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Wendy Hudson, Royal Hospital For Women: A Whole System Approach to Managing Patient Flow in Obstetrics- Royal Hospital for Women, Randwick NSW
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Wendy Hudson, Royal Hospital For Women: A Whole System Approach to Managing Patient Flow in Obstetrics- Royal Hospital for Women, Randwick NSW


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Wendy Hudson, Patient Flow Manager, Royal Hospital For Women, Randwick delivered this presentation at the 2014 Hospital Bed Management & Patient Flow Conference, Australia's foremost patient flow …

Wendy Hudson, Patient Flow Manager, Royal Hospital For Women, Randwick 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:

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  • 1. Royal Hospital for Women
  • 2. Royal Hospital for Women Only Women’s Hospital in NSW Major referral quaternary hospital 4200 birth per annum •3000 publicly insured •1200 privately insured
  • 3. Maternity-Towards Normal Birth in NSW PD2010-045 •Increase the number of spontaneous labours •Decrease the number of labour interventions Launched June 2007 at the RHW Direction to NSW Maternity services regarding increasing the vaginal birth rate in NSW and decreasing caesarean section operation rate To develop, implement and evaluate strategies to support women and to ensure that midwives and doctors have the knowledge and skills necessary to implement this policy
  • 4. Models of Care Midwives Clinic and GP Shared Care Midwifery Group Practice (MGP) 40% of births Malabar Community Midwifery Link Service Obstetricians Clinic Private Obstetrician- 10% Maternal Fetal Medicine Specialist Midwifery Clinic for Women with Special needs Working toward the Eligible Midwife
  • 5. Midwives in Group Practices 6 Midwifery Group Practice of midwives –women of all risk (2008) Homebirth service (2011/12) Malabar Community Midwifery Link Service Maternal Fetal Medicine Midwifery Group Practice (2011) MGP care for more than approximately 1500 women – half of the publicly insured women
  • 6. Care Coordination: Planning from Admission to Transfer of Care in NSW Public Hospitals PD2011_015 Transfer of Care = Discharge From booking to final appointment of care 5 stages of care coordination: 1. Pre Admission/Admission 2. Multidisciplinary Team Review 3. Estimated Date of Discharge 4. Referrals & Liaison for patient Transfer of Care 5. Transfer of Care out of the hospital
  • 7. Postnatal Transfer of Care= Discharge Discharge home within 4 to 12 hours of birth Transfer of Care from time of birth of the baby Vaginal birth -72 hours- 3 days Caesarean Section - 120 hours- 5 days Midwifery Group Practice (MGP) Midwifery Service Programme (MSP) Private Patient All women receive Midwifery Support at home for at least two weeks after the baby is born (Target 100% in metro services by 2015)
  • 8. Midwifery Support Programme- MSP Provide Postnatal support in the woman’s home Discharge- <48 hours Normal Birth Discharge < 72 hours Caesarean Eligible Medically well Breastfeeding independently Feeding baby independently if formula feeding Following medical review if complicated antenatal, intra partum, postpartum episode
  • 9. MSP- Births - Accepted 450 2010 400 Confined Births MSP Accepted 2010 350 300 2011 Confined Births 250 MSP Accepted 2011 200 150 2012 Confined Births 100 MSP Accepted 2012 50 2013 0 Confined Births MSP Accepted 2013
  • 10. Length of Stay - LOS 60.00% 50.00% Woman % 40.00% 30.00% 20.00% 10.00% 0.00% < 24 hrs 24-48 hrs 2-4 days ≥5 Case load Midwifery 11.59% 21.36% 44.09% 22.95% Core Midwifery 4.05% 22.25% 50.29% 23.41% Total 8.27% 21.76% 46.82% 23.16%
  • 11. Length of Stay - LOS 4.0 3.5 3.0 2.5 Days 2.0 1.5 1.0 0.5 0.0 Caesarean Instrumental Unassisted vaginal All Case load Midwifery 3.4 3.1 2.4 2.8 Core Midwifery 3.5 3.0 2.6 2.9 All 3.5 3.1 2.5 2.8
