the Emergency Department (ED) of more than 24 …...Between February and June 2019, only two mental...
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Acknowledgements • Todd McEwan – Director of Acute Care Services, SVHS – Project Executive Sponsor • Agency for Clinical Innovation, NSW Ministry of Health • Anna Thornton – Director of Nursing, SVHS – Project Authorising Sponsor • A/Prof Anthony Schembri – CEO, SVHS • ED Governance Steering Committee, SVHS • Hospital Staff, SVHS • Dr Emily Stone – Staff Specialist, Thoracic Medicine, SVHS – Project clinical lead • Erin Hudswell – Nurse Manager – Patient Flow, SVHS • Kathryn Zeitz – Interim Director, Medicine Stream, SVHS (2017-2018) • Jessica Moran – Manager Clinical Redesign at Gosford Hospital, CCLHD • Dr Mark Benzimra – Staff Specialist, Thoracic Medicine, SVHS • Dr Nicholas Babidge – Director of Mental Health, Head of Psychiatry, SVHS – Project clinical lead • Dr Allan Cameron – Consultant Physician, NHS Greater Glasgow and Clyde, UK • A/Prof Sandy Beveridge – Staff Specialist, Director of Gerontology, SVHS – Project clinical lead • Saarte Berendsen Russell – Nurse Researcher, RPAH ED, SLHD • Shiraz