model of cardiology care - agency for clinical innovation...nsw health clinical services redesign...

Model of Cardiology Care(Incorporating Chest Pain Evaluation, Integrated Chest Pain Managementand Bed Management)

NSW Department of Health73 Miller StreetNORTH SYDNEY 2060Tel: (02) 9391 9000Fax: (02) 9424 5994www.health.nsw.gov.au

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© NSW Department of Health

ISBN 978-1-74187-144-9 SHPN 06/185

Further copies of this document can be downloadedfrom the Australian Resource Centre for HealthcareInnovations (ARCHI) website:http://www.archi.net.au/e-library/build/moc

Design by Elisabeth Sampson (02) 4968 1337

August 2006

2 NSW Health Clinical Services Redesign Program Models of Care for CardiologyAugust 2006. For the latest version of this model visit the ARCHI website at www.archi.net.au

Abbreviations

AED Automated External Defibrillator

APFU Area Patient Flow Unit

AHS Area Health Service

ACS Acute Coronary Syndrome

CAN Cardiac Assessment Nurse

CCU Coronary Care Unit

CPEA Chest Pain Evaluation Area

CPI Clinical Practice Improvement

ECG Electrocardiograph

ED Emergency Department

EMU Emergency Medical Unit

ETAMI Early Triage of Acute MyocardialInfarction

HDU High Dependency Unit

IT Information Technology

KPI Key Performance Indicator

NSW New South Wales

NUM Nursing Unit Manager

PCI Percutaneous Coronary Intervention

STEACS ST Elevation Acute Coronary Syndrome

SSU Short Stay Unit

TASC Towards a Safer Culture Program

Abbreviations 2Acknowledgments 4Foreword 5Executive Summary 6Section One: The Need for ChangeBill’s Story Prior to the New Model 8Eric’s Story Prior to the New Model 10Matt’s Story Prior to the New Model 12Background: The State-wide Cardiology Project 14Problems with the Current Journey 15Section Two: Cardiology Model of CareOverview of the Model 16Chest Pain Evaluation Areas 18

Bill’s Story Under the New Model 18Essential Components 20Chest Pain Evaluation Area (CPEA) 21Use “Good Practice” Chest Pain Processes 237 Day a Week Exercise Stress Testing 26Outpatient Chest Pain Clinics 27

Integrated Chest PainEric’s Story Under the New Model 28Essential Components 30First Responder Scheme 31Integrated Clinical Management 32

Bed ManagementMatt’s Story Under the New Model 34Essential and Highly Desirable Components 3623 Hour Beds 38“Hot Beds” 42Ward By-pass 43Data Driven Bed Re-aggregation 44Co-location of Cardiology Related Units 45Short-term Use of Flex Beds in Peak Demand 46Day Angioplasty for Appropriate Patients 47Medi-Hotel 48

Implementing Chest Pain (Process Map) 50Section Three: ResourcesReferences 52

Table of Contents

NSW Health Clinical Services Redesign Program Models of Care for Cardiology 3August 2006. For the latest version of this model visit the ARCHI website at www.archi.net.au

Acknowledgments


Chest Pain Evaluation Area Working Party

Dr Drew Fitzpatrick, (Working PartyChair), Chair Greater Metropolitan ClinicalTaskforce Cardiac CoordinatingCommittee, and Director of Cardiology,Nepean Hospital,

Virginia Booth, Cardiology Clinical NurseConsultant, Royal Prince Alfred Hospital

Dr Adam Chan, Director, EmergencyMedicine, St George Hospital

Jeff Cobin, Ambulance Liaison Officer,Sydney South West Area Health Service

Dr Keith Edwards, Deputy DirectorEmergency Department, LiverpoolHospital

Cate Ferry, Towards a Safer CultureProgram Manager, Clinical ExcellenceCommission

Catherine Foster, A/Nurse ManagerEmergency Department, John HunterHospital

Dr John French, Director CardiologyLiverpool Hospital

Tony Gately, Ambulance/Patient SafetyManager, Ambulance Service of NSW

Margo Gill, Greater Metropolitan ClinicalTaskforce Cardiac CoordinatingCommittee Consumer Representative

Dr Travis Grant, Project Manager, Accenture

Dave Hodge, Director Clinical Services,Ambulance Service of NSW

Alison Latta, Manager of Clinical ServicesPlanning, NSW Health

Chris Lees, Clinical Projects, AmbulanceService of NSW

Karen Lintern, Clinical Nurse Consultant,Liverpool Hospital

Stephanie Lucas, Patient Flow Manager ,Mona Vale Hospital

Jonathan Magill, Clinical NurseConsultant, Prince of Wales Hospital

Pam McAllan, Clinical Manager,Emergency Department, WollongongHospital

Jill Morrow, Area Cardiac Liaison OfficerHunter New England Health

Olga Munoz, Patient Flow Officer, MonaVale Hospital

Dr Richard Paoloni, EmergencyDepartment Director, Concord Hospital

Dr Anette Pantle, Director Clinical PracticeImprovement, Clinical ExcellenceCommission

Felicity Perrin, Towards a Safer CultureProgram Coordinator, Armidale Hospital

Paul Stewart, State Cardiology Strategy,Ambulance Service of NSW

Keith Stockman, External Partner,Accenture

This Model of Carewas developed by themembers of NSWHealth’s State-wideCardiology Project.NSW Health would liketo acknowledge thefollowing people fortheir contribution.


Brett Abbenbroek, (Working Party Chair),State-wide Coordinator Critical CarePlanning, NSW Health

Joel Bardsley, Patient Flow Manager,NSW Ambulance

Andrew Bridgeman, Senior Nurse Manager,Patient Access, St George Hospital

Dr David Brieger, Cardiologist, ConcordHospital

Renee de Neve, Network Nurse Manager,Cardiovascular, Blacktown/Mt DruittHospitals

Rhys Dive, Ambulance Liasion, SydneyWest Area Health Service

James Dunne, Nurse Unit ManagerCardiology, St George Hospital

Sarah Fenning, Nurse Unit Manager,Cardiac Cath Lab, John Hunter Hospital

Dr Peter Fletcher, Director Cardiology,John Hunter Hospital

Margo Gill, Greater Metropolitan ClinicalTaskforce Cardiac CoordinatingCommittee Consumer Representative

Dr Travis Grant, Project Manager, Accenture

Dr Phil Harris, Director Cardiology, RoyalPrince Alfred Hospital

Sue Heath, Acting Nurse Unit ManagerCardiology/Cath Lab, Nepean Hospital

Barb Hodges, Patient Flow Manager,Royal North Shore Hospital

Jane Kerr, Area Cardiac ServiceCoordinator, Tamworth Hospital

Dr Len Kritharides, Director of Cardiology,Concord Hospital

Caroline Lawn, Clinical Nurse Consultant,Coronary Care Unit, Liverpool Hospital

Karen Lintern, Clinical Nurse Consultant,Cardiac Services, Liverpool Hospital

Stephanie Lucas, Patient Flow Manager,Mona Vale Hospital

Jill Morrow, Area Cardiac ServiceCoordinator, Hunter New England AreaHealth Service.

Margery Mundy, Cardiology ClinicalSenior Nurse Manager, Critical Care,Central Coast Sector, NorthernSydney/Central Coast AHS

Olga Munoz, Patient Flow Manager, MonaVale Hospital

Sally Newport, Nurse Unit Manager,Cardiac Cath Lab, Liverpool Hospital

Sylvia O’Rourke, Clinical Nurse Specialist,Cardiac Assessment, Nepean Hospital

Dr Mark Perrin, Cardiology Registrar, StVincent’s Hospital

Dr David Rees, Staff Specialist, St GeorgeHospital

Alan Reinten, Acting Operation CentreManager Sydney, NSW Ambulance Service

Neil Rickwood, Nurse Unit ManagerCoronary Care Unit St Vincent’s Hospital

Sue Samuels, Acting Co-NetworkOperations Manager Cardiovascular,Nepean Hospital

Gail Smith, Acting Senior Nurse Manager,Medicine, Wollongong Hospital

Keith Stockman, External Partner,Accenture

Sharon Verhoeven, Acting CardiacServices Manager, Nepean Hospital

Deb White, Nurse Unit Manager, CardiacCath Lab, Gosford Hospital

Jimmy Yap, Nurse Unit Manager, CardiacCath Lab, Westmead

Integrated Chest Pain Working Party and the Ambulance and Emergency Department Working Party

Foreword


NSW Health is developing new models ofcare for adult acute cardiology patients,through the Clinical Services RedesignProgram. The program is currentlysupporting clinicians and managers toredesign and improve a range of patientjourneys across multiple care centres inarea health services.

