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Long Stay Patient Project “Stranded Patients”. 08 April 2013 Presented by Andrew Davies Project Leaders: Alicia Sutton, Charlotte Porter. ADHB %
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1
08 April 2013
Presented by Andrew Davies
Project Leaders: Alicia Sutton, Charlotte Porter
Long Stay Patient Project“Stranded Patients”
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ADHB %<6 Hour Performance
3
Patient presents to ED
ED Specialist Assessment
Inpatient Specialist
Admit to ward Discharge
Discharge
3 hours 2 hours 1 hour
6 Hour Goal (Key Metric)
ED Performance is Primary Influencer
Ward Performance is Primary Influencer
Diagnostic Services (Labs, Radiology, etc.)
Allied Health
Primary Care Facilities
Other Key Performance Influencers
Elective Scheduling
Project Scope: Hospital-wide initiative involving all parts of the hospital
Bed Management
Also In Scope
The Problem: Not just in ED
4
Why Focus on Long Stay Patients?
Voice of staff
Recommended next steps from other acute flow projects (e.g. Daily Rapid Rounds)
Literature Review– Healthcare Advisory Board –
Maximizing Hospital Capacity (2002)
5
ADHB General Medicine – Evaluating the Opportunity
Patients with Over 10 Day Length of Stay
LOS > 10 Days
LOS > 10 Days
Patients with Over 21 Day Length of Stay
LOS > 21 Days
LOS > 21 Days
ADHB General Medicine Discharges from July 2004 to March 2013
6
The Project
Initiated Long-Stay Patient Project in General Medicine – April 2012
Clinical note review conducted of all > 21 day patients discharged from December 2010 to December 2011
Implemented first improvements from July 2012 to December 2012
Leveraged results and actions to other service areas
7
Causes for Delay - Over 21 Day Patients
Top CausesRest Home / Private Hospital PlacementPPPRSocial Work Input Older Peoples Health Review & Placement
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Other Observations During Audit
Significant variation in practice of how the plan for the stay is managed
No standard Admission to Discharge process followed for 1st time Rest Home / Private Hospital patients
No escalation criteria to involve Service Manager, Nurse Advisor & Clinical Director.
Poor visibility of current long-stay patients leading to variation in management
9
Increase Visibility in Service of Long Stay Patients
Daily Long Stay Patient report automated, reviewed by Nurse Specialists & Charge Nurses (July – 2012)
NHI Family Name Event No Admit Date Time LOS Days Ward Code Ward Stay Type
ABC1234 Pitt 3902162 02/10/2012 12:21 69.6 65 Ward stay
ABC1235 Ford 3927162 14/11/2012 14:09 26.5 68 Ward stay
ABC1236 Holden 3930640 20/11/2012 12:14 20.6 65 Ward stay
ABC1237 Mitsubishi 3931019 21/11/2012 02:12 20.0 68 Ward stay
ABC1238 Nissan 3931592 21/11/2012 18:59 19.3 68 Ward stay
ABC1239 Millner 3932454 23/11/2012 01:29 18.0 66 Ward stay
ABC1240 Osbaldiston 3934113 26/11/2012 11:29 14.6 67 Ward stay
ABC1241 McGregor 3934241 26/11/2012 13:53 14.5 66 Ward stay
ABC1242 Denison 3934331 26/11/2012 15:39 14.5 65 Ward stay
ABC1243 Griffin 3934450 26/11/2012 18:51 14.3 65 Ward stay
