Fiona Webster, Austin Health: Is it really about Boarder Security?
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Fiona Webster, Austin Health: Is it really about Boarder Security?

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Fiona Webster, Executive Director-Acute Operations, Austin Health delivered this presentation at the 2014 Hospital Bed Management & Patient Flow Conference, Australia's foremost patient flow ...

Fiona Webster, Executive Director-Acute Operations, Austin Health delivered this presentation at the 2014 Hospital Bed Management & Patient Flow Conference, Australia's foremost patient flow improvement meeting, showcasing innovative case studies and pioneering best practice in the nation’s hospitals.

Over 150 hospitals and state and federal departments of health throughout Australia and New Zealand have attended this conference over the past years. For more information about the annual event, please visit the conference website: http://www.healthcareconferences.com.au/bedmanagement14

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Fiona Webster, Austin Health: Is it really about Boarder Security? Fiona Webster, Austin Health: Is it really about Boarder Security? Presentation Transcript

  • Is it really about Boarder Security? Getting the patient to the right bed at the right time Fiona Webster Executive Director Acute Operations
  • Introduction • Organisational bed profiling: Bed realignment project undertaken in conjunction with CSIRO, to guide allocation of new and existing resources across Austin Health • Flow strategies: morning beds, PPA, flex, Ready to Go • Predictive planning activity model used for capacity planning Balancing elective & emergency surgical demand • Surgical Template: Tying theatre bookings to a bed
  • The problem… • Ageing population • Rising community expectations • Increased ability to treat • End of life decision making • Emergency Department as a default for primary care • Lack of GP treatment for residents of nursing homes • Growing costs – budget pressure
  • Background • Patients requiring admission to Austin Health arrive through a variety of routes: • • • • • • Emergency department Elective surgery admissions Planned admissions – (Day oncology, endoscopy, sleep studies etc) Inter hospital transfers – (tertiary referrals) Intra-hospital transfers (Talbot/HRH) Direct admissions from the community (unwell patient seen at outpatients) • International repatriations 4
  • Targets • NEAT (National Emergency Access Targets) • Emergency department four-hour access target for patients in all triage categories – 80% • % of Cat 1-5 Patients seen within time – 80% • NEST (National Elective Surgery Targets) • 100% of Cat 1 in 30 days • 88% of Cat 2 treated within 90 days • 97% of Cat 3 patients treated within 365 days • Reducing the average waiting time for overdue patients • Targets don’t cover all activity – so too strong a focus on targets causes perverse incentives 5
  • You can’t have your NEST and NEAT it too...
  • Balancing demand Vascular Surgery Neurosurgery Neurology Cardiology Cardiac Surgery Thoracic Surgery Respiratory Medicine Inter hospital transfers Colorectal Surgery Gastroenterology Liver Transplant Orthopaedic Surgery Plastic Surgery Urology Infectious Diseases General Medicine Renal Medicine Planned admissions Ophthalmology Oncology Haematology Acute spinal Paediatrics ICU ENT Rehabilitation Awaiting placement Intra hospital transfers Aged care Emergency patients Elective surgery patients Direct admissions • • • • • • 1000 bed hotel Patients arrive without bookings Their departure date and time is unknown Very few future bookings Very specific room requirements Always full – people queuing to get in
  • Why... • • • • • • • Planned and unplanned patients compete for the same bed Need to match patients to the ‘right’ bed Essentially always at 100% occupancy except for holiday slow downs Only funded for a ‘full bed’ that is rapidly turned over Emergency demand – 78% of overnight bed days Variable, unknown length of stay makes predicting bed availability difficult Acuity of the case will always win (long wait simple cases bumped)
  • Why... • Exit block waiting for patients to be picked up by other services • Limited ‘flex’ capacity due to bed constraints • Cancelling patients becomes the pressure release • Clinician admission decisions is impacted by bed availability
  • Patient arrivals by hour • Patient discharges do not match the time of patients arriving
