Electronic ED Journey Board

Janet Hardwick

B App Sci - Nursing, M Management.

Assistant Director of Nursing – Patient Flow

Missing Co Presenter

Somewhere off the East Coast of Australia

Metro South Health

• Located in South East Qld

– 1 million people (23% of Qld pop.)

– 3,856 square kms

• 6 public hospitals

– Princess Alexandra, Logan, Beaudesert, QEII,

Redlands and Wynnum

– Community and Primary Health

– Mental Health

– Oral Health

• 8 Clinical Streams

– Cancer, Surgical, Medicine & Chronic Diseases, Women’s &

Children's, Aged Care & Rehabilitation, Mental Health, Emergency &

Clinical Support Services, Patient Flow, Ambulatory Care and

Hospital Avoidance

Background

• Four random audits conducted during READi identified inaccurate

recording of the transfer time for 16 out of 20 ED patients.

• During the diagnostic phase of the It’s Time Project it was identified

that EDIS data entry into the Treating Team fields had poor

compliance and were often inaccurate or omitted.

• Two electronic touch screen journey boards installed in low

compliance wards in 2012 resulted in a dramatic sustained increase

in compliance with recording EDD’s

• A touch screen electronic ED journey Board (EDJB) was proposed

as a solution to overcome data integrity issues and to increase PA’s

NEAT percentage.

EDJB ~ a Module of Patient Flow Manager V10

• Approached Health IQ to develop the EDJB as a

module of Patient Flow Manager V10.

• PFU staff met with Product Manager and

Business Analyst of Health IQ to outline our

specifications for the EJB.

• Designed to be simple, intuitive but powerful &

based on the principles of Lean Methodology.

Objectives

• Provide at a glance a visual display with real time EDIS information

regarding an individual patients journey

• Highlight when patients are approaching configured NEAT time

targets by the use of differentiating colours.

• Visual display of NEAT status of ED

• Facilitate timely entry of patient review, bed requests, bed ready

and transfers to ward.

• Clearly identify where time is spent during the various stages of the

patient journey from triage to ward transfer

• Increase compliance with NEAT

• Highlight barriers to achieving NEAT

• Generate reports

EDJB Benefits

• Can interface with corporate systems

• Supports touch and non touch screens

• Accessible from any computer in the hospital,

mobile phone or iPad without the need to install

any client software

The Solution • EDJB displays all current ED patients in table view:

– Current location

– UR

– Last Name

– First Name

– Age

– Arrival Date

– Time since Triage

– Time seen by ED Dr

– Inpatient Team Review Request

– Time seen by Inpatient Team

– Ward Bed Request

– Ward awaiting admission

– Bed Ready

– Actual ED Departure

Implementation

• QEII well positioned and keen to pilot

– Screen customised for QEII

• Several go live dates since August last year!!

• The first delay related to unscheduled leave by

developer

• Subsequent delays related to:

– Financial constraints for purchase of screens,

– Redundancies

– IT moratorium

– Communication issues

– Major technical issues

What it looks like ~ QEII View

Referral to Inpt Team

attendance 1 hr.

Triage to Referral

1.5 hrs.

Consult attend to

ready to depart 1 hr.

Ready until actual

depart 20 mins

Where to next

• Pilot ASAP

• Design enhancements

– Dials NEAT by Discharges, Admissions & overall

– NEAT by doctor/team

• Pilot at Redland Hospital & other districts

• Evaluate

• Disseminate results

Bed Occupancy Audit Tool BOAT

Janet Hardwick

B App Sci - Nursing, M Management.

