Primary Care- Hospital Interface

“acute unselected medical admissions”

Is there a better way ?

? Help for HSE 374 million budget overrun

• National Policy and Reconfiguration

• Year on Year ED – Trolley crisis

• Numbers of older more complex acute medical illness presenting to hosp

• Renewed focus on Acute Medical Care

• 6hr Emergency access targets

LEVERS FOR CHANGE

Cork University Hospital

Irelands only level 1 trauma centre 850 bed hospital 40 + specialties 250,000 patient episodes annually 9,000 births per year 180,000 out-patient attendances per year 3,250 multi-professional staff €250m capital development programme Large change programme being implemented

AMU - Cork University Hospital January 2011 opened with 23 acute medical

beds Direct GP referrals from February 2011 Direct transfers from ED / Trolleys Consultant Physician continuous presence on

the unit Up skilling of nursing staff Culture shared team approach promoting high

quality care with proactive rapid assessment and discharge planning

Key Elements:

48 hour Length of Stay Same day Diagnostics Senior decision maker on the floor Daily specialist in each service CIT daily to facilitate discharge and

handover in the community

Improve access for patients to prompt medical assessment by a senior clinical decision maker

Uncouple the necessity for overnight admission for a procedure or investigation is a key paradigm shift

Improve patient flow and reduce wait for in-patient bed.

AIM:

Total Admissions, Discharges and transfers from Jan 10th to December 2011

2400 acute medical patients admitted 2,065 medical patient discharges 48% discharged in 48 hours 25% in 24 hours Average length of stay 61.29 hrs Length of Stay for General Acute Medicine

in hospital reduced from 10.4 - 6.5 days for first 6 months 2011

Additional resources ??

1.5 WTE Consultant Physician Weekly rotation NCHD team 3 . WTE Nursing Staff 1 . WTE Care Assistant – Radiology Reconfiguration of General Ward 35 beds

to 23 short stay unit

Capital Infra structure rebuild 1.5 millionincluding equipment

Length of Stay – Total Medicine

AvLOS 2010 = 9.07 daysV

AvLOS 2011 = 7.07 days

Reduction overall = 2 days

Bed days Saved = 20,512 (equivalent to 56 beds)

Cost savings significant if allow 1100 euros per bed

Phase 2 AMAU Jan 11th2012

Initially phased opening Mon-Fri (0800hrs-2000hrs)

Continuous Consultant Physician presence

Same – Day Diagnostics

AMU review Clinics to support same day discharge strategy

Aim for 25% - 30% same day discharge

Additional Resources?

2 further WTE Consultant Physician posts

3 NCHD posts ( Transfers 1 ED –CUH 2 - SIVUH )

Transfer Nursing Staff from ED /MSSU

8 trolleys for 13 bay assessment area.

Activity:

Impact of Service Changes

Transfer of Cardiology services end Nov ’11 Closure ED SIVUH 8pm – 8am end Nov ’11 Change in pathway for trauma rehabilitation to

SIVUH – Dec ’11 Increased acute General Medical Activity 13% Full closure of SIVUH ED – July ’12 Transfer emergency surgery ex SIVUH - July ’12 Not a steady state at any stage in

2012

AMU Patient Throughput

Number of Patients Admitted to MSSU ( other sources)

676

Number of Patients Assessed in AMAU ( 981 MSSU)

3726

Number of Patients Assessed in AMU Review Clinic

1158

Total Number of Patients Assessed in AMU 5560

AMAU Discharge Outcomes

94

150

199

188

238

185 182187

177

234

58

90

104

93

115

90

107 107103

79

11

23 24

60

8880

98

8388

173

04 6

1 5 2 40 1 10

50

100

150

200

250

J an-12 Feb-12 Mar-

12

Apr-12 May-

12

J un-

12

J ul-12 Aug-12 Sep-12 Oct-12

Number of Patients

Month Discharged Same Day

Admitted to MSSU

Admitted to CUH

Transferred to Other Hospital

Length of Stay – ALL Medicine

AvLOS 2011 = 7.07 day

V

AvLOS 2012 = 6.2 days

Reduction overall = approx 3 days (24+beds)

CUH Trolley Count –12th October

Outcome:

Better patient care Better patient/staff experience Improved access for primary care Better clinical outcomes Appropriate clinical environment Reduced elective waiting times for

admission/day cases, etc. Less trolley waits Improved efficiency Better value for money

Key Reasons for Success!

Team approach - Patient focused

Continuous presence of senior clinicians on the floor

Priority access to Diagnostics

Partnership with Primary Care with improved access /communication

Work Practices:

Daily Consultant ward rounds 8am, 5pm and “Hot “ review Mid-day

AMU Physician continual presence, no other fixed commitments

AMU Physician for unit provides phone advice for primary care

Summary:

AMU’S improve the quality and the safety of care

Reduce in-hospital length of stay Increased direct discharge rates Improved efficiency of hospital resources Greater patient and staff satisfaction

Conclusion :

Good for patients

Good for service

Good for tax payer

Success is not final, failure is not fatal: It is the courage to continue that counts. Winston Churchill