St John Project Transport to the Medical Home
20,000 Days Campaign Learning Session 3 11-12 March 2013
Project Manager: Jo Goodfellow
What do we want to achieve?
To increase the number of Status 3 and 4 patients who are transported by St John to a primary care / community setting as an alternative to transporting to the Emergency Department
….and why?The number of self presentations to ED across Auckland is increasing by around 10% pa putting pressure on DHBs. A proposal developed with St John was presented to and endorsed by GAIHN’s Alliance Clinical Network and Leadership Team (October / November 2011)
Clinicians from the regions EDs, primary care sector and Accident and Medical sector were consulted and together with St John developed clinical guidelines for the paramedics to support their decision making on the scene (November 2011)
Setting the Scene
Low acuity patients who call 111
A pathway for low acuity patients to be transported to an A&M by St John as an alternative to ED was established in December 2011 with the cost of the treatment paid for by POAC
This was a result of increasing pressure on EDs from the continued rise in unplanned presentations, predominately self-referrals
Ambulance transports account for around 33 percent of all hospital presentations and the number of transports in the region has increased by 3.84 percent over the last 12 months
36% of all transports to ED go to Middlemore, 28% to Auckland Hospital, 23% to North Shore, 9% to Waitakere, and 4% to Starship
82% of all ambulance calls are Moderate (Status 3) or Minor (Status 4). In the last 12 months, St John attended 126,869 calls in Auckland which resulted in 102,141 transports to an ED or other medical facility
Since the establishment of the pathway, approximately 1400 patients have been transported (regionally) to an A&M who would otherwise have been taken to an ED
St John Project Driver Diagram
To increase the number of low acuity
(St John status 3 & 4)
patients being
transported to, and
managed in a primary
care setting from 5 to 10 patients per day, by 01 July 2013
Patient
General Practitioner
(GP)
St John
Availability of St John
Education of crews
Education
Capacity
St John Project Driver Diagram
Doctor availability
Location of patient
1° 2°
Education
Change Concepts
Increase capacity
Increased public awareness of primary care to be treated in primary care
‘Relaunch’ pathway with St John crews to assist in embedding into practice
Extend transport to include more
A&Ms and GPs for pt treatment
Hours of service of A&Ms / GP practices
Communication with GPs regarding
involvement in pathway
Specific Change Ideas
Accident & Medical Centre
Opening hours
Patient expectation
Patient status
Triage by call centre
Pt choice of ED, or primary
care
Location of A&M or GP
Driver decision where to take pt
Medical skill/confidence
Change Packages
Secondary Drivers
(Theory of change)
Change Ideas Tested
Regionally agreed guidelines developed
ED clinicians in support of project and confident guidelines ensure patient safety
Individual A&M centres consulted and processes agreed
All centres keen to come on board and sign an MoU with POAC
Regional implementation of the guidelines and pathway
Initial teething issues in individual A&Ms
Some variation in practice within the A&M centres
Pt transfer to A&M centre
Additional 4 A&M centres included in project for CMDHB area
