Is it really about Boarder Security?

Getting the patient to the right bed at the right

time

Fiona Webster

Executive Director

Acute Operations

Introduction

• Organisational bed profiling: Bed realignment project undertaken

in conjunction with CSIRO, to guide allocation of new and

existing resources across Austin Health

• Flow strategies: morning beds, PPA, flex, Ready to Go

• Predictive planning activity model used for capacity planning -

Balancing elective & emergency surgical demand

• Surgical Template: Tying theatre bookings to a bed

The problem…

• Ageing population

• Rising community expectations

• Increased ability to treat

• End of life decision making

• Emergency Department as a default for primary care

• Lack of GP treatment for residents of nursing homes

• Growing costs – budget pressure

Background

• Patients requiring admission to Austin Health arrive through a

variety of routes:

• Emergency department

• Elective surgery admissions

• Planned admissions – (Day oncology, endoscopy, sleep studies etc)

• Inter hospital transfers – (tertiary referrals)

• Intra-hospital transfers (Talbot/HRH)

• Direct admissions from the community (unwell patient seen at

outpatients)

• International repatriations

4

Targets • NEAT (National Emergency Access Targets)

• Emergency department four-hour access target for patients in

all triage categories – 80%

• % of Cat 1-5 Patients seen within time – 80%

• NEST (National Elective Surgery Targets)

• 100% of Cat 1 in 30 days

• 88% of Cat 2 treated within 90 days

• 97% of Cat 3 patients treated within 365 days

• Reducing the average waiting time for overdue patients

• Targets don’t cover all activity – so too strong a focus on targets

causes perverse incentives

5

You can’t have your NEST

and NEAT it too...

Balancing demand

Vascular Surgery Neurosurgery Neurology

Cardiology Cardiac Surgery Thoracic Surgery Respiratory Medicine

Colorectal Surgery Gastroenterology Liver Transplant

Orthopaedic Surgery Plastic Surgery Urology Infectious Diseases

General Medicine Renal Medicine

Ophthalmology Oncology Haematology

Acute spinal Paediatrics ICU ENT

Aged care Rehabilitation Awaiting placement

Emergency patients

Elective surgery patients

Direct admissions

Inter hospital transfers

Planned admissions

Intra hospital transfers

• 1000 bed hotel

• Patients arrive without bookings

• Their departure date and time is unknown

• Very few future bookings

• Very specific room requirements

• Always full – people queuing to get in

Why...

• Planned and unplanned patients compete for the same

bed

• Need to match patients to the ‘right’ bed

• Essentially always at 100% occupancy except for

holiday slow downs

• Only funded for a ‘full bed’ that is rapidly turned over

• Emergency demand – 78% of overnight bed days

• Variable, unknown length of stay makes predicting bed

availability difficult

• Acuity of the case will always win (long wait simple cases

bumped)

Why...

• Exit block waiting for patients to be

picked up by other services

• Limited ‘flex’ capacity due to bed

constraints

• Cancelling patients becomes the

pressure release

• Clinician admission decisions is

impacted by bed availability

Patient arrivals by hour

• Patient

discharges do not

match the time of

patients arriving

Our problem…

Bed management and patient flow

- New patients arrive before current patients leave

- Highly specialised services

- Idiosyncratic variation between one clinician and the next

- Person dependant systems and processes

- Lack of flexibility in managing capacity

- Still largely paper based (or have moved to the

spreadsheet!)

- Don’t know what’s coming in the door until its here

- Lack of tools to predict demand

How do we make it better..