Assistant Director of Nursing – Patient Flow

Background

• BOAT evolved from a tool developed by Central North Adelaide Health Service in 2008

• Originally described by Dr Carol Haraden – “The Wasted Capacity Measurement Tool” 2006

Institute for Healthcare Improvement USA

• Both tools focused on bed occupancy and utilisation

Evolution of BOAT

BOAT

YEAR

Criteria Sub

Categories

Codes # pages

with

code

Audit

Sheet

Application

2010 13 x 98 3 1 per ward Excel &

Acess

2011 13 35 136 4 1per 5 beds Konika

Minolta

2012 6 13 81 1 1per 5 beds Abbyy

Flexicapture

• Significant modifications made to the capacity audit tool used by the Royal Adelaide Hospital • Bed utilisation criteria (10 criteria & 28 codes) • Excel spread sheet • Hospital beds not patients

Evolution of BOAT continued

BOAT

Year

Audit

Days

#

Teams

Bed

Occupancy

Bed

Utilisation

Patient

Tracking

# Clinical

Areas

2010 14 2 Yes Yes No 27

2011 7 2 Yes Yes Yes 29

2012 7 3 Yes Yes Yes 30

• 2010 Bed occupancy and utilisation

• 2011 Emergency Board tracked

• 2012 Emergency Board, ED patients waiting admission, MRO’s and

Outlies tracked

2010

AM PM

35.1

35.2

35.3

35.4

33.1

33.2

33.3

33.4

31.1

31.2

31.3

31.4

29.1

29.2

27.1

27.2

27.3

27.4

25.1

25.2

25.3

25.4

23.1

23.2

23.3

23.4

24.1

24.2

26.1

26.2

26.3

26.4

28.1

28.2

28.3

28.4

#1 Active treatment The bed is occupied by a patient and they are receiving care. This includes someone who will be returning to the bed after surgery, a patient receiving treatment and is temporarily out of the ward such as Physiotherapy. This patient needs the bed. 1 Patient receiving active treatment 1a Patient in OT returning to bed 1b Patient in Dialysis returning to bed 1c Patient in DDR returning to bed 1d Patient having allied health therapy returning to bed 1e Patient attending OPD appointment 1f Patient attending Procedural area eg angiogram, endoscopy, EEG 1g Patient absent whereabouts unknown 1h Patient is a NON DOSA 1i Patient is on the Emergency board 1j Waiting intra ward transfer 1k Patient attending Doctor’s exam 1l Out lie status unknown 1m Education returning to bed 1n End of life bed #2 Outpatient The bed has a patient who could have been managed as an outpatient.

2a DDR Patient admitted to access an investigation eg MRI or CT scan 2b Rural or remote patients overnight stay (to provide a place to stay) 2c ASIS patients 2d HITH patients 2e Cardiology Patient admitted for ECHO 2f Patient admitted due to no outpatient appointment times available (specify) 2g Inpatient stay extended to enable OPD attendance 2h No access to community services or support at home

#3 Another service prior to discharge Bed has a patient but awaiting another service before discharge can be scheduled 3a Specialist opinion 3b GATE assessment 3c ACAT assessment 3d Accepted and Waiting Rehab bed - BIRU, Day Hospital, Spinal (specify) 3e Disability services

3f Allied Health review – Dietician, Speech pathology, Social Work, Physio, OT general, hand, (specify)

3g Pathology tests 3h Tests – please specify ie stress test, ultrasound 3i Procedures – please specify eg PICC, Chemo 3j ASIS 3k HITH #4 For discharge but delayed The bed is occupied by a patient who is ready for discharge but is delayed. Reasons may include:- 4a Waiting Discharge medication 4b Waiting pathology review 4c Waiting to see a Medical Officer prior to discharge 4d Waiting IHT, accepted no bed available

4e Waiting IHT, accepted bed available, no transport 4f Waiting IHT, no accepting doctor 4g Patient/family refusing IHT to step down facility 4h Patient/family refusing to be listed/transfer to N/home 4i Patient could be managed in the Transit Lounge 4j Patient/Patient family refusing discharge 4k Waiting home modifications 4l Waiting NH Placement 4m Other ****** 4n Waiting for DDR 4o Mental Health review 4p Waiting Accommodation 4q Allied Health 4r Waiting for Ix / Procedures 4s Waiting out of District services

