Emergency Department Diversion Strategies


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Graeme Malone ASM, Director, Advanced Care, Ambulance Service of New South Wales delivered this presentation at the 6th annual Hospital Bed Management & Patient Flow conference 2013 in Melbourne. For more information on the annual event, please visit the conference website: http://bit.ly/1f3Pp03

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Emergency Department Diversion Strategies

  1. 1. 6th Annual Hospital Bed Management & Patient Flow Conference Melbourne 25 February 2013 Ambulance Emergency Department Diversion Strategies Graeme Malone ASM A/Executive Director Service Development and Planning
  2. 2. excellence in care Overview About NSW Ambulance Trends in demand Consequence of demand Changing role of paramedics Diversion strategies - alternative care pathways and non- transport options Future models
  3. 3. excellence in care NSW Ambulance Service is the 3rd largest in the world In 2011/12 provided: over 1,183,795 responses Average 3,234 responses/day ~ one every 26.7 seconds 865,725 emergency responses (2,365/day) 4,360 staff ( 90% paramedics) Facts & Figures
  4. 4. excellence in care Emergency & time-critical ins & transports Projected 2.8% growth/ yr 25% of all ED presentations arrive via ambulance as a result of 000 call
  5. 5. excellence in care demand for Ambulance Services is contributing to ED congestion Has a significant impact on Ambulance resources Increased : case cycle times timely availability to respond Demand
  6. 6. excellence in care A consequence of demand Every 27 seconds we need to respond to a 000 call
  7. 7. excellence in care RAMPING …and the flow on effect
  8. 8. excellence in care Changing role of paramedics Historically callers to Triple Zero “000” for assistance to address unplanned health care needs irrespective of health problem - 2 choices: 1.Transport to an ED 2. Decline transport The evolving Role of Ambulance has changed the paradigm: “From Driver to Clinician”
  9. 9. excellence in care The focus was on transporting some stabilising treatment occurred triage and treatment occurred at ED Paramedic curriculum was vocational Old paradigm
  10. 10. excellence in care Paramedic education is in the tertiary system Patient assessment, triage and treatment occurs as the first priority Referral or transport are provided according to the clinical needs of the patient A smaller proportion of patients being transported to hospital care New clinical paradigm
  11. 11. excellence in care Telephone Triage Dispatch Options Ambulance Release Teams Low Acuity Patient Pathways Extended Care Paramedics Authorised Care Plans Frequent Callers Alternative care pathways and non-transport options: Diversion Strategies
  12. 12. excellence in care Telephone Triage . Health Advisory Centre 5,867 calls given advice/referral (2010/11) MPDS ? Resource Options
  13. 13. excellence in care Dispatch Options
  14. 14. excellence in care Ambulance Release Team (ART) ART is a Qualified Paramedic (double) crew deployed to EDs experiencing offload pressures Deployments based on pre agreed „triggers‟ Can take up to 4 low acuity patients to release crews into community to respond Effective in releasing crews, do not assist with ED pressures or patient flow
  15. 15. excellence in care Low Acuity Patient Pathways
  16. 16. excellence in care Low Acuity Patient Pathway (LAP) A broad intervention across the Ambulance workforce Focuses on the provision of skills in clinical decision making Assessment of patients‟ competence in decision-making The application of a set range of clinical pathways that enhance safety and provide non-ED management options to low risk patients
  17. 17. excellence in care LAP training Focuses on the provision of skills in: > clinical decision making (patient assessment; hx taking) > risk identification and mitigation (information to patient/carer, information sharing, patient referral, documentation) Provides paramedics with a safe and systematic approach to the management of non-transport situations
  18. 18. excellence in care LAP non-transport and referral Patients fitting a clinical pathway profile who have no „red flags‟ may be presented with a non-transport option (self-care, recommendation for care, immediate referral or “third door” options when available) Identification of medium and high risk patients for transport to an ED Paramedics will not refuse transport if a patient requests transport
  19. 19. excellence in care Extended Care Paramedic (ECP)
  20. 20. excellence in care Extended Care Paramedic (ECP) • Enhance clinical role of a group of paramedics • Better meet the needs of the NSW community • By providing safe & effective healthcare choices for non acute conditions. Address the health needs of the Low Acuity Patient Calling Triple OOO • By Paramedics providing treatment/discharge or referral for appropriately identified low acuity patients. Reduce ED Presentations Identify „sick‟ or high risk patients and ensure that these patients are transported to the ED Consequently, low risk patients identified and only these patients are offered alternatives to the ED
  21. 21. excellence in care Scope of practice In addition to providing emergency care, ECPs: > Replace catheters > Provide wound assessment and care > dressings / adhesives / sutures > Replace PEG tubes > Provide falls screening and assessment > Provide aged care screening and assessment > Provide care for minor injury / illness > Commence pharmacotherapy > Refer patients > Discharge patients from care ECP
