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Prof. George Braitberg, Melbourne University & THe Royal Melbourne Hospital - “Chunks of Time”, Safe and Timely Care - What Can We Do in the ED to Improve Patient Flow?

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Prof. George Braitberg delivered the presentation at the 2014 Emergency Department Management Conference. …

Prof. George Braitberg 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

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  • 1. Making it accountable 6th Annual Emergency Department Management Conference Prof George Braitberg Professor of Emergency Medicine University of Melbourne and Melbourne Health
  • 2. Lets Start Kokoda June 28 to July 7
  • 3. Emergency Departments have been compared with Air Traffic Control, but are in fact a more complex setting with more complex work. Unlike airports, patients just “show up” without warning, requiring attention – aeroplanes tend not to do this.
  • 4. The Perfect Storm • A problem exists that doesn’t go away despite the good intentions, expended energy and input from a number of talented people • The problem is known to cause an adverse outcome in the environment in which it exists • The problem is large enough that it affects people and processes outside its own environment • The problem is mutifactorial and hence a number of changes must be taken for the problem to be resolved • The problem expresses itself across a number of domains: – Safety – Morale – Performance – Satisfaction – Personal and Professional beliefs
  • 5. means every part is accountable Acute Sub Acute Care Driving Whole-of-System Reform
  • 6. Before they arrive … Telephone Triage is probably not the answer..
  • 7. Before they arrive …... Call Referral Paramedic Locum Community Nursing Services
  • 8. Coordinated community care Linking prehospital care providers to divert patients away from the hospital Before they come Hospitals have a role to play
  • 9. Accountability • Patient • Community • Prehospital Services
  • 10. Hopefully I haven't “muddied” your understanding
  • 11. Disposition Presentation & Triage Inpatient Team Assessment Emergency Assessment Assessment AmbulanceAmbulance ‘Walk in’‘Walk in’ SpecialistsSpecialists OtherOther Other HospitalOther Hospital Inpatient WardInpatient Ward Dispatch AreaDispatch Area Registration Triage Assessment and Treatment Assessment & Treatment Pathology Radiology Fast Track Hospital Transfer Handover Admissionand transfer to ward Resuscitation HomeHome Short Stay Emergency Department Patient Flow *18% improvement in grant funding from improved admission data ProjectedImprovements *50% saving in letter production *50% saving of clinician time at Handover Staff capacity improvement = 10% Decrease in Adverse Events per annum = 880 Increase in funding per annum = $2.1m * *10% efficiency improvement across all activities 55% reduction in business risk (Adverse Events) *$2.1m made up of $2m from Emergency Department DHS Grant; $120k from improvement in Emergency Department 4 hour target performance Wait 1 Wait 6Wait 3 Wait 4Wait 2 Wait 5 Diagnostics Access Block increases duration of all wait periods y= 5.5819x+ 243.93 R2 = 0.1962 0 100 200 300 400 500 600 700 800 0 5 10 15 20 25 30 35 40 EDLOS Time ElapsedBetweenArrival andTestsBeingPerformed When is the “decision to admit” made? The Health Service…….
