In search of the most efficient and safest patient flow for acute presentations

to ED

Ian Scott

Director of Internal Medicine and Clinical Epidemiology,

Princess Alexandra Hospital

Associate Professor of Medicine,

University of Queensland, Brisbane

Emergency Management ConferenceSydney20/7/16

Courier Mail14/12/12

NHPA report2011-12

A wicked problem

A wicked problem

A wicked problem

A wicked problem

Dangers of congestion

• Longer ED stay independently predicts longer inpatient LOS

– 2.35 days for ED LOS >12 hrs; 0.39 days for ED LOS ≤4 hrs

» Liew et al Med J Aust 2003

• 34% increase in risk of 10-day death of patients admitted when ED overcrowded

» Richardson Med J Aust 2006

• ED overcrowding in Perth’s tertiary hospitals - estimated annual excess 120 deaths

» Sprivulis et al Med J Aust 2006

• Increased readmissions and ED return visits; inappropriate follow up care (discharge planning)

» Forero & Hillman, ‘Access block and overcrowding: A literature review’, Prepared for Australasian College of Emergency Medicine

• Prolonged pain, patient/carer dissatisfaction, violence, ambulance diversions/ramping, reduced efficiency

» Derlet & Richards Ann Emerg Med 2000

Congested hospitals

• In UK, DoH found bed-occupancy rates >85% in acute care hospitals associated with delays in emergency and elective admissions

– Shaping the future NHS: long term planning for hospitals and related services. London: Department of Health, 2000

• Occupancy rates >92% critical occupancy for increased risk of serious adverse events

– Boyle et al. Probability of Severe Adverse Events as a Function of Hospital Occupancy. IEEE Journal of Biomedical & Health Informatics 2014; 18: 1-15

ED flows – complex adaptive system

‘Dead time’

Problems within ED

• Delayed discharge of low-risk patients due to lack of timely senior ED clinician input

• Delays in patient flow relating to patients with behavioural problems

• Needless processing of packaged patients through ED

• Unpredictable surges in ED admissions diverted from other hospitals

• Lack of clear patient disposition rules

• Limited capacity of SSW to accept patients from ED

• Ad hoc processing of non-urgent patients

ED-inpatient interface (EDii)

ED Wards

Complex adaptive system

Problems at the EDii

• Delayed identification of patients eligible for rapid inpatient admission

• Limited ED to medical consultant liaison in expediting disposition decisions

• Underutilisation of day-time medical workforce for admitting patients

• Uneven load sharing of admissions between after-hour registrars

Problems at the EDii

• Delays in inpatient teams responding to, and accepting, ED requests for patient review or admission

• Delays in review and admission of non-urgent patients by in-patient teams

• Delays in patient flow due to waits for investigations

• Confusion as to most appropriate inpatient team to receive ED admission referrals

Problems hospital wide

• Delayed discharge of patients to community from inpatient units

• Delayed transfer of patients requiring residential care

• Limited use of hospital substitution programs

• Lack of detailed, timely NEAT performance data and developing quality framework

But nothing was changing

• In 2010 we had known all this for at least 5 years– Accenture – KPMG– QH – CARU

• Past ‘technical fixes’ had not solved most of these problems– Expanding ED; building MAPU; blitz elective surgery

• Anecdotal perceptions; fingerpointing; antagonistic silos

Technical fixes

• New ED opened PAH Nov 2010– Extra 15 acute cubicles; total: 25 acute; 6 resus; 14 SSW; 4 MH

• New MAPU opened February 2011– Extra 30 beds

• 20% increase in ED presentations over next 12 mo– additional 26 ambulance arrivals per day

• 25% increase in medical admissions• 18% increase in median time in ED

– 315 min (2010) to 373 min (2011)• 22% increase in median time in ED for admitted patients

– 448 min (2010) to 583 min (2011)

• Mean time in ED for all patients: 5.9 hours in 2011• 40% admission rate

Adaptive vs technical changeRonald Heifetz: Leadership Without Easy Answers 1994

• Technical change– New drug, operation, service (new ED/MAPU)– Straightforward changes with clear pathway– No change to underlying construct– Extension of previous traditions/learning

• Adaptive change– Fundamental changes to construct– Requires new learning– Elicits sense of dislocation and emotional distress– No tried and true solutions– Needs tailoring to local conditions and relationships

Common mistake: trying to fix what is essentially an adaptive problem with a technical fix

NEAT targets as a catalyst for change

The 4-hr NEAT target was not seen as THE solution or an end in itself

It served as a catalyst for redesigning the patients’ entire hospital journey in order to deliver better quality care and optimise patient outcomes

The primary drivers were not financial or reputational salvationalthough they were considerations

Governance

NEAT strategies

Reforms within ED• ED consultant assigned to Ambulatory Care area to fast track patients

able to be discharged home

• More rapid transfer of patients with behavioural problems to mental health waiting area

• Change in admission procedures to avoid unnecessary transit of planned, clinically stable admissions and interhospital transfers via the ED