  • Our problem… Bed management and patient flow - New patients arrive before current patients leave - Highly specialised services - Idiosyncratic variation between one clinician and the next - Person dependant systems and processes - Lack of flexibility in managing capacity - Still largely paper based (or have moved to the spreadsheet!) - Don’t know what’s coming in the door until its here - Lack of tools to predict demand
  • How do we make it better.. • • • • ? ? ? ? • • • • Open more beds… Discharge more patients in the morning… Plan less surgery in Winter Divert more patients into other programs / services HITH Transit Lounge ED Short Stay Acute Assessment
  • Right patient, right bed, first time Understand your bed profile • The current bed allocation at Austin has been in place since the redevelopment opened in 2005 • We want to be able to place a patient in an appropriate bed within four hours • Patients get the best care when they are on their home ward with a team that is able to manage their care collaboratively • We needed to profile our beds to take account of work that would move to our new Surgery Centre, demand for tertiary services and demand from the Emergency Department
  • Bed allocation model 14
  • Beds needed by ED patients 15
  • ED bed demand 16
  • Right number of beds Provide units with the right number of beds to meet demand: • Moved elective work to The Surgery Centre • Relocated 8 Urology beds to a new ward • Will soon relocate Colorectal Unit to a new ward • Looking at up-skilling staff to flow patients into a neighbouring ward (building core competencies across ward environments)
  • Beds at the right time of day • Nov 12 – Admissions and discharges don’t balance until 2pm • Deficit of ~13 beds in the morning • Patients wait in ED for a bed • How long does it take to turn over a bed? • Beds on some units take longer to come up
  • Planned patient arrivals (PPA) We need morning beds • Every ward should prepare one or two patients who can be discharged by 8am so that they can accept a patient by 9am • The afternoon shift identifies the potential patients • prepares patient for discharge • organises transport or transit lounge • seeks a discharge script/early morning medical review • Sometimes these patients are planned transfers to another facility • Helps us start flow early and get patients to the right ward
  • Morning flex capacity If we have a deficit of beds in the morning PPAs are not enough!! • Establish morning flex capacity • 4 surgical beds that open for the AM shift (ASTU) • 3 cardiac beds open in the morning (cath lab recovery area) • 8 Acute Assessment Unit (AAU) beds AM/PM shifts • Agreement for paediatrics to flex within ratios to take morning patients • Beds are closed back as patients are discharged (or by a time deadline) • Small amount of overnight flex available (four beds)
  • Greater use of transit lounge
  • Starting flow early helps Beds are in balance two hours earlier
  • Access to beds from ED is better • Still a long way to go but less winter impact
  • Decline in boarders • Fewer boarders means better care and shorter LOS
  • Better communication Ward communication identified early as problem to patient flow: • • • • Unable to reach person who makes decision ED unable to communicate with ward in-charge Bed manager also couldn’t find person responsible for patient flow decisions Tea breaks held up flow because of communication Introduction of: • Minimum Deliverables of patient flow standards: ‘In-charge’ responsibilities for patient flow decisions. (Organisationally rolled out) • Gave each ward a CISCO phone (used only for patient flow)
  • Ready-to-go? • Discharge Summaries in ED are not being completed in a timely manner. Resulting in inpatient ward areas unable to : • Admit the patient on to Medtrak • Therefore cannot administer medications, order meals, process pathology • Cannot be found by relatives via Medtrak and creating safety concerns • Confusion regarding suitability for transfer to inpatient wards, causing rework through additional phone conversations with the ED. Consequences to this include: • Decreased motivation by ward staff to expedite admissions • Wards feeling that data on performance not reflecting true nature • Increased staff frustration on inability to achieve targets due to delay of transfers