  • 12. 0 100 200 300 400 500 600 2009-8 2009-9 2009-10 2009-11 2009-12 2010-1 2010-2 2010-3 2010-4 2010-5 2010-6 2010-7 AverageLOS(mins) Month Average LOS Admit/Transfer Patients by Month
  • 13. Welcome to Hotel Austin What are the metrics of flow failure? Response of a queuing system in the presence of crowding is non- linear – As utilisation increases, waits and rejections (queue failure) increase exponentially queuelength&failures 10 20 30 40 50 60 70 80 90 100 % system utilisation (occupancy)
  • 14. Overcrowding defines hospital and Emergency Department access block
  • 15. Consequences
  • 16. Fatovich DM, Nagree Y and Sprivulis P.Emerg Med J 2005;22:351–354. Richardson D. MJA 2006; 184 (5): 213-216 Waiting Times increase
  • 17. Welcome to Hotel Austin Treatments are delayed • Time to thrombolysis in myocardial infarction – (Schull et al Toronto) – Annals Emerg Med 2004, December
  • 18. Adverse events occur • SARS – Schull, Emerg Med J 2003;20:400–401 – Canadian index case – 18 hour access block – Infected 128 – Killed 17 • Adverse Events In a study of 3935 Emergency patients, adverse events in the ED were associated with errors of omission, diagnostic issues and high preventability. 55% of events were judged to be preventable with those resulting in death and disability more likely to be preventable (p < 0.04) Adverse Event Study, Hendrie J, Sammartino L, Silvapulle, M. J. Braitberg G, EMA 2007 (2 papers)
  • 19. • SA coroner, Vassallo, 2003 – Sent home from ‘blocked ED’ – “good doctors make bad decisions in bad circumstances” – DHS & Hospital criticised • J. Em Med (Canada) 2004 – Child with Toxic Shock – Excessive waiting T – 19 recommendations to the Ontario Health Ministry
  • 20. Patients stay longer in the wards……
  • 21. Welcome to Hotel Austin Patients die
  • 22. Hospital Overcrowding increases 7 day mortality Overcrowding Hazard Scale Multiply hospital occupancy and the ED access block as a combined score MJA 2006; 184 (5): 208-212 An Overcrowding Hazard Scale score > 2 independently predicted an increased Day 7 mortality rate
  • 23. Richardson D. MJA 2006; 184 (5): 213-216 There were 7% more presentations and 43% more deaths in the OC cohort compared with the NOC cohort
  • 24. Access block is Ageist • Deconditioning • Confusion • Dehydration • Immobility • Constipation • Pressure injury • Falls • Medication error • Delayed allied health • Delayed discharge planning • Suboptimal nutrition • A trolley is not a ward bed • An ED is not a ward • ED staff are not ward staff • Over 26 % of ED attendances are elderly (>70) • This group have twice the average admission rate
  • 25. Big Picture Causes Workforce Our workforce models have remained unchanged for many years. There are pockets of innovation and the introduction of Nurse Practitioners, Advanced practice nursing, primary contact physiotherapists have helped orientate the “system” to new ideas. But these innovations are still operating on the fringe in a system heavily reliant on doctors doing doctor thing and nurses doing nursing things. Our future workforce thinking must change. Social changes The demise of the extended family and changes in the demographics of marriage and childbearing have led to more elderly people living alone, and with greater feminisation of the workforce fewer people can be carers. The default solution for many partially dependent people is referral to an acute hospital.
  • 26. Funding models Payments to hospitals and healthcare providers are rigid and reward rapid treatment of uncomplicated conditions. In the community setting, payment is for episodes of care rather than continuity of care. Complicated emergencies, time-consuming conditions involving multiple medical specialties, and social issues stretch the time and financial resources required, and are dealt with piecemeal. Patients with complex or multiple problems find themselves disproportionality in a hospital setting heavily focussed on acute medical treatment. Hospital penicillin is stronger. We think in terms of hospital beds. We treat, we don’t prevent. We can be part of the problem and not the solution. Age and Chronic Disease
  • 27. Things can seem overwhelming at times
  • 28. …and then there is us • Breaking down silos, professional boundaries – moving to care provision by competency not care group or type of degree • Moving from “patient care revolves around me” to “what can I do to provide the best care for my patient • Using IT but not relying on IT • Identifying the change agents • Identifying core business roles • Getting rid of waste Is this the biggest impact of NEAT?
  • 29. It can be done
  • 30. Health Services needed to reorganise and re-engage
  • 31. Southern Health Emergency Core Business Position statement • Southern Health Emergency endorses and supports Southern Health’s vision, values and purpose in order to plan and deliver safe, effective and people-focused emergency health services. • Southern Health Emergency recognises that we need to work in partnership with stakeholders to improve health outcomes in our community. • To achieve a safer and healthier environment patients must spend only that time required to receive appropriate emergency care in the Emergency Department. • As an organisation, Southern Health will refocus their processes and resources to ensure patients are safely discharged from the Emergency Department at that time.