The State-wide Cardiology Project isworking with clinicians and health serviceteams to redesign better patient journeysfor adult Acute Coronary Syndromepatients. We recognised the importance ofkey stakeholder engagement and soughtearly and ongoing input from area healthservice representatives, includingCardiology, Emergency Department,frontline clinical, Patient Flow ManagementTeam, and Clinical Redesign Unit staff, aswell as Ambulance NSW, ClinicalExcellence Commission, GMCT CardiacCoordinating Committee, and consumerrepresentatives. The State-wide CardiologyProject Steering Committee includes a widerange of stakeholders.

The key phases of the project included adiagnostic and a design stage usingproven methodologies based on sounddata. It is critical to note that the solutionsin this model have been generated byworking parties comprising multi-disciplinarystaff from across NSW health facilities.These solutions have been prioritised forimmediate implementation due to theirimportance in improving cardiologyservices.

This model is part of the solution designand will be an asset in the implementationof the projects. This project will alsobenefit from expert solution design “SWATteams”. These teams will help accelerateand guide “good practice” solutionimplementation, working in partnershipwith the staff at each site.

This model offers implementation solutions,which have been developed by frontlinestaff, to assist frontline staff to delivertimely access and high quality care forcardiology patients.

Dr Tony O’Connell

MB BS FANZCA FJFICMDirector Performance Improvement andClinical Services Redesign Program, NSW Health

This Model of Care was developed fromthe work undertaken by the members ofNSW Health’s State-wide CardiologyProject as part of the Clinical ServicesRedesign Program.

This project has focused on adult patientswith Acute Coronary Syndrome (ACS). Theproject included consideration of demandmanagement strategies and patienttransfer services. It has not consideredspecific solutions for surgical processes,cardiac rehabilitation or communityservices. These will be described in futureModels of Care.

There are a number of issues which canmake the journey experienced by patientsless than optimal. These issues relate toinitial chest pain evaluation, chest painmanagement and bed management. Thereis also significant variation in practice andin the configuration of Cardiology bedsacross NSW hospitals.

The model presents a range of solutionsto address the above issues.

Essential components to ensuringappropriate initial evaluation of chest paininclude the establishment of Chest PainEvaluation Areas (CPEA), the use of “goodpractice” chest pain processes that areowned by a staff member, the availabilityof 7 day a week exercise stress testing aswell as the provision of care in outpatientchest pain clinics for selected patients.

Essential to good chest pain managementis the introduction of a First ResponderScheme and integrated clinicalmanagement. These solutions allowpatients to receive early pre hospitaltreatment under protocol as well as to betaken to the most appropriate hospital,rather than the nearest one.

Bed management can be improved withthe introduction of measures including theestablishment of 23 hour beds and hotbeds for primary angioplasty cases.Metropolitan hospitals without cardiacintervention services should be able totransfer patients direct to the CardiacCath Lab at another hospital to have aprocedure and bring them back to recoverin the original hospital, bypassing theneed for ward admission in the otherhospital.

Short term use of flex beds, the co-location of cardiology related units andday only angioplasty for appropriatepatients are some of the ways to ensure abetter flow of patients within and acrosshospitals.

Together, these solutions will create asmoother, more seamless journey forpatients. Health care providers will be ableto provide timely, high quality care to morepatients at less cost.


Executive Summary

Why Implementthis Model?

Improved assessment, treatment andmanagement ofpatients.

A smoother, moreseamless journeyfor patients.

Cost savings inproviding carethrough reductionsin re-admissionsand Access Block.


Bill’s Story Prior to New Model

When I got to the hospital I explainedwhat was happening to the nurse. Sheasked lots of questions and checked myblood pressure.

The nurse said I had to wait in the waitingroom for a doctor but she didn’t say howlong the doctor might be. I was going toask but she looked busy.

It felt like I was waiting forever. I was inpain and felt really sick. I was scaredbecause I didn’t know what washappening. After about an hour I wastaken to a bed. Another nurse asked morequestions and asked me about the pain.She gave me some pain relief and hookedme up to a monitor. Still there was nodoctor. After a while the doctor arrivedand said she would have to do some testsand that she would see me when theresults were back. She didn’t say howlong they’d take and she rushed off.

About two hours later the doctor saidshe’d looked at my test results and that Ihad to have another blood test. This timeshe told me how long the results wouldtake - 8 hours. I heard her tell the nursethat she would try to get a specialist(Cardiologist) to look at me.

By this time I was feeling annoyed but toosick to make a fuss. I still didn’t know whatwas wrong with me or how long I had tobe in hospital.

After many more hours the doctor cameback and said she had my test results.She’d spoken with the specialist but hewas too busy to see me until later in theday. Eventually, the nurse came back andtold me I need some sort of exercisestress test. They wanted me to do itbefore I went home because I was at riskof having a heart attack.

Bill’s Story

Bill is 55 years old,overweight and anoccasional smoker.

One day, Bill has somechest pain and he ispersuaded to visit hislocal EmergencyDepartment (ED).

This is his story.

Bill arrives in ED with chest pain. ED doctor orders tests. Reviews results and orders

another blood test.

All results are back but Cardiology Registrar

too busy to review for several hours.

Bill waits to see a doctor.

Given painrelief under protocol.

1.5 Hour 2 Hours 8 Hours

Section One - The Need for Change


To have this test I had to be in a ward inthe hospital. That took a couple morehours to sort out. Finally, they took me upto Cardiology Ward. They kept me therefor a whole day and then told me therewas no spare doctor to do the test. Mywife and family came in and my bosswanted to know when I’d be back at workbut I couldn’t tell them anything.

It took another two days until they gaveme the test. The test didn’t take long todo. I don’t know why I had to wait so longfor them to do it. After all that they saidthe test showed nothing wrong and Icould go home. All that time in hospital,almost four days, for nothing.

ED doctor decides to give Bill exercise stress test. He has to be admitted to Cardiology

ward to have test.

Exercise stress test cancelled because no clinician available to perform it.

Performed two days later.

Test results are negative. Bill sent home.

Bed found for Bill.

4 Hours 24 Hours

Total Time Elapsed

What’s Wrong withthis Story?

• Bill has to wait too longfor initial tests anddiagnosis. After fourdays in hospital, Bill isdischarged withouttreatment.

• He is not told how longhe has to wait for ateach stage of his journey.

• Some of the delay toBill’s care is becausetreatment has to becarried out bySpecialist staff that aretoo busy to see him.

• He is scheduled for anexercise stress test butthis is delayed. There isno appropriatelystaffed 7 day a weekexercise stress testingservice at the hospital.

TOTAL TIMEELAPSED:

4 days

Eric’s Story Prior to New Model

Late one morning, Eric is mowing the lawnwhen he develops severe pain in his chestwhich travels down his left arm. He goesinto the house to find his wife, clutchinghis chest. He is very pale and quitedistressed.

His wife Deidre dials 000 and asks for anAmbulance. The Ambulance arrives withineight minutes and the crew assesses Eric.They apply oxygen, perform vital signsand connect Eric to their portable 3 leadheart monitor. Eric has ongoing pain andthey administer pain relief.

They take Eric to the nearest hospital.

On arrival at the hospital Eric has lowblood pressure, a weak pulse and hasongoing pain. He is transferred to theResuscitation Bay where a 12 lead ECGshows acute ST Elevation Acute CoronarySyndrome (STEACS).

Eric’s Story

Eric is a 64 year oldman who has a historyof high blood pressureand high cholesterol.He currently smokes25 cigarettes a dayand lives a sedentarylifestyle.

He has severe chestpain at home one day.

This is his story.


Eric is a smoker with high blood pressure and

high cholesterol.

The Ambulance arrives and delivers basic care. The Officers do not have

a 12 lead ECG on board.

They take Eric to the nearest hospital rather than one with a Cardiac Cath Lab.

He has severe chest pain at home. His wife calls 000.

HospitalNo Cardiac

Cath Lab

The Cardiology Registrar arrives 30minutes later to assess Eric. His conditionhas now stabilised and his pain hassettled. There is no Cardiac Cath Lab atthis hospital and the nearest hospital withthese facilities is 40 minutes away.

It is now 60 minutes since Eric called theAmbulance. Eric is given thrombolytictherapy because of the time delay in himundergoing a primary PercutaneousCoronary Intervention (PCI). Therapy iscommenced and Eric is transferred to theCoronary Care Unit (CCU).

Eric is diagnosed as suffering amyocardial infarct and he has lost a largeamount of heart muscle.