• Implementation of a ‘no bypass’ rule for the EDs of the four hospitals

• Explicit streaming criteria (following initial senior ED clinician assessment and triaging) of patients to short-stay wards, MAPU, wards, critical care wards

• Expansion of the ED SSW from six to 14 beds with recruitment of an additional 4.8 full-time equivalent (FTE) nurses and 1.0 FTE clinical nurse consultant

• All patients presenting with Australian Triage Scale category 3–5 to be seen by EDstaff in order of attendance, not clinician preference

Reforms involving ED–ii

• Direct to ward admissions of clinically stable patients meeting prespecified criteria

• Admitting teams, not ED staff, made responsible for organising additional investigations before transfer

• Explicit streaming criteria for general medicine or subspecialty admission

• Requirement for inpatients teams to respond to ED referrals within 60 min of notification

• ED Information System (EDIS) notes to be used as primary working documents

• Medical registrars unencumbered by other duties for processing ED referrals

• Close liaison between ED and MAPU staff for screening MAPU eligible admissions

• Daily weekday rounding of all ED beds by on-take general medicine/MAPU/ED teams

• Admissions by specialty units up to 5pm

• Extended evening shifts of admitting regs

Hospital-wide reforms

• Discharge of patients from inpatient wards and the ED over extended hours (0800–2000 hours) Monday–Sunday

• EDD documentation and criteria-led discharge

• Daily debriefing between registrars and consultants on inpatient wards

• Access to step-down nursing care/hospital beds (n = 20) in off-campus sites for patients awaiting residential care

• Establishment of on-site hospital in the home (HITH) care teams and rapid review clinics for in-patient stays

• Back transfers to referring regional hospitals, referring nursing homes or hospice care as soon as clinically appropriate.

Monitoring and feedback

• NEAT performance data circulated to all areas of the hospital in various forms: – daily morning report, ED dashboard– monthly NEAT reports for each speciality unit/ward– monthly patient phase for all admissions to specific inpatient

units– monthly reports indicating delays in patient movements to wards

• Audits, case reviews, routinely collected administrative data

• Monthly meetings of NEAT taskforce

• Weekly NEAT quality and safety review meetings

• Safety indicators monitored on a monthly basis by the NEAT Taskforce

Monitoring and feedback

Unit specific feedback

Daily morning report

ED statboard

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NEAT

Presentation Month

NEAT in Tertiary Hospitals

Princess Alexandra Hospital

NEAT Admit NEAT Dischg NEAT PAH %Admit % DNW % Discharg

Effects

Slope = -1.061 ± 0.132

Y-intercept = 131 ± 6.821

X-intercept = 123

R2 = 0.854

P<0.0001

Emergency HSMR vs NEAT

Sullivan et al Aust Health Rev 2014

What is the ideal NEAT?

• Evidence that a time-based target has been associated with a reduction in in-hospital mortality for emergency admissions to Australian hospitals

• Concerns remain regarding a time-based target alone being used to drive redesign efforts at improving access to emergency care

• Such targets should be coupled with close monitoring of patient outcomes of emergency care

• Target thresholds need to be evidence based and separate targets should be reported for admitted, discharged and all patients presenting to ED

Aust Health Rev 2016

Evidence-based NEAT

Sullivan et al Med J Aust 2016

Evidence-based NEAT

Sullivan et al Med J Aust 2016

Is it safe?

Staib et al Emerg Med Australas 2016

Who benefits most?

Sullivan et al Aust Health Rev 2016

What are best metrics of patient flow?

Is it sustainable?

New initiatives

• Maximising ED referrals to inpatient teams by 2 hours– 75-80% of referrals– Agreed ED workup protocols for specific high volume patient groups

• Syncope, chest pain, atrial fibrillation, CAP, seizures, TIA/stroke, # NOF

• Parallel processing rather than linear processing

• ‘Take it and own it – the clock’s running’– Specialty unit delays in accepting/transferring patient

Accepting registrar must commit to 4 hours– CASPER– MASPER

• Dedicated medical registrars who receive ED referrals for admission• Responsible for organising on-referral to other medical units if first-call

unit does not accept

• Direct admissions to MAPU (bypass ED)– Referrals of stable patients from OPD, GP

• Improved orientation of regs to NEAT processes

Complexity science and system theory

• Viewing ED flows across EDii as a complex adaptive system

• System theory works

• Changing systems is hard work and requires serious commitment– Overcoming traditions and entrenched practices

– Requires leadership to overcome obstacles

– Requires commitment from sense of urgency combined with actionable possibilities

Success factors

• Multidisciplinary collaboration– fostering trust between departments

• Support and commitment from CEO/Board• Task-orientated collaborative teams

– Involving and led by clinicians (leaders within)– Supported by analysts, informaticians, administrative staff– Actionable plans

• Regular, accurate feedback to all relevant staff• Learning from other peer institutions• Ongoing reinforcement• Turning NEAT targets into patient narratives and

uniting staff behind a common goal