ABC1244 Sutton 3935235 27/11/2012 21:44 13.2 66 Ward stay
ABC1245 Meyrick 3935539 28/11/2012 14:18 12.5 68 Ward stay
ABC1246 Reeves 3935616 28/11/2012 14:52 12.5 65 Ward stay
ABC1247 Devaliant 3936436 29/11/2012 17:04 11.4 65 Ward stay
Current Gen Med Patients as at 11/12/2012 00:00:00, staying 10 days or longer
10
Increase Visibility in Service of Long Stay Patients
Long Stay Patient Report reviewed and discussed weekly at General Medicine Production Meeting (October 2012)– Issues escalated to Service Manager, Nurse Advisor & Clinical Director– Charge Nurses, Nurse Specialists & Nurse Educators also attend
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Increase Visibility in Service of Long Stay Patients
Include LOS on Patient Status at a Glance whiteboards on Wards 65, 66, 67, 68 (January 2013)
Visible in Nursing Station and can be flagged at Daily Rapid RoundsCurrent LOS
Added to Whiteboards
12
Results: Proportion of Over 10 Day LOS Patients
Daily Rapid Rounds implemented (Feb 2010)
New medical model of care implemented (Dec 2011)– Split Acute (APU) &
Inpatient Ward– 4-8 p.m. on-call
consultant on-site– Additional weekend
medical staff Long Stay Project
Commenced (Apr 2012) Long Stay Patient Visibility
and Standard Escalation Practices implemented (Sep-Dec 2012)
1
2
3
4DxFyear
Fquarter
2012/2013
2012/2013
2012/2013
2011/2012
2011/2012
2011/2012
2011/2012
2010/2011
2010/2011
2010/2011
2010/2011
2009/2010
2009/2010
2009/2010
2009/2010
2008/2009
2008/2009
2008/2009
2008/2009
2007/2008
2007/2008
2007/2008
2007/2008
FQ3
FQ2
FQ1
FQ4
FQ3
FQ2
FQ1
FQ4
FQ3
FQ2
FQ1
FQ4
FQ3
FQ2
FQ1
FQ4
FQ3
FQ2
FQ1
FQ4
FQ3
FQ2
FQ1
0.10
0.09
0.08
0.07
0.06
Pro
port
ion
_P=0.07974
UCL=0.09504
LCL=0.06443
1
11
Proportion of Gen Med Discharges Over 10 Day LOS
1 2 3 4
Quarterly Proportion of > 10 Day LOS Patients since July 2007 Key Projects
Lowest Proportion of > 10 Day Patients Ever @ 6.1% (January to March 2013)
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DxYear
DxCalQ
2013
2012
2012
2012
2012
2011
2011
2011
2011
2010
2010
2010
2010
2009
2009
2009
2009
2008
2008
2008
2008
2007
2007
2007
2007
2006
2006
2006
2006
2005
2005
2005
2005
2004
2004
Q1
Q4
Q3
Q2
Q1
Q4
Q3
Q2
Q1
Q4
Q3
Q2
Q1
Q4
Q3
Q2
Q1
Q4
Q3
Q2
Q1
Q4
Q3
Q2
Q1
Q4
Q3
Q2
Q1
Q4
Q3
Q2
Q1
Q4
Q3
4.0
3.9
3.8
3.7
3.6
3.5
3.4
3.3
3.2
3.1
3.0
2.9
Days
__X=3.577
UCL=3.837
LCL=3.317
1
1
6
11
1
5
111
1
1
General Medicine Average LOS All Discharges (incl non-WIES)
Results: General Medicine Average Length of Stay
Daily Rapid Rounds implemented (Feb 2010)
New medical model of care implemented (Dec 2011)– Split Acute (APU) &
Inpatient Ward– 4-8 p.m. on-call
consultant on-site– Additional weekend
medical staff Long Stay Project
Commenced (Apr 2012) Long Stay Patient Visibility
and Standard Escalation Practices implemented (Sep-Dec 2012)
1
2
3
4
1 2 3 4
Quarterly Average LOS Patients since July 2004 Key Projects
Shortest Quarterly Average Length of Stay Ever @ 2.97 (January to March 2013)
14
DxYear
DxCalQ
2013
2012
2012
2012
2012
2011
2011
2011
2011
2010
2010
2010
2010
2009
2009
2009
2009
2008
2008
2008
2008
2007
2007
2007
2007
2006
2006
2006
2006
2005