Eric is given thrombolytic therapy and transferred to the Coronary Care Unit.

It would have been better if he could have had the therapy earlier in the Ambulance.

Eric stays in hospital for 8 days.Eric stays in hospital for 8 days.At the hospital Eric is triaged Category 1. He has acute

ST Elevation Acute Coronary Syndrome (STEACS).

30 minutes later the cardiologist assesses

Eric. There is no Cardiac Cath Lab at this hospital.

What is Wrong withthis Story?

• Eric is taken to thenearest hospital, notthe most appropriateone. The nearestCardiac Cath Lab is40 minutes away.

• It takes 30 minutesfor the Cardiologistto assess Eric.

• As the Ambulancedid not have a 12lead ECG, the crewwere not able todiagnose and startvital thrombolytictherapy.

Matt’s Story Prior to the New Model

It is only 8.30am and there are 27 patientsin the ED requiring admission to hospital.Of these, nine are cardiology patients.There are two patients at rural hospitalsthat need to be transferred, one requiringa CCU bed and the other requiring a wardbed. There is also one patient who hascome in for an elective procedure who willrequire a CCU bed.

The hospital is at 100% capacity and thenumber of predicted discharges is low.

There is a significant wait for cardiologyinpatient beds. One patient has beenwaiting for 36 hours. Of the ninecardiology patients waiting for beds:

• two have atypical chest pain with normalelectrocardiographs (ECGs) and normalcardiac markers

• three require monitoring in the CCU forabnormal heart rhythms

• one patient has presented within theprevious hour following a heart attack

• three require admission for managementof fluid congestion related to heartfailure.

Matt receives calls from the hospital’sExecutive Director, the Area ExecutiveDirector, and the Ambulance LiaisonOfficer all asking what strategies he willbe using to give patients access to timelycare.

The CCU Nurse Unit Manager (NUM)confirms that there is likely be four CCUbeds available later that day. Two of thebeds are likely to come from patients whohad elective procedures the previous daybut are awaiting medical review, ECG andthe result of blood tests. There is noprotocol for these patients and they waitfor the CCU ward round. The other twobeds are likely to come from two CCUpatients who are waiting to go to the ward.

Matt’s Story

Matt is the BedManager at a largemetropolitan teachinghospital with cardiaccatheterisation facilities.

The hospital is atcapacity and, althoughit is only 8.30am, thereare 30 patients requiring admission tothe hospital.

This is the story ofMatt’s day.


27 people requiring admission

Rural hospitalPatient requiring elective procedure

What’s Wrong withthis Story?

• Patients are waitingtoo long for care andhaving procedurespostponed.

• There is no effective dischargeplanning protocol.

• Having so manypatients waiting foradmission is overcrowding theED.

• The urgently requiredtreatment of apatient is delayedbecause there are no“hot beds” for emergency patients.

• The transfer ofpatients from ruralhospitals is delayed.

The ward NUM confirms that it is likelythere will be four beds but they will not beavailable until later in the afternoon. So theCCU will not have beds available until then.

The Cardiac Cath Lab accepts the patientwho suffered a heart attack for an urgentprocedure to try and open their blockedarteries. There are many calls exchangedto make a CCU bed available for thispatient as the hospital has no designated“Hot Bed”. The patient has the procedurebut the negotiations for beds delay it bymore than one hour.

The CCU beds are not cleared until earlyin the afternoon. The delay in access tosuitable beds has resulted in adownstream impact on all the patientswaiting for beds.

• The two elective Primary Angioplastypatients have their procedures cancelled.

• The two patients from the rural hospitalhave their transfers delayed by another24 hours.

• The three patients with symptomaticheart failure continue to wait. All threehave been in the ED for more than 24hours.

• The two patients with atypical chestpain have waited for more than 24 hoursfor an exercise stress test.

Matt continues to field calls from theHospital’s Executive Director, the AreaExecutive Director, and the AmbulanceLiaison Officer. As there are limitations toopening additional beds they decide tocancel elective procedures and non urgentinter-facility transfers. This does little toalleviate the problem. There is still AccessBlock, poor Off Stretcher Times anddelays in elective procedures.


NUM CCU Hospital Director

Area DirectorAmbulance Liaison

Matt Bed

Manager

Matt Bed

Manager

HOSPITAL

Beds 100% capacity

NUM Ward

Background: The State-wide Cardiology Project

This Model of Carewas developed by themembers of NSWHealth’s State-wideCardiology Project aspart of the ClinicalServices RedesignProgram.

The project isredesigning serviceconfiguration and clinical services forCardiology patientsacross NSW, with aparticular emphasis onmetropolitan hospitals.

The project has focusedon adult patients withACS. The project hasincluded considerationof demand managementstrategies and patienttransfer services. It hasnot considered surgicalprocesses, cardiacrehabilitation or community services.


Objectives of the State-wideCardiology Project• Enable timely and equitable access to

effective and appropriate care to adultacute cardiology patients across NSW.

• Treat adult acute cardiology patients inorder of clinical priority.

• Reduce variations in the length of stayfor acute cardiology patients betweenand within facilities.

• Enable access by health service teamsto a practical and co-ordinatedcardiology service.

In-ScopeThe project was conducted within theSydney metropolitan area health servicesand Hunter New England Area HealthService with engagement and input fromrural area health services. The primaryrecipients of the services are:

• Sydney West Area Health Service

• Sydney South West Area Health Service

• South Eastern Sydney Illawarra AreaHealth Service

• Northern Sydney Central Coast AreaHealth Service

• Hunter New England Area HealthService

The project focussed on:

• adult ACS patients requiringinvestigative cardiology tests andinterventional cardiology procedures

• demand management strategies inrelation to acute cardiology patients and

• patient transfer services for acutecardiology patients.

Out of ScopeThe project (and this Model of Care) hasnot focused on:

• purchasing of equipment

• patient flow processes for cardiacsurgery

• paediatrics

• Chronic Heart Failure

• cardiac rehabilitation

• community services for cardiologypatients.

Current Problems with the Journey


Key chest pain evaluation issuesinclude:• limited use of chest pain pathways

• sub-optimal use of exercise stresstesting

• significant Access Block.

Key chest pain managementissues include:• delays in provision of appropriate

treatment to some patients, includingdelays in defibrillation

• differences in clinical management ofchest pain patients by the AmbulanceService

• insufficient continuity of care betweenAmbulance vehicles and hospital EDs

• delays in reperfusion for some patients,including inequity of access to primaryangioplasty, and/or delays inadministration of thrombolysis therapy.

Key bed management issuesinclude:• variation in multi-day patient flow in

major hospitals with Cardiac Cath Labs

• delays in inter-facility transfer of patientsfrom rural and metropolitan hospitals

• high bed occupancy

• significant number of ‘outlier’ patients

• sub-optimal Cardiac Cath Lab utilisationdue to lack of available beds.

Current Problems

There are a number ofissues which can makethe journey for patientswith chest pain sub-optimal. These issuesrelate to initial chestpain evaluation, chestpain management andbed management.

There is also significant variation inpractice and in theconfiguration ofCardiology bedsacross NSW hospitals.

Cardiology Model of Care

The Cardiology Modelof Care contains solutions that willimprove the patientjourney and theirexperience. It willenable timely accessto effective and appropriate care forpatients experiencingchest pain.


Section 2: Chest Pain Model of Care

Call 000

Direct to hospital with no Catheter Laboratory

Direct to hospital with Catheter Laboratory

Ambulance with 12 lead ECG responds

Ambulance Officers starts treatment on the way to hospital under protocol

Ambulance Officers transmit ECG data to hospital

HOME

Metro Hospital

Chest Pain Evaluation Area

Ward

Emergency

HospitalNo Cardiac Cath Lab

• Chest Pain Evaluation Area. • Use “good practice” chest pain processes.• 7 day a week exercise stress testing.• Use outpatient clinics (where appropriate).• Data driven bed re-aggregation.

••••a•


HospitalNo Cardiac Cath Lab

HOME

Rehabilitation

Go to Cardiac Cath Lab hospital rather than closest hospital

Chest Pain Evaluation Area

CO

-LOC

ATION

Hotbed

Coronary Care Unit

Cardiac Cath Lab

Cardiology Ward

23hourbed

Cardiac Cath Lab Hospital

Elective procedure

No Entry

Emergency

Sole Contact OfficerTransmit data

Hospitalwith Cardiac Cath Lab

Ward By-pass

Outpatient Clinic

Flexbed

• First Responder Scheme.• Integrated clinical management. • Basic clinical management by Ambulance Officer.• 12 lead electrocardiogram (ECG)/Ambulance administered thrombolysis. • Early Triage of Acute Myocardial Infaction (ETAMI).

