1

Valuing Our Patients’ Time - Adult ED Bed Request to Ward Admission- Children’s ED

26th March 2012Jane LeesJoyce ForsythTim DenisonDr. Richard Aickin

Patient Handovers via Ward Hotline Phones

OUR GOAL: OUR GOAL: All Patients are transferred to our Wards in less than 30min once a bed request is made

3

Where We Began…

Source: Working Group for Achieving Quality in Emergency Departments. 2008. Recommendations to Improve Quality and the Measurement of Quality in New Zealand Emergency Departments. Wellington: Ministry of Health.

Auckland Q1 200970% < 6 Hours

(Starship @ 84% < 6 Hrs)(Adult @ 62% < 6 Hrs)

4

Adult Performance to 6 hour goal - 2008 to 2012

2008 & 2009 Baseline for Admitted Patients: 44% < 6 Hours

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Count of Patients with > 6 Hours in ED by Service

Count 242 214 7175244 4547 1428 1342 390 387 386 300

Percent 1.6 1.4 4.734.5 29.9 9.4 8.8 2.6 2.5 2.5 2.0Cum % 93.9 95.3 100.034.5 64.4 73.8 82.7 85.2 87.8 90.3 92.3

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Pareto Chart of Over 6-Hour Patients by Service2009 - Service Patient Under at ED Discharge

For Inpatient Services, the most opportunity for improvement was in General Medicine, followed by General Surgery and Orthopaedics

6

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

7

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

“1-Hour” Project – Bed Request to Ward Admission

Admit to Ward

Admit to Ward

Bed Management

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Baseline - Adult ED Bed Request to Ward Admission

Baseline – Bed Request to Ward Admission

Average wait to be transferred to an Inpatient Ward = 8 Hours

7% < 1 Hour

8 Hours

Low is Good

9

Many Causes for Delays to LOS

Primary Root Causes

1. Delays to LOS Bed Block– Patients wait for decisions,

referrals, reviews, diagnostics, documentation, equipment, treatment, etc… prolonging their stay

– Weekend care – sometimes treatment not progressed and patients not discharged

2. Bed Request to Admit Process– Even when a bed is available it

could take hours to admit a patient to a ward

– Up to 14 individuals involved and over 50 steps in the process

Patient Length of StayIs longer than strictly

necessary for care

TheatrePre-op

Communication External Factors

Patient &Family

Awaiting OPH Bed

Awaiting Bed in Rehab +

Waiting for AcuteTheatre Space

Transplants block OR

Waiting for test E.g. CTs

Vac dressing in Situ

Easier to keep patientIn hospital than discharge

Diagnostics &Other Services

Staff / Culture

Stoma Education

Slow to coordinate homeHelp support on Discharge

Family unhappy with d/c destination decision

Electives don the ‘sick’role & heal more Slowly

Wait for family to agree on family meeting time

Not discharging on A Friday or W/E

“Keep everyone” tertiaryTrauma centre

Waiting for reviewsFrom other services

Lack of communication on daily basis with Drs, Allied Health, Nurses etc.

House Surgeon – Too much paperwork

Wait on ElectronicDischarge Summary

Nursing staff shortages

Discharge expectationsNot communicated with patient/family

Lack of coordination withspecialties

Weight Bearing StatusNot documentedOPH / Other Referrals

Lost (e.g. Fax Machine Error)

Patient not on home ward

Fellow not communicatingLOS plan with H/O

Charge Nurse not awareOf OT / PT / SW hold ups

PT has not got rightColoured Dr dot

Private Hospital blocks bedNo consistent policy onReturning patients to other DHBs

Referring hospital not keenTo take patient back

Taikura Trust – waiting forReview / assessment

NASC – waiting forReview / assessment

No hospice bed avail

Prisoners stay longerDue to less care available

Wait for OPIVA Service

Wait for Gastro InvestigationProcedure ERCP (2x wkly)

Cancelled lists

No incentive to Expedite recovery

Fellows / Registrar decision Making conservative – keep patient

Patient “waiting to be seen by consultant”