Measures Summary
Feb
2013
Jan2
013
Dec
2012
Nov
2012
Oct
2012
Sep
2012
Aug
2012
Jul2
012
Jun2
012
May
2012
Apr
2012
Mar
2012
Feb
2012
Jan2
012
Dec
2011
Nov
2011
Oct
2011
Sep
2011
Aug
2011
Jul2
011
Jun2
011
May
2011
Apr
2011
Mar
2011
Feb
2011
Jan2
011
Dec
2010
Nov
2010
Oct
2010
Sep
2010
Aug
2010
Jul2
010
Jun2
010
May
2010
Apr
2010
Mar
2010
Feb
2010
Jan2
010
Dec
2009
Nov
2009
Oct
2009
Sep
2009
Aug
2009
Jul2
009
Jun2
009
May
2009
Apr
2009
Mar
2009
Feb
2009
Jan2
009
600
550
500
450
400
Month/ Year
No o
f C
ase
s
_X=506.0
UCL=624.9
LCL=387.0
Pilot start Formal Launch of Project
Feb
2013
Jan2
013
Dec
2012
Nov
2012
Oct
2012
Sep
2012
Aug
2012
Jul2
012
Jun2
012
May
2012
Apr
2012
Mar
2012
Feb
2012
Jan2
012
Dec
2011
Nov
2011
Oct
2011
Sep
2011
Aug
2011
Jul2
011
Jun2
011
May
2011
Apr
2011
Mar
2011
Feb
2011
Jan2
011
Dec
2010
Nov
2010
Oct
2010
Sep
2010
Aug
2010
Jul2
010
Jun2
010
May
2010
Apr
2010
Mar
2010
Feb
2010
Jan2
010
Dec
2009
Nov
2009
Oct
2009
Sep
2009
Aug
2009
Jul2
009
Jun2
009
May
2009
Apr
2009
Mar
2009
Feb
2009
Jan2
009
160
120
80
40
0
Month/ year
Movin
g R
ange
__MR=44.7
UCL=146.1
LCL=0
Dec2011Sep2011
Ambul Presentation to MMH EC (Triage Cat 4)
Feb
2013
Jan2
013
Dec
2012
Nov
2012
Oct
2012
Sep
2012
Aug
2012
Jul2
012
Jun2
012
May
2012
Apr
2012
Mar
2012
Feb
2012
Jan2
012
Dec
2011
Nov
2011
Oct
2011
Sep
2011
Aug
2011
Jul2
011
Jun2
011
May
2011
Apr
2011
Mar
2011
Feb
2011
Jan2
011
Dec
2010
Nov
2010
Oct
2010
Sep
2010
Aug
2010
Jul2
010
Jun2
010
May
2010
Apr
2010
Mar
2010
Feb
2010
Jan2
010
Dec
2009
Nov
2009
Oct
2009
Sep
2009
Aug
2009
Jul2
009
Jun2
009
May
2009
Apr
2009
Mar
2009
Feb
2009
Jan2
009
600
500
400
Month/ Year
Num
ber
of
Case
s
_X=514.7
UCL=634.8
LCL=394.5
Pilot Start Formal Launch of Project
Feb
2013
Jan2
013
Dec
2012
Nov
2012
Oct
2012
Sep
2012
Aug
2012
Jul2
012
Jun2
012
May
2012
Apr
2012
Mar
2012
Feb
2012
Jan2
012
Dec
2011
Nov
2011
Oct
2011
Sep
2011
Aug
2011
Jul2
011
Jun2
011
May
2011
Apr
2011
Mar
2011
Feb
2011
Jan2
011
Dec
2010
Nov
2010
Oct
2010
Sep
2010
Aug
2010
Jul2
010
Jun2
010
May
2010
Apr
2010
Mar
2010
Feb
2010
Jan2
010
Dec
2009
Nov
2009
Oct
2009
Sep
2009
Aug
2009
Jul2
009
Jun2
009
May
2009
Apr
2009
Mar
2009
Feb
2009
Jan2
009
160
120
80
40
0
Month/ Year
Movin
g R
ange
__MR=45.2
UCL=147.6
LCL=0
Sep2011Dec2011
I-MR Chart of Ambul. Presentation to MMH EC (TC 4&5)
Feb
2013
Jan2
013
Dec
2012
Nov
2012
Oct
2012
Sep
2012
Aug
2012
Jul2
012
Jun2
012
May
2012
Apr
2012
Mar
2012
Feb
2012
Jan2
012
Dec
2011
Nov
2011
Oct
2011
Sep
2011
Aug
2011
Jul2
011
Jun2
011
May
2011
Apr
2011
Mar
2011
Feb
2011
Jan2
011
Dec
2010
Nov
2010
Oct
2010
Sep
2010
Aug
2010
Jul2
010
Jun2
010
May
2010
Apr
2010
Mar
2010
Feb
2010
Jan2
010
Dec
2009
Nov
2009
Oct
2009
Sep
2009
Aug
2009
Jul2
009
Jun2
009
May
2009
Apr
2009
Mar
2009
Feb
2009
Jan2
009
20
15
10
5
0
Month/ Year
No o
f C
ase
s
_X=8.72
UCL=17.13
LCL=0.31
Formal Launch of ProjectPilot Start
Feb
2013
Jan2
013
Dec
2012
Nov
2012
Oct
2012
Sep
2012
Aug
2012
Jul2
012
Jun2
012
May
2012
Apr
2012
Mar
2012
Feb
2012
Jan2
012
Dec
2011
Nov
2011
Oct
2011
Sep
2011
Aug
2011
Jul2
011
Jun2
011
May
2011
Apr
2011
Mar
2011
Feb
2011
Jan2
011
Dec
2010
Nov
2010
Oct
2010
Sep
2010
Aug
2010
Jul2
010
Jun2
010
May
2010
Apr
2010
Mar
2010
Feb
2010
Jan2
010
Dec
2009
Nov
2009
Oct
2009
Sep
2009
Aug
2009
Jul2
009
Jun2
009
May
2009
Apr
2009
Mar
2009
Feb
2009
Jan2
009
12
9
6
3
0
Month/ Year
Movin
g R
ange
__MR=3.16
UCL=10.34
LCL=0
Sep2011 Dec2011