Essential Desirable• 23 hour beds. • Co-location of • Hot beds. Cardiology related units.• Ward by-pass for • Flex Beds. metro hospitals. • Day Angioplasty.• Data driven bed

• Medi Hotel.reaggregation.

Chest Pain Evaluation Areas- Essential Components

Bill’s Story

Bill is 55 years old,overweight and anoccasional smoker.

A year after his initialchest pain, Bill experiences anothersimilar episode.

This is his story underthe new CardiologyModel of Care.


At the hospital I explained my symptomsto the nurse. She asked me somequestions and checked my blood pressureand pulse.

Almost immediately I was sent to a specialarea for people with chest pain near the ED.

A special Cardiac Nurse explained that Iwould have to have some tests. She askedme some questions about my pain andput me on a monitor. She said she wasstarting treatment as part of a standardprocess (chest pain pathway) for peoplewith chest pain. She gave me someoxygen and took some blood.

The nurse performed an ECG and gaveme some aspirin. Soon after a doctorcame in and examined me. He said I hadan intermediate risk for a condition calledAcute Coronary Syndrome. Shortly afterthat my chest pain disappeared.

After only about an hour the nurse said myresults were back. They were normal.

Bill arrives in ED with chest pain. Bill’s pain goes away and his test results are normal.

1 Hour

Bill goes to Chest Pain Evaluation Area. A Cardiac Assessment

Nurse commences treatment in line with a chest pain pathway.

What is Good Aboutthis Story?

• There is a Chest PainEvaluation Area inthe hospital.

• Within minutes ofarriving at the ED Billhas been medicallyassessed and is inthe care of a qualifiedstaff member.

• Bill receives careaccording to a chestpain pathway.

• An exercise stresstest is completed toverify the chest painis not cardiac related.

• Bill goes home afterthree hours withinformation to reducehis risk of heartattack.


She went and told the doctor. She cameback and said that to be on the safe sidethey would give me an exercise stresstest.

They said it would be done in an hour andexactly an hour later the nurse took me tothe equipment. It was in the same area soI didn’t have to go far. She explained whatwas going to happen and then theCardiology doctor came in and did thetest.

The test was negative and the Cardiologydoctor said he thought my pain was mostlikely related to an old shoulder injury. Hesaid I could go home, which was greatnews. He warned me to contact thehospital again if the chest pain came back.

The doctor gave me a prescription foranti-inflammatory medications and told meto see my local doctor. The nurse providedinformation about the need to stopsmoking and to have a healthier diet. Sheoffered me some good tips and places togo for more information.

They gave me very good care. I didn’thave to wait long at all and I knew whatwas happening every step of the way.

The Cardiac Registrar diagnoses the pain to be coming from

a shoulder injury.

1 Hour

Total time3 Hours

Bill undergoes an Exercise Stress Test in the Chest Pain Evaluation Area.

The test is negative.

Bill is offered information on smoking cessation

and healthy diet.

Bill is discharged with a prescription for anti-inflammatory

medications and instructions to see his GP.

Chest Pain Evaluation Areas– Essential Components

Essential Components of Chest PainEvaluation Areas

• Chest Pain EvaluationArea (CPEA).

• Use “Good Practice”Chest PainProcesses.

• 7 Day a WeekExercise StressTesting.

• Outpatient Chest PainClinics.


Benefits• Improved assessment, treatment and

management for patients with chestpain, leading to improved patient safetyand outcomes.

• 10%-15% reduction in longer staycardiology admissions i.e. many patientswill be processed via CPEA and notadmitted to a cardiology bed.

• A dramatic reduction in Access Blockcan be achieved if patients are admittedto the CPEA for their initial assessmentand treatment.

• Potential reduction in re-admissionsand/or morbidity/mortality of cardiologypatients.

• Potential decrease in cost of treatingchest pain patients.

Chest Pain Evaluation Area(CPEA)

ChestPain

Pathway

Use “Good Practice” ChestPain Processes

7 Day a Week Exercise Stress Testing

Outpatient Chest Pain Clinics

Chest Pain Evaluation Area (CPEA)

EssentialComponents of Chest PainEvaluation Areas





Chest Pain EvaluationAreas (CPEAs) providea dedicated area for therapid treatment ofpatients with chestpain.

Ideally they have staffskilled in cardiac careand specialist equipment. Their mosteffective location willvary at each hospital.

Characteristics• Dedicated area used for evaluation of

chest pain.

• Dedicated staff skilled in cardiac care,who can initiate treatment underprotocol.

• 12 lead ECG machine and exercisestress test equipment available.

Benefits• Rapid treatment for patients.

• Reduced admissions.

• Improved ED bed availability.

• Reduced Access Block.

Barriers to overcome

The location of the CPEA needs to beflexible. The locations most likely todeliver sustainable success are:

• in or next to the ED

• within Short Stay Units (SSU) orEmergency Medical Units (EMU)

• in Cardiology Units.

The table on the next page illustrates thepros and cons of the various CPEAlocations.



Pros and Cons of Locations for Chest Pain Evaluation Areas

• Play a key role in determiningACS patients.

• Currently own most steps of thechest pain pathway.

• Patients admitted to the CPEAto reduce Access Block.

• Improves availability of beds inED and SSU.

• Quick admission to CPEA mayreduce Access Block.

• Improved patient access toskilled staff familiar with thecondition.

• Cardiologist can decide onadministering Heparin.

Emergency Department (ED) Short Stay Units (SSU)Emergency Medical Units (EMU)

Cardiology Units

Pros

Cons

• Improves ED bed availabilitywhile not impacting space inCardiology Units.

• Patients admitted to the CPEAto reduce Access Block.

• Reduces pressure to admit ordischarge when diagnosis is notyet known.

• May be long duration of ED beduse (wait for second troponinresult).

• Patient needs to be admitted toCPEA to improve Access Block.

• Physical constraints. ED maylack space for CPEA beds andequipment.

• Some facilities do not have aSSU. May require investmentsin infrastructure and staffing.

• Requires strong links with EDand Cardiology to ensureoptimal care delivery andpatient safety.

• Higher investment if space notavailable.

• Patient safety issue if they do not have ACS. Efficient ED patientscreening is critical.

• Potential for delayed access to senior clinicians.

• Patient safety issue if patientbecomes unstable when cliniciansnot there.

• Reduced ED involvement may impact buy-in and co-ownership.

Use “Good Practice” Chest Pain Processes


Characteristics• Cooperative design by ED and

Cardiology departments is critical.

• Choose a pathway proven to deliverimproved outcomes for patients. TheTowards a Safer Culture (TASC) pathwayor a tailored pathway should beimplemented, depending on sitepreferences. Regardless of choice,pathways must adhere to process ‘goodpractice’ principles.

• Pathways are to be supported byelectronic data entry capabilities.

• Provision of data via mechanisms suchas dashboards is required to deliverimproved insight into patient outcomes(e.g. outcomes attributed to differenttreatments).

• Audits are to be conducted. Thisnecessitates robust IT processes toautomate manual processes to reducethe data processing time.

Benefits• Improved assessment, treatment and

management for patients with chestpain, leading to improved patient safetyand outcomes.

• Potential reduction in re-admissions.

Barriers to overcome• Insufficient leadership and executive

support.

• Lack of a process owner, e.g. CardiacAssessment Nurse (CAN) at each site.






Hospitals need toadopt a chest painpathway to deliver atimely and accuratemanagement plan forthe patient.

The pathway should beco-operatively designedby the ED andCardiology Departments.

ChestPain

Pathway

See the National Heart Foundation of Australia, Cardiac Society of Australia and NewZealand Guidelines for the Management of Acute Coronary Syndromes, 2006.

www.heartfoundation.com.au/downloads/ACS_Guidelines_MJA_170406_Summary.pdf


The high level roles of a chestpain process owner are:• identification and placement of chest

pain patients on the chest pain pathway

• co-ordination of care delivery tasks forevery patient on the pathway

• liaison between ED and Cardiology

• co-ordinating exercise stress testing,including strategy for 7 day exercisestress tests

• case management of certain conditions

• co-ordination and/or administration ofThrombolysis (if appropriate).

• education and training of staff in thechest pain pathway (e.g. new Registrars)

• data collection for performancemonitoring and communication to staffand patients.

High Risk

IntermediateRisk

Low Risk

Cardiac Assessment Nurse facilitates communications between the ED and the ward for this group of patients.

.

.

.

.