• ? Open more beds…

• ? Discharge more patients in the morning…

• ? Plan less surgery in Winter

• ? Divert more patients into other programs / services

• HITH

• Transit Lounge

• ED Short Stay

• Acute Assessment

Understand your bed profile

• The current bed allocation at Austin has been in place since

the redevelopment opened in 2005

• We want to be able to place a patient in an appropriate bed

within four hours

• Patients get the best care when they are on their home ward

with a team that is able to manage their care collaboratively

• We needed to profile our beds to take account of work that

would move to our new Surgery Centre, demand for tertiary

services and demand from the Emergency Department

Right patient, right bed, first time

Bed allocation model

14

Beds needed by ED patients

15

ED bed demand

16

Right number of beds

Provide units with the right number of beds to meet demand:

• Moved elective work to The Surgery Centre

• Relocated 8 Urology beds to a new ward

• Will soon relocate Colorectal Unit to a new ward

• Looking at up-skilling staff to flow patients into a neighbouring

ward (building core competencies across ward environments)

Beds at the right time of day • Nov 12 – Admissions

and discharges don’t

balance until 2pm

• Deficit of ~13 beds in

the morning

• Patients wait in ED for

a bed

• How long does it take

to turn over a bed?

• Beds on some units

take longer to come up

Planned patient arrivals (PPA)

We need morning beds

• Every ward should prepare one or two patients who can be

discharged by 8am so that they can accept a patient by 9am

• The afternoon shift identifies the potential patients

• prepares patient for discharge

• organises transport or transit lounge

• seeks a discharge script/early morning medical review

• Sometimes these patients are planned transfers to another

facility

• Helps us start flow early and get patients to the right ward

Morning flex capacity

If we have a deficit of beds in the morning PPAs are not enough!!

• Establish morning flex capacity

• 4 surgical beds that open for the AM shift (ASTU)

• 3 cardiac beds open in the morning (cath lab recovery area)

• 8 Acute Assessment Unit (AAU) beds AM/PM shifts

• Agreement for paediatrics to flex within ratios to take morning

patients

• Beds are closed back as patients are discharged (or by a time deadline)

• Small amount of overnight flex available (four beds)

Greater use of transit lounge

Starting flow early helps

Beds are in balance two hours earlier

Access to beds from ED is better

• Still a long

way to go but

less winter

impact

Decline in boarders

• Fewer

boarders

means

better care

and shorter

LOS

Better communication Ward communication identified early as problem to patient

flow:

• Unable to reach person who makes decision

• ED unable to communicate with ward in-charge

• Bed manager also couldn’t find person responsible for patient flow

decisions

• Tea breaks held up flow because of communication

Introduction of:

• Minimum Deliverables of patient flow standards: ‘In-charge’

responsibilities for patient flow decisions. (Organisationally rolled out)

• Gave each ward a CISCO phone (used only for patient flow)

Ready-to-go? • Discharge Summaries in ED are not being completed in a timely

manner. Resulting in inpatient ward areas unable to :

• Admit the patient on to Medtrak

• Therefore cannot administer medications, order meals, process

pathology

• Cannot be found by relatives via Medtrak and creating safety

concerns

• Confusion regarding suitability for transfer to inpatient wards,

causing rework through additional phone conversations with the ED.

Consequences to this include:

• Decreased motivation by ward staff to expedite admissions

• Wards feeling that data on performance not reflecting true nature

• Increased staff frustration on inability to achieve targets due to delay

of transfers

What we wanted to achieve

a) Clarity when the patient is ready to be transferred to the

ward

b) Standardised communication

c) Less rework

d) Patients transferred out of ED without delay as clinically

appropriate…provide capacity for incoming pts/ ambulance

• ED management 2 hrs

• Bed management allocation 20 mins

• Pull pt to ward 1-2 hrs (decreasing towards 60 mins for wards)

Ready to go criteria…

• Patient needs to be medically stable, not meeting MET criteria

(unless documented/communicated as altered)

• Unit handover has occurred

• Discharge summary completed

• Interim medication and fluid orders completed

Issues that need to be resolved around this are:

Who is responsible for ensuring final ‘sign off’ of the above 4 criteria (process owner)

How are outstanding tasks escalated?

