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Dr Debbie Hawkins Director MVH MAU
Mona Vale Hospital - MAU
Clinical Audits Pathway to Improvement
Dr Debbie Hawkins Director MAU, Mona Vale Hospital
October 2014
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Dr Debbie Hawkins Director MVH MAU
Mona Vale Hospital - MAU Background
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• 8 bedded unit co-located on medical ward
• Achieved all 4 KPIs in 11 of last 14 months
• Majority of admissions Triage Category 2 or 3
• 28% of all ED admissions go through MAU
• >50% of all medical admissions go through MAU
• Average 20 patients per bed/month
• 96% occupancy in 2013/14
• Best performing MAU in NSW 2013
Dr Debbie Hawkins Director MVH MAU
Mona Vale Hospital - MAU What makes a successful MAU?
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• Shared organisational vision of the role of the MAU and how it delivers so effectively in terms of patient outcomes.
• Cohesive, multi-disciplinary team focussed on early
intervention and holistic care. • Close working relationships with Emergency Department and
other units - streamlines patients journey. • Clinical audits used to demonstrate opportunities for
improvement, in particular, clinical pathways which provide standardised best practice approach.
Dr Debbie Hawkins Director MVH MAU
Mona Vale Hospital - MAU Some completed clinical audits
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• Chest pain • Atrial fibrillation • STEMI • CTPAs • Pneumonia • Nursing home patients • Syncope • ICU admission from ED • Medical patient documentation
• Acute appendicitis – role of ultrasound
• Renal colic • Diverticulitis • UTI in children • Asthma • Bronchiolitis • Croup • Tonsillitis • Epistaxis
Dr Debbie Hawkins Director MVH MAU
Mona Vale Hospital - MAU Why audits work
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• Use of data demonstrating room for improvement in clinical management helps engage physicians in developing the solution – specifically pathways.
• Pathways are not then imposed, the data speaks for itself, building ownership in the outcomes.
• Combined audits involving ED and MAU data have allowed shared development of pathways – many of which start in the ED.
• Changes in practices as a result of audits leads to less clinical variation, improved patient management, less unnecessary interventions and decreased LOS.
• Audits are a conduit for improving the “core business” of the MAU.
Dr Debbie Hawkins Director MVH MAU
Mona Vale Hospital - MAU Example 1 – Chest Pain
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Purpose • To facilitate use of NSW Chest Pain pathway in ED • JMOs to become familiar with and use pathway
Looked at... • Are patients risk stratified in ED? • Is management in accordance with the stratification in ED and MAU?
Findings • 33% patients not stratified in ED • 25% receive suboptimal treatment • 100% are restratified in MAU • Good adherence to pathway for all MAU patients
Actions • NSW pathway incorporated into MAU notes • ED “paperless” so reluctant to use pathway. So:
o Laminated pathway prominently displayed o All Drs required to risk stratify at handover o JMOs (& senior ED staff) now conversant with pathway
Results LOS (days) 2011/12
1.3
2013/14
1.1
PEER
1.3
Dr Debbie Hawkins Director MVH MAU
Mona Vale Hospital - MAU Example 2 - Pneumonia
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Purpose • To determine whether patients are treated in accordance with CORB guidelines for management of pneumonia
Looked at... • Retrospective audit looking at patients admitted to medical ward with community acquired pneumonia
Findings • CORB score documented in 10% patients at admission • < 50% given correct antibiotic for CORB score • < 15% given correct oral antibiotic after original intravenous therapy • < 50% are treated with antibiotics for 7 days • 10% specified in discharge summary need for GP to repeat CXR
Actions • Results sent to ED staff and physicians • Pneumonia pathway developed emphasising role of CORB score in
determining antibiotic treatment
Results LOS (days) 2011/12
2.5
2013/14
1.7
PEER
3.2 Re-audit 4 months later
• CORB score documented in 40% of patients at admission • Appropriate antibiotics given in 70% of cases • Correct stepdown oral meds in 68% of cases
Dr Debbie Hawkins Director MVH MAU
Mona Vale Hospital - MAU Other Examples
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CTPAs • Led to introduction of PE algorithm for diagnosis of PE in ED. • 13% reduction in no CTPAs order (re-audit in process) • Pathway for management of PE on the ward just completed
Results LOS (days) 2011/12
2.1
2013/14
1.7
PEER
4.7
Syncope • Led to development of a syncope risk assessment tool for use in ED with recommendation all high risk patients admitted (mainly to MAU)
• Pathway developed Results LOS (days)
Uncomplicated
Complicated
2011/12
1.6 1.9
2013/14
1.3 1.7
PEER
1.7 5.2
Dr Debbie Hawkins Director MVH MAU
Mona Vale Hospital - MAU Other Examples (cont.)
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Atrial fibrillation
• Huge variability in pharmacological management of AF • Development of pathway with cardiologists • Used in ED & MAU • Considerably less clinical variation in approach • Appropriate rate v rhythm control
Results LOS (days) 2011/12
1.7
2013/14
1.2
PEER
2.1
Dr Debbie Hawkins Director MVH MAU
Mona Vale Hospital - MAU
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
Average LOS, Days
Top 20 DRGs - 2013-14
MVH
Peers
MVH MAU vs Peers; LOS by DRG
Dr Debbie Hawkins Director MVH MAU
Mona Vale Hospital - MAU IMPROVING PERFORMANCE Avg LOS in MAU for top 20 DRGs – 3yr comparison
Dr Debbie Hawkins Director MVH MAU
Mona Vale Hospital - MAU IMPROVING PERFORMANCE 21% Increase in throughput 2011 -2014
Dr Debbie Hawkins Director MVH MAU
Mona Vale Hospital - MAU IMPROVING PERFORMANCE Average total hours in ED for all MAU patients decreased by 43%
Dr Debbie Hawkins Director MVH MAU
Mona Vale Hospital - MAU IMPROVING PERFORMANCE Avg LOS in MAU decreased by 41%
Dr Debbie Hawkins Director MVH MAU
Mona Vale Hospital - MAU IMPROVING PERFORMANCE Ave LOS of MAU patients transferred to ward decreased by 35%
Dr Debbie Hawkins Director MVH MAU
Mona Vale Hospital - MAU IMPROVING PERFORMANCE Readmission rates of MAU-home or MAU-ward-home discharges decreased by 12%
Dr Debbie Hawkins Director MVH MAU
Mona Vale Hospital - MAU Summary
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• Clinical audits have shown to be a pathway to improvement.
• Use of data showing opportunities for improvement in patient management increases clinician engagement and ownership of solutions.
• Allow introduction of a methodical approach to eliminate clinical variation with standardised, evidence based pathways.
• Cross fertilisation between ED and MAU.
• Several pathways implemented with good buy in, focussed on main DRGs – ie get good at the “core business” of MAU.
• Small improvements have significant impact on streamlining patient management and decreasing LOS (equates to > 1100 bed days in top 20 DRGs 2013/14).
• Don’t reinvent the wheel – there are good , evidence based guidelines out there which just need tailoring to your organisation.
Dr Debbie Hawkins Director MVH MAU
Mona Vale Hospital - MAU
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Thank You