.

Case Study: Cardiac Assessment NurseA key to success ishaving a CardiacAssessment Nurse(CAN) as the processowner, responsible forthe passage ofpatients on the pathway.

7 Day a Week Exercise Stress Testing







Hospitals must have thecapability to deliverexercise exercise stresstests 7 days per week.

Characteristics• Delivery of exercise stress testing 7 days

a week in hospitals. The rate of use willdepend on the hospital’s patientdemographics.

• Non-exercise stress testing (Echo andNuclear Medicine exercise stress tests)should be performed within 48 hours.The hospitals should engage inscheduling dedicated time slots for theED patients, and should be able toeffectively communicate the bookingstatus in case of any changes.

- Use of nuclear medicine servicesreduces impact on ED andCardiology, but has highassociated costs.

- Echocardiograph facilities areeffectively utilised as an arearesource (e.g. service availableto peripheral hospitals).

• Flexibility in staffing is required to useexercise stress test machine. Processowners (e.g. CAN) should be trained inconducting exercise stress tests.Doctors must be in close proximity.Advanced cardiology trainees couldconduct weekend exercise stress tests(e.g. conduct tests on Saturday andSunday morning as implemented atJohn Hunter Hospital).

• Prompt reporting of exercise stress testsis required for timely decisions on thepatient management plan. The processowner should be accountable fororganising these tasks.

• Where an ED patient is unable to accessexercise stress testing (e.g. smallerhospitals), the patient should beconsidered for 48 hours observation orfollow up within 48 hours.

Benefits• Rapid access to exercise stress testing

7 days per week.

• Improved patient flow.

• Avoids unnecessary hospital stay.

Barriers to overcome• Staffing: Access to appropriately trained

staff over weekends.

• Cost of weekend coverage.

• Access to equipment.

Outpatient Chest Pain Clinics


Characteristics• Patient is not admitted or discharged

earlier than usual but is given rapidfollow up (i.e. within 3 days) as anoutpatient.

• Additional tests (e.g. ECG, exercisestress tests, x ray and blood tests) canbe conducted and the overallmanagement plan improved.

• This is an optional enhancementsuitable for some low risk patients.

Benefits• A reduction in admission rates.

• The potential to improve revenuecapture from appropriate cases.

Barriers to overcome• This solution may not suit some

patients, some facilities or Cardiologists.

• The outpatient referral is only viable ifsenior clinicians are allowed to referpatients.

EssentialComponents of ChestPain EvaluationAreas



• 7 Day a Week ExerciseStress Testing.


An optional enhancement is to bookan outpatient appointment (whereappropriate) with aCardiologist as part ofthe patient management plan.

HOSPITAL HOSPITAL

Acute patientsCPEA

Outpatient Clinic

Admission-Cardiology Ward/ CCU/Cardiac Cath Lab


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Integrated Chest Pain Management


Eric’s Story

Eric is a 64 year oldman who has a historyof high blood pressureand high cholesterol.He currently smokes25 cigarettes a dayand lives a sedentarylifestyle.

This is his story underthe new CardiologyModel of Care

Late one morning, Eric is mowing thelawn when he develops severe pain in hischest which travels down his left arm. Hegoes into the house to find his wife,clutching his chest. He is very pale andquite distressed.

His wife Deidre dials 000 and asks for anAmbulance. The Ambulance arrives withineight minutes and the officers assess Eric.They apply oxygen and perform vital signs.They administer aspirin as per the protocoland attach a 12 lead ECG to Eric andtransmit the results to a major localhospital.

The Ambulance Officers monitor the timeof Eric’s initial call and liaise with theagreed single point of contact at thehospital, in this case an ED StaffSpecialist.

They discuss the likely time of arrival atthe hospital. The Staff Specialist confirmsthat Eric is likely to be suffering from aSTEACS, based on the interpretation ofthe 12 lead ECG that was transmitted.

Eric is a smoker with high blood pressure and

high cholesterol.

The Ambulance arrives and delivers basic care. The officers transmit data

from a 12 lead ECG to the hospital.

The hospital’s single point of contact liaises directly with

the Ambulance Officers.

He has severe chest pain at home. His wife calls 000.

Hospital

12 Lead ECG


What is Good Aboutthis Story?

• Ambulance and hospital staff worktogether to ensurerapid assessment,provisional diagnosisand treatment underan agreed protocol.

• Rapid treatmentreduces the loss ofheart muscle andenhances recovery.

He is discharged home within several days and attends outpatient cardiac rehabilitation.

The Ambulance Officer delivers thrombolytic therapy under

protocol because Eric is some distance from hospital.

Eric recovers well in the Coronary Care Unit

of the hospital.

HOME

As the nearest hospital with cardiaccatheterisation facilities is 75 minutesaway, and the nearest rural hospital is 65minutes away, the Ambulance Officeradministers thrombolytic therapy in linewith the agreed protocol.

Eric receives thrombolytic therapy within45 minutes of his first call to 000. He isthen transferred to the nearest hospital.Eric is triaged in the ED, his conditionstabilised and he is transferred to a bed inthe CCU.

Eric recovers from his myocardial infarctwell, with only very minor loss of hearttissue muscle. He is discharged homeseveral days later to a cardiacrehabilitation program.

Integrated Chest Pain Management- Essential Components

Essential Components of Integrated ChestPain Management

• First ResponderScheme.

• Integrated ClinicalManagement. - Basic clinical

management byAmbulance Officer.

- 12 lead ECG/Ambulanceadministered thrombolysis.

- Early Triage ofAcute MyocardialInfaction (ETAMI).


FIRST AIDFIRST AID

First Responder Scheme

Hospital

Hospital andambulance talking

12 Lead ECG

Integrated Clinical Management


First Responder Scheme





- 12 leadECG/Ambulanceadministered thrombolysis.


The First ResponderScheme involves training voluntaryworkers to be certifiedmedical support staffso that they can provide first levelassistance to chestpain patients.

First Responders aredeployed where anAmbulance wouldhave to travel a long distance to reach apatient and the patientneeds urgent medicalattention.

Characteristics • Experienced, trained persons and non-

traditional First Responders areappointed to deliver timely andappropriate care to improve patientoutcomes – especially in areas wherethere may be a delay in Ambulancearrival (e.g. rural setting).

• First responders may include Policeofficers or members of the public (e.g.first aid providers).

• Lists of First Responders and their levelof skill are managed by the AmbulanceService of NSW.

• Registry of Automated ExternalDefibrillators (AEDs), their location, andtheir maintenance history needs carefulmanagement.

Benefits• Patients receive rapid assistance.

Barriers to overcome• Recruiting training and supporting First

Responders.

FIRST AIDFIRST AID

Integrated Clinical Management






- 12 lead ECG/Ambulanceadministered thrombolysis.


Integrated clinicalmanagement seeks tocreate a smooth,seamless journey forchest pain patientsfrom the time theAmbulance is calledthrough to the ED andtheir time in theCardiology departments.

Basic ClinicalManagement

Closest hospitalfor assessment

Primary Angioplasty(ETAMI)

Hospital administered thrombolysis

Ambulance administeredthrombolysis

Perform 12 lead ECG. Ambulance Officer monitors time of patient call to likely time of treatment.

Ambulance Officers transmit ECG to hospital single point of contact (ED or Cardiology).Doctor can communicate with the Ambulance Officer and patient.

Ambulance services provide minimum standard level of care: • Oxygen • Aspirin, if appropriate • Pain relief, if appropriate.

Hospital single point of contact provides next step of instructions to AmbulanceOfficers and/or GP as per the developed strict 'decision making' protocols/pathway.

If ECG does not show abnormalities or cannot be transmitted, transportto the closest hospital.

If ECG does show relevant abnormalities:

send to hospital with Cardiac Cath Lab for primary angioplasty (e.g. ETAMI) or,

send to closest hospital for thrombolysis, or

accredited Ambulance Officers administer thrombolysis at scene as clinicallyindicated, guided by the developed 'decision making' protocol/pathway.

Hospital

Hospital andambulance talking

12 Lead ECG


Benefits• Rapid assessment and treatment of

chest pain patients, including integrationof risk stratification between theAmbulance and ED (eg STEACSpathway).

• Improved communication betweenAmbulance and ED staff.

• Improved time to reperfusion.

• Improved patient outcomes/survivalrates.

• Efficient use of resources if Ambulanceis directed to most appropriatedestination.

Barriers to overcome• Rigour of data collection and KPI

analysis will be important in order tomonitor and manage compliance andperformance.

• High establishment costs.

• Need to ensure Ambulance ‘time atscene‘ is captured.