  • 12. When Normal Birth Expectations do not Occur Constraints to the transfer of care of the obstetric patient increasing LOS: Standard care- maternal or neonatal complications Complex cases• MFM patients- surgical consults • In utero transfers for prematurity • Psychosocial admissions for mental health • CUPS (Chemical Use in Pregnancy) • FAC’s (Family and Community Services) Privately insured patients- counterintuitive to LOS Co –located hospital -Sydney Children’s Hospital
  • 13. When Normal Birth Expectations do not Occur SUB-OPTIMAL OUTCOMES  Uncontrolled hypertension Sudden hypotension  Pulmonary oedema  Renal failure  Eclamptic seizures  Intracerebral haemorrhage  Fetal compromise  Maternal death
  • 14. Complex Case Presentation Catherine T -28 years old transferred at 30 weeks gestation Transfer from Dubbo Hospital via air ambulance  Threatened Premature Labour (TPL)  Pregnancy Induced Hypertension (PIH)  Unstable maternal medical condition on admission to RHW
  • 15. Catherine deteriorated within 8 hours of admission  Emergency LSCS for Severe Hypertension of Pregnancy, TPL, Fetal Distress  Massive blood loss- develops disseminated intravascular coagulopathy (DIC) Transferred directly to ICU at Prince of Wales Hospital Day 3 - develops Fatty Liver
  • 16.  Remains in POWH ICU for 11 days  Readmitted to RHW Acute Care Ward  Day 5 - wound breakdown of LSCS site  Day 13 – deterioration T/f POWH ICU Day 18 T/f Postnatal Services RHW Day 25 discharged
  • 17. Neonate Baby girl of Catherine weight- 940 grams at birth  delivered by LSCS and transferred to NICU  Ventilated 9 days CPAP for 3 days Remained in Special Care Nursery for 7weeks and 4days NETS t/f to Dubbo Hospital
  • 18. Implications to Care Coordination Increased LOS ICU and ACU admission Pathology costs Nursing hours Premature infant and LOS in NICU transfer costs to referral hospital transfer of care of neonate- 7 weeks and 4 days
  • 19. Implications on Transfer of Care Transfer of woman from out of area with no local supports Psychosocial – •lack of engagement with newborn •constraints to partner relationship Admission to ICU x 2 Maternal medical complications •Liver function •Renal impairment •Thrombocytopenia Prematurity of Newborn
  • 20. Bed Management Strategies Know your core business and be able to define it. Make your processes transparent to ensure everyone is on the same page. Develop an organisational governance structure that exhibits clear leadership Manage organisational change by expressing, modelling and reinforcing behaviours Define clear pathways for accountability to ensure expectations are clear.
  • 21. Bed Management Strategies Daily Patient Flow/Bed Management meeting Multidisciplinary meeting with medical, midwifery and allied health teams Discuss all birthing unit admissions and plans for the proceeding two days Review of expected discharges - EDD’s Planned antenatal admissions - medical inductions, ECV-Breech, Pregnancy Day Stay
  • 22. Bed Management Strategies MoH Patient Flow PortalExpected Date of Discharges -EDD’s Monitor delays in system- WFW - waiting for what Monitor inter hospital transfers Bed Management Module
  • 23. Bed Management Strategies MOH Predictive Tool Manage workload / activity across the week rather than a day at a time. Demand analysis at area, network, hospital and department /speciality level. Have an Executive team ready to make decisions on preserving capacity and acting early. Look at options to utilise capacity when there is an unscheduled drop in demand
  • 24. Acknowledgment Maternity-Towards Normal Birth in NSW PD2010-045 Care Coordination; Planning from Admission to Transfer of Care in NSW Public Hospitals Procedures. PD2011_031 Inter facility Transfer Process for Adult Patients Requiring Specialist Care PD2010_030 Critical Care Tertiary Referral Networks (Paediatrics) PD2010_031 Children and Adolescents – Inter Facility Transfers PD2010_069 Critical Care Tertiary Referral Networks (Perinatal) MOH Patient Flow Portal Australian Maternity Reform Through Clinical Redesign- Donna Hartz et al. (2012) Caseload Midwifery Care Versus Standard Maternity Care for Women of Any RiskProfessor Sally Tracey et al. (Sept 17, 2013)