Identification icon activated via medtrak to announce patient ready to move

Identification of ED need for PSA assistance for transfer from ward areas

Identifying who is responsible for ensuring the discharge summary completed

0

10

20

30

40

50

60

70

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

RTG Compliance - last 30 days

% Admitted to ward with RTG Patients Admitted To Ward

What percentage of pts have a RTG?

Improved to 62%

Before November - All Wards

Now - All Wards

Improved

13.2%

85% Patients

transferred to

wards within

2 hours

Better bed management

Split elective and emergency streams

• The Surgery Centre is not impacted by emergency demand

• Provides more beds for Emergency Demand

Increased flex capacity

• Having the ability to open extra beds at short notice at marginal cost

Better bed management

• Predictive planning

• Demand projections

• Booking templates

Bed Management

information

Direct Admission/

Interhospital transfer

ERC

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Level 8 electives

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SAEC 8E SAEC 8W SAEC 8N SAEC

Monday 1 0 3 0 0 5 1 5 6 11 5

WEE

K 1

Tuesday 1 3 1 2 1 6 1 11 6 17 4

Wednesday 1 5 1 2 0 4 1 11 6 17 3

Thursday 0 3 1 2 0 3 2 8 6 14 3

Friday 1 3 1 1 1 4 0 8 6 14 3

Monday 1 4 3 2 0 3 0 9 6 15 4

WEE

K 2

Tuesday 1 4 3 2 1 5 0 11 6 17 5

Wedensday 1 4 2 1 0 5 0 10 6 16 3

Thursday 0 3 1 4 1 4 1 11 6 17 3

Friday 1 3 1 2 1 3 0 8 6 14 3

Monday 1 6 2 1 0 5 0 12 6 18 3

WEE

K 3

Tuesday 1 5 0 1 0 6 2 12 6 18 3

Wednesday 1 4 0 2 1 5 0 11 6 17 2

Thursday 0 4 0 1 1 3 0 8 6 14 1

Friday 1 3 1 1 1 5 1 9 6 15 4

Monday 1 4 2 1 1 4 0 9 6 15 4

WEE

K 4

Tuesday 1 6 0 2 1 5 3 12 6 18 5

Wednesday 1 3 1 1 1 4 2 8 6 14 5

Thursday 0 3 0 2 2 5 1 10 6 16 3

Friday 1 4 0 0 2 4 0 8 6 14 3

Elective

Admission

Template

Day surgical

procedures: SAEC

Day medical

procedures: AAU,

ACC

Further

medical

assessment AAU

Step down medical bed: Ward 10, rehabilitation bed

Overnight surgical I/P

Extended

Stay: ACC /MH

High acuity

admission ICU/HDU

6W HDU

CCU

Respiratory

State-wide services/ Trauma

agreements: Spinal, vertebral column, LTUx

Psychiatric services

Single room/ Isolation

requirements

Standard day… 1500-1600 Planning for next day

• Review EDDs, ETBS capacity to finish the day,

• Consultation with wards & external stakeholders where required

• Send alerts to liaison nurse/ ESAM role & medical (surgical) teams for assistance

in extreme bed access situations

• Reorder tomorrow’s lists, defer work where appropriate

• Review direct admissions list and ensure plan for transferring patients.

1930hrs

• Ensure patients in AAU have bed plans for closure

• daily operational shift reporting

• Ensure capacity is at optimal level (additional beds open etc)

2030hrs finish and handover to AHSM

Standard day... 0700…

• accept Night activity handover

• Allocate patients in ED to opening capacity (AAU/ASTU etc)

• Early discharge confirmation & Allocation of PPAs

• Placement of long waiting patients

• Early assessment, triage of theatre flow & beds balanced against competing

areas of demand (ICU, other hospitals, emergency department, other)

0800-1200: Surgical flow position

• Establish & coordination/management of issues (reorder list, alternative post

op destination, change to day procedure, cancel etc )

• Confirm movement and placement of patients

• Ensure minimisation of HIPs and boarders management

• Facilitate discharge planning assistance to wards

• Assist ETBS (Emergency Theatre) with treating patients in time & access to

OR

48 I/P ED admissions

25-30 elective admits

@12+ direct admissions

+/- OPD, Failed D/c, ACC

admissions etc

37

Performance

Alert

Additional demand

Organisational Awareness

Forecasting the activity ahead...