• Paramedic training to administerthrombolysis.

• Resource implication for the ECGreceiving department.

There are two processes used to transportemergency patients to NSW hospitals viathe Ambulance Service.

The traditional approach involves thedelivery of a patient suffering from chestpain to the nearest hospital. AmbulanceOfficers also provide a minimum standardof care (aspirin, oxygen, narcotic painrelief) to the patient before they arrive athospital.

The Early Triage of Acute MyocardialInfaction (ETAMI) is being trialled in theWestern Sydney (Westmead Hospital) andNorthern Sydney Central Coast (RoyalNorth Shore Hospital) area health services.

It supports a key part of the IntegratedClinical Management process by providingthe capacity to access primaryangioplasty for patients experiencingSTEACS. It builds on the 12 lead ECGprocess delivered by Ambulance Officers.

• If the ECG shows ST elevation, thehospital’s single-point-of-contact willnotify the Cardiologist on call.

• On-call Cardiac Cath Lab staff arenotified of a pending angioplasty beforethe patient reaches the ED, therebyshortening the time to clinicalintervention for patient diagnosed withan Acute Myocardial Infaction.

• The Ambulance delivers the patient tothe ED at the appropriate Cardiac CathLab hospital bypassing metropolitanhospitals if necessary.

Bed Management

Matt’s Story

Matt is the BedManager at a largemetropolitan teachinghospital with a CardiacCath Lab.

Although it is only8.30am there are 30patients requiringadmission to the hospital including anumber of cardiology patients.

This is the story ofhow Matt tackles theproblem under theCardiology Model ofCare.


It is only 8.30am and there are 27 patientsin the ED requiring admission to hospital.Of these, nine are cardiology patients.There are two patients at rural hospitalsthat need to be transferred, one requiringa CCU bed and the other requiring a wardbed. There is also one patient who hascome in for an elective procedure who willrequire a CCU bed.

Of the nine cardiology patients waiting forbeds:

• two have atypical chest pain with normalECGs and normal cardiac markers

• three require monitoring in the CCU forabnormal heart rhythms

• one patient has presented within theprevious hour following a heart attack

• three require admission for managementof fluid congestion related to heart failure.

Matt considers what strategies he will useto ensure an effective flow of patientsthrough the hospital.

Following a review of its bed configuration,the Cardiology Department has thecapacity to more effectively accommodatea variety of patient types. The CCU andcardiology ward beds are co-located andthe beds are managed by one NUM. Thebed manager liaises with the NUM whoconfirms that there are a number of freebeds, which allows some of the patients inthe ED to immediately access ward andCCU beds.

27 people requiring admission

Rural hospitalPatient requiring elective procedure


What’s Good Aboutthis Story?

• The CCU andCardiology beds areco-located and jointly managed providing greater flexibility and capacity to accommodate a variety of patients.

• “Hot beds” are inplace for patientswith ACS.

• 23 hour beds forACS patients withdefined dischargeprotocols.

The most urgent patient in the ED, whohas had a heart attack, is sent immediatelyto the Cardiac Cath Lab for primaryangioplasty, and then to the ‘hot bed’ inCCU, which is routinely identified toaccommodate urgent patients (as they arerequired).

The other available beds are 23 hourbeds. They were vacated at 7.30am asthey contained patients with well definedadmission and discharge protocols. Thetwo booked elective PercutaneousCoronary Intervention (PCI) patients areadmitted to 23 hour beds.

Matt also liaises with the rural hospitaland, after receiving standardisedhandover forms, agrees to transfer thetwo most acute patients to the remaining23 hour beds.

Matt is confident that the bedmanagement strategies within theCardiology Department are sufficient toaccommodate demand. He recognisesthat not all days will be as straightforwardas this one but is confident that the ‘flexstrategies’ negotiated with theCardiothoracic Department would helphim to manage some of the sudden peaksin demand likely to occur in the future.

Matt Bed

ManagerHotbed

Coronary Care Unit

Cardiac Cath Lab

Cardiology Ward

23hourbed

Hospitalwith Cardiac Cath Lab

Flexbed

NUM CCU Matt Bed

Manager

Bed Management- Essential and Highly Desirable Components


Essential Components

• 23 Hour Beds

• “Hot Beds”

• Ward By-pass

• Data Driven Bed Re-aggregation

Highly DesirableComponents

• Co-location ofCardiology RelatedUnits

• Short-term Use ofFlex Beds in PeakDemand

• Day Angioplasty forAppropriate Patients

• Medi-Hotel

Benefits• Greater equity of patient access due to

improved inpatient bed availability.

• Optimising the Cardiac Cath Labthroughput by an improvement in thealignment of appropriate patients andappropriate beds in preparation forCardiac Cath Lab processing.

• Greater certainty for patient transfers,allowing more time to coordinate thetransport and nurse escorts.

• Reduction in the Access Block.

• Greater flexibility to meet sudden peaksin demand.

• Bed use tailored to clinical needs,freeing up inpatient beds for acute care.

• Improved staff and patient satisfactiondue to improvements in operationalefficiency.

• Effective resource utilisation.

Essential components of bed management

23hoursonly

8 am 7 am

23 Hour Beds

Hotbed

“Hot Beds”

Metropolitan Hospital

CardiacCath Lab Hospital

Ward By-pass forMetropolitan

Hospital Patients

HOSPITAL

CardiologyDepartment A

Department B Department C

Data Driven Bed Re-Aggregation


Highly desirable components of bed management

Cardiology

Cardiac Cath Lab

Coronary Care Unit

Central Management

Co-location of CardiologyRelated Units

8 am 8 pm

Angioplasty procedure Patient discharged

Day Angioplasty forAppropriate Patients

HOSPITAL MEDI - HOTEL

Medi-Hotel (‘Unsupervised’Accommodation)

Short-term Use of Flex Bedsin Peak Demand

Cardiology Flex Beds

23 Hour Beds

Characteristics • The number of 23 hour beds and their

proportion relative to multi-day bedsneeds to be data driven. It must reflectthe ‘demand and supply’ factors of eachhospital.

• Preferred use by the Cardiac Cath Labsto maximise usage.

• Clear protocols and guidelines for theuse of the beds must be establishedand enforced.

• Must be supported by criteria drivenpatient discharge.

- Set discharge time e.g. 7am.

- Discharge documentation andmedication prepared the nightbefore.

- Review by a consultant inexceptional cases.

• Defined hours of operation (e.g. closeddaily, closed for the duration of theweekend).

• 23 hour beds could be in the CardiologyWard or in a SSU.

• Patients are scheduled to the CardiacCath Labs and, where possible, relevantstaff are informed in advance, (e.g. inter-facility transfer). Where Area PatientFlow Units (APFU) exist they can workwith the Cardiac Cath Lab to proactivelyschedule transfer patients to 23 hourbeds (i.e. at least 24 hours in advance

where possible). This will aid in timelytransfer of patients (e.g. allows time toco-ordinate transport and nurse escort,where appropriate).

• Without the need for an inpatient wardbed the patient can be discharged onthe same day.

Benefits• Equity of patient access to cardiology

services across NSW.

• Improved patient care by providingfaster access to clinical care.

• Greater certainty for patient transfers,allowing more time to co-ordinate transport.

• Streamlined use of resources. ImprovedCardiac Cath Lab throughput andreduced waiting lists due to higherturnover.

• Improved staff and patient satisfactionby minimising delays for critical care.

Barriers to overcome• Insufficient leadership and executive

support.

• Barriers to resources for ideal bed re-aggregation and co-location.

• Variations to costs depending availabilityof existing infrastructure and resources.

Essential Components of BedManagement

• 23 Hour Beds

• “Hot Beds”

• Ward By-pass


Hospitals with CardiacCath Labs should pursue ‘preferentialbeds’ (23 hour beds) tohelp ensure timely discharge, encourageuse of “follow onangioplasty”, and provide more reliableaccess for feeder hospital patients.

Measures should be inplace to ensure 23 hourbeds do not replace theuse of day procedurebeds.


23hoursonly

8 am 7 am


CCUCardiac Cath Lab

23 hour beds for Metropolitan hospital patient post-Cardiac

Cath Lab (when required)

23 hour beds for rural patients

23 hour beds for elective patients

post-Cardiac Cath Lab (when required)

Lab 1 Lab 2

Cardiology Ward

23 Hour Beds

Short Stay Beds

Illustration of 23 Hour BedsPatients Suitable for23 Hour Beds

• Inter-hospital transferpatients, pre andpost Cardiac CathLab procedure.

