eAcuteeAcute

Dr Paul SullivanDr Paul Sullivan

Clinical Director of Quality Improvement,Clinical Director of Quality Improvement,Salford Royal Foundation TrustSalford Royal Foundation Trust

Senior Quality Improvement Fellow,Senior Quality Improvement Fellow,Centre for Healthcare Improvement Research,Centre for Healthcare Improvement Research,

Imperial College, LondonImperial College, London

Risks of hospital stayRisks of hospital stay

Risk of infectionRisk of infection Risk of medical accidentsRisk of medical accidents Medication errorsMedication errors Loss of controlLoss of control Discomfort, sleeplessnessDiscomfort, sleeplessness DisruptionDisruption

Medical Reasons?Medical Reasons?

Treatment only available in hospitalTreatment only available in hospital

MonitoringMonitoring

Risk of rapid deteriorationRisk of rapid deterioration

Temporary increase in care needsTemporary increase in care needs

SurveySurvey

Daily review of general medical inpatients in a Daily review of general medical inpatients in a medical ward– 240 bed daysmedical ward– 240 bed days

Classified into 19 “reasons”Classified into 19 “reasons”

15% of patients did not need to be in hospital15% of patients did not need to be in hospital

Survey of medical wardsSurvey of medical wards

23% of medical in-patients “stable”23% of medical in-patients “stable”

Review of cases by expert panel – 9.6% Review of cases by expert panel – 9.6% could be managed at homecould be managed at home

Of patients delayed for <2 weeks,Of patients delayed for <2 weeks,

43% were due to medic behaviour43% were due to medic behaviour

Survey of medical wardsSurvey of medical wards

Daily visit to medical wards, each team Daily visit to medical wards, each team contactedcontacted

Able to identify that 15% of in-patients Able to identify that 15% of in-patients could be managed in virtual ward systemcould be managed in virtual ward system

Average LOC after identification 10 daysAverage LOC after identification 10 days

Things have moved on since thenThings have moved on since then

Delays in diagnostics removedDelays in diagnostics removed

LOS saved likely to be 1-2 daysLOS saved likely to be 1-2 days

Reasons for delayReasons for delay

Waiting for testWaiting for test Waiting for resultsWaiting for results Waiting for opinionWaiting for opinion Waiting for senior reviewWaiting for senior review

Why?Why?

Medics apprehensive about discharge – Medics apprehensive about discharge – loss to f/u, delay to first OPAloss to f/u, delay to first OPA

Team need to make a decision(s) straight Team need to make a decision(s) straight after the next test(s)after the next test(s)

No knowledge of OP servicesNo knowledge of OP services

Is there a better way of managing these Is there a better way of managing these patients?patients?

Could they be at home?Could they be at home?

Survey on 28 bed EAU 2006Survey on 28 bed EAU 2006

Could this patient be safely and effectively Could this patient be safely and effectively managed at homemanaged at home

Audit on 28 bed AMU Audit on 28 bed AMU

Could this patient be safely and effectively Could this patient be safely and effectively managed at homemanaged at home

2-7 patients each day2-7 patients each day

AlternativesAlternatives

Traditional OPD setting has limitsTraditional OPD setting has limits

Time between available follow up slotsTime between available follow up slots

Patient “visible” only at clinic visitPatient “visible” only at clinic visit

Availability of diagnosticsAvailability of diagnostics

Time to next FOLLOW UP slotTime to next FOLLOW UP slot

Gen med Gen med 2-11 weeks2-11 weeks CardiologyCardiology 17 weeks17 weeks GIGI 8 weeks8 weeks ChestChest 7 weeks7 weeks

AlternativesAlternatives

Priority patients Priority patients cancan be managed at home by be managed at home by individual cliniciansindividual clinicians

Time consuming, no support, numbers limitedTime consuming, no support, numbers limited

Risk of loss to follow upRisk of loss to follow up

eAcuteeAcute

An electronic patient list to which multiple users can add and which can be seen by all members of the Acute Medicine team.

Every weekday at 10am = virtual ward round

This is attended by Acute Medicine consultants, mid grades and FY doctors and the advanced practitioner nurse on the EAU.

Every patient is discussed every week-day.

Junior staff are available to arrange tests, liaise with diagnostic depts etc.

