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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

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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

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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)

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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

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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

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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

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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

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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

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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

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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)

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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)

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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

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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

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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

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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

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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

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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

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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

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10

11

13

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14

15

15

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19

20

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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