• Elective patients postangioplasty/stent(who cannot remainin recovery beds).

• Elective patientsrequiring ‘follow on’angioplasty.

• ElectricalCardioversions preand post-procedure.

• Post-operative elective pacemakerprocedures.

• Pre and post-hospital transfer pacemaker procedures.

• Outpatient transoesophagealechos.

23 Hour Beds


Patients from metropolitan hospitals can usually be transferred directly to Cardiac CathLabs on the day of their intervention, in some cases patients are transferred back to thefeeder hospitals. If they need to remain in the Cardiac Cath Lab hospital for observationa 23 hour bed should be used. If the patient’s stay is likely to be extended, they shouldbe admitted to a multi-day bed.

MetroHospital

Transfer back toMetro Hospital

Discharged

Cardiology/CCU

Patient notsuitable for

transfer back

Patientsuitable for

transfer back

Patient notsuitable for23 hour bed

23hourbed

Cardiac Cath Lab

Supporting Transfer for Patients from Metropolitan Hospitals

23 Hour Beds – Metro Hospitals


Patients from rural hospitals can be transferred directly to 23 hour beds that areassigned to particular rural regions. Bed Managers or the Area Patient Flow Unit (APFU)and the Cardiac Cath Lab may co-ordinate scheduling activities for rural patients. If thepatients’ condition is complicated post-intervention (and they require several days inhospital), they should be transferred to a multi-day bed.

Given the relatively uncomplicated journey of elective angioplasty patients, 23 hourbeds can be used for them to recover whenever required. This may reduce the numberof elective patients being cancelled due to a lack of available beds.

23 Hour Beds to Support Angioplasty for Elective Patients

Supporting Transfer for Patients from Rural Hospitals

Supporting Transfer for Elective Patients

Discharged

Cardiology/CCUPatient notsuitable for23 hour bed

23hourbed

Elective

Longer recovery period,

e.g. Angioplasty

Cardiac Cath Lab

RuralHospital

Discharged

Cardiology/CCUPatient notsuitable for23 hour bed

23hourbed

23hourbed

Patients assigned byAPFU and Cardiac Cath Lab

Cardiac Cath Lab

23 Hour Beds – Rural Hospitals

“Hot Beds”

Characteristics • A well defined strategy which is

executed for a primary angioplastypatient ‘hot case’ or complexangioplasty patient.

• A CCU patient (less-acute, whenappropriate and safe) is pre-identified totransfer from a CCU bed to a non-CCUbed (e.g. Ward bed, HDU bed) if anappropriate emergency patient requiresurgent CCU care.

• This strategy can include maintaining anempty “hot bed” whenever practicable.Approach does not require a ‘hot bed’ tobe vacant at all times.

Benefit• A defined escalation plan to

accommodate primary angioplastypatients helps to improve patient flowand helps deliver more timely treatment.

Barriers to overcome• “Hot bed” strategy requires a well

defined usage criteria to prevent bed notbeing available when required.


• 23 Hour Beds

• “Hot Beds”

• Ward By-pass


“Hot Beds” are preidentified beds in theCCU that are used foremergency cases.

Access to “hot beds”for primary angioplastycases helps toimprove patient flowand helps deliver moretimely treatment.


Hotbed

Patient pre-identified to transfer from CCU bed to a

non-CCU bed if an emergency

patient requires admission.

CCUCCU

“Hot Bed” For Speed of Access for Emergency Patients

Hotbed


• 23 Hour Beds

• “Hot Beds”

• Ward By-pass


The Ward By-pass Strategy enables anangioplasty patient tobe treated withoutbeing admitted intohospital.

Characteristics• Patients in metropolitan hospitals who

require angiography are transporteddirectly to the Cardiac Cath Lab (ratherthan to a ward bed) for tests andprocedures. They recover in therecovery or day area. The patients aretransported back to their originalhospital bed or discharged directly fromthe Cardiac Cath Lab hospital if clinicallyappropriate.

• Patients in metropolitan hospitals whorequire angioplasty can be transportedback to the metropolitan hospital post-intervention if clinical risk and transportscheduling allows.

• Agreements between metropolitanhospitals and Cardiac Cath Lab hospitalsmust be established. Joint protocoldevelopment is required.

• Adequate Cardiologist and nursingsupport at metropolitan hospitals isrequired.

• All patients transported into hospitalwith interventional service need to becaptured on IT system.

Benefits• Reduced bed occupancy at the feeder

hospitals leading to greater CardiacCath Lab throughput, particularly forpatients in metropolitan hospitals.

• Up-skilling of cardiology teams inmetropolitan hospitals improves overallcare delivery skills.

Barriers to overcome• Guidelines for assessment prior to

transfer are critical for promotion ofpatient safety.

• Some facilities lack an adequaterecovery or day area.

• Recovery area may have limitedoperating hours.

• Agreement from feeder hospitals to takepatients back post-test or intervention.

• Upskilling of staff in feeder hospitals.

“Ward By-pass” for Metropolitan Hospital Patients


Patient inMetro Hospital

Patient Recovers in Metro Hospital

Patient arrives in Cardiac Cath Lab

for test or procedure

Transport toCardiac Cath Lab Hospital

Return Transport to Metro Hospital

Ward By-pass Strategy

Metropolitan Hospital

CardiacCath Lab Hospital

Data Driven Bed Re-aggregation

Characteristics• Data driven bed re-aggregation on a

regular basis, (e.g. every 2 years) tosupport changes in demand.

• This strategy is an important foundationfor other components of this model. It isimportant that Cardiac Cath Labhospitals have a sufficient inpatient bedbase to support other bed strategiessuch as 23 hour beds and “hot beds”.

• Requires confidence that length of stayis stable and relatively optimal. Othersolutions to help reduce length of staysuch as improved discharge planning

and improved rehabilitation programsmay be required to improve overalloperational efficiency.

Benefits• This is a data driven and evidence-

based method to help match thenumber of beds to number of patients.


• Improved staff and patient satisfaction.

• The visibility of demand and supply ofbeds, and ability to model differentscenarios, provides support to proactivecapacity planning.

Barriers to overcome• Make data driven bed capacity planning

an extensively embedded process thatis a routine part of hospital culture.

• Other specialties may need to contributebed space and budget to cardiology,which requires careful changemanagement processes.


• 23 Hour Beds

• “Hot Beds”

• Ward By-pass


Hospitals that havebeen proven to haveinsufficient cardiologybeds (based on analysis of historicaldata, length of stayand capacity planning scenarios) need to re-aggregate theirbeds (i.e. increase thenumber of cardiologybeds) to enable timelypatient admissions.


Data Driven Bed Re-aggregation

Issue: Mismatched bed and patient numbers Solution: Bed re-aggregation modelling

HOSPITAL

CardiologyDepartment A

Department B Department C

Highly DesirableComponents of BedManagement




• Medi-Hotel (‘UnsupervisedAccommodation’)

The co-location of cardiology relatedunits such as theCardiology Ward, CCU,Cardiac Cath Lab andCardio-thoracic Unitcan improve operational efficiency.

Characteristics• Cardiology services located in close

physical proximity.

• Central bed management capabilities.

• Single management structure.

Benefits• More effective use of resources (space

and staff).

• Less distance to transfer patients fromCardiac Cath Lab to post-interventionrecovery beds.


• Facilitates staff rotation and skilldevelopment.

• Creates flexibility during peaks indemand (e.g. cardiology patients can‘flex up’ into cardio-thoracic beds duringpeaks in demand).

Barriers to overcome• Local physical practicalities may reduce

suitability of this solution in the shortterm.

• Some sites may require someinvestment to co-locate services.

Co-location of Cardiology Related Units


Potentially post-intervention recovery and

short stay beds

Potentially CCU, post-intervention recovery,

step down coronary care, and cardiothoracic

surgery units

Cardiology

Cardiac Cath Lab

Coronary Care Unit (CCU)

Central Management

Co-location of Cardiology Related Units

Cardiology

Cardiac Cath Lab

Coronary Care Unit

Central Management

Short-term Use of Flex Beds in Peak Demand

Characteristics• Temporarily increases the number of

beds for cardiology patients in periodsof high demand. Source of “flex beds”need to be tailored to each facility, butmay include the use of:

- ‘over-census’ bed (if and whenappropriate)

- pre-identified beds in anadjacent ward

- cardio-thoracic beds.

• “Flex beds” are ideally located in closeproximity to cardiology beds.

• Requires agreement from relevantstakeholders, and development of welldefined bed usage criteria. This strategyis only effective if the cardiology bedbase is appropriately configured to freelyaccommodate patients on a routinebasis.

