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Patient Flow and Bed Management Improvement Strategies - Princess Alexandra Hospital

Patient Flow and Bed Management Improvement Strategies - Princess Alexandra Hospital



Janet Hardwick, Assistant Director Nursing Patient Flow, Princess Alexandra Hospital delivered this presentation at the 6th annual Hospital Bed Management & Patient Flow conference 2013 in Melbourne. ...

Janet Hardwick, Assistant Director Nursing Patient Flow, Princess Alexandra Hospital 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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    Patient Flow and Bed Management Improvement Strategies - Princess Alexandra Hospital Patient Flow and Bed Management Improvement Strategies - Princess Alexandra Hospital Presentation Transcript

    • Electronic ED Journey Board Janet Hardwick B App Sci - Nursing, M Management. Assistant Director of Nursing – Patient Flow
    • Missing Co Presenter Somewhere off the East Coast of Australia
    • Metro South Health • Located in South East Qld – 1 million people (23% of Qld pop.) – 3,856 square kms • 6 public hospitals – Princess Alexandra, Logan, Beaudesert, QEII, Redlands and Wynnum – Community and Primary Health – Mental Health – Oral Health • 8 Clinical Streams – Cancer, Surgical, Medicine & Chronic Diseases, Women’s & Children's, Aged Care & Rehabilitation, Mental Health, Emergency & Clinical Support Services, Patient Flow, Ambulatory Care and Hospital Avoidance
    • Background • Four random audits conducted during READi identified inaccurate recording of the transfer time for 16 out of 20 ED patients. • During the diagnostic phase of the It’s Time Project it was identified that EDIS data entry into the Treating Team fields had poor compliance and were often inaccurate or omitted. • Two electronic touch screen journey boards installed in low compliance wards in 2012 resulted in a dramatic sustained increase in compliance with recording EDD’s • A touch screen electronic ED journey Board (EDJB) was proposed as a solution to overcome data integrity issues and to increase PA’s NEAT percentage.
    • EDJB ~ a Module of Patient Flow Manager V10 • Approached Health IQ to develop the EDJB as a module of Patient Flow Manager V10. • PFU staff met with Product Manager and Business Analyst of Health IQ to outline our specifications for the EJB. • Designed to be simple, intuitive but powerful & based on the principles of Lean Methodology.
    • Objectives • Provide at a glance a visual display with real time EDIS information regarding an individual patients journey • Highlight when patients are approaching configured NEAT time targets by the use of differentiating colours. • Visual display of NEAT status of ED • Facilitate timely entry of patient review, bed requests, bed ready and transfers to ward. • Clearly identify where time is spent during the various stages of the patient journey from triage to ward transfer • Increase compliance with NEAT • Highlight barriers to achieving NEAT • Generate reports
    • EDJB Benefits • Can interface with corporate systems • Supports touch and non touch screens • Accessible from any computer in the hospital, mobile phone or iPad without the need to install any client software
    • The Solution • EDJB displays all current ED patients in table view: – Current location – UR – Last Name – First Name – Age – Arrival Date – Time since Triage – Time seen by ED Dr – Inpatient Team Review Request – Time seen by Inpatient Team – Ward Bed Request – Ward awaiting admission – Bed Ready – Actual ED Departure
    • Implementation • QEII well positioned and keen to pilot – Screen customised for QEII • Several go live dates since August last year!! • The first delay related to unscheduled leave by developer • Subsequent delays related to: – Financial constraints for purchase of screens, – Redundancies – IT moratorium – Communication issues – Major technical issues
    • What it looks like ~ QEII View Referral to Inpt Team attendance 1 hr. Triage to Referral 1.5 hrs. Consult attend to ready to depart 1 hr. Ready until actual depart 20 mins
    • Where to next • Pilot ASAP • Design enhancements – Dials NEAT by Discharges, Admissions & overall – NEAT by doctor/team • Pilot at Redland Hospital & other districts • Evaluate • Disseminate results