Audit Sheet

Codes

2011

Audit Sheet

Codes

2012 Codes Audit Sheet

Rationale for Implementing BOAT

• Increased reporting of bed utilisation issues

• No evidence to support individuals varying

perceptions regarding bed utilisation throughout PA

• READi (Rapid Emergency Admission to Destination Initiative)

had identified greatest delay to ED patient transfer

to an inpatient bed was bed allocation

• The DASE (Delayed Assessment Separation Events) project

identified significant discharge delays

Objectives

• Undertake a systematic approach using a

standardised tool to assess bed occupancy &

utilisation

• Provide a snapshot of bed utilisation at PA

• Identify reasons/causes of inefficient bed utilisation

that impedes flow of inpatients

• Identify local strategies which sustain efficient

patient flow

• Develop an action plan to address identified

barriers & promote strategies that are sustainable

Communication

• BOAT is now custom & practice

• Information session daily at the Bed

Management Meeting week prior to audit

• NUM’s emailed

• Screen savers

• PA People

• Nursing Newsletters

Implementation

• Audit Conducted Wednesday 22nd to Tuesday 28th August

2012 by Patient Flow Unit (PFU)

• Three teams of two

• All inpatient beds & patients assessed according to BOAT

codes twice a day for 7 consecutive days between

1000 – 12000 & 1600 – 1800 hrs.

• Audit conducted in same sequence

• Board round conducted with Team Leader in each ward

• At conclusion of round visual inspection of every bed

• BOAT data recorded & collated by PFU

Other Information Sources

• Chart audits

• Patient Flow Manager reports used to track outlies and ED patients

• EDIS utilised to identify patient admission times

• Residential care waiting lists

• HBCIS & Viewer

• HIMS (Health Information Management Service)

• Rehabilitation waiting lists

• Day in the Life of PAH (Dashboard developed by A Scanlon)

• Previous results from Bed Occupancy Audits

All information sourced from ward staff during morning and afternoon audits

Limitations of BOAT 2012

• Point in time data

• Inconsistencies in handover information

• Nursing staff generally modified their care after 3 to 4 days

• Issues with codes, to be included in next audit

– QCAT hearings

– Over census

– Non resourced empty beds

– GATE Nursing and GATE Medical review to be coded as separate codes

– Palliative Care to be coded for treatment and review

– Equipment required for discharge

• Not the whole story important to continue to track some patients until discharge

Results

• Results collated & validated using Abbyy Flexicapture and then exported to Excel

• Data Analyst created a semi automated database for queries

• Numbers are reported as total head count of patients each day – i.e if patient was reported in both AM and PM in the category it is count as 1 patient

• Results collated and disseminated separately by

• Ward / Unit

• Division

• Whole of Hospital

• An Executive Report provided to Hospital Executive

• Results utilised to support strategies identified in the 12 month Bed Management Plan 2012 / 2013

Identified Areas that have Improved since

BOAT 2011

• Emergency Board

• Patients waiting for Allied Health review

• Bed swaps within wards & inter ward transfers

All information sourced from ward staff during morning and afternoon audits

BOAT YEAR Bed Moves Transfers Total

2011 466 221 687

2012 16 118 134

2012 Identified Areas for Improvement

• Management of empty beds

• Bed allocation of Emergency patients

• Outlie management

• Delays to discharge

– Dispensing discharge medications

– Medical reviews

– Discharge transport

– Inter hospital transfers

• Clinical handovers

All information sourced from ward staff during morning and afternoon audits

Total Patients Audited in AM

2010, 2011, 2012

Patients receiving Active Treatment AM Audit

2010, 2011, 2012

All information sourced from ward staff during morning and afternoon audits

Empty Beds Not Allocated

2010, 2011, 2012

Empty Beds Allocated

2010, 2011,2012

Delays to Discharge

2010, 2011, 2012

All information sourced from ward staff during morning and afternoon audits

Empty Beds Building 1 (excluding ICU, CCU & ESU)

7 Days 255 empty beds were available 1000-1200 7 Days 351 empty beds were available 1600-1800

Weekday 155 empty beds were available 1000-1200 Weekday 235 empty beds were available 1600-1800

• No hidden beds • 37 weekday WAAs in AM • 28 weekday WAAs in PM • Empty bed trending up in

comparison to 2010 & 2011

1000-1200 1600-1800

Empty Beds by Day of Week

Building 1 (excluding ICU, CCU & ESU)

255 empty beds were available 1000-1200 351 empty beds were available 1600-1800

• Includes all empty beds

Outlies (Building 1 )