Consultants do not Round daily

Out of area elective Patients admitted earlier

Day before

Wait for transportTo be coordinated

Estimated Discharge Date & PlanNot agreed / communicated Team unaware of

Patient handover

More older patients

Waiting for blood results

Wait for PT/OT/SW Assessment

51 20

15

4158 17

KeyOriginal votes from team meeting

Total votes in category#

22

12

11

Lack of direct communication btw Surgeon & Allied Health

Add’l Votes by Drs, Nurses, Allied Health

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13

Late referrals to Allied Health

Allied Health EquipmentShortages

Nursing, Allied Health, House Surgeon staff shortages Social Situation

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9

Bed Request to Admit Process

14 Roles

57 Steps (++ Variation)

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Solutions Implemented

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Daily Rapid Rounds (1 of 2)

Issue: Patients stay longer in hospital as a result of inadequate communication between doctors, nurses, Allied Health and other multidisciplinary team members

Solution: Daily Rapid Rounds - A short daily ward meeting with nurses, doctors, and Allied Health to coordinate their patients’ plan for hospital stay and make that plan visible on a patient-status-at-a-glance board

Benefits: Great team communication, quick referrals, and quick problem solving means patients wait less and are ready to go home earlier

Charge Nurse

Social Worker Doctors

Physio-therapist

Occupational TherapistStaff

NursesSystem

Updated Live

Ward 68 Daily Rapid Round Team

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Daily Rapid Rounds (2 of 2)

2011 & 2012

0.4 day reduction in Average LOS

Equivalent to 2,100 bed

days per year

Orthopaedics also observed a 2,000 bed day per year benefit after

Rapid Rounds

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Nurse Facilitated Discharging (General Medicine)

Issue: Patients may be ready for discharge but have to wait for next medical ward roundSolution: Senior nurses can discharge patients if patient meets criteria set by medical

teams – Nurse Facilitated Discharging is initiated by doctorsBenefits: Reduced LOS, increased weekend discharging, earlier in day and after hours

discharging

Dr. X X12/2/2010 10:00

934199

Sa t 13/02/10 or Sun 14/02/10 11:00 a .m.

L)LL Pn eumon i a

Afebr i le 24 hou rs off I V a n ti bi oti cs

O2 sa ts > 90% off oxygen

Mobi l i si n g i n depen den tly

( Flu CXR)XXX

GP 6 weeks ( a fter CXR) or ea r l i er i f con cern s

XXX

CNA or Cha rge Nurse X13/02/2010 11:15 a .m.

Spi ked temp > 38°C on I V An ti bi oti csComplete if Criteria NOT Met

Example:

Complete if Criteria Met

Doctor to complete / paste label

EXAMPLE

Note: i f cr i ter i a n ot met on Sa tu rda y, plea se revi ew on Sun da y

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Baseline After

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I Chart Control: Average number of NFD's per week in General MedicineSuccessful Weekly Nurse Facilitated Discharges

3 / wkNFD

per

Wee

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AfterBefore

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Patient Status at a Glance

Issue: System not up to date with Estimated Discharge Dates, plan for patients stay not visible to ward staff, patient information duplicated on white boards

Solution: 42” monitors, redesigned and colour coded patient status – able to eliminate most physical whiteboards

Benefits: Patient Status at a Glance – saves staff time, easy to see patient’s plan for stay, estimated discharge dates kept up-to-date

Tab to view the AED whiteboard helps create an awareness /

transparency of number of patients waiting for beds etc.

Drop down colour coded allied health referral status

Access to all patient information including a

link for Concerto

The patients discharge destination i.e. home,resthome, OPH etc

Used to indicate where the patient is scheduled for i.e. another ward, transition lounge,

Patie

nt In

form

ation

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Rapid Improvement Event

Rapid improvement event (RIE) - part of the Lean methodology and provides a mechanism for making radical changes to current processes and activities within very short timescales.

Week long 5 day event at Auckland City Hospital

Goal – Patient transfer to the ward in nine minutes of Bed allocation

Core Group – ED Charge Nurses, Ward Charge Nurses, Clerical staff, Orderlies, Nurse Advisors, Bed Managers.

Advisory Group – Service Managers Sponsors – Director of Performance,

Nurse Director, Clinical Director Emergency Department

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Transfer of Care

Issue: Patient handovers were a source of frustration for both AED and ward staff. AED staff: “Handover takes too long as the ward staff ask too many questions”. Ward staff: “Handover information is often inaccurate”

Solution: Standardise process for handover using ISOBAR across wards and AED. Review transfer of care form inline with ISOBAR format. Bedside handover using ISOBAR for AED-APU transfers. Education package.