    • Bed Occupancy Audit Tool BOAT Janet Hardwick B App Sci - Nursing, M Management. Assistant Director of Nursing – Patient Flow
    • Background • BOAT evolved from a tool developed by Central North Adelaide Health Service in 2008 • Originally described by Dr Carol Haraden – “The Wasted Capacity Measurement Tool” 2006 Institute for Healthcare Improvement USA • Both tools focused on bed occupancy and utilisation
    • Evolution of BOAT BOAT YEAR Criteria Sub Categories Codes # pages with code Audit Sheet Application 2010 13 x 98 3 1 per ward Excel & Acess 2011 13 35 136 4 1per 5 beds Konika Minolta 2012 6 13 81 1 1per 5 beds Abbyy Flexicapture • Significant modifications made to the capacity audit tool used by the Royal Adelaide Hospital • Bed utilisation criteria (10 criteria & 28 codes) • Excel spread sheet • Hospital beds not patients
    • Evolution of BOAT continued BOAT Year Audit Days # Teams Bed Occupancy Bed Utilisation Patient Tracking # Clinical Areas 2010 14 2 Yes Yes No 27 2011 7 2 Yes Yes Yes 29 2012 7 3 Yes Yes Yes 30 • 2010 Bed occupancy and utilisation • 2011 Emergency Board tracked • 2012 Emergency Board, ED patients waiting admission, MRO’s and Outlies tracked
    • 2010 AM PM 35.1 35.2 35.3 35.4 33.1 33.2 33.3 33.4 31.1 31.2 31.3 31.4 29.1 29.2 27.1 27.2 27.3 27.4 25.1 25.2 25.3 25.4 23.1 23.2 23.3 23.4 24.1 24.2 26.1 26.2 26.3 26.4 28.1 28.2 28.3 28.4 #1 Active treatment The bed is occupied by a patient and they are receiving care. This includes someone who will be returning to the bed after surgery, a patient receiving treatment and is temporarily out of the ward such as Physiotherapy. This patient needs the bed. 1 Patient receiving active treatment 1a Patient in OT returning to bed 1b Patient in Dialysis returning to bed 1c Patient in DDR returning to bed 1d Patient having allied health therapy returning to bed 1e Patient attending OPD appointment 1f Patient attending Procedural area eg angiogram, endoscopy, EEG 1g Patient absent whereabouts unknown 1h Patient is a NON DOSA 1i Patient is on the Emergency board 1j Waiting intra ward transfer 1k Patient attending Doctor’s exam 1l Out lie status unknown 1m Education returning to bed 1n End of life bed #2 Outpatient The bed has a patient who could have been managed as an outpatient. 2a DDR Patient admitted to access an investigation eg MRI or CT scan 2b Rural or remote patients overnight stay (to provide a place to stay) 2c ASIS patients 2d HITH patients 2e Cardiology Patient admitted for ECHO 2f Patient admitted due to no outpatient appointment times available (specify) 2g Inpatient stay extended to enable OPD attendance 2h No access to community services or support at home #3 Another service prior to discharge Bed has a patient but awaiting another service before discharge can be scheduled 3a Specialist opinion 3b GATE assessment 3c ACAT assessment 3d Accepted and Waiting Rehab bed - BIRU, Day Hospital, Spinal (specify) 3e Disability services 3f Allied Health review – Dietician, Speech pathology, Social Work, Physio, OT general, hand, (specify) 3g Pathology tests 3h Tests – please specify ie stress test, ultrasound 3i Procedures – please specify eg PICC, Chemo 3j ASIS 3k HITH #4 For discharge but delayed The bed is occupied by a patient who is ready for discharge but is delayed. Reasons may include:- 4a Waiting Discharge medication 4b Waiting pathology review 4c Waiting to see a Medical Officer prior to discharge 4d Waiting IHT, accepted no bed available 4e Waiting IHT, accepted bed available, no transport 4f Waiting IHT, no accepting doctor 4g Patient/family refusing IHT to step down facility 4h Patient/family refusing to be listed/transfer to N/home 4i Patient could be managed in the Transit Lounge 4j Patient/Patient family refusing discharge 4k Waiting home modifications 4l Waiting NH Placement 4m Other ****** 4n Waiting for DDR 4o Mental Health review 4p Waiting Accommodation 4q Allied Health 4r Waiting for Ix / Procedures 4s Waiting out of District services Audit Sheet Codes
    • 2011 Audit Sheet Codes
    • 2012Codes Audit Sheet
    • Rationale for Implementing BOAT • Increased reporting of bed utilisation issues • No evidence to support individuals varying perceptions regarding bed utilisation throughout PA • READi (Rapid Emergency Admission to Destination Initiative) had identified greatest delay to ED patient transfer to an inpatient bed was bed allocation • The DASE (Delayed Assessment Separation Events) project identified significant discharge delays
