Peter WardSenior PhysiotherapistAcute Medicine

Driving Healthcare Change Through HSCP ResearchFebruary 28th, 2014

Carole MurphySenior Occupational TherapistEmergency Department

BackgroundHistorically OT and Social Work providing

services within this settingNo physiotherapy, SLT or Dietetics services

availableCare pathways established in response to

Government policy and organisational change

Impetus for ChangeClinical Care Programs, 2010Lis Nixon Report, 2011Establishment of Special Delivery Unit

(SDU), 2011

Service Objectives Provide rapid access to

MDT assessment for patients in ED, AMAU and SSU who are deemed medically fit for D\C that day

Reduce unnecessary non-medical admissions to hospital

If appropriate, support early discharge from hospital, improve throughput and prevent re-admission

Design PhaseEstablishment of a steering group with

representatives from the key HSCP groups

Responsibility with the clinicians to oversee the design phase

This included development of:1. Care pathway2. Single assessment tool3. Role of teamlead

Referral to the BRAT service should be considered for patients who are medically fit to be discharged that day and present with the following: Frail Elderly+/- Living AloneFalls PreventionUpper/Lower Limb FracturesConfusionExacerbation of Chronic Condition

Does patient present with new difficulties with transfers/ mobility?Does the patient present as confused? Does the patient appear unkempt?

YES

Is there a concern regarding patient’s ability to cope at home?

Referral to BRAT not indicated. Patient at previous functional status with adequate supports in place.

YES

Contact BRAT Team Lead. Dect: 8457

Referral to BRAT not indicated. Patient at previous functional status with adequate supports in place.

No

NO

Team LeadRotational team lead

between Occupational therapy, Physiotherapy and MSW

Responsibilities include - Morning handover - Carries BRAT phone - Screens appropriate patients - Completes common

assessment form as appropriate

- Contacts relevant profession

Aims of StudyTo establish a profile of the patients referred

to the BRAT serviceTo analyse the patient profile of those

readmitted to the hospital within thirty days of BRAT review

To determine the efficacy of the BRAT service in relation to cost saving, bed day saving and admission avoidance

Beaumont Rapid Assessment Team 2012/13From February 1st 2012-January 31st 2013 - 280 patients reviewed in 253 working days

(1.1 patients\day) - Average age: 76 years and 9 months; Range

23-102 - 186 females, 94 males (2:1 ratio) - 46.8% lived alone - 48% were 80 years old or over

Age Categories

Age Total Reviewed %

0-6437,498 39

0.1%

65-799,324

106 1.1%

80-893,849

109 2.8%

90+650

26 4%

Total51,321 280

.54%

Discharge V Admission

Gender Distribution of Admissions

Reason for Referral (Total & Discharge)

Onward Destination

Re-presentations44 (23.6%) people of the 186 init1ally

discharged re-presented within 30 days

Of these 44: - 75% were deemed medical re-presentation - 25% were related to ongoing physical/functional issues

Average time to represent was 11.5 days (Range 1-30)

Age of re-presenters

Team PerformanceAverage response time: 19 minutes

44.7% seen within 10 minutes

Cost SavingsAverage Medical LOS was 12.57 days

770 bed days saved

Average cost of medical bed is €950 per night

Saving calculated at €731,500

Challenges to Service ProvisionMedical complications

Limited access to: Home Care Packages

Access to step down facilities:- rehabilitation- interim care- respite

No Out of Hours Service

Limitations of StudyShort time frame for researchCost estimate is quite conservativeDifficult to establishing an exact cost saving

due to: - complexity of the group of patients reviewed - costs are based on hospital averages and

therefore do not address the individual variables which can arise in the ‘frail elderly’

- Doesn’t take into account those under ED service or subsequent cost of re-presentations

Positive Service OutcomesCoordinated MDT assessment at point of

entry to Beaumont hospitalTeam lead and the common assessment form

enhances communicationEquipment provisionOnward referral to both in-house &

community servicesPrioritisation for rehabilitation and discharge

planning

Conclusion Provide rapid access to

MDT assessment for patients in ED, AMAU and SSU who are deemed medically fit for D\C that day

Reduce unnecessary non-medical admissions to hospital

If appropriate, support early discharge from hospital, improve throughput and prevent re-admission

AcknowledgementsMembers of BRATHSCP ManagersSenior Nursing StaffEmergency Department ConsultantsRebecca Mahon – 3rd year Physiotherapy Student

RCSIDr. Frances Horgan – Senior Physiotherapy lecturer

RCSIHospital ManagementHSCP Education & Development Advisory Group

ReferencesNixon L, Wolford S. Reports into the

Emergency Care Pathways in Beaumont Hospital (2010)

Beaumont Hospital HIPE Hospital Inpatient Enquiry) Data, (2012-2013)

Beaumont Hospital Annual Report 2011Report of the unannounced monitoring

assessment at Beaumont Hospital, Dublin. HIQA (2013)