NEAT and the Admitted Patient All things in moderation…

Acknowledgments

• Dr Judy Flores • Dr Ian Scott • Dr James Collier • Mr Alan Scanlon • Dr Michael Daly • Ms Michelle Winning • PAH Executive team

• Why is inpatient NEAT important? • How did we improve at PAH? • Is NEAT safe and how do we monitor inpatient

NEAT safety? • What is the future of inpatient NEAT?

Mr C

• Mr C in ED with Type 1 diabetes • Vomitting ++++ • BSL 30 • No ketones

What’s wrong?

• This is not a patient focussed approach • Stressful • They are both good doctors • Why can’t these doctors easily agree what

should happen to this patient?

2

• Why is inpatient NEAT important? – Inpatient NEAT is access block – Big volume hospitals can’t meet NEAT without

inpatient NEAT improvement – Inpatient NEAT improvement requires the whole

of system reform that NEAT was meant to introduce.

Wooden spoon

Courier Mail 14/12/12 NHPA report 2011-12

Why should inpatient teams care about NEAT?

• Because the CEO told us to • Because it might be good for patients and

efficiency

NEAT cautionary tales • Mid Staffordshire trust

• Time to disposition plan <4 h associated with 57% increase in mortality in

general medicine patients, corrected for age, gender and triage category – No increased risk with ED LOS <8 h

• Mitra et al Intern Med J 2012

• Increase in proportion of admitted GM patients

– lower triage score (ATS 4) (29.2% vs 21.9%; p<0.001). – aged less than 50 years (9.4% vs 7.8%; p=0.01) – patients with low triage scores (ATS 4 and 5) increased LOS

• Adjusted median 6.0 days vs 5.2 days (p=0.008) • Nash et al RMH 2013

Harms of ED access block and overcrowding

• Length of ED stay independently predicts inpatient LOS. – Average excess LOS for inpatients: 0.39 days for ED LOS ≤4 hrs; 2.35 days for ED LOS >12 hrs

» Liew et al Med J Aust 2003

• 34% increase in risk of death at 10 days among admitted patients presenting during periods of ED overcrowding

» Richardson Med J Aust 2006

• ED overcrowding in Perth’s three tertiary hospitals associated with an estimated excess 120 deaths in 2003

» Sprivulis et al Med J Aust 2006

• Among patients well enough to leave ED after being seen, longer ED LOS (≥6 hrs) compared to shorter LOS (<1 hr) resulted in 80% increase in death and 100% increase in admission at 7 days in high acuity patients

» Guttmann et al BMJ 2011

• Increased readmissions and ED return visits; inappropriate follow up care (discharge planning) » Forero & Hillman, ‘Access block and overcrowding: A literature review’, Prepared for Australasian College of Emergency

Medicine

• Prolonged pain, patient/carer dissatisfaction, violence, ambulance diversions/ramping, reduced

efficiency » Derlet & Richards Ann Emerg Med 2000

2013 Admissions

Hospital Admissions NEAT Compliant Admissions

GCH 28321 14726

PAH 27426 13164

TPCH 24481 13219

RBWH 23989 11919

Logan 23187 11361

Diminishing Returns

• Current NEAT interventions to date- – Cost -$750k (recurrent) – NEAT improvement- ~45% (25-70)

• Next Intervention (planned and approved, but not yet

implemented) – Cost $2.5mill – Projected NEAT improvement- 10%

4 x the cost for ¼ the gain

• How did we improve at PAH?

NEAT and the admitted patient

• Initial focus on discharged patients (the “easy” cohort). Relatively easy as only involves one specialty (FACEM)

• Admitted NEAT harder: involves FACEM and then “negotiation” and transfer of care to FRACP/FRACS etc

• “ silos” of care • Patient care focus can get lost with competing

demands • Emergency admissions have never been core business

for inpatient units (we like outpatients, elective admissions, research, inpatients…)

In order for a patient to be admitted to a hospital what has to happen within 4 hrs?

• Probably the most important event for the patient is that two doctors from very different specialities and cultures have to agree on a plan for that patient’s care..

How has PAH overcome these differences?

• Keep patient at the centre of discussions • Frequent communication and troubleshooting • Resources to allow collaboration (consultant

time) • Strict safety monitoring and joint review of

PAH NEAT dashboard: allowing data rather than anecdote/emotion to guide the discussion

• Is improving the inpatient NEAT safe?? -limitations of data -we were given time KPI but no quality framework

NEAT Dashboard Princess Alexandra Hospital Pre Implementation Post Implementation

2011 2012 2012 / 2013

Quality and Clinical Outcome Measures

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Re-presentation to PAH ED < 48 hrs of discharge from ED 3.4 2.8 2.6 2.8 3.1 3.1 3 3.8 3.8 3.4 3.1 3.2

Inpatient mortality for patients admitted from PAH ED (%) 2 2.4 2.5 2.6 2.3 2.3 2 1.6 1.7 1.2 1.1 1

PAH Standardised Hospital Mortality Ratio 80 85 85 74 61

RRT calls to PAH inpatients admitted < 24 hrs from PAH (rate per 1000 admissions) 4.9 8.1 7.3 6.7 9.4 8.3 10 8.9 9.9 14 13 13

Cardiac Arrest calls to PAH inpatients admitted < 24 hrs from PAH (rate per 1000 admissions) 1.4 0.9 0.9 1 1.1 0.4 1.1 1.4 1 0.8 1.1 0.5

PAH NEAT Safety Dashboard

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In Hospital Mortality for ED Patients

PAH Admitted NEAT Percent In Hospital Mortality for ED Patients

Summary

• Inpatient NEAT inolves the sickest, most complex (and most costly) patients presenting to an ED

• The care of the admitted patient requires close collaboration between 2 different specialties. For the first time, this interface is important. Patients benefit from this increased cooperation

• Improved NEAT compliance at PAH has been associated with a reduction in deaths in patients being admitted from the ED (the death rate has halved) “potential non-statistical” lives saved during PAH NEAT period of 437

The Future of Inpatient NEAT

• Substantial gains in safety and efficiency at inpatient NEAT of 60%

• To increase inpatient NEAT, will require significant recurrent expenditure

• Unclear benefits for patients • May be even more difficult to raise target in

regional hospitals (physicians less common)

The Future of Inpatient NEAT

• Must keep focus on patients and quality of care • Suggest moderate inpatient NEAT target and

add robust quality framework