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George Braitberg, Monash University; Responding to the Most Vulnerable: A Systems Approach to Ambulance Ramping
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George Braitberg, Monash University; Responding to the Most Vulnerable: A Systems Approach to Ambulance Ramping

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Professor George Braitberg, Program Medical Director Emergency and Ambulatory Care & …

Professor George Braitberg, Program Medical Director Emergency and Ambulatory Care &
Professor of Emergency Medicine, Monash University & Director of Emergency Medicine,
Monash 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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  • 1. Ambulance offload What is the ethical thing to do? George Braitberg
  • 2. Who we are? • 3 Campuses • 4 Emergency Departments – MMC Adults – MMC Paediatrics – Dandenong – Casey • 180,000 attendances
  • 3. Core Principles • Initiate timely assessment and management in order to – Determine clinical priorities – Formulate a provisional diagnosis – Implement initial time critical interventions – Refer appropriately
  • 4. This story starts in March 2013…
  • 5. At hospital time is the single most important factor contributing to a deterioration in response times for AV
  • 6. 14 Presentations by Hour MMC Clayton 12 10 Walk -ins 8 6 4 2 Ambulance 0 1 2 3 4 5 6 7 8 9 10 11 12 Hour of day 13 14 15 16 17 18 19 20 21 22 23 24
  • 7. MONASH HEALTH HOSPITAL PART OF NAPTHINE’S STATE OF FAILURE Posted on 31. Oct, 2013 in Clayton Update Mr Lim said annual reports tabled in Parliament show Victorian patients are suffering at hospitals across the state as they wait longer for emergency care, elective surgery and for ambulances to arrive. “our hospitals are worse now that they were three years ago.” Monash Clayton is feeling the pressure too, failing key indicators on: Percentage of ambulance transfers within 40 minutes 58.4% (target is 90%)
  • 8. http://www.heraldsun.com.au/news/victoria/four-cardiac-patients-die-during-long-wait-for-paramedics/story-fni0fit3-1226748519386
  • 9. The time taken to transfer patients to beds at hospitals can impact on our ability to leave the hospital and therefore respond to triple-0 calls, says Ambulance Victoria’ general manager of regional services, Tony Walker.” http://www.theage.com.au/victoria/bed-closures-to-cause-ambulancedelays-20130117-2cwar.html#ixzz2UYzfYtnm
  • 10. Chain of Survival revisited Despatched ambulance arrives at patient, now asystolic Call 000 Nearest ambulance ramped at Hospital ED Ambulance sent from 10km away (most available) Asystolic patients do not leave hospital alive Crit Care Resusc 2006; 8: 321–327
  • 11. Linear relationship between hospital delays and ambulance arrival at scene performance The detail is in the length of the “tail”.
  • 12. Two key messages from Access Block data 1. Access block is unsafe and targets our most vulnerable patient groups 2. The undifferentiated patient in the community and in the ED waiting room are the most “at risk” There were 7% more presentations and 43% more deaths in the OC cohort compared with the NOC cohort Richardson D. MJA 2006; 184 (5): 213-216
  • 13. So we know the problem…what next • Accountability • Understanding • Whole of hospital response.. Capacity and ownership • Treatment Spaces • First do no harm…
  • 14. The Three Laws of Health Service Administration 1. 2. 3. A Health Service may not injure a human being or, through inaction, allow a human being to come to harm. A Health Service must provide services to its patients, except where such services would conflict with the First Law. A Health Service must provide sustainable policies protect its own existence as long as such protection does not conflict with the First or Second Laws. Borrowed from “The Three Laws of Robotics” Isaac Asimov 1942
  • 15. Accountability Understanding
  • 16. Care for the most Vulnerable patient • The ED will offload ambulances in preference to taking a patient from the waiting room with the same triage category • Ambulances leave the ED with shorter hospital times and patients leave the ED to the ward to make capacity for the undifferentiated waiting room patient
  • 17. Ethical Rationale: Kantianism • For every ambulance and crew at a hospital waiting to offload a patient there is one less ambulance and crew available to respond to a new call. • Hence the pool of available ambulance resources is reduced and more time will be needed to find and divert an ambulance to attend the 000 call • Who are the people most affected and who would benefit most? • For the sickest patient in the community, evidence shows this patient will survive and have a better quality of life if an ambulance arrives sooner • In Kantian terms, this fulfills the categorical imperative by applying a universal rule that places human life on a scale where the patient with the potential for more need, is attended to earlier.