Predictive planning & templating

Issues:

• No consistency in number of electives booked requiring IP beds

• Level of acuity on each day would exceed ICU/HDU capacity, or ward ability to

manage complexity

• Waste ++- Theatre cancellations, staff present but not able to work and poor

customer service/ focus

• Lack of accountability and fairness (some units able to access theatre/ beds

more than others)

Solution:

• All surgical activity operate from a template, Clinical wards operate off Predictive

planning to manage their daily/ weekly demand

• CSIRO ward bed profiling information used for wards to plan for both NEST & NEAT

Scheduling Activity; SAEC: TOTAL 8E 8N 8W

7N/

3N 6 S TOTAL

UGI x 2, Plastics x 1 OMFS x 1 ENT x2, 1 x ERCP, 1x radiology, 8 Urol 2x6S, Ortho 2x 8N (trauma), Ortho x 3 8N, Plastic 1x8N, UGI 1 x 8E 1 6 0 0 2 9

CRS4 x 1, UGI x1, Orthox1, HPB x2, ERCP x1, Radiology x1, Cardiology

x1, 8 Urol 1x6S, CRS4 2x8E, UGI 1x8E, HPB 2x8W, Ortho 4x8N( 1 Trauma), plast 1 x8N3 5 2 0 1

11

UGI x1, HPB x2, UROLO x 1 ENT x1 , ERCP x1, Radiology x2, 8 Urol 3x6S, UGI 1x8E, CRS4x1 HPB 2x8W Ortho x 2 ( trauma) 2 2 2 0 3 9

HPB x1, Ortho x1 ( truama), ENT x2, Radiology x2, Vascular x2 8 Urol 2x6S, CRS4 1x8E, HPB 2x8W, Ortho 3x8N ( 1x trauma) UGI 1x8E 2 3 2 0 2 9

Urol x1, HPB x1, Plastic x1, CRS4 x1, ERCP x1, Radiology x1, Vascular x1, 7 Urol 2x 6S, CRS4 1x8E, HPB 1x8W, Ortho 4x8N ( 1x Truama), Plas 1x8N, 1 5 1 0 2 9

UGI x1, Ortho x 2 ( Trauma), 1x ERCP, 1x radiology 5 Urol 3x6S, UGI 1x8E, HPB 2x8W, Ortho 2x8N, Plastics x1 8N 1 3 2 0 3 9

Urolx1, 1x ERCP, 2x radiology, 1x Cardiology, ENT x1 7 Urol 2x6S, CRS4 2x8E, UGI 1x8E, ortho 3x8N ( 2xT), plastic Quad hand l i s t ( 3N) 3 3 0 1 2 9

UGI x1, plas x1, urol x 1 ENT x2, 2x radiology, 1x ERCP, 8 Urol 2x6S, UGI 2x8E, Ortho 3x8N, plas 1x8N 2 4 0 0 2 8HPB x2 (1 for tenkoff), Urolx1, 1x radiology, 1 x cardiology, 2 x Vascular,

ENT x 1 8 Urol 2x6S, CRS4 x1 8E, UGIx1, HPB 2x8W(IM 1x8E &7N)ortho 2x8N, ( 1X truama)3 3 2 1 2 11

Urol x1, HPB x1, Plastic x2, Ortho x1( Truama), UGI x1, ERCP x1, Radiology

x1, OMFS x1 9 Urol 3x6S, CRS4 x1 8E, UGI 1x8E, HPB 1x8W, Ortho 3x8N, plas 1x8N2 4 1 0 3

