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Dr Michele Genevieve and Dr Matt Summerscales - SJG Midland Public Hospital
- 1. Toddler trying to run... 20 months old and counting DR MICHELE GENEVIEVE AND DR MATT SUMMERSCALES, HEADS OF DEPARTMENT, SJG MIDLAND PUBLIC HOSPITAL
- 2. Background Who are we? How it all started.. Closed the 110 bed hospital with 47,000 presentations a year ED bed capacity 18 + 7 EDSSU = 22 beds Opened a new 307 bed hospital with predicted 60,000 presentations a year. ED bed capacity 36 +12 EDSSU = 48 beds Rapidly faced 67,000 presentations a year
- 3. What were our aims? Be a Department where people want to work Be innovative Provide timely, quality care with compassion Senior review and decision making up front
- 4. Where were we this time last year? Getting to grips with change management Presentations seemingly stabilised for past 4 months, (but heading into winter) Struggling to meet KPIs ATS WEAT Avoid diversion and ramping 162 164 166 168 170 172 174 176 178 180 Average presentations to ED per day Jan- June 2016 0 10 20 30 40 50 60 70 80 90 WEAT Jan- June 2016 % WEAT target
- 5. What were our challenges? - Geographical staffing of areas - Providing good quality education to our trainees - Avoiding non compliant EDSSU admissions - Reducing diversion and ramping - Urging the hospital to give us rights of admission - Maintaining improvements whilst avoiding change fatigue - Increasing staffing levels to meet service demand - Provision of medical cover for our EDSSU
- 7. The corridor
- 8. What were our challenges? - Geographical staffing of areas - Providing good quality education to our trainees - Avoiding non compliant EDSSU admissions - Reducing diversion and ramping - Urging the hospital to give us rights of admission - Maintaining improvements whilst avoiding change fatigue - Increasing staffing levels to meet service demand - Provision of medical cover for our EDSSU
- 9. Educational challenges Medical professionalism Modelling behaviour Emotional intelligence Communication skills With medical colleagues and superiors With nurses With patients and families With junior doctors Clinical skills Supervision of junior’s skills Decision making skills Learning to lead Time management skills Resilience
- 10. What were our challenges? - Geographical staffing of areas - Providing good quality education to our trainees - Avoiding non compliant EDSSU admissions - Reducing diversion and ramping - Urging the hospital to give us rights of admission - Maintaining improvements whilst avoiding change fatigue - Increasing staffing levels to meet service demand - Provision of medical cover for our EDSSU
- 11. Avoiding non compliant EDSSU admissions Documentation education Administrative registrar 3 hours per day to ensure adequate documentation and to negotiate with coders regarding contentious admissions Improved EDSSU admission management plan form to incorporate ARDT type of admission and ensure medical staff aware of the management and documentation required to meet ARDT compliant admission
- 12. What were our challenges? - Geographical staffing of areas - Providing good quality education to our trainees - Avoiding non compliant EDSSU admissions - Reducing bypass and ramping - Urging the hospital to give us rights of admission - Maintaining improvements whilst avoiding change fatigue - Increasing staffing levels to meet service demand - Provision of medical cover for our EDSSU
- 13. Avoiding diversion and ramping WA DoH issued us with a “please explain” regarding the level of ramping at our facility We visited other Perth facilities to discover their processes and procedures to avoid diversion and ramping We elected to create a “waiting room” for patients on trolleys and to staff it with our clinical resource nurse (or triage liaison nurse) This allowed the paramedics to leave despite the patient not being allocated an assessment space in the department Is this “internal ramping”? Is this a long term strategy?