Benefits: Improved quality of handover, reduced time, improved staff satisfaction

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Communication

Issue: Phone tag for patient handovers, long wait for a nurse to come to the phone for handover (when asked by ward clerk), AED can’t get through to ward due to engaged phones.

Solution: Handover hotline.

Benefits: Dedicated phone for handover and after hours bed management handover. Reduces ‘waiting’ for calls to be answered. Ward RN carries the phone - eliminates the need for ward clerks to search for RN to take handover.

Patient Handovers via Ward Hotline Phones

OUR GOAL: OUR GOAL: All Patients are transferred to our Wards in less than 30min once a bed request is made

HOTLINE RINGS

Bed availability confirmed with Bed

Manager

RN prepares for new patient

HOTLINE RINGSHandover received

Patient arrives

CHIPS updated

Less

than

30m

in

PROCESS REQUIREMENTS

- Charge Nurse or Team Coordinator

-ALL calls must be answered on 1st attempt- Designated holder of hotline must have knowledge of ward bed status

- Ensure Hotline holder is available to take call - If RN has patient load – he/she to explain to her patient’s that the phone may ring for a new patient handover

ALL calls must be answered on 1st attempt

- Nurse is aware of patient arrival time - Can prioritise workload to enable new patient to be met at reception

- Ward Clerk may update within normal hours - RN must complete PSAG update for new patient after hours . - All new patients must have an up to date EDD

Answered by designated RN holding Hotline

Phone

ALL calls must be answered on 1st attempt

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Bed Request Confusion

Issue: No standard process for a Doctor to communicate a bed request

Solution: All bed requests to “Flow Coordinator”, Flow Coordinator clearly identifiable with new Green scrub top, and

Benefits: Easily identifiable in Green top, 1 point of contact. Reduced frustration with not being able to clearly identify who is performing the ‘flow’ role.

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Documentation

Issue: Doctor would request bed and leave without completing documentation (A/D Plan, 6-Hour Plan, or communicate patient special needs e.g. sideroom)

Solution: Flow Coordinator reviews 10-second checklist with doctor at time of bed request

Benefits: Patient is ready for handover at time of bed request. No phone-tag and delay to find out special needs or complete docs

Bed Request Checklist

Date: ……………… Time: …………..…..

PP

WARD APU

YES NO N/A

Patient Details

Ward or APU

DOCUMENTATION

PREFERRED LOCATION

A to D Planner / 6 Hour Plan

IV Fluids

Medications

BED MANAGEMENT REQUIREMENTS

Side Room

Isolation

Watch / Security Required

Flexi Monitor

Parameters Set

Flexi Form Complete and Sent

YES NO N/A

ADDITIONAL INFORMATION

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Global Transparency

Issue: Poor visibility of available beds at a glance.

Solution: Developed intranet web page that displays “flight deck” view of bed status

Benefits: Anyone, anywhere in hospital has a view of available beds. Saves time. At a glance view of occupancy and expected discharges within 4hrs

Capacity of each ward can be quickly seen

Available Beds easy to spot

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Orderly Requests

Issue: Orderlies were requested by placing a file in “toast rack”. No ability to prioritise requests or whether the orderly were aware of a request. No visibility when request was completed. Orderlies did not have a designated place to wait “on the floor” between jobs.

Solution: Requests placed in box with motion detector and light trigger. This can be seen in a new orderly bay and nursing staff can see at a glance if an orderly is requested and when request has been actioned (light goes off).

Benefits: Quicker response time, able to escalate if no orderly is visible in bay, can see around department if orderly is requested, fewer calls for orderly over intercom = less interruptions for staff

Place clinical notes in box for orderly

request

Light goes on when notes are in box

Designated space within ED for orderlies

to wait for jobs

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Visual Tools

Issue: Patients and families interrupt flow coordinator and other staff with queries – no way for patients & families to establish where to go to ask questions!

Solution: Improved visual management on the AED floor. Red feet at reception area to indicate a place to wait for inquiry.