Ambul Presentation to MMH EC (Triage Cat 5)
Version: 1.0Dated: 04/03/2013
St JohnCollaborative Dashboard-February
Created by:
Contacts:
Improvement Advisor: Prem Kumar
Project Mgr : Monique Davies & Jo Goodfellow Clinical Leader: Campbell Brebner
Pt Transport to A&M- Region
Jan13Dec12Nov12Oct12Sep12Aug12Jul12Jun12May12Apr12Mar12Feb12Jan12
4
3
2
Month/ Year
Avera
ge c
ase
s
__X=2.657
UCL=3.681
LCL=1.633
Jan13Dec12Nov12Oct12Sep12Aug12Jul12Jun12May12Apr12Mar12Feb12Jan12
2.5
2.0
1.5
1.0
Month/ Year
Sam
ple
StD
ev
_S=1.723
UCL=2.457
LCL=0.988
Tests performed with unequal sample sizes
Number of Cases managed in Primary Care by St JohnAverage per day
J an13Dec12Nov12Oct12Sep12Aug12Jul12Jun12May12Apr12Mar12Feb12Jan12
100
80
60
40
Month/ Year
Tota
l N
um
ber
of
case
s
_X=69.69
UCL=98.50
LCL=40.88
Jan13Dec12Nov12Oct12Sep12Aug12Jul12Jun12May12Apr12Mar12Feb12Jan12
40
30
20
10
0
Month/ Year
Movin
g R
ange
__MR=10.83
UCL=35.40
LCL=0
Total Number of Cases managed in Primary Care by St John by Month
Jan1
3
Dec
12
Nov
12
Oct
12
Sep
12
Aug
12
Jul1
2
Jun1
2
May
12
Apr
12
Mar
12
Feb1
2
Jan1
2
0.20
0.15
0.10
0.05
0.00
Month/ Year
Pro
port
ion
_P=7.9%
UCL=0.1727
LCL=0
Tests performed with unequal sample sizes
Percentage of Subsequent Admisssion to Hospital by St John
Feb2
013
Jan2
013
Dec
2012
Nov
2012
Oct
2012
Sep2
012
Aug
2012
Jul2
012
Jun2
012
May
2012
Apr
2012
Mar
2012
Feb2
012
Jan2
012
Dec
2011
Nov
2011
Oct
2011
Sep2
011
Aug
2011
Jul2
011
Jun2
011
May
2011
Apr
2011
Mar
2011
Feb2
011
Jan2
011
Dec
2010
Nov
2010
Oct
2010
Sep2
010
Aug
2010
Jul2
010
Jun2
010
May
2010
Apr
2010
Mar
2010
Feb2
010
Jan2
010
Dec
2009
Nov
2009
Oct
2009
Sep2
009
Aug
2009
Jul2
009
Jun2
009
May
2009
Apr
2009
Mar
2009
Feb2
009
Jan2
009
2000
1800
1600
1400
Month/ Year
No o
f C
ase
s
_X=1742.6
UCL=1996.1
LCL=1489.1
Pilot Start Formal Launch of Project
Feb2
013
Jan2
013
Dec
2012
Nov
2012
Oct
2012
Sep2
012
Aug
2012
Jul2
012
Jun2
012
May
2012
Apr
2012
Mar
2012
Feb2
012
Jan2
012
Dec
2011
Nov
2011
Oct
2011
Sep2
011
Aug
2011
Jul2
011
Jun2
011
May
2011
Apr
2011
Mar
2011
Feb2
011
Jan2
011
Dec
2010
Nov
2010
Oct
2010
Sep2
010
Aug
2010
Jul2
010
Jun2
010
May
2010
Apr
2010
Mar
2010
Feb2
010
Jan2
010
Dec
2009
Nov
2009
Oct
2009
Sep2
009
Aug
2009
Jul2
009
Jun2
009
May
2009
Apr
2009
Mar
2009
Feb2
009
Jan2
009
300
200
100
0
Month/ Year
Movin
g R
ange
__MR=95.3
UCL=311.5
LCL=0
Sep2011 Dec2011
Ambul Presentation to MMH EC_Triage Cat 1,2,3
Feb2
013
Jan2
013
Dec
2012
Nov
2012
Oct
2012
Sep2
012
Aug
2012
Jul2
012
Jun2
012
May
2012
Apr
2012
Mar
2012
Feb2
012
Jan2
012
Dec
2011
Nov
2011
Oct
2011
Sep2
011
Aug
2011
Jul2
011
Jun2
011
May
2011
Apr
2011
Mar
2011
Feb2
011
Jan2
011
Dec
2010
Nov
2010
Oct
2010
Sep2
010
Aug
2010
Jul2
010
Jun2
010
May
2010
Apr
2010
Mar
2010
Feb2
010
Jan2
010
Dec
2009
Nov
2009
Oct
2009
Sep2
009
Aug
2009
Jul2
009
Jun2
009
May
2009
Apr
2009
Mar
2009
Feb2
009
Jan2
009
2600
2400
2200
2000
Month/ Year
Num
ber
of
case
s
_X=2257.3
UCL=2542.1
LCL=1972.5
Pilot Start Formal Launch of Project
Feb2
013
Jan2
013
Dec
2012
Nov
2012
Oct
2012
Sep2
012
Aug
2012
Jul2
012
Jun2
012
May
2012
Apr
2012
Mar
2012
Feb2
012
Jan2
012
Dec
2011
Nov
2011
Oct
2011
Sep2
011
Aug
2011
Jul2
011
Jun2
011
May
2011
Apr
2011
Mar
2011
Feb2
011
Jan2
011
Dec
2010
Nov
2010
Oct
2010
Sep2
010
Aug
2010
Jul2
010
Jun2
010
May
2010
Apr
2010
Mar
2010
Feb2
010
Jan2
010
Dec
2009
Nov
2009
Oct
2009
Sep2
009
Aug
2009
Jul2
009
Jun2
009
May
2009
Apr
2009
Mar
2009