  • 18. Ethical Considerations Utilitarianism • Applying the Utilitarian considerations of consequentialism, welfarism and aggregationism • We must balance the consequences of the patient offloaded into a non nursed area against the benefit of an earlier community response to the undifferentiated patient
  • 19. Whole of hospital response.. Capacity and ownership The one over policy The over-census policy aims to “load” distribute the problem over the organisation and avoid the funnelling effect of one area being burdened disproportionately
  • 20. Which Emergency Department is safer?? ********** ********* * +++++++ Waiting room * Hospital A  No over-census policy + + + + + + + + + + + + + Which patients are most unsafe? + + +++++++ +++++++ + +++++ ++++ + + + + + Hospital B  Active over-census policy Each + sign represents a patient in the ED waiting for a bed in a 20 bed acute cubicle Department. Each * represents a patient waiting to be seen an undifferentiated patient
  • 21. Treatment Spaces • Increase hospital capacity • Increase ED space utilisation with MOC changes: – Vertical v horizontal – Assessment areas – Improved utilisation of short stay beds • Introduction of team based care
  • 22. Short Stay Policy • Admit all SSU patients to SSU within 4 hours of their arrival to ED. • Once the patient is on a clinical pathway and/or is awaiting a diagnostic test the most likely outcome (> 75%) is a non admission disposition, the patient should be admitted to the short stay unit • Process: – Flag suitable patients by completing the Obs Ward criteria on Symphony as early as possible – The ED senior doctors must approve all patients admitted to SSU – SSU admission criteria (Obs Ward) must be completed no later than 15 minutes after admission. – Goals of Admission MUST be comprehensive – Notes MUST accompany admission and handover completed via the ISBAR format • Patients must fulfil the following criteria for SSU admission: – Do not meet MET call criteria and be behaviourally appropriate – Have a doctor assigned OR a RAP assessment done – Have all initial workup completed prior to transfer to SSU
  • 23. SSU utilisation 8,000 7,000 No 6,000 ED Presentations 5,000 SSU Admissions Linear (ED Presentations) Linear (SSU Admissions) 4,000 3,000 2,000
  • 24. How have we gone?
  • 25. AV offload MMC 2,000 90 Intervention 1,800 80 1,600 70 1,400 60 1,200 No 50 1,000 40 800 30 600 20 400 10 200 0 0 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Month Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 AV Presentations % offload< 40 min
  • 26. DH Intervention 1,800 100 1,600 90 80 1,400 70 1,200 60 1,000 50 AV arrivals % offload < 40 min 800 40 600 30 400 20 200 10 0 0 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14
  • 27. Intervention All Campuses 4,500 100 4,000 90 80 3,500 70 3,000 60 2,500 50 AV presentations % Offload< 40 min 2,000 40 1,500 30 1,000 20 500 10 0 0 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14
  • 28. Casey Intervention 900 100 800 90 80 700 70 600 60 500 50 AV Presentations % offload< 40 min 400 40 300 30 200 20 100 10 0 0 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14
  • 29. Key Points 1. Gain understanding of the problem and the ethical response to the solution: 1. We have identified the most vulnerable population and made a decision that the community patient is the one with the most risk 2. Review model of care options to improve flow 3. Gain organisational buy-in with the model that works best at a site level: – Beds, processess, one over, elective v emergency admission …. 4. Avoid the “blame game”