Presented by Madhu Permal

Nurse Unit Manager

Transit Care Hub

Princess Alexandra Hospital

Brisbane, QLD

Email:madhu.permal@health.qld.gov.au

Introduction

Transit Lounge - a common tactic to expedite patient flow but difficult to implement well.

• Journey of designing and building a new Transit Lounge at Princes Alexandra Hospital (PAH) from a Nurse Perspective

• Model of Care and KPI

• Strategies to increase utilization

Overview of Transit Care Hub (TCH)

Aim:

• To provide an efficient and effective flow of patients through the hospital by facilitating timely discharges, creating earlier access to inpatient beds.

Key Objectives:

• Provide patient centred care for all cohorts of patients.

• Provide streamlined work practices resulting in improved

patient satisfaction.

• Provide a safe and comfortable environment for all cohorts of

patients.

• Support patient flow into and away from PAH to assist with

capacity demand.

Current Service: The suitability of patients coming to Transit Care Hub is determined by the inclusion and exclusion criteria.

• Management of discharged patients waiting for transport, discharge

medications and education, or last dose of IV antibiotics. • Transfer of patients from other health care facilities for appointments or

admission.

• Managing transport for Outpatients arriving for their appointments and

their returns • Management of routine admissions and emergent admissions waiting

for an inpatient bed

• Management of patients requiring pre and post procedural hydrations

Core Staff working in TCH: • Nursing Staff ( NUM, 1 CN, 1 RN, 2 EN’s)

• Administration Staff: 2 Administration officers

• Support Officers: Operational support officers, pharmacists and

volunteers.

The Team:

Work together focusing on high standard of delivery which is critical

for achieving optimum patient outcomes.

Are committed to quality improvement and care delivery that is best

practice to enhance the patient journey.

Always strive for excellence in the provision of patient care which

includes a structured framework and is underpinned by evidence based

practice.

Activity of Transit Care Hub – 2012 to May 2015

2175

2554

3024 2979 2923

0

500

1000

1500

2000

2500

3000

3500

NO

.OF

PTS

Total Monthly Activity, January 2015 to May 2015, PAH Transit Care Hub

Transit Care Hub Total Activity January to May 2015

Average / Day : 135pts

Total No. of Outpatients, Discharges and Admissions,

January to May 2015

Total : 13489pts

Old Transit Lounge: Located adjacent to the foyer in the front entrance of the hospital • Hrs of operation- 7am to 7:30pm • 28 spaces , included 6 trolley spaces & 22 chairs • Four Ambulance parking bays • 2 community transport vehicles parking bays. • 7 short term parking bays for private pick up & drop off • 1 disabled parking bay •

Problems associated with the Old Transit Lounge: • Unsuitable environment in terms of patient experience, patient safety,

privacy and confidentiality. • NUM not located in Transit Lounge / no direct leadership • Lack of space and facilities • Overcrowding

• Reluctance to utilise the area for discharges

• Extensive waiting times • Name of the department ‘ Transit Lounge ’ not capturing the multi-

faceted aspect of the PAH Transit Lounge.

Oxford online Dictionaries define a transit lounge as:

‘A lounge at an airport for passengers waiting between flights’

Redesigning and Rebranding

Initial Review (2013) • Redevelopment plans for PA Hospital Foyer area. • Review of the model care for future services, nursing care,

patient services and patient flow

All recommendations were in line with Queensland Health’s strategic outcomes for the Health system and health services that ‘services are innovative, safe and effective, and designed around those who use them’.

The review officer engaged key stakeholders and services which impacted on or utilised the Transit Lounge. Stakeholders were engaged in a variety of ways, including: • One to one formal and informal meetings • Group meetings • Patient interviews • A literature review to identify current research on Transit /

Discharge Lounges

• A review of previous recommendations, proposals and business cases

• Benchmarking against like organisations • Data analysis to identify current activity and the impact of any

changes in model or service

Recommendations Increasing complexity of patients level of care and increase in numbers meant there needed to be:

• more space in TCH, better facilities for staff and patients. • more suitable and patient centred model of care • TL to be relocated to an alternative and more clinically appropriate

environment with good transport access and linked to the main hospital

• TL to be re-branded as the Transit Care Hub (TCH)

• TL to focus on Discharge processes in conjunction with current Patient Flow Unit strategies / initiatives

• The NUM to be physically located or co-located in TL to ensure visible leadership

Designing The New Transit Care Hub: Design was focused on clinical requirements, organisational needs, patient safety and patient satisfaction.

• Appointment of a project officer • Review of the model of care. • Review reports from previous years • Site visits to other hospitals • Gaining knowledge of interstate transit lounges • Meetings – high level including representatives from all

divisions and group staff meetings.

• Meetings with other departments like NPDU, Drs and clinical experts.

• Ongoing consultation- internal and external e.g. architect,

work health & safety, patient safety, workforce unit etc.

• Review consumer feedback and patient satisfaction results

• Rebranding – change of name to suit the service delivery and change of colour.

• Marketing strategy – to increase utilisation

Cont …

General Design Requirements: • Direct access to support facilities including clean utilities,

supplies and storage. • Direct access to pharmacological supplies and storage • Direct access to emergency personnel • Available space for the movement of trolleys and beds within

the area.

• Easy access for all external transport.