    • Objectives • Undertake a systematic approach using a standardised tool to assess bed occupancy & utilisation • Provide a snapshot of bed utilisation at PA • Identify reasons/causes of inefficient bed utilisation that impedes flow of inpatients • Identify local strategies which sustain efficient patient flow • Develop an action plan to address identified barriers & promote strategies that are sustainable
    • Communication • BOAT is now custom & practice • Information session daily at the Bed Management Meeting week prior to audit • NUM’s emailed • Screen savers • PA People • Nursing Newsletters
    • Implementation • Audit Conducted Wednesday 22nd to Tuesday 28th August 2012 by Patient Flow Unit (PFU) • Three teams of two • All inpatient beds & patients assessed according to BOAT codes twice a day for 7 consecutive days between 1000 – 12000 & 1600 – 1800 hrs. • Audit conducted in same sequence • Board round conducted with Team Leader in each ward • At conclusion of round visual inspection of every bed • BOAT data recorded & collated by PFU
    • Other Information Sources • Chart audits • Patient Flow Manager reports used to track outlies and ED patients • EDIS utilised to identify patient admission times • Residential care waiting lists • HBCIS & Viewer • HIMS (Health Information Management Service) • Rehabilitation waiting lists • Day in the Life of PAH (Dashboard developed by A Scanlon) • Previous results from Bed Occupancy Audits All information sourced from ward staff during morning and afternoon audits
    • Limitations of BOAT 2012 • Point in time data • Inconsistencies in handover information • Nursing staff generally modified their care after 3 to 4 days • Issues with codes, to be included in next audit – QCAT hearings – Over census – Non resourced empty beds – GATE Nursing and GATE Medical review to be coded as separate codes – Palliative Care to be coded for treatment and review – Equipment required for discharge • Not the whole story important to continue to track some patients until discharge
    • Results • Results collated & validated using Abbyy Flexicapture and then exported to Excel • Data Analyst created a semi automated database for queries • Numbers are reported as total head count of patients each day – i.e if patient was reported in both AM and PM in the category it is count as 1 patient • Results collated and disseminated separately by • Ward / Unit • Division • Whole of Hospital • An Executive Report provided to Hospital Executive • Results utilised to support strategies identified in the 12 month Bed Management Plan 2012 / 2013
    • Identified Areas that have Improved since BOAT 2011 • Emergency Board • Patients waiting for Allied Health review • Bed swaps within wards & inter ward transfers All information sourced from ward staff during morning and afternoon audits BOAT YEAR Bed Moves Transfers Total 2011 466 221 687 2012 16 118 134
    • 2012 Identified Areas for Improvement • Management of empty beds • Bed allocation of Emergency patients • Outlie management • Delays to discharge – Dispensing discharge medications – Medical reviews – Discharge transport – Inter hospital transfers • Clinical handovers All information sourced from ward staff during morning and afternoon audits
    • Total Patients Audited in AM 2010, 2011, 2012
    • Patients receiving Active Treatment AM Audit 2010, 2011, 2012 All information sourced from ward staff during morning and afternoon audits
    • Empty Beds Not Allocated 2010, 2011, 2012
    • Empty Beds Allocated 2010, 2011,2012
    • Delays to Discharge 2010, 2011, 2012 All information sourced from ward staff during morning and afternoon audits
    • Empty Beds Building 1 (excluding ICU, CCU & ESU) 7 Days 255 empty beds were available 1000-1200 7 Days 351 empty beds were available 1600-1800 Weekday 155 empty beds were available 1000-1200 Weekday 235 empty beds were available 1600-1800 • No hidden beds • 37 weekday WAAs in AM • 28 weekday WAAs in PM • Empty bed trending up in comparison to 2010 & 2011 1000-1200 1600-1800
    • Empty Beds by Day of Week Building 1 (excluding ICU, CCU & ESU) 255 empty beds were available 1000-1200 351 empty beds were available 1600-1800 • Includes all empty beds