10

UGI x1, ENT x2, 1x ERCP, 1 xradiology, plastics x 1, OMFS x 1 7 Urol 1x6S, UGI 2x8E, HPB 1x8W, Ortho 3x8N( 1x Truama), Plas 1x8N 2 5 1 0 1 9

UGI x1, plastic x1, HPB x1, CRS4 x1, ortho x 2 ERCP x1, Radiology x1, 8 Urol 1x6S, CRS4 x2 8E, UGI 1x8E, HPB 2x8W, Plast 1x8N, ortho 3x8N (1xtruama) 3 4 2 0 1 10

HPB x2,, ENTx2, radiology x2, ERCP x1, 7 Urol 2x6S, UGI 1x8E, CRS4 1x8E, HPB 2x8W, Ortho (2x truama) 2 2 2 0 2 8

UGI x1,Ortho x1 vascular x2 , 2x radiology, 1x Cardiology, ENT x1 8 Urol 2x6S, CRS4 1x8E, UGI 1x8E, HPB 2x8W, Ortho 5x8N 2 5 2 0 2 11

CRS4 x2, Plas x1, urol x1, HPB x1, 1 xradiology, 1 xERCP, Vascular x1, 8 urol 3x6S, CRS4 1x8E, HPB 1x8W, Ortho 3x8N (8N x1 Truama), Plas 1x8N1 4 1 0 3 9

HPB x1, Urol x 1, UGI x 1, plastic x1, ortho x1, radiology x1, ERCP x1 7 Urol 3x6S, UGI 1x8E, HPB 1x8W, plas 1x8N, Ortho 2x 8N (+2x 8N Truama) 1 4 1 0 3 9

Urology x 1, HPB/T x 2 UGI x1, plastic x1, ERCP x1, Radiology x2, 8 Urol 2x6S, CRS4 2x8E, HPB/T x 2 8W, UGI 1x8E, Ortho 1x8N, plastic 1x 8N 3 2 2 0 2 9

UGI x1, HPB x1, radiology x2, ERCP x1, ENTx1 6 Urol 2x6S, UGI 2x8E, HPB 1x8W, Ortho 3x8N, plas x1 8N 2 4 1 0 2 9

HPB x2 ( 1 for tenchoff), 1 x Ortho ENT x1, Vasc x1, radiology x1,1 x

cardiology 7 urol 2x6S, HPB 2x8W (IM 2x7N), Ortho 2x8N (8N x1 trauma) 0 3 2 2 2

9

HPB x1, plastic x2, Ortho x1, radiology x1, ERCP x1, 1 x cardiology, Vascular

x1, 8 Urol 3x6S, CRS4 1x8E, HPB 1x8W, Plas 1x8N, Ortho 3x8N1 4 1 0 3

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week commencing 28.10.13 All Seasons template 2013 v5 updated 31.10 .13W

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Matching operating units each day with # of

beds, holding each unit accountable

Predictable Surgical elective bed numbers, also

assists with booking appropriately balanced lists

Predictive Planning (individual ward example)

Ward 7 South Date:

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Admissions

Elective admissions booked 3 4 2 3 2 0 0

ED Admissions: 2 1 2 2 1 2 1

Intensive Care admissions 1 0 0 2 1 1 0

Urgent direct admissions 1 1 1 * * * *

Other:

Admissions Total: 7 6 8 7 3 3 1

Discharges Projected: 6 7 3 7 5 4 4

Balance/ Plan: 1 1 -5 0 2 1 3

# of external referrals still

waiting:

Planning Patient Flow: Weekly projection

Additional Issues:

1 22

1 x Complex Pt +

2 awiting

subacute

transfers

Plan; postpone X,

Priority d/w Dr B,

for A+C to be

admitted

Ward taking

responsibility for

balancing demand

Medical unit

engagement

Organisational view…

42

Questions