  • 32. Emergency Department Core Business Statement Initiate timely assessment and management in order to • Determine clinical priorities • Formulate a provisional diagnosis • Implement initial time critical interventions • Refer appropriately To achieve 4 hour EDLOS, Southern Health Emergency will: Define „Chunks‟ of time Bring the most appropriate clinician to “front of house” as soon as possible (Primary Contact Physiotherapist) Define Core Clinical Business Reduction of non value added time at Reception and Triage Define Consultant in charge PD Initiation of timely patient care by the appropriately competent clincian (SONNA) Define Nurse In Charge PD Patient Streaming and allocation Develop a Staffing to Patient Flow Model Ambulance off stretcher redesign solutions (Change the currency from cubicle/stretcher to appropriate space) Introduce Point of Care testing Managing the queue Initiate the Category 2 doctor Transfer of care Admission- ward/ other Transfer/ Transport/Discharge Interventions/Refer to Unit Primary Assessment Junior Dr Consults within ½ Hour Initial Requests Assessment/ Analgesia Procedures 30 min 90 min 120 min 180 min “Chunks of Time” The ED side of 4 hours are ours Emergency Departments needed to become accountable for what they could control
  • 33. Clinicians need to be accountable Sacred cows need to be dispelled: – Hospitals wards are for sick people – Changing a bed card should be easier than selling a Gary Glitter concert ticket – We are here for the patients – Everyone should be respected for the work they do – It is not “us” versus “them” – We are part of the solution, but not the whole solution
  • 34. How to improve? Study of 600 patients presenting to a tertiary ED showed an exceptionally good correlation between ED diagnosis and subsequent discharge diagnosis of 98% The average time to notification of the inpatient team was 3.07 h after arrival. Post notification analysis showed the EDLOS on average increased by 55 minutes with IP review overall Processes and impediments in moving patients from the Emergency Department. Pilot Study. Oakley E and Braitberg G. EMA . 2005 If the ED clinical decision was appropriate then the best way to narrow this gap is not to have inpatient review in the ED at all
  • 35. Admission- ward/ other Transfer/ Transport/Discharge Interventions/Refer to Unit Primary Assessment Junior Dr Consults within ½ Hour Initial Requests Assessment/ Analgesia Procedures 30 min 90 min 120 min 180 min “Chunks of Time” 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% Jul Aug Sep Oct Nov Dec Jan Feb % doctor to speciality request within 2 hours % Linear (%) Internal target NEAT target 70.0% 72.0% 74.0% 76.0% 78.0% 80.0% 82.0% 84.0% Jul Aug Sep Oct Nov Dec Jan Feb % of discharge patients with EDLOS < 4 hours 0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0% 40.0% 45.0% 50.0% Jul Aug Sep Oct Nov Dec Jan Feb % admitted to an IP bed (including Short Stay) within 4 hours
  • 36. Senior Decision Maker • Assessment area • Masters- apprentice • Patient satisfaction • Up front diagnostics • Early referral • Accountability for ambulance • “Go to” person
  • 37. January time components
  • 38. Individual metricsDear George, Please find below graphs which identify how you are performing according to the agreed Emergency Physician KPIs. These KPIs to remind you are: 1. See patients within 30 minutes of arrival (KPI = 80%) 2. Bed Request within 120 minutes of commencing your consultation (KPI = 80%) 3. 360 minutes to get a patient into Short Stay (KPI = 90%) All SMS will receive this email but only you know which number is yours, everyone else is de- identified. Seeing how one performs in a group of peers is often the best form or feedback. Please note this data only includes the cases for which you were assigned as the primary clinician, not handovers or where you supervised junior staff. Numbers are dependent on your fractional appointment and whether you have had any period of significant lead – the least number of patients makes the data more susceptible to swings. I have chosen to take 2 months as a “snapshot” and will provide you with data 2 monthly on an ongoing basis. In particular I would urge you to look at trends across data periods. I hope you find this feedback useful. You are number x
  • 39. Individual metrics