    • Outlies (Building 1 ) 158 patients located outside home ward • 51 of the outlies were not reviewed each day (Sunday 20) • 11 Patients had 2 or more days not reviewed & had significantly longer LOS and RSI% (PAH & HRT coded DRG’s)
    • Emergency Board (only patients on Emergency Board at 1000hrs & 1600 hrs identified) 89 Patients on Emergency Board• 18 patients on board for more than one day • 9 of these patients were outlies
    • Total Patients Delayed to Discharge 304 patients were delayed to discharge during BOAT
    • Delays to Discharge by Category 0 10 20 30 40 50 60 70 80 Pathology Allied Health Procedures Patient Family Assessment *Rehab Bed Discharge Transport IHT Placement / Com Needs Med Review Discharge Meds *Rehab Bed included Delay to Treatment for GARU Bed 75 patients delayed waiting on discharge medications 62 patients delayed waiting on Medical Review 61 patients delayed waiting on placement or community needs
    • Delays to Discharge - Discharge Medications 75 patients were delayed to discharge waiting for discharge medications 83% of these delay related to dispensing 90% of dispensing delays occurred during the AM round
    • Delays to Discharge ~ Dispensing of Discharge Medication Friday showed the highest delays in Discharge Medication Dispensing – 13 out of 14 occurred on the AM round
    • Residential Care or Supported Accommodation 3% of all patients during BOAT were delayed to discharge waiting residential care or support accommodation 49% of these patients were waiting residential care beds.
    • Residential Care or Supported Accommodation by Bed days 33 patients delayed to discharge waiting residential care or support accommodation 96 bed days lost waiting for residential care or supported accommodation during BOAT 673 bed days lost by patients waiting from time during BOAT to ultimate discharge date Bed days inclusive Include all days from first handover to last day handover as waiting for residential care or supported accommodation.
    • Inter-hospital Transfers Out • 6 patients transferred same day • 9 patients waiting beds in Metro South • 32 patients waiting beds outside Metro South 187 bed days occupied by 41 patients waiting transfer. 9 bed days occupied by Metro South patients
    • Delay to Discharge waiting Discharge Transport 56.4% of patients (22) delayed waiting transport were waiting for private transport Friday - 5 private transport patients waiting in wards whilst transit lounge was open Total Patients
    • Waiting Rehabilitation Beds Total Inpatients Patients waiting a rehabilitation bed 70 bed days were lost in the acute wards by patients waiting for a Rehabilitation Beds • 17 bed days accounted for by waits for a bed in GARU (8 patients) • 25 bed days accounted for by patients on GARU review list (14 patients) • 7 bed days accounted for by waits for a bed in BIRU (2 patients) • 8 days account for by patients on BIRU monitor list (2 patients) • 4 bed days accounted for by waits for a bed in SIU (2 patients) • 20 bed days accounted for by waits to Non-PAH rehab beds 6 2 22 7 Other 3% waiting Rehab Bed BIRU SIU GARU Non-PAH Other
    • Delayed to Treatment or Discharge Waiting Assessment 111 bed days were lost waiting on Assessments by 58 patients 14 bed days were lost by 12 patients waiting Medical Referral for the assessment
    • Delayed to Discharge Waiting Government Agencies 68 bed days were lost waiting on Government Agencies 75% of QCAT were in IMU 2 patients handover as QCAT had no record in notes 53% of Home Mods/Equip was in Rehab wards
    • Delays by Patient or Family 39 bed days were lost due to family or patient decisions 22 of these bed days were due to refusing discharge
    • Handover 92% of handover was by T/L or NUM. • Inconsistencies were evident on patient information. • Disease processes appeared well understood • Incidents where handover sheets not up to date • Not all wards either have or use journey boards. • Discharge planning – reactive & at end • Focussed on the shift not the journey • Outlie management issues evident
    • Where to next • Implement intervention strategies to tackle identified areas requiring improvement • Modify tool again • Conduct BOAT 2013 in last week of June • Roll out to all of Metro South
    • For further information email: Janet_Hardwick@health.qld.gov.au