- 14. What were our challenges? - Geographical staffing of areas - Providing good quality education to our trainees - Avoiding non compliant EDSSU admissions - Reducing bypass and ramping - Urging the hospital to give us rights of admission - Maintaining improvements whilst avoiding change fatigue - Increasing staffing levels to meet service demand - Provision of medical cover for our EDSSU
- 15. One year on What have we achieved? Early senior review and decision making (PRIME- Preliminary Rapid Initial Management Episode) Admission rights Consultant in “Blue” area Ramping avoidance strategy Resource nurse to staff the “trolley lobby” and allow paramedics to leave EDSSU compliant admissions improved from 70% to 90%
- 16. One year on What has this resulted in? ATS KPI compliance WEAT improvements Ramping is rare Nil diversion in 2017
- 17. ATS compliance Early struggles with ATS 2 and 3 Solved with concentrating seniors on ATS 2s Long term struggles with ATS 3 Improved greatly with PRIME and its later iterations
- 18. ATS improvement ATS 2 KPI Compliance ATS 3 KPI Compliance 0 10 20 30 40 50 60 70 80 90 100 2016 2017 KPI abatement level 0 10 20 30 40 50 60 70 80 2016 2017 KPI abatement level
- 19. WEAT improvements ATS 3 compliance had side effect of improvement in WEAT Early decision making Blue consultant senior early decision making in “discharge“stream DoH spotlight on WEAT in WA with “please explain“ to each hospital Executive engagement and WEAT project officer assigned
- 20. What did we suggest? Rights of admission Centralised bed management system Real time data dashboard Change staffing to cover times of day when time to see patient was longest Inpatient staffing to cover admissions Medical registrar in ED Surgical registrar not in theatre Transfer policy to tertiary/quaternary site Emergency Department Admission Centre Emergency Medicine project to analyse inefficiencies
- 21. Rights of admission Late adopters of rights to admission ED senior doctor decides patient requires admission Calls and speaks to inpatient team registrar Ward Bed request submitted immediately following referral for admission Inpatient team has 60 mins before patient will leave ED and go to ward Transfer of care form completed for patients not assessed by inpatient team in ED
- 22. Centralised Bed Management system Late adopters Individual wards no longer responsible for “putting their hand up” to take patient appearing on bed request list Daytime bed manager to allocate beds After hours nurse manger to allocate beds after hours Don’t recommend this approach
- 23. Real time data dashboard Inspired by QLD and Gold Coast Currently at early design stage
- 24. Shift times alterations Change that was initially unpopular Concept of the “early night” shift Late evening in the discharge area Cohorting of medical staff in one area overnight and decanting “sorted”inpatients to the discharge area
- 25. Inpatient team staffing Medical registrar dedicated for admissions 10-1800 Evening medical registrar and night medical registrar ? Surgical team ? O&G team? Paeds team?
- 26. WEAT improvements Despite increasing presentations WEAT Average presentations per day 150 155 160 165 170 175 180 185 190 195 200 2016 2017 0 10 20 30 40 50 60 70 80 90 WEAT 2016 WEAT 2017 target
- 27. WEAT improvements Despite consistent admission rate WEAT Admission Rate 0 5 10 15 20 25 30 35 2016 2017 0 10 20 30 40 50 60 70 80 90 WEAT 2016 WEAT 2017 target
- 28. WEAT breakdown 0 10 20 30 40 50 60 70 80 90 100 Discharge WEAT 2015 2016 2017 0 10 20 30 40 50 60 70 Admission WEAT 2016 2017
- 29. Yet to come BUT ON THE WAY…
- 30. EDAC Why is the ED the location for the queue for an inpatient bed? The discharge lounge is a 4 bed, 3 recliner chair clinical area on the ground floor of the hospital. Could easily be altered to be a 6 bed cardiac monitored area. Used by Day surgery unit to decant their discharges waiting to go home. Wards are not utilising optimally Winter results in 4-9 inpatients awaiting a bed in the ED at 0800 Idea to use this area to decant patients waiting for inpatient bed
- 31. Transfer policy Should we keep patients requiring care by specialities not provided at our facility in our ED for up to 3 days? Currently being negotiated at state level
- 32. Project to analyse inefficiencies Inefficiencies? Waiting time Documentation duration Communication time Flag for nurses IT Dashboard/dept overview Geography