• Access - flat and under cover as patients are transported by

walking, wheelchair, and trolleys

• Adequate size to accommodate recliner chairs, trolleys, beds and wheelchairs and bariatric equipment.

• Open plan room with a central administration desk with clear

visibility of all areas • Focus room for confidential meeting for patient privacy • Adequate storage area and bench space • Televisions in patient area

• Easy access to all clinical areas including OPD and inpatient

units, medical imaging, ambulatory care services

Cont …

TCH is relocated to the ground floor, next to patient flow unit of PA Hospital with a floor space of approx. 1500 – 3000 sq. which includes:

• 48 spaces, including 12 trolley bay, 18 recliner chairs, 2 round

tables with 6 chairs

• 2 patient toilets with bariatric access

• Patient beverage bay

• 6 computer desk spaces, Dr’s write up area, x2 portables

• 1 focus room for pt. privacy

• wheel chair bay

• Clean & Dirty utility room and Store room

• 2 patient electronic journey board.

New Transit Care Hub

Model of Care & KPI Framework that establishes how patients are cared for in TCH. TCH is a nurse led service that works with the interdisciplinary team to ensure the correct service is delivered to the correct patient at the correct time.

Aim: • to provide equitable, consistent and a systematic

approach to transiting patients in or out of PA Hospital. • To provide flexibility to ensure all patient individual

needs are met.

Principles underlying the TCH Model of Care:

• All patients entering the department are assessed for

cognition, mobility and care requirements to determine

patient safety in the TCH.

• Patients being discharged from an inpatient ward and

exiting the PA Hospital are given a supportive, safe

environment and continuity of care whilst awaiting

transport home or to another facility.

• Patients awaiting admission, procedures or outpatients

appointments are provided the care required for their

individual admission, procedure or appointment

National Standard Objective KPI

Governance for Safety and Quality in Health Service Organisations

The Transit Care Hubs will be identified as a pivotal service within the MSHHS

Measure through key stakeholder feedback – 6 monthly

Partnering with Consumers

To improve patient satisfaction

The compliments to

complaints ratio trends in a positive direction – 6 monthly

To improve satisfaction from internal and external key stakeholders (inpatients and

transport services)

The compliments to

complaints ratio trends in a positive direction – 6 monthly

Medication Safety

All medications given in the TCH are documented and signed for

100% of medication given are documented as per MSHHS Policy

Clinical Handover To implement standardised handover across all Transit Care Hubs

Evidence of clinical handover – revised discharge handover

sheet Evidence of patient

involvement through bed side handover

National Standard Objective KPI

Recognising and Responding to Clinical Deterioration in acute

health care

Effective handover to reduce the number of patients requiring

acute/urgent care entering the transit lounge

Number of patients that deteriorate and require change in pathway as a

percentage of the total number of patient through

the TCH

Service Delivery To minimise the length of stay in TCH

Trend LOS (hours) that the patient is in the Transit Care Hub .

Increase the number of referrals from inpatient services to TCH

Number of discharges to transit lounge compared to number of total discharges

for wards that use the TCH – WEEKLY % & MONTHLY

STATS

To increase awareness to all divisions regarding their utilisation of TCH

Collecting monthly patient numbers sent to TCH by Ward.

Send monthly report/STATS to all divisions and NUMS

12. Provision of Care To [provide a patient cantered care

Effectiveness measured through patient satisfaction survey – 6 monthly

On HBCIS (PMI)patients transferred to TCH

Pt details added to TCH access database

Care Given documented in patient clinical record

Pt discharged in HBCIS

Management of Discharged Patients in TCH

Management of Admissions : Routine & Emergent

On HBCIS patient transferred to TCH

Pt details added to TCH access database

Pts treating team notified. Medical admission and initial treatment is commenced in TCH

Nursing care given and documented in pts. clinical record. Pt transferred to ward when bed available

Patient details, arrival time, mode of transport added to TCH access database

Liaise with all OPD dept. & radiology dept. and send patients to their OPD clinic with wards-men

Liaise with various transport companies to facilitate their return and update return on database

Management of Outpatients

Improvements and strategies to Increase Utilisation • Implementation of the new client focused model of care

• Appointment of TCH Nurse Unit Manager • Implementing client focused work instructions and processes

• Recruiting staff with multi-skilled clinical experience, problem solving and communication skills

• Improving awareness and communication between TCH internally and

externally • Reporting activity to all divisions

• Pull strategy

Pull Strategy

Hospital Bed Occupancy audit results showed:

• High number of discharge patients waiting in inpatient beds who could

be managed in TCH.

PULL Rounds:

• Conducted by NUM/CN of TCH

• Liaise with ED In-Charge every morning regarding any suitable

admissions waiting for ward bed.

• Liaise with patient flow unit every morning

• Attend bed meeting to get update of all the wards & prioritise rounds

• Ward rounds- meet up with nurse in charge, discharge facilitators and

case managers with all definite & potential discharges.

• Start pulling patients to TCH

Where from Here ….. • Patient Satisfaction Survey • Review of the pull strategy • Change the seating arrangement for patients • Clinical skills for staff development • Ongoing review of processes to improve the utilisation of TCH

As hospitals weigh the merits of implementing, continuing, or

disbanding a TCH, it should be noted that if a TCH is going to

work, it must be professionally staffed, well equipped and led by

someone who is passionate about patient flow.

QUESTIONS