If tests are inappropriately delayed we notice immediately and rectify

Results are seen immediately and consultant level decisions follow

Patients can be reviewed as often as needed by telephone

Patients can be recalled to EAU for bloods or clinical assessment

We have arrangements with radiology, cardiology and endoscopy so that virtual ward patients are accorded high priority

eAcuteeAcute

In-patientIn-patient Out-patient (Ambulatory)Out-patient (Ambulatory)

Junior staff available to arrange tests, deliver Junior staff available to arrange tests, deliver cards to diagnostics, speak to other services cards to diagnostics, speak to other services e.g. radiologistse.g. radiologists

No staff available No staff available

If tests missed for whatever reason (card lost, If tests missed for whatever reason (card lost, patient DNA, test postponed) it is immediately patient DNA, test postponed) it is immediately spotted and rectifiedspotted and rectified

Patient cannot be guaranteed to have test and Patient cannot be guaranteed to have test and clinician may not know if test missedclinician may not know if test missed

If further action is indicated by a test result, it If further action is indicated by a test result, it can be taken immediately.can be taken immediately.

Results generally not reviewed until next Results generally not reviewed until next outpatient appointmentoutpatient appointment

Patient has daily review Patient has daily review Reviews limited by time between outpatient Reviews limited by time between outpatient visitsvisits

Historically, inpatients have been regarded as Historically, inpatients have been regarded as more urgent and have tests done quickly.more urgent and have tests done quickly.

There are often longer waits for outpatient There are often longer waits for outpatient investigations.investigations.

This is the eAcute ward

Ideal forIdeal for

Time-Critical investigationTime-Critical investigation

High risk if inadvertent delaysHigh risk if inadvertent delays

High risk if DNAHigh risk if DNA

Ideal forIdeal for

Rapid/serial decisions on test resultsRapid/serial decisions on test results

Test 2 depends on test 1Test 2 depends on test 1

Early/frequent communication with ptEarly/frequent communication with pt

ResultsResults

0

20

40

60

80

100

120

140

160

Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov

0

5

10

15

20

25

30

35

40

bed days saved

patients

ResultsResults

Low Rockall UGI bleed

?VTE

Other

uss abdo

discuss

review radiology

await result

ett

pos blood cul

monitor bloods

ct brain

24h tape

rv clinically after we

ImplementationImplementation

Not as easy as it seemsNot as easy as it seems

Critical featuresCritical features

Watertight – IT solution idealWatertight – IT solution ideal

Access 24/7, anywhereAccess 24/7, anywhere

Embedded in daily workEmbedded in daily work

Redundancies – can’t be forgottenRedundancies – can’t be forgotten

I know, with absolute certainty, that if I I know, with absolute certainty, that if I send a patient home on Sunday, a trusted send a patient home on Sunday, a trusted consultant will pick up the issues on consultant will pick up the issues on Monday.Monday.

Critical featuresCritical features

PrioritisationPrioritisation

Patients are regarded as in-patients by:Patients are regarded as in-patients by: RadiologyRadiology EndoscopyEndoscopy Echo, ETTEcho, ETT

How did we do that?How did we do that?

Our story….Our story….

Developing IT solutionDeveloping IT solution

Making it work in the normal dayMaking it work in the normal day

Getting radiology to prioritiseGetting radiology to prioritise

Getting other departments to prioritiseGetting other departments to prioritise

SustainingSustaining

Constant vigilance for fall off in Constant vigilance for fall off in prioritisationprioritisation

Local ownershipLocal ownership

Keeping it team wideKeeping it team wide

Just add hot water!Just add hot water!

4096 bed days in 24 4096 bed days in 24 monthsmonths

5.7 beds free on any 5.7 beds free on any dayday

Roll out – estimate Roll out – estimate additional 5-10 bedsadditional 5-10 beds

23 minutes per day 23 minutes per day for 2 consultants and for 2 consultants and teamteam

50 minutes per day 50 minutes per day for a JDfor a JD

TransferTransfer Make it watertight – daily case review prevents delays, loss to follow up etc.

Timetable daily senior case review so it is guaranteed. Several people need to be involved to ensure that this happens every day, regardless.

Develop an electronic patient list that is visible to all members of the team all the time – initial attempts with individual paper lists failed

Choose an area with high patient throughput so that there are always some virtual patients to review, otherwise it is difficult to maintain the habit.

Start with a single investigation, we used CT pulmonary angiogram, and get clinical directors involved.