- 33. Discussion Maintaining Quality Quality, Timely Care vs Training Requirements Managing Change
- 34. Maintaining Quality Improvements to flow and processes contribute to improved quality: Early Senior Decision Making Eliminating inefficiencies allows for increased clinical care time Quality processes must also run in parallel to flow improvements: Morbidity and mortality Quality Committees ACHS Hospital committees Quality Action plan and improvements Interdisciplinary Medical Professionalism projects
- 35. Quality, Timely Care vs Training Requirements Focus on Training requirements prior to opening: Paid Registrar and RMO teaching built into rosters. Primary Exam and Fellowship Exam programmes OSCE programme and mock exam Senior RMO teaching Planned time for Simulation EMC Clinical Support Consultant Mon-Fri for WBA’s Consultant Portfolio Research and Audit Medical Students and Supervisor Hospital Grand Rounds Registrar roles with learning objectives. Lone Reg – clinical care Team Reg – managing a team
- 36. Managing Change Change Fatigue The state of exhaustion employees reach when they have experienced too much change. It’s real Deliberately stop any further changes Allow processes to embed No more changes even if you do need to implement further. Resist the temptation
- 37. TAKE HOME POINTS Everybody likes a good take home summary
- 38. For Hospital Executives and Mere Mortals: The following are the nine key principles in making patient management more efficient and effective: 1. Match capacity to demand 2. Monitor patient flow in real time 3. Help shape demand 4. Manage, reduce, or eliminate variability 5. Reduce waste (anything that does not add value to the service or to the encounter) 6. Forecast and predict demand for services 7. Understand the implications and insights of queuing and queuing theory - pooled vs dedicated queues. Servicing less complex patients at times of high utilisation. 8. Understand the implications and insights of the Theory of Constraints - a chain is only as strong as its weakest link. Work on your bottlenecks. 9. Appreciate that the ED is part of a system A Design for Operational Excellence The Hospital Executive’s Guide to Emergency Department Management © 2010 HCPro, Inc. 7
- 39. NHS Improvement - Improving patient flow through urgent and emergency care Published this month https://improvement.nhs.uk/resources/improving-patient-flow-through- urgent-and-emergency-care/
- 40. NHS Improvement - Improving patient flow through urgent and emergency care Six principles underpin good non-elective patient flow: 1. Flow is a team sport –All organisations, departments and staff groups in and outside hospitals need to collaborate. 2. Flow needs focus from the top – there should be senior clinical and executive leads for flow. 3. Flow is seven days a week – attendances and admissions occur relatively consistently through the week and so should reviews, transitions and discharges. 4. Flow is about case mix – use analytical tools to understand the acuity of patients attending the ED and how this varies across the day and the week. Use this information to match resources to demand. 5. Flow needs patient input – pathways and individual patient journeys should be regularly reviewed 6. Flow needs to be maintained at times of pressure – systems will come under significant stress. Tried and tested escalation processes should be implemented when they do, to protect assessment and short stay wards, clinical decision units, ambulatory emergency care and acute assessment services. Escalation should be meaningful and the whole system needs to act to relieve pressure where it occurs.
- 41. NHS Improvement - Improving patient flow through urgent and emergency care THE BEST BITS: A full capacity protocol (FCP) is recommended Patients requiring inpatient care are moved out of the ED to an inpatient ward area. This is achieved by, for example, a ward caring for one extra patient until a bed becomes available elsewhere for that person following discharge of another patient. Moving the risk from ED to the wards Does the hospital want to hold all its risk in ED?
- 42. Final Take Home Summary – If you can’t think of anything to do: How can I improve the care I give to vulnerable groups: Paediatrics Mental Health Elderly Indigenous Socially Disadvantaged