  • 40. Rapid Acceptance Protocol Rapid Acceptance Protocols – General Surgery Right Iliac Fossa Pain/Appendicitis Identity: This is Dr Jane Doe from Dandenong ED Situation: I have a stable patient with right iliac fossa pain and suspected appendicitis. Background: Age Comorbidities History Examination findings: Investigations: Assessment: Appendicitis Request: Will you accept this patient to the ward under the Rapid Acceptance Protocol and is there anything else I need to do? Rapid Acceptance Protocols – Gastroenterology Stable Gastrointestinal Bleeding Identify: This is Dr Joe Blogs from Clayton ED Situation: I have a stable patient with a suspected GI bleed (haematemesis &/or melaena) Background: Age Comorbidities History Examination findings: Investigations: Assessment: Stable Gastrointestinal Bleeding Request: Will you accept this patient to the ward under the Rapid Acceptance Protocol and is there anything else I need to do? 1. Stable Gastrointestinal Bleeding 2. Jaundice 3. Decompensated Chronic Liver Disease – Ascites, Jaundice, Encephalopathy 4. Acute Pancreatitis (typical pain and elevated serum lipase) 5. Right Upper Quadrant Pain/Biliary Colic/Cholecystitis 6. Sigmoid Diverticulitis 7. Pilonidal/Perianal Abscess
  • 41. Owning ambulance transfer times Call 000 Nearest ambulance ramped at Hospital ED Ambulance sent from 10km away (most available) Despatched ambulance arrives at patient, now asystolic Crit Care Resusc 2006; 8: 321–327 Asystolic patients do not leave hospital alive
  • 42. Linear relationship between hospital delays and ambulance arrival at scene performance The detail is in the length of the “tail”.
  • 43. Ambulance Offload Policy • In order to adopt a ‘whole of system’ approach and recognise the benefits to the community Melbourne Health will implement a new system for ambulance arrivals. • Ambulance arrivals that cannot be offloaded to the waiting room will be prioritised to be offloaded into a cubicle before a walk-in patient with the same clinical urgency (ATS), irrespective of waiting time. • Patients in the waiting room for longer periods should be reassessed to ensure their triage category is unchanged.
  • 44. Reorganisation of the way we work across the acute sector
  • 45. Acute Medicine Model of Care • Flexibility of beds • ED articulates with APU, RAMU, Ambulatory Care & Community Care • Community triage lead by teams with consultant supervision: In Reach, Out Reach, HITH, MATS all coordinated by acute care physicians with direct access to Short Stay, MAU, wards and subacute • Minimal duplication in care improves Quality of care • Observation Medicine and Shared Management Plans with APU/RAPU • Cost saving • Bed day savings If the right patient is in the right clinical space the benefits are self evident If the right physician is in the right clinical space the benefits to the patient are self evident Emergency Physicians General Physicians Intensivists?
  • 47. What we wont see in 5-10 years • White coats (cant find them now!) • Ties • Territorial abysses • Silos • Belief that a certificate/Fellowship confers competency (it only recognises the start of the journey) • We are only accountable to our own clinical practice • Access Block, Bed Management are no longer someone else’s responsibility or problem
  • 48. Conclusions 1. Accountability is the key to “ownership” 2. We need to recognise each other’s contribution to the solution and not blaming one another for the problem 3. Not just “whole of hospital”, needs to be “whole of system”. 4. Things are changing 5. Every journey starts with a single step.” Confucius
  • 49. Questions?
  • 50. An ode to Access Block apologies to the “Hotel California” by the Eagles In a blocked full department, airconditioned in there Warm smell of colitis, rising up through the air Up ahead in the distance, I saw a shimmering light My head grew heavy and my sight grew dim I had a patient to admit in sight As I stood in the doorway…. I heard the code overhead And I was thinking to myself, Code Yellow HEWS, it must be 10am Then as I looked to the heavens to show me the way There were voices down the corridor, I thought I heard them say Welcome to the Public Hospital System Such a lovely place Such a lovely face Plenty of room at the Public Hospital System Any time of year, you can find a bed here”.