take those data and create different models in a computerized environment, rather than a physical one, and predict the consequences, benefits and trade-offs to the patient."

Beyond the Emergency Department, the Health Care Systems Engineering team believes integrating medicine and systems engineering throughout health care could remedy the country's struggling system.

"It's all about connecting the right patient at the right time with the right provider — the first time," Dr. Huddleston says. "By re-engineering the health care system to support this, saving lives depends less on heroics and more on science."