Benefits: Reduced staff interruptions, reduced patient frustration

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Capacity Triggers

Issue: Unclear escalation response when hospital resourced beds are near capacity

Solution: Monday-Friday daily capacity meeting with service managers and 48 hour bed capacity forecasting

Benefits: Improved utilisation of resourced beds across services including use of ‘flexed beds’, advanced notice of impact to elective patients (last resort)

Occupancy Acute Bed Requests Regular Flex Extra Flex Super FlexOverall 92% Medical 6 31W - 2 83 - 4 38W - 15

ED 43% Surgical 2 31E - 10 yes OPH - 4 Wha - 14APU 77% 41 - 4 SHDU - 2 42 - 4

42 - 2 97 - 4Acute Theatre Hours 7 81 - 3

TODAY TOMORROWDaily (Weekday) Surgical Acutes Ward TCI EDD Available D TCI EDD D

Vascular 2 41 5 3 4 2 3 2 -1 Cardiology 6 42 10 4 6 0 2 4 2

76 3 5 3 5 5 2 -3 78 0 2 0 2 0 2 2

2 61 6 10 8 12 1 7 675 5 3 2 0 5 3 -2 77 1 2 0 1 0 3 3

Renal 4 71 5 3 0 -2 6 4 -2 Urology 5 73 6 5 9 8 4 4 0

ORL 4 74 6 6 5 5 7 4 -3 81 1 6 0 5 0 0 083 3 0 1 -2 2 1 -1

Total Upper Q -37 51 49 38 36 35 36 1

Surgical Summary

Beds to be freed in next 24 hours 36

Less current Acute Bed Requests -2

Less expected Surgical Acutes -37

Net Surgical Beds in 24 Hours -3 TODAY TOMORROW

Daily (Weekday) Medical Acutes Ward TCI EDD Available D TCI EDD D 31MED 0 2 0 2 0 0 0

Cardiology 31W 8 4 7 3 4 4 0Cardiology CCU34 1 1 9 9 1 2 1Cardiology 38APU 0 0 0 0 0 0 0Haem / Onc 62 0 1 -1 0 2 0 -2 Haem / Onc 64 0 5 0 5 0 1 1

Neuro / Med Specs 4 63 1 2 2 3 0 2 2Gen Med 65 0 5 2 7 0 6 6Gen Med 66 0 6 3 9 0 7 7Gen Med 67 1 5 1 5 0 5 5Gen Med 68 0 6 0 6 0 4 4

Respiratory 4 72 3 3 0 0 2 7 5

Total Upper Q -38 14 40 23 49 9 38 29

Medical SummaryBeds to be freed in next 24 hours 49Less current Acute Bed Requests -6

Less expected Medical Acutes -38

Net Medical Beds in 24 Hours 5

TOTAL Surgical & Medical Beds in 24hr 2

5

4

24

General Surgery

Gastro

Orthopaedics

Neurosurgery

11

1

7

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Daily Reporting & Review of Breaches

Issue: Daily 6-Hr performance not visible. Difficult to have timely problem solving.

Solution: Automated report of previous day’s patients who spent over 6 hours in ED emailed to staff. Key information for each patient visible to support root-cause analysis.

Benefits: Improved visibility of performance, increased urgency with staff, easy to identify corrective actions in a timely manner, reviewed & coded at daily meeting

Overall Performance

Time Stamps: ED Start, Sign-on, Referral, Inpatient Sign-on, Bed Request, BR Complete, ED End

Inpatient Services

Patient Referral Reason

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Results Sustained: Sub-measure – When Bed is Ready

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Admit Week Beginning Monday

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AED to Ward - Patient Transfer TimesFrom Ward Bed Ready to ED Discharge

Low Is Good

Our Goal = 30 Min

27

Results Sustained – ED Bed Request to Ward Admission

2009 = 7.2% < 1hr

2010 = 14% < 1hr

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2009 2010 2011

1hr Goal

2012

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Avg Hours AED Bed Request to Ward Admission

Low Is Good

80% Reduction in the Time Patients Wait

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Sustaining Change – Business as Usual

Standard work Daily reporting and

analysis of variance Breach meeting Weekly target tracking Audit of standard

operating procedures Visual communication

for staff

0 5 10 15 20

602_Clerical Error

320_ED Diagnostics Incomplete - Wait for ED Assessment Sign On to Referral

310_Multiple Presentations in Short Time Frame - Wait for ED Sign On

321_ED Assessment Incomplete - Wait for ED Assessment Sign On to Referral

311_Staff Shortage - Wait for ED Sign On

210_IP Unavailable - Wait for Inpatient Specialist Sign On

220_IP Diagnostics Incomplete - Wait for In-Patient Specialist Decision to Admit /Discharge