2005
2005
2005
2004
2004
Q1
Q4
Q3
Q2
Q1
Q4
Q3
Q2
Q1
Q4
Q3
Q2
Q1
Q4
Q3
Q2
Q1
Q4
Q3
Q2
Q1
Q4
Q3
Q2
Q1
Q4
Q3
Q2
Q1
Q4
Q3
Q2
Q1
Q4
Q3
4.0
3.9
3.8
3.7
3.6
3.5
3.4
3.3
3.2
3.1
3.0
2.9
Days
__X=3.577
UCL=3.837
LCL=3.317
1
1
6
11
1
5
111
1
1
General Medicine Average LOS All Discharges (incl non-WIES)
Results: General Medicine Average Length of Stay
1 2
Quarterly Average LOS Patients since July 2004
0.5 day reduction in Average LOS~ 6,000 bed days/yr
4
15
What Next - We need to focus on the whole system with initiatives on each part of the journey
Comm
unity (Hom
e)
Comm
unity (Hom
e)
GP APU
ED
CLINIC
Radiology
DCCM
OperatingRooms
WARD
Medical
Surgical
REHABFollow
-up Clinic
ResidentialCare
HospiceOther
DHBs / Private
Provider
Supply Chain
Labs
Pharmacy
Therapies
Patient Transit
IMTS
Hospital Ops
3
Demand Management Flow Improvement
2
1Residential
Care
11
10
4
5
11
13
12
14
15
15
16
17
36
7 7
18
18
19
20
8
9
9
7
4
18
15
16
Initiatives to reduce acute demand to secondary facilities
Comm
unity (Hom
e)
Comm
unity (Hom
e)
GP APU
ED
CLINIC
Radiology
DCCM
OperatingRooms
WARD
Medical
Surgical
REHABFollow
-up Clinic
ResidentialCare
HospiceOther
DHBs / Private
Provider
Supply Chain
Labs
Pharmacy
Therapies
Patient Transit
IMTS
Hospital Ops
3
Demand Management
2
1Residential
Care
4
5
36
7 7
8
9
9
7
4
1. Avoidable presentations from ARRC
2. Reduce the % of St John transports for status 3 and 4 patients
3. Use of the GAIHN predictive risk algorithm
4. Cluster model for ARRC5. Gen Med Acute clinics6. Advance Care plan
(Implementation)7. Acute clinic pathways8. Reducing Readmissions
1. Avoidable presentations from ARRC
2. Reduce the % of St John transports for status 3 and 4 patients
3. Use of the GAIHN predictive risk algorithm
4. Cluster model for ARRC5. Gen Med Acute clinics6. Advance Care plan
(Implementation)7. Acute clinic pathways8. Reducing Readmissions
16
1717
Initiatives to improve the flow within secondary facilities
Comm
unity (Hom
e)
Comm
unity (Hom
e)
GP APU
ED
CLINIC
Radiology
DCCM
OperatingRooms
WARD
Medical
Surgical
REHABFollow
-up Clinic
ResidentialCare
HospiceOther
DHBs / Private
Provider
Supply Chain
Labs
Pharmacy
Therapies
Patient Transit
IMTS
Hospital Ops
Flow Improvement
ResidentialCare
11
10
11
13
12
14
15
15
16
17
18
18
19
20
18
10. Integrated Ops centre11. Management of escalation
practices 12. Improved utilization of bed
capacity at GSU13. Elimination of duplicated
documentation between AED and IP specialties
14. National shared care plan15. Matching medical
resources to demand16. Coordination between AED
and IP17. Stranded Patients18. Proactive discharging19. Medical HDU and
enhanced DCCM admission criteria
20. Ward based flow improvement initiatives
10. Integrated Ops centre11. Management of escalation
practices 12. Improved utilization of bed
capacity at GSU13. Elimination of duplicated
documentation between AED and IP specialties
14. National shared care plan15. Matching medical
resources to demand16. Coordination between AED
and IP17. Stranded Patients18. Proactive discharging19. Medical HDU and
enhanced DCCM admission criteria
20. Ward based flow improvement initiatives