DESIGN FOR

FLOW

DR YUSUF NAGREE

EMERGENCY PHYSICIAN

FIONA STANLEY HOSPITAL

Joondalup

Swan District/Midland

Fremantle

SCGH

RPH

Armadale

Rockingham

Perth 2007

Three tertiary

hospitals – Royal

Perth (adult), Sir

Charles Gairdner

(adult), Fremantle

(mixed)

Four outer

metropolitan –

Armadale,

Rockingham,

Swan Districts,

Joondalup

One paediatric –

Princess

Margaret

One O/G – King

Edward

Joondalup

Swan District/Midland

Fremantle

SCGH

RPH

Armadale

Rockingham

Reid Review

Closure of Royal

Perth

Reconfigure

Fremantle to non-

acute hospital

Construction of new

tertiary in the fast

growing South

suburbs: this was to

be a ‘merging’ of

Royal Perth &

Fremantle

‘Upgrade’ to

Joondalup in the

Northern Suburbs

Political pressure –

Royal Perth to

remain open

Fiona Stanley

Hospital

DESIGNING FIONA

STANLEY

Mammoth task

Designing a hospital from ground up

Merging of two hospital cultures – RPH & FH

Rarely undertaken before

Also, non clinical services contracted out

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

10,000

Adults

Children

Total

Fiona Stanley Hospital

Patient Attendances

4 Hour Performance

DESIGNING FIONA

STANLEY

Design phase

• Consortium of architects

• Multiple clinical user reference groups

• Consumer input

• Changes in scope – 80% single rooms, cardiothoracics,

trauma, phased construction

DESIGNING FIONA

STANLEY

$2 billion Fiona Stanley Hospital – largest building project ever undertaken by the State Government

Equivalent of four city blocks

150,000sqm of floor space over five main buildings

6300 rooms in the main building

783 beds, including 140 rehabilitation beds

83% single patient rooms in main hospital

More than five hectares of natural bushland, landscaped parks, internal gardens, courtyards and

plazas

3600 basement, ground level and multi-storey car parking bays

DESIGNING FIONA

STANLEY

Public/Private partnership – non clinical services contracted

out to Serco:

Porters

Catering

Cleaning

Communications

Linen

Building maintenance

IT / Telephony / Switchboard

Medical Records*

DESIGNING FIONA

STANLEY

IT

Fully wireless

Paperless Hospital

Multi-function bedside computers:

Patients – internet, meal ordering

Clinicians – log on to clinical systems

Sophisticated handheld paging / telephone units

BYOD integration

DESIGNING FIONA

STANLEY

IT Issues

Ultimately led to delay in hospital opening

WA Health:

• multiple different systems interfaced together

• some ‘home grown’, others off-shelf

• Most systems integrated across metro

• IT run as partnership with Fujitsu (Health Information

Network)

DESIGNING FIONA

STANLEY

IT Issues

Massive task in configuration of all existing systems

Difficulties because clinical services not finalised – trauma, obstetrics, CDTH

Interfacing of new systems required:

• eg. E-diet which was the electronic meal ordering system which interfaced with Serco’s system but also required interfacing with the clinical systems so allergies came across

• Three IT players involved

• WA health

• Fujitsu

• Serco / BT

• Other major WA health projects underway – Windows 7, PAS system

DESIGNING FIONA

STANLEY

Paperless System

Realisation that current hybrid of systems couldn’t support a fully

paperless system – eg. Medications management

Hardware requirements also made fully paperless difficult – eg.

Recording of observations

BYOD functionality would not be ready in time

“Off-shelf” products to support fully paperless could not interface with

other WA health systems: risk that FSH would be ‘electronically isolated’

from the rest of the State

Dilemma – couldn’t go to paper system as medical records infrastructure

not there

DESIGNING FIONA

STANLEY

Paper-lite

Bossnet eventually selected

Medication charts and observation charts paper

Progress notes and discharge summaries electronic

Paper based forms scanned at end of patient episode

DESIGNING FIONA

STANLEY

Clinical Design

4 Hour/NEAT big focus

Lot of planning around flow

4 hour rule since 2008– excellent results compared to rest of

Australian

Aim to design FSH to ensure 4-hour performance

DESIGNING FIONA

STANLEY

Service Stream Model

Service 1: Cardiovascular, thoracic, renal, endocrine, haem/onc, aged care

Service 2: allied health, imaging, physics, immunology, ID, pathology, theatres, pharmacy

Service 3: mental health, womens, children, newborns, state rehab

Service 4: ED, general surgery, acute medical, gastro, trauma, head/neck, orthopaedics, neurosciences, neurology

Aim to be autonomous, self managing with medical & nursing co-directors. Heads of Services & Nurse Unit Managers to lead individual departments

DESIGNING FIONA

STANLEY

Clinical Service Plans

About 18 months prior to opening,

HoS and NuMs appointed

Development of department clinical

service plans

Detailed plans – over 50

Numerous clinical guidelines where

appropriate

Cross department / service interfaces

articulated – eg. # NOF

ED plan – 147 pages

DESIGNING FIONA

STANLEY

Unplanned / Acute Services

Concentrated around three units:

Emergency Department + Short Stay (ESSU)

Acute Medical Unit (AMU)

Acute Surgical Unit (ASU)

Other:

Orthopaedics, Intensive Care, Cardiology

DESIGNING FIONA

STANLEY

Emergency Department Design

Huge department – over 3000 sqm

Five discrete areas:

• Resuscitation – 15 cubicles: chest pain, trauma, ATS ½

• Assessment – 16 cubicles: non ambulant, less acute

• Green / Ambulant – 10 spaces

• Short Stay – 15 beds

• Paediatrics – 14 beds: autonomous – separate entrance,

triage, waiting room (4 bed ESSU)

DESIGNING FIONA

STANLEY

Emergency Department Staffing

Each area separately staffed:

• Nursing area lead and Consultant (no consultant in

Ambulant)

• Nursing Staff

• Medical Staff

• Ward Clerk (not in Ambulant)

No choice due to distances involved

DESIGNING FIONA

STANLEY

Emergency Department Staffing

Assistant Nursing Unit Managers (ANUM)

Mental health team – Psych liaison nurse + registrar

Drug / Alcohol CNS (business hours)

Allied health team (physio / OT / social worker)

Nurse practitioners & Advanced Scope physiotherapists

DESIGNING FIONA

STANLEY

Flow

Flow was paramount from the ED

Patients triaged as usual – triage nurse made determination as to

which area patient was – Resus, assess, green…

Area co-ordinator monitor EDIS screen and would ‘pull’ patient

into their area as soon as possible. Aim was to have minimal

number of people in the waiting room

No corridor patients other than front door off-load area

FLOW AT FIONA

STANLEY

“Rules”

• ED to make a decision by 2 hours – JMOs to discuss

with senior with 30 min

• Inpatient teams to review patients within 30 min of

referral

• One way referral system

• Patients to leave ED within 60 min of bed request even

if not reviewed by inpatient team and clinically stable

Escalation process when above time points breached

FLOW AT FIONA

STANLEY

Wards to ‘pull’ patients from ED when bed available

Patients go to ward when bed available

Safety:

• Not certain wards – eg. ICU, CCU, MH

• ADDS 0-3

• Sign off by senior ED clinician

• Ward registrar informed

FLOW AT FIONA

STANLEY

High visibility of Flow

Enterprise Bed Management

(EBM) system – high visibility of

hospital / ED throughout the

campus

Daily bed status reports

Pop up messages on computers

Paging when Code Red/Code

Black

FLOW AT FIONA

STANLEY

Emergency Short Stay

24 hour admissions – under ED consultant

ED consultant rostered morning & evening with junior support

Cases

• Overdoses

• Situational crisis

• Alcohol intoxication / withdrawal

• Pyelonephritis

• Cellulitis

• Vertigo

• Gastro-enteritis

• Head injury

• Snake bite

FLOW AT FIONA

STANLEY

Chest Pain Assessment Unit

Joint cardiology / ED unit in the short stay ward

TIMI 0-1 – managed solely by ED

TIMI 2-4 – CPAU

Under ED bed card

2 x daily cardiology reg ward rounds – organise tests / follow-up

ED JMOs to do paperwork

FLOW AT FIONA

STANLEY

Acute Medical Unit

50 bed unit with 8 high acuity beds (ionotropes, NIV)

Staffed by consultant physicians (0800-2200)

3 x daily MDT ward rounds (0800, 1115, 1500)

All patients referred from ED seen within 4 hours by consultant 0800-2000 (14 hours overnight)

Extended hours pharmacy and allied health

Didn’t opt for “all patient” model – specialty teams would admit – eg. Respiratory. After-hours, AMU registrar may do the admission paperwork

Aim for 48 hours in AMU then decant to appropriate unit – AMU consultants have admitting rights to other units

FLOW AT FIONA

STANLEY

Acute Surgical Unit

Operated in a similar model to the AMU but 3 x daily ward

rounds not mandated

Senior surgical registrars

Undifferentiated abdominal pain would go to the ASU whilst

waiting CT scans, ultrasounds

FLOW AT FIONA

STANLEY

Other

# NOF page

Code Stroke, Code STEMI

ICU service

• Must respond

• Provide management advice

• Facilitate beds

FLOW AT FIONA

STANLEY

Ward over-census

Ward over-census used

Wards required to go over-census when ED ramping

Can use other areas of the hospital to go over-census

eg. Hospital gym area, State Rehab centre

Detailed over-census plan including safety issues

Advantages

1 extra patient/ward is safer than 20 extra patients in ED

Provides visibility to ward about bed situation

Avoids delaying discharges on ward

LESSONS

Under-estimate demand

Under-estimate Portering requirements

• When flow is paramount, you need high availability of portering to

enable patient movement

Under-estimate senior staffing requirements

• Acute surgical unit. Senior staff in theatre leaving junior surgical

registrars to see consults

Require central bed co-ordination / escalation

IT interfacing / configuration

Under-estimate computer hardware requirements & clinician behaviour

Look after junior staff – shift times

LESSONS

Worked Well

• Hospital wide engagement, especially Heads of Department, to drive culture

• Set of “rules” adhered to by everyone (eg. Patients must be seen in ED

within 30 minutes)

• Early, frequent senior decision making

• Develop a “pull culture” and ownership of areas though with central co-

ordination

• Over census can be a useful tool

LESSONS

Emergency Department Design

Seriously think about staffing & flow considerations if embarking down pod

structure

FLOW AT FIONA

STANLEY

Finely Tuned System

?