  22. 22. excellence in care Outcomes Activity 2007 – 2010: 31,696 responses 26,086 patient contacts Non-transport rate of 39.5% (Non transport rate for standard ambulance is 14%) Referrals: 47.1% of non-transported patients were referred to an alternate healthcare provider 90% of referrals were successful at the time of patient contact 72% of referrals were to the patient‟s GP 98.9% satisfied or very satisfied with ECP care
  23. 23. excellence in care Frequent Callers
  24. 24. excellence in care Frequent Callers 2009/10 we identified 938 frequent callers who made >5 calls/yr ~14,578 calls resulting in: ~11,428 transports to EDs (09-10 financial year)
  25. 25. excellence in care Identified a resource to developed project to: Provide clarity of the criteria for identification of a patient as a „frequent user‟ Develop a clear referral and management process Three months into the project Frequent Caller Project
  26. 26. excellence in care Chronic disease Nursing homes Police Schools Socio- economic Mental health Transport Carers Treat and refer Telephone triage Endstage disease Behavioural Interagency Care plans Frequent callers - factors, settings
  27. 27. excellence in care Types of Frequent Caller Patients Acute Frequent Callers: Callers who make a high volume of calls to Ambulance over a relatively short-time frame i.e twelve months Enduring Frequent Callers: Callers who repeatedly make a high volume of calls over a period of years Specific Patient Groups e.g Mental Health
  28. 28. excellence in care Total Number of Calls from Patients making >10 calls per/Yr
  29. 29. excellence in care Ambulance FC cost >10 calls per/yr $5,674M $5,689M $5,810M 2009-2010 2010-2011 2011-2012 (using Health Economics 2010 Data of $582 per call out) Ambulance FC cost >10 calls per/Yr
  30. 30. excellence in care Brief Overview of Model FC identified following review of Patient Data Designated Ambulance resource notified of FC patient Clinical Review of presentations to Ambulance . Determine type of intervention Review effectiveness of interventions / frequency of presentations
  31. 31. excellence in care Intervention Type 1) Notification to LHD only 2) Notification to Patient only. 3) Notification to Patient, LHD and development of multi- agency plan 4) Designated Case Management 5) Notification to police. Interventions
  32. 32. excellence in care Patient Reason for Referral Length of Intervention to date Number of calls prior to intervention (time frame) Number of calls since intervention commenced Reduction in number of calls Average cost saving Patient A Enduring high end frequent caller for past 3 years. 2 months 55 calls in the 5 months prior to intervention. Median 11, Range 10-14 12 10 (45%) $5820 Patient B Enduring mid-range frequent caller for past 2 years. 2 months 26 calls in the 5 months prior to intervention. Median 5.2 Range 4-7 6 5 (45%) $2910 Patient C Enduring high mid- range frequent caller for past 2 years. 1 month 35 calls in the 4 months prior to intervention. Median 8.75 Range 6-13 2 6 (75%) $3492 Patient D Enduring high mid- range frequent caller for past 2 years. 1 month 7 calls in a two week period prior to intervention 0 7 (100%) $4074 Patient E Emerging Frequent Caller – High use in the past 2 months 1 month 13 calls in a two month period prior to intervention 6 7 (46%) $4074 TOTAL $20,370 Interventions are in development or have recently commenced with a further 15 patients There has been an average 50% reduction in calls from these patients Similar interventions could be targeted at approximately 80 patients per year In 2011/2012, 80 patients were responsible for 3773 calls A 50% reduction (1886 calls) would result in a cost saving of $1,097,652 (1886 calls x $582 per call* = $1,097,652) FC Initial analysis of data post-intervention
  33. 33. excellence in care Authorised Care Plans
  34. 34. excellence in care Reduce the number of avoidable transports to ED for patients with specific medical conditions requiring pre- authorised medications or procedures To reduce unnecessary use of Ambulance resources in these circumstances Improve the patient‟s experience by providing tailored care and a better understanding of EOL issues for palliative patients To develop a system for the effective management of patients requiring specific treatment and management Program objective
  35. 35. excellence in care There are three aspects to the program for patients identified through their treating clinicians: Authorised Paediatric Palliative Care Plan under the care of the Children‟s Hospital Network or their treating clinician Authorised Adult Palliative Care Plan for adult patients under the care of their treating clinician Authorised Care Plans: administration of pre-authorised medications and procedures outside of Ambulance practice Authorised Care Plans
  36. 36. excellence in care 43% of the occasions when paramedics attended a location where a patient had a current Ambulance Palliative or Authorised Care Plan did not require transportation to the Emergency Department or treating facility. YTD Registered Care Plans – Paediatric Palliative Care n= 58; Adult Palliative Care n=11; Authorised Care n= 233 Outcome
  37. 37. excellence in care More options
  38. 38. excellence in care Innovative practice models The right care Allocate the right resources Use Ambulance and other health resources well Provide the right care in the right setting Provide the right care for the patient’s condition
  39. 39. excellence in care Potential future Emergency patient care pathways Before 000 call Before dispatch Treatment at scene . Transport Hospital ED Mental Health Other clinical specialty areas or care providers Preventive health improvement strategies Phone advice & referral Patient withdraws request - programed review of need Increased LAP ECP  Patient decides no transport in line with care plan  Patient remains in residential facility Promote alternate provider organisations