221_IP Assessment Incomplete - Wait for In-Patient Specialist Decision to Admit /Discharge

223_IP Multiple Referrals Made - Wait for In-Patient Specialist Decision to Admit /Discharge

113_Bed Currently Unavailable (Any) - Awaiting patient discharge/move

129_Patient - not clinically stable enough to transfer

114_Bed Currently Unavailable (Single Room) - Awaiting patient discharge/move

120_AED - handover not initiated in timely manner - Delay to Patient Transfer

111_Bed Unavailable Indefinitely - Bed Management - Patient requires outlying

126_Ward - handover not available to receive in a timely manner - Delay to PatientTransfer

All

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AED Breach Codes - 9 to 15 March 20120 5 10 15 20

602_Clerical Error

320_ED Diagnostics Incomplete - Wait for ED Assessment Sign On to Referral

310_Multiple Presentations in Short Time Frame - Wait for ED Sign On

321_ED Assessment Incomplete - Wait for ED Assessment Sign On to Referral

311_Staff Shortage - Wait for ED Sign On

210_IP Unavailable - Wait for Inpatient Specialist Sign On

220_IP Diagnostics Incomplete - Wait for In-Patient Specialist Decision to Admit /Discharge

221_IP Assessment Incomplete - Wait for In-Patient Specialist Decision to Admit /Discharge

223_IP Multiple Referrals Made - Wait for In-Patient Specialist Decision to Admit /Discharge

113_Bed Currently Unavailable (Any) - Awaiting patient discharge/move

129_Patient - not clinically stable enough to transfer

114_Bed Currently Unavailable (Single Room) - Awaiting patient discharge/move

120_AED - handover not initiated in timely manner - Delay to Patient Transfer

111_Bed Unavailable Indefinitely - Bed Management - Patient requires outlying

126_Ward - handover not available to receive in a timely manner - Delay to PatientTransfer

All

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AED Breach Codes - 9 to 15 March 2012

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Next Steps – An Example in General Medicine

Opportunity in Patients Referred from 10 p.m. to 8 a.m.

Most breaches on night shift – only 1 Registrar on duty

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Starship Children’s Emergency Department

32

Child Health approach

Why do seperately/differently within same organisation?

– EDs have different structure and function•Children’s ED includes•Functions of the adult admission planning unit•12 hr short stay admission for acute cases•Hospital RMO after hours staffing limited to 1 Paed Medical Registrar

• Admission work up and initiation of treatment is by CED clinicians, with handover to inpatient Registrar at time that child is ready for ward

• Less emphasis on the “2hr” phase for medical cases, more on “1hr” (for transfer to ward when child’s condition is ready for this)

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Child ED Performance to 6 hour goal - 2010 to 2012

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Child ED Triage Performance - 2010 to 2012

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Children’s Hospital challenges

•Smaller total numbers, large daily fluctuations in acute admissions, limited surge capacity

•165 beds vs 650 beds in adult services•31,000 CED attendances vs 57,000 AED + 11,000 APU

•Historically:•Difficulties in predicting acute volumes•Disconnect with electives planning

•High rates of last minute cancellations on day of planned admission

•High proportion of child admissions needing isolation•Nursing complexity with increasing skew toward tertiary electives over local secondary paediatric admissions

36

Child Health Improvements

Weekly capacity planning meeting

– Modelling of short term acute trends•Increasing accuracy as we gain experience with this tool•Usually within +/- 10%

– Joined up with elective admission scheduling•Fewer last minute cancellations•Best elective performance during winter months for many years

Improved communication of over-capacity status to Clinicians– Review of criteria for alerts– Text message and email early in the day

37

Is this all about bed capacity?

38

Bed capacity

Important but not the whole story

Both Adult and Children’s Hospitals are being driven hard

Both have occupancy >90% and not infrequent overcapacity alerts

Both have shown sustained improvement in 6 hour targets

There comes a point where further improvements will be in only small increments and investment in capacity is vital.