Dr Sally McCarthy - Emergency Care Institute - NEAT The Longer Term

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Dr Sally McCarthy delivered the presentation at the 2014 Emergency Department Management Conference.

The 2014 Emergency Department Management Conference explored areas such as how to improve access to care, clinical redesign, NEAT compliance, patient flow, point of care testing, geriatric care, and enhance the performance of Emergency Department.

For more information about the event, please visit: http://bit.ly/edmanagement14

Published in: Health & Medicine
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Dr Sally McCarthy - Emergency Care Institute - NEAT The Longer Term

  1. 1. (?After) NEAT: the longer term Dr Sally McCarthy FACEM, MBA Director, Emergency Care Institute, NSW Agency for Clinical Innovation July 2014
  2. 2. The story so far • Focus on time EFFICIENCY • Reduced time in ED • Impetus to create / improve inpatient data • Focus on whole patient journey/ care pathways • Focus on “integrated care” • Initial work on clinical, and particularly medical, engagement • More attention to quality
  3. 3. Or, the story so far • Reduced time in ED: variable • Inpatient performance lagging • Where is the data? • Insufficient focus on proactive improvement • Dysfunctional relationships under even more strain • “gaming” rather than changing • Little attention to quality • Remains the ED’s problem
  4. 4. Impact of explicit targets May 2014 AHHA
  5. 5. Time based targets, safety and quality impact • Direct impacts of reducing ED overcrowding • Significant increase in quality focus • Recognition of importance of positive changes in leadership and management activity for success • Some early positive clinical benefits measured • Await evaluation research • Need standard set of indicators of quality of clinical care and consumer experience
  6. 6. UK outcomes The four hour target to reduce emergency department ‘waiting time’: A systematic review of clinical outcomes Peter Jones, Karen Schimanski EMA 2010 Oct; 22(5):391–98 “There is no clear evidence that the target to ED completion of 98% of patients in 4 h in itself has had any effect on the quality of care in ED in the UK.”
  7. 7. November2013
  8. 8. Impact on mortality Emergency department overcrowding, mortality and the 4-hour rule in Western Australia. Geelhoed GC, de Klerk NH Med J Aust 2012 Feb 6;196:122-6. CONCLUSION: Introduction of the 4-hour rule in WA led to a reversal of overcrowding in three tertiary hospital EDs that coincided with a significant fall in the overall mortality rate in tertiary hospital data combined and in two of the three individual hospitals. No reduction in adjusted mortality rates was shown in three secondary hospitals where the improvement in overcrowding was minimal. However, debate about methodology in correspondence = too early to tell
  9. 9. Clinical quality indicators being used to commission urgent & emergency care – by % of responses (England only) CEM – The Drive for quality – System benchmarks for EDS in the UK – Report May 2013
  10. 10. Where should we look now? • Variation – Provider, unit, facility, system • High frequency patient cohorts • High problem patient cohorts • What about EFFECTIVENESS? • Culture within the health system
  11. 11. Where should we look now? • Transparent freely available data • Benchmarking • Research into outcomes • Disruptive technology • Community expectation?
  12. 12. HOW TO JUDGE PERFORMANCE?
  13. 13. Commonwealth fund published 2014
  14. 14. DynamicPerformance
  15. 15. DynamicPerformance
  16. 16. Areas for focus • The individual • Within the ED/ inpatient unit • Facility level • System as a whole
  17. 17. THE INDIVIDUAL
  18. 18. Impact of cultural and behavioural factors
  19. 19. DOES INDIVIDUAL VARIATION MATTER?
  20. 20. Opportunity
  21. 21. WITHIN THE ED / INPATIENT UNIT
  22. 22. 12,701 16,158 26,354 21,120 26,042 43,162 43,696 43,960 19,838 28,412 25,929 21,780 20,671 52,989 51,982 46,529 32,342 51,479 35,113 53,864 45,437 39,044 43,345 44% 44% 38% 19% 20% 12% 24% 8% 32% 35% 36% 20% 25% 24% 27% 33% 40% 37% 29% 30% 41% 39% 33% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 3% 5% 7% 7% 8% 9% 10% 11% 11% 11% 14% 19% 0% 10% 20% 30% 40% 50% 0 10,000 20,000 30,000 40,000 50,000 60,000 N209-Goulburn Base Hospital S201-Broken Hill Base Hospital B210-Hornsby and Ku-Ring-Gai Hospital H272-Port Macquarie Base Hospital R219-Wagga Wagga Base Hospital B202-Gosford Hospital D215-Campbelltown Hospital B206-Wyong Hospital L216-Orange Health Service A202-Canterbury Hospital H208-Coffs Harbour Base Hospital H214-Lismore Base Hospital K211-Dubbo Base Hospital A208-Royal Prince Alfred Hospital Q230-John Hunter Hospital D224-Westmead Hospital H223-The Tweed Hospital B218-Royal North Shore Hospital D227-Bankstown / Lidcombe Hospital D209-Liverpool Hospital D210-Nepean Hospital C208-Prince of Wales Hospital P208-Wollongong Hospital % Admit to EDSSU or NEAT Admit Number of ED presentations Year to Date ED Presentations Admit to EMU as % of ED Presentations NEAT Admitted Admitted to EDSSU as % of ED presentations ED Presentations NEAT Admitted Patients (all) WOHP sites ranked by proportion of ED presentations admitted to EDSSU From snapshot data WE 29/9/13
  23. 23. 12,701 16,158 19,838 20,671 21,120 21,780 25,929 26,042 26,354 28,412 32,342 35,113 39,044 43,162 43,345 43,696 43,960 45,437 46,529 51,479 51,982 52,989 53,864 44% 44% 32% 25% 19% 20% 36% 20% 38% 35% 40% 29% 39% 12% 33% 24% 8% 41% 33% 37% 27% 24% 30% 0% 0% 0% 5% 0% 3% 0% 0% 0% 0% 9% 11% 14% 0% 19% 0% 0% 11% 8% 10% 7% 7% 11% 0% 10% 20% 30% 40% 50% 0 10,000 20,000 30,000 40,000 50,000 60,000 N209-Goulburn Base Hospital S201-Broken Hill Base Hospital L216-Orange Health Service K211-Dubbo Base Hospital H272-Port Macquarie Base Hospital H214-Lismore Base Hospital H208-Coffs Harbour Base Hospital R219-Wagga Wagga Base Hospital B210-Hornsby and Ku-Ring-Gai Hospital A202-Canterbury Hospital H223-The Tweed Hospital D227-Bankstown / Lidcombe Hospital C208-Prince of Wales Hospital B202-Gosford Hospital P208-Wollongong Hospital D215-Campbelltown Hospital B206-Wyong Hospital D210-Nepean Hospital D224-Westmead Hospital B218-Royal North Shore Hospital Q230-John Hunter Hospital A208-Royal Prince Alfred Hospital D209-Liverpool Hospital % Admit to EDSSU or NEAT Admit Number of ED presentations Year to Date ED Presentations Admit to EMU as % of ED Presentations NEAT Admitted Admitted to EDSSU as % of ED presentations ED Presentations NEAT Admitted (All Pts) WOHP sites ranked by number of ED presentations From snapshot data WE 29/9/13
  24. 24. Additional indicators proposed for weekly snapshot
  25. 25. FACILITY / SYSTEM LEVEL
  26. 26. Which target group of patients?
  27. 27. Thinking about prevention
  28. 28. HOW MUCH OF WHAT WE ARE DOING IS EFFECTIVE / APPROPRIATE?
  29. 29. Case studies • Fully dependent vascular dementia: 3 recent ED presentations: 3 CT scans, multiple blood tests, Xrays, no goals of care, no advance care plan, yet family “fully understand” • Facility for DD young people with terminal conditions: all have advance care plan which finishes with “call the ambulance” • 87Year old female previously fit and active, presents with presyncope, anaemia and PE, mass felt in liver and confirmed on US. Decision: palliative, lives normally for next 5 months, dies with full palliation
  30. 30. Effectiveness
  31. 31. Looking for appropriateness • Mini-audit over 2 days of all CTs ordered from ED: 60% judged not appropriate as did not conform to any recognised indication, did not influence management • What is actually the role of the ED? And does everyone understand it?
  32. 32. Possible target groups in ED?
  33. 33. Who are the frequent presenters?
  34. 34. COMMUNITY EXPECTATION?
  35. 35. The influence of media
  36. 36. The influence of media
  37. 37. What are the challenges? • More people with complex illnesses seeking more care • Increasing demand on the ED • Can do more = do more • People still die
  38. 38. What are the challenges? • More people with complex illnesses seeking more care • Increasing demand on the ED • Can do more = do more • People still die
  39. 39. Financial decisions • Fed v state • Public / private • Linked up care • Out of pocket costs • ……Fee for service system
  40. 40. Bang for buck • Prevention v cure • Early childhood investment • Etc
  41. 41. Game changers • Internet and personal devices – Prescriptions on line – Personal vital signs and health monitoring – Communication, knowledge – Individual telehealth? • New therapies
  42. 42. Where should we look now? • Variation – Provider, unit, facility, system • High frequency patient cohorts • High problem patient cohorts • What about EFFECTIVENESS? • Culture within the health system
  43. 43. Where should we look now? • Transparent freely available data • Benchmarking • Research into outcomes • Disruptive technology • Community expectation?

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