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EAcute Dr Paul Sullivan Clinical Director of Quality Improvement, Salford Royal Foundation Trust Senior Quality Improvement Fellow, Centre for Healthcare

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  • eAcute

    Dr Paul Sullivan

    Clinical Director of Quality Improvement,Salford Royal Foundation Trust

    Senior Quality Improvement Fellow,Centre for Healthcare Improvement Research,Imperial College, London

  • Risks of hospital stayRisk of infectionRisk of medical accidentsMedication errorsLoss of controlDiscomfort, sleeplessnessDisruption

  • Medical Reasons? Treatment only available in hospital Monitoring Risk of rapid deterioration Temporary increase in care needs

  • SurveyDaily review of general medical inpatients in a medical ward 240 bed days Classified into 19 reasons

    15% of patients did not need to be in hospital

  • Survey of medical wards23% of medical in-patients stable Review of cases by expert panel 9.6% could be managed at home Of patients delayed for
  • Survey of medical wardsDaily visit to medical wards, each team contacted Able to identify that 15% of in-patients could be managed in virtual ward system Average LOC after identification 10 days

  • Things have moved on since then

    Delays in diagnostics removed LOS saved likely to be 1-2 days

  • Reasons for delay

    Waiting for testWaiting for resultsWaiting for opinionWaiting for senior review

  • Why?Medics apprehensive about discharge loss to f/u, delay to first OPA Team need to make a decision(s) straight after the next test(s) No knowledge of OP services

  • Is there a better way of managing these patients? Could they be at home?

  • Survey on 28 bed EAU 2006Could this patient be safely and effectively managed at home

  • Audit on 28 bed AMU Could this patient be safely and effectively managed at home 2-7 patients each day

  • AlternativesTraditional OPD setting has limits Time between available follow up slots Patient visible only at clinic visit Availability of diagnostics

  • Time to next FOLLOW UP slot Gen med 2-11 weeksCardiology17 weeksGI8 weeksChest7 weeks

  • AlternativesPriority patients can be managed at home by individual clinicians Time consuming, no support, numbers limited Risk of loss to follow up

  • eAcute

  • 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

  • eAcute

    In-patientOut-patient (Ambulatory)Junior staff available to arrange tests, deliver cards to diagnostics, speak to other services e.g. radiologistsNo staff available If tests missed for whatever reason (card lost, patient DNA, test postponed) it is immediately spotted and rectifiedPatient cannot be guaranteed to have test and clinician may not know if test missedIf further action is indicated by a test result, it can be taken immediately.Results generally not reviewed until next outpatient appointmentPatient has daily review Reviews limited by time between outpatient visitsHistorically, inpatients have been regarded as more urgent and have tests done quickly.There are often longer waits for outpatient investigations.

  • This is the eAcute ward

  • Ideal forTime-Critical investigation High risk if inadvertent delays

    High risk if DNA

  • Ideal for

    Rapid/serial decisions on test results Test 2 depends on test 1 Early/frequent communication with pt

  • Results

    Chart1

    346

    659

    11615

    10525

    11332

    14033

    14428

    13826

    15235

    13535

    12224

    14529

    14026

    11828

    13533

    14232

    12927

    11524

    bed days saved

    patients

    Sheet1

    bed days savedpatientsav los

    June3465.6666666667

    July6597.2222222222

    August116157.7333333333

    September105254.2

    October113274.1851851852

    Nov98273.6296296296

    Dec101205.05

    Jan

    Sheet1

    &A

    Page &P

    bed days saved

    patients

    Sheet2

    ugi bleed17Low Rockall UGI bleed17

    ?pe25?VTE32

    ?dvt7Other36

    uss abdo3uss abdo3

    discuss4discuss4

    review radiology3review radiology3

    await result6await result6

    ett6ett6

    pos blood cul3pos blood cul3

    monitor bloods6monitor bloods6

    ct brain2ct brain2

    24h tape224h tape2

    rv clinically after we1rv clinically after we1

    Sheet2

    Sheet3

    bed days savedpatientsav los

    Jun3465.6666666667

    Jul6597.2222222222

    Aug116157.7333333333

    Sep105254.2

    Oct113323.53125

    Nov140334.2424242424

    Dec144285.1428571429

    Jan138265.3076923077

    Feb152354.3428571429

    Mar135353.8571428571

    Apr122245.0833333333

    May145295

    Jun140265.3846153846

    Jul118284.2142857143

    Aug135334.0909090909

    Sep142324.4375

    Oct129274.7777777778

    Nov115244.7916666667

    &A

    Page &P

    bed days saved

    patients

  • Results

  • Chart2

    17

    32

    36

    Sheet1

    bed days savedpatientsav los

    June3465.6666666667

    July6597.2222222222

    August116157.7333333333

    September105254.2

    October113274.1851851852

    Nov98273.6296296296

    Dec101205.05

    106.622.84.9596296296

    Sheet1

    &A

    Page &P

    bed days saved

    patients

    Sheet2

    ugi bleed17Low Rockall UGI bleed17

    ?pe25?VTE32

    ?dvt7Other36

    uss abdo3uss abdo3

    discuss4discuss4

    review radiology3review radiology3

    await result6await result6

    ett6ett6

    pos blood cul3pos blood cul3

    monitor bloods6monitor bloods6

    ct brain2ct brain2

    24h tape224h tape2

    rv clinically after we1rv clinically after we1

    Sheet2

    Sheet3

  • Chart3

    3

    4

    3

    6

    6

    3

    6

    2

    2

    1

    Sheet1

    bed days savedpatientsav los

    June3465.6666666667

    July6597.2222222222

    August116157.7333333333

    September105254.2

    October113274.1851851852

    Nov98273.6296296296

    Dec101205.05

    106.622.84.9596296296

    Sheet1

    &A

    Page &P

    bed days saved

    patients

    Sheet2

    ugi bleed17Low Rockall UGI bleed17

    ?pe25?VTE32

    ?dvt7Other36

    uss abdo3uss abdo3

    discuss4discuss4

    review radiology3review radiology3

    await result6await result6

    ett6ett6

    pos blood cul3pos blood cul3

    monitor bloods6monitor bloods6

    ct brain2ct brain2

    24h tape224h tape2

    rv clinically after we1rv clinically after we1

    Sheet2

    Sheet3

  • Implementation

    Not as easy as it seems

  • Critical featuresWatertight IT solution ideal Access 24/7, anywhere Embedded in daily work Redundancies cant be forgotten

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

  • Critical featuresPrioritisation Patients are regarded as in-patients by:RadiologyEndoscopyEcho, ETT

  • How did we do that?

  • Our story.Developing IT solution Making it work in the normal day

    Getting radiology to prioritise

    Getting other departments to prioritise

  • SustainingConstant vigilance for fall off in prioritisation Local ownership Keeping it team wide Just add hot water!

  • 4096 bed days in 24 months 5.7 beds free on any day Roll out estimate additional 5-10 beds23 minutes per day for 2 consultants and team 50 minutes per day for a JD

  • Transfer 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.