Benefits • Greater flexibility and bed management

capabilities.

• Ability to proactively manage suddenpeaks in demand.

• Reduced outliers.

Barriers to overcome• Agreement from non-cardiology

stakeholders.

• Careful adherence to bed usage criteria.Ability to rapidly “flex down” must beconsistently displayed.

• Skills of staff supporting the “flex beds”must be agreed and monitored.






“Flex beds” canaccommodate patientsfor a short period oftime during peaks indemand. These bedscan be located inclose proximity to thecardiology ward or inother wards and aremade available duringhigh patient flow.


Cardiology Flex Beds






Traditionally, the treatment of patientsrequiring angioplastyinvolves patientsspending approximately 2-3days in an inpatientbed. However, recentlythe Cardiac Societyhas suggested thatsome patients can besafely provided angioplasty on a day-only basis.

Characteristics• Select angioplasty patients admitted as

a day-only patient.

• A defined patient selection criterion isrequired to ensure patient safety.

• Patients are in recovery bed for fourhours.

• Increased efficiency when combinedwith 23 hour bed strategy.

• Adheres to National Heart Foundation ofAustralia, Cardiac Society of Australiaand New Zealand Guidelines for theManagement of Acute CoronarySyndromes, 2006.

Benefits• Reduced number of bed days.

• Improved access to beds for othercardiology patients.

Barriers to overcome• Hesitation or reluctance of some

cardiology teams and patients to acceptthis model of care.

Day Angioplasty for Appropriate Patients


8 am 8 pm

Patient dischargedPatient has Angioplasty procedure

Patient moved to recovery bed

Day-Only Angioplasty

8 am 8 pm

Angioplasty procedure Patient discharged

Medi-Hotel (‘Unsupervised’ Accommodation)

Characteristics• Guidelines must be developed for

suitable patients, e.g. electiveangioplasty patients who have metclinical and social criteria, includingpatient demographics.

• Located close to hospital with suitablefacilities such as elevators.

• Patients are provided with appropriatecommunication devices to establishimmediate contact with hospital staff inthe case of an emergency. For example,a telephone linked to ED and medicalcall back up.

• Patients return from the medi-hotel thenext morning for clinical review beforegoing home at 7am.

• Can be a routine strategy to helpmanage cost of care delivery or astrategy used in defined times only (i.e.when the hospitals temporarily reachtheir maximum capacity).

• Some facilities in close proximity to eachother may choose to share a singlemedi-hotel.

Benefits• Patient does not occupy a ward bed,

therefore increased access to moreacute patients.

• Lower operating costs.

• Medi-hotel is offered at no expense tothe patient, and may also accommodatea family member or carer.

Barriers to overcome• Lack of suitable supply of ready-made

medi-hotels in close proximity tohospitals.

• Establishment cost in somecircumstances.

• Cultural reluctance from some cliniciansand patients.






Some patients do notrequire constant medical supervisionafter their cardiologyintervention but cannotbe confidently discharged.

In peak times, thesepatients can be transferred to medi-hotels until the cardiology staff aresatisfied that they aresafe for discharge.


HOSPITAL MEDI - HOTEL


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Implementing Chest Pain Model of Care

Process Map

Visit the online versionof this and otherprocess maps on theARCHI website atwww.archi.net.au/elibrary/build/moc

Here you will be ableto access more information on each ofthe steps to implementthe model.

You will have accessto tools and templatesas well as hints andlessons learned byothers who have implemented themodel.


Governance Establish Governance.Form Steering Committee.

Patient JourneyHow do patients flow

through the model

Policies and Protocols

PeopleUnderstand who the staff are, how

they function and what role theyplay in the patient journey

Resources

Communication

Map patient journey (include carer and/or familyperspective).

Understand current systems.

Stakeholder analysis.

Staff profile.

Conduct a resource survey.

Develop a communication plan for internal andexternal target groups.

PlanningWhere are you now?

Note: This process map is for implementing Chest Pain Evaluation Areas. A processmap for bed management is on the Models of Care website atwww.archi.net.au/elibrary/build/moc


Develop and execute protocols.

Form CPEA team.

Deliver required resources.

Execute communication plan.

Identify how feedback will be used to inform project.

Monitor and evaluate KPIs.

Monitor patient journey.

Monitor protocols.

Develop a review process.

Monitor resource use and planupgrades.

Ensure ongoing communicationstrategy with patients and staff.

PreparationMake it happen

OperationaliseMake it stick

Develop a Process Map.

Develop a Project Plan.

Set KPIs.

Establish Business Rules.

Check patient journey.

References

American College of Cardiology and American Heart Association, 2005. Guidelines forthe management of patients with ST-elevation myocardial infarction-Executive summaryhttp:// www.acc.org/clinical/guidelines/stemi/Guideline1/PrehospitalIssues.htm accessed19/05/2005.

Aroney, C., Aylward, P., Kelly, A., Chew, D. and Clune, E., (Acute Coronary CareSyndrome Guidelines Working Group), 2006. Guidelines for the management of acutecoronary syndromes 2006. Medical Journal of Australia. Vol. 8:8, S1-S30.

Aroney, C., Boyden, A. N., Jelinek, M. V., Thompson, P., Tonkin, A. M. and White, H.,2001. Current guidelines for the management of unstable angina: a new diagnostic andmanagement paradigm, Internal Medicine Journal. 31:2, 104-111.

Boufous, S., Kelleher, P. W., Pain, C. H., Dann, L. M., Ieraci, S., Jalaludin, B. B., Gray,A-L., Harris, S. E. and Juergens, C. P., 2003. Impact of chest-pain guideline on clinicaldecision-making, Medical Journal of Australia, Vol.178:8, 375-380.

Braunwald, E., Antman, E., Beasley, J., Califf, R., Cheitlin, M., Hochman, J., Jones, R.,Kereiakes, D., Kupersmith, J. Levin, T., Pepine, C., Schaeffer, J., Smith, E., Steward,D., Theroux, P., Gibbons, R., Alpert, J., Faxon, D., Fuster, V., Gregoratos, G., Hiratzka,L., Jacobs, A. and Smith, S., (Committee on the Management of Patients with UnstableAngina), 2002. Guideline update for the management of patients with unstable anginaand non-ST-segment elevation myocardial infarction-2002: summary article: a report ofthe American College of Cardiology and American Heart Association Task Force onPractice Guidelines, American College of Cardiology Foundation and the American HeartAssociation, Inc. DOI: 10.1161/01.CIR0000037106.76139.53.

Chest Pain Centre, 2004. University hospital offers the region’s first fast track point-of-care pathway for chest pain patients, University of Louisiana Health Care.

Committee to update the 1997 exercise testing guidelines, 2002. Guideline update forexercise testing: Summary article: A report of the American College of Cardiology/American Heart Association Taskforce on Practice Guidelines, Circulation 106:1883-1892. DOI:10.1161/01.CIR.0000034670.06526.15.

NHS Modernisation Agency, (Coronary Heart Disease Collaborative), 2002. CoronaryHeart Disease Collaborative Service Improvement Guide, Department of Health, UnitedKingdom.

NHS Modernisation Agency, (Coronary Heart Disease Collaborative), 2005. Making adifference. An overview of the work of the Coronary Heart Disease Collaborative,Department of Health, United Kingdom.

Coronary Heart Diseases Policy Team, 2005. Leading the way progress report: thecoronary disease national service framework, Department of Health, United Kingdom.

Demand Management Group NHS Modernisation Agency, 2002. The Big Wizard, Step4 – Managing Demand, Department of Health, United Kingdom.

Department of Health, 2004. Achieving timely ‘simple’ discharge from hospital,Department of Health, United Kingdom.

Department of Human Services, 2000. Review of Chest Pain Evaluation Areas. Finalreport prepared by KPMG Consulting, Victorian Government Health Information.

Dougan, J., Mathew, T., Riddell, J., Spence, M., McGlinchey, P., Nesbitt, G., Smye, M.,Menown, I. and Adgey, A., 2001. Suspected angina pectoris: a rapid-access chest painclinic, Quality in Management, 94:12:679-686.

For more informationabout the CardiologyModels of Care visitthe Models of Care section of the ARCHIwebsite

www.archi.net.au

Here you will find anelectronic copy of thisdocument, resourcesand have the opportunity to participate in workshops and onlinediscussion groups.


Section Three - Resources

NSW Health Clinical Services Redesign Program Models of Care for Cardiology 53August 2006. For the latest version of this model visit the ARCHI we

model of cardiology care - agency for clinical innovation...nsw health clinical services redesign...

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