Feb2
009
Jan2
009
400
300
200
100
0
Month/ Year
Movin
g R
ange
__MR=107.1
UCL=349.9
LCL=0
Sep2011 Dec2011
Ambul Presentation to MMH EC_Overall
Implementation
Implementation Areas
Changes to Support Implementation
Standardisation Review of current regional St John guidelines
Define process for paramedics to liaise with the medical home
Documentation Prepare a communications plan
Define project governance and reporting arrangements
Training St John developing a plan to educate paramedics
Communication plan to educate GPs and practice staff about the change
Measurement The number of patients
transported to the medical home
to an Accident and Medical (A&M) centre
subsequently transferred to hospital (from A&M and medical home)
transported to a primary provider and then self presents to ED within 7 days
Resourcing Continue to work to roll out in April 2013 – it is not anticipated that there will need to be an increase in resource
Adapted from “The Improvement Guide. A Practical Approach to Enhancing Organizational Performance” Gerald Langley et al., 2009, p180.
Risk & Mitigation StrategiesRisk Current situation Mitigation
High rate of subsequent transports to ED 9% of patients currently referred on to hospital (not all transported by St John)
Review of guidelines to ensure appropriate for transport to medical home
Clinical governance review by POAC of all St John referrals
Patients become aware of the pathway and use it as a way to access free care (particularly those who are ‘friends of St John’)
No indication of this occurring – no cases where an individual who is a ‘friend of St John’ has been transported to an Accident & Medical facility (A&M) more than once
Continue to monitor
Ensure guidelines are clear that only those patients who would normally be transported to ED are included in the scheme
Monitor impact of enhanced triage at St John call centre and number of low acuity call outs
Patients who would have previously been transported to their medical home anyway and paid their usual co-payment, are included
Ensure guidelines are clear that only those patients who would normally be transported to ED are included in the scheme
Monitor impact of enhanced triage at St John call centre and number of low acuity call outs
Clinical governance review of appropriateness and any scope creep
Achievements to date
Expansion of St John Transport project to the Medical Home (starting April 2013)
The reason for expansion of the project is to ensure patients who don’t require ED treatment are transported, when necessary, to the best possible place. The medical home is often more appropriate than an A&M facility due to the capability to provide continuity of care with ongoing education for the patient, including re-engagement with the medical home.
As St John is already making the decision not to transport patients to an ED (under the original scheme) this expansion is unlikely to increase the number of affected patients, but gives patients more appropriate options for care. Further work during 2013 / 14 needs to be undertaken to ensure Primary Care’s continued capability to be able to accept urgent patients from St John.
Patient and family experience
Recently this project has received HRC funding (as part of the review of the Auckland Regional After Hours Network) and patient interviews will be conducted as part of this process over the ext few months