158 patients located outside home ward

• 51 of the outlies were not reviewed each day (Sunday 20)

• 11 Patients had 2 or more days not reviewed & had significantly longer LOS and RSI%

(PAH & HRT coded DRG’s)

Emergency Board (only patients on Emergency Board at 1000hrs & 1600 hrs identified)

89 Patients on Emergency Board

• 18 patients on board for more than one day • 9 of these patients were outlies

Total Patients Delayed to Discharge

304 patients were delayed to discharge during BOAT

Delays to Discharge by Category

0 10 20 30 40 50 60 70 80

Pathology

Allied Health

Procedures

Patient

Family

Assessment

*Rehab Bed

Discharge Transport

IHT

Placement / Com Needs

Med Review

Discharge Meds

*Rehab Bed included

Delay to Treatment for

GARU Bed

75 patients delayed waiting on discharge medications 62 patients delayed waiting on Medical Review 61 patients delayed waiting on placement or community needs

Delays to Discharge - Discharge Medications

75 patients were delayed to discharge waiting for discharge medications 83% of these delay related to dispensing 90% of dispensing delays occurred during the AM round

Delays to Discharge ~ Dispensing of

Discharge Medication

Friday showed the highest delays in Discharge Medication Dispensing – 13 out of 14 occurred on the AM round

Residential Care or Supported Accommodation

3% of all patients during BOAT were delayed to discharge waiting residential care or support accommodation

49% of these patients were waiting residential care beds.

Residential Care or Supported Accommodation by

Bed days

33 patients delayed to discharge waiting residential care or support accommodation

96 bed days lost waiting for residential care or supported accommodation during BOAT

673 bed days lost by patients waiting from time during BOAT to ultimate discharge date

Bed days inclusive

Include all days from first

handover to last day

handover as waiting for

residential care or

supported

accommodation.

Inter-hospital Transfers Out

• 6 patients transferred same day • 9 patients waiting beds in Metro South • 32 patients waiting beds outside Metro South

187 bed days occupied by

41 patients waiting transfer.

9 bed days occupied by

Metro South patients

Delay to Discharge waiting Discharge Transport

56.4% of patients (22) delayed waiting transport were waiting for private transport

Friday - 5 private transport patients waiting in wards whilst transit lounge was open

Total Patients

Waiting Rehabilitation Beds

Total Inpatients Patients waiting a

rehabilitation bed

70 bed days were lost in the

acute wards by patients waiting

for a Rehabilitation Beds

• 17 bed days accounted for by

waits for a bed in GARU

(8 patients)

• 25 bed days accounted for by

patients on GARU review list

(14 patients)

• 7 bed days accounted for by

waits for a bed in BIRU

(2 patients)

• 8 days account for by patients on

BIRU monitor list (2 patients)

• 4 bed days accounted for by

waits for a bed in SIU

(2 patients)

• 20 bed days accounted for by

waits to Non-PAH rehab beds

6

2

22 7

Other

3% waiting Rehab Bed

BIRU

SIU

GARU

Non-PAH

Other

Delayed to Treatment or Discharge

Waiting Assessment

111 bed days were lost waiting

on Assessments by 58 patients

14 bed days were lost by 12

patients waiting Medical Referral

for the assessment

Delayed to Discharge

Waiting Government Agencies

68 bed days were lost

waiting on Government

Agencies

75% of QCAT were in IMU

2 patients handover as

QCAT had no record in notes

53% of Home Mods/Equip

was in Rehab wards

Delays by Patient or Family

39 bed days were lost due to

family or patient decisions

22 of these bed days were

due to refusing discharge

Handover 92% of handover was by T/L or NUM.

• Inconsistencies were evident on

patient information.

• Disease processes appeared well

understood

• Incidents where handover sheets not

up to date

• Not all wards either have or use

journey boards.

• Discharge planning – reactive & at

end

• Focussed on the shift not the journey

• Outlie management issues evident

Where to next

• Implement intervention strategies to tackle

identified areas requiring improvement

• Modify tool again

• Conduct BOAT 2013 in last week of June

• Roll out to all of Metro South

For further information email:

Janet_Hardwick@health.qld.gov.au