  • What we wanted to achieve a) Clarity when the patient is ready to be transferred to the ward b) Standardised communication c) Less rework d) Patients transferred out of ED without delay as clinically appropriate…provide capacity for incoming pts/ ambulance • ED management 2 hrs • Bed management allocation 20 mins • Pull pt to ward 1-2 hrs (decreasing towards 60 mins for wards)
  • Ready to go criteria… • • • • Patient needs to be medically stable, not meeting MET criteria (unless documented/communicated as altered) Unit handover has occurred Discharge summary completed Interim medication and fluid orders completed Issues that need to be resolved around this are: Who is responsible for ensuring final ‘sign off’ of the above 4 criteria (process owner) How are outstanding tasks escalated? Identification icon activated via medtrak to announce patient ready to move Identification of ED need for PSA assistance for transfer from ward areas Identifying who is responsible for ensuring the discharge summary completed
  • What percentage of pts have a RTG? Improved to 62% RTG Compliance - last 30 days 80.0% 70 70.0% 60 60.0% 50 50.0% 40 40.0% 30 30.0% 20 20.0% 10.0% 10 0.0% 0 % Admitted to ward with RTG Patients Admitted To Ward
  • Before November - All Wards
  • Now - All Wards Improved 13.2% 85% Patients transferred to wards within 2 hours
  • Better bed management Split elective and emergency streams • The Surgery Centre is not impacted by emergency demand • Provides more beds for Emergency Demand Increased flex capacity • Having the ability to open extra beds at short notice at marginal cost Better bed management • Predictive planning • Demand projections • Booking templates
  • total elective ward total ED surg ward required Total combined ward (av. 14b/day) total SAEC SAEC 1 1 8E 0 3 SAEC 3 1 8W 0 2 SAEC 0 1 8N 5 6 SAEC 1 1 5 11 6 6 11 17 5 4 1 0 1 5 3 3 1 1 1 2 2 1 0 0 1 4 3 4 1 2 0 11 8 8 6 6 6 17 14 14 3 3 3 WEEK 2 Monday Tuesday Wedensda y Thursday Friday 1 1 4 4 3 3 1 0 1 4 3 3 WEEK 3 Monday Tuesday Wednesda y Thursday Friday 1 1 Monday Tuesday Wednesda y Thursday Friday ERCPs WEEK 1 Monday Tuesday Wednesda y Thursday Friday WEEK 4 Bed Management information Elective Admission Template Level 8 electives Direct Admission/ Interhospital transfer 2 2 0 1 3 5 0 0 9 11 6 6 15 17 4 5 2 1 1 1 4 2 0 1 1 5 4 3 0 1 0 10 11 8 6 6 6 16 17 14 3 3 3 6 5 2 0 1 1 0 0 5 6 0 2 12 12 6 6 18 18 3 3 1 0 1 4 4 3 0 0 1 2 1 1 1 1 1 5 3 5 0 0 1 11 8 9 6 6 6 17 14 15 2 1 4 1 1 4 6 2 0 1 2 1 1 4 5 0 3 9 12 6 6 15 18 4 5 1 0 1 3 3 4 1 0 0 1 2 0 1 2 2 4 5 4 2 1 0 8 10 8 6 6 6 14 16 14 5 3 3
  • Day surgical procedures: Extended Stay: SAEC ACC /MH Psychiatric services High acuity admission ICU/HDU 6W HDU CCU Respiratory Further medical assessment AAU Day medical procedures: AAU, ACC Single room/ Isolation requirements State-wide services/ Trauma agreements: Spinal, vertebral column, LTUx Overnight surgical I/P Step down medical bed: Ward 10, rehabilitation bed
  • Standard day… 1500-1600 Planning for next day • • • • • Review EDDs, ETBS capacity to finish the day, Consultation with wards & external stakeholders where required Send alerts to liaison nurse/ ESAM role & medical (surgical) teams for assistance in extreme bed access situations Reorder tomorrow’s lists, defer work where appropriate Review direct admissions list and ensure plan for transferring patients. 1930hrs • • • Ensure patients in AAU have bed plans for closure daily operational shift reporting Ensure capacity is at optimal level (additional beds open etc) 2030hrs finish and handover to AHSM
  • Standard day... 48 I/P ED admissions 25-30 elective admits @12+ direct admissions +/- OPD, Failed D/c, ACC admissions etc 0700… • • • • • accept Night activity handover Allocate patients in ED to opening capacity (AAU/ASTU etc) Early discharge confirmation & Allocation of PPAs Placement of long waiting patients Early assessment, triage of theatre flow & beds balanced against competing areas of demand (ICU, other hospitals, emergency department, other) 0800-1200: Surgical flow position • Establish & coordination/management of issues (reorder list, alternative post op destination, change to day procedure, cancel etc ) • • • • Confirm movement and placement of patients Ensure minimisation of HIPs and boarders management Facilitate discharge planning assistance to wards Assist ETBS (Emergency Theatre) with treating patients in time & access to OR
  • Organisational Awareness Performance Additional demand Alert 37
  • Forecasting the activity ahead...
  • Predictive planning & templating Issues: • • • • No consistency in number of electives booked requiring IP beds Level of acuity on each day would exceed ICU/HDU capacity, or ward ability to manage complexity Waste ++- Theatre cancellations, staff present but not able to work and poor customer service/ focus Lack of accountability and fairness (some units able to access theatre/ beds more than others) Solution: • • All surgical activity operate from a template, Clinical wards operate off Predictive planning to manage their daily/ weekly demand CSIRO ward bed profiling information used for wards to plan for both NEST & NEAT
  • week commencing 28.10.13 All Seasons template 2013 v5 SAEC: updated 31.10 .13 TOTAL 8 Urol 2x6S, Ortho 2x 8N (trauma), Ortho x 3 8N, Plastic 1x8N, UGI 1 x 8E Urol 1x6S, CRS4 2x8E, UGI 1x8E, HPB 2x8W, Ortho 4x8N( 1 Trauma), plast 1 x8N HPB x1, Ortho x1 ( truama), ENT x2, Radiology x2, Vascular x2 8 8 8 Urol x1, HPB x1, Plastic x1, CRS4 x1, ERCP x1, Radiology x1, Vascular x1, 7 Urol 2x 6S, CRS4 1x8E, HPB 1x8W, Ortho 4x8N ( 1x Truama), Plas 1x8N, UGI x1, Ortho x 2 ( Trauma), 1x ERCP, 1x radiology 5 7 8 Urol 3x6S, UGI 1x8E, HPB 2x8W, Ortho 2x8N, Plastics x1 8N Scheduling Activity; Cardiology UGI x1, HPB x2, UROLO x 1 ENT x1 , ERCP x1, Radiology x2, Week 2 Urolx1, 1x ERCP, 2x radiology, 1x Cardiology, ENT x1 UGI x1, plas x1, urol x 1 ENT x2, 2x radiology, 1x ERCP, HPB x2 (1 for tenkoff), Urolx1, 1x radiology, 1 x cardiology, 2 x Vascular, ENT x 1 Urol x1, HPB x1, Plastic x2, Ortho x1( Truama), UGI x1, ERCP x1, Radiology x1, OMFS x1 8 Week 1 CRS4 x 1, UGI x1, Orthox1, HPB x2, ERCP x1, Radiology x1, x1, Urol 3x6S, UGI 1x8E, CRS4x1 HPB 2x8W Ortho x 2 ( trauma) Urol 2x6S, CRS4 1x8E, HPB 2x8W, Ortho 3x8N ( 1x trauma) UGI 1x8E Urol 2x6S, CRS4 2x8E, UGI 1x8E, ortho 3x8N ( 2xT), plastic Quad hand list ( 3N) Week 2 Week 1 UGI x 2, Plastics x 1 OMFS x 1 ENT x2, 1 x ERCP, 1x radiology, Urol 2x6S, UGI 2x8E, Ortho 3x8N, plas 1x8N Urol 2x6S, CRS4 x1 8E, UGIx1, HPB 2x8W(IM 1x8E &7N)ortho 2x8N, ( 1X truama) Urol 3x6S, CRS4 x1 8E, UGI 1x8E, HPB 1x8W, Ortho 3x8N, plas 1x8N Urol 1x6S, UGI 2x8E, HPB 1x8W, Ortho 3x8N( 1x Truama), Plas 1x8N UGI x1,Ortho x1 vascular x2 , 2x radiology, 1x Cardiology, ENT x1 7 8 7 8 CRS4 x2, Plas x1, urol x1, HPB x1, 1 xradiology, 1 xERCP, Vascular x1, 8 urol 3x6S, CRS4 1x8E, HPB 1x8W, Ortho 3x8N (8N x1 Truama), Plas 1x8N HPB x1, Urol x 1, UGI x 1, plastic x1, ortho x1, radiology x1, ERCP x1 Urol 3x6S, UGI 1x8E, HPB 1x8W, plas 1x8N, Ortho 2x 8N (+2x 8N Truama) UGI x1, HPB x1, radiology x2, ERCP x1, ENTx1 7 8 6 HPB x2 ( 1 for tenchoff), 1 x Ortho ENT x1, Vasc x1, radiology x1,1 x cardiology 7 HPB x1, plastic x2, Ortho x1, radiology x1, ERCP x1, 1 x cardiology, Vascular x1, 8 UGI x1, plastic x1, HPB x1, CRS4 x1, ortho x 2 ERCP x1, Radiology x1, HPB x2,, ENTx2, radiology x2, ERCP x1, Week 4 Urology x 1, HPB/T x 2 UGI x1, plastic x1, ERCP x1, Radiology x2, Matching operating units each day with # of beds, holding each unit accountable Urol 1x6S, CRS4 x2 8E, UGI 1x8E, HPB 2x8W, Plast 1x8N, ortho 3x8N (1xtruama) Urol 2x6S, UGI 1x8E, CRS4 1x8E, HPB 2x8W, Ortho (2x truama) Urol 2x6S, CRS4 1x8E, UGI 1x8E, HPB 2x8W, Ortho 5x8N Urol 2x6S, CRS4 2x8E, HPB/T x 2 8W, UGI 1x8E, Ortho 1x8N, plastic 1x 8N Week 4 Week 3 UGI x1, ENT x2, 1x ERCP, 1 xradiology, plastics x 1, OMFS x 1 Week 3 9 Urol 2x6S, UGI 2x8E, HPB 1x8W, Ortho 3x8N, plas x1 8N urol 2x6S, HPB 2x8W (IM 2x7N), Ortho 2x8N (8N x1 trauma) Urol 3x6S, CRS4 1x8E, HPB 1x8W, Plas 1x8N, Ortho 3x8N 7N/ 8E 8N 8W 3N 6 S TOTAL 1 6 0 0 2 9 3 5 2 0 1 2 2 2 3 2 2 0 0 3 2 11 9 9 1 5 1 0 2 9 1 3 2 3 3 4 2 0 0 0 1 0 3 2 2 9 9 8 3 3 2 1 2 11 2 4 1 0 3 2 3 2 2 5 4 2 5 1 2 2 2 0 0 0 0 1 1 2 2 9 10 8 11 1 4 1 0 3 9 1 3 2 4 2 4 1 2 1 0 0 0 3 2 2 9 9 9 0 3 2 2 2 1 4 1 0 3 Predictable Surgical elective bed numbers, also assists with booking appropriately balanced lists 10 9 9
  • Predictive Planning (individual ward example) Planning Patient Flow: Weekly projection Ward 7 South Date: Monday Tuesday Wednesday Thursday Friday Saturday Sunday Elective admissions booked 3 4 2 3 2 0 0 ED Admissions: 2 1 2 2 1 Intensive Care admissions 1 0 0 2 1 Urgent direct admissions 1 1 1 * * * * Admissions Total: 7 6 8 7 3 3 1 Discharges Projected: 6 7 3 7 5 4 4 Balance/ Plan: 1 1 -5 0 2 1 3 Admissions Ward taking 1 2 responsibility for 1 0 balancing demand Other: Additional Issues: # of external referrals still waiting: 1 x Complex Pt + 2 awiting subacute transfers 2 Plan; postpone X, Priority d/w Dr B, for A+C to be admitted 1 2 Medical unit engagement
  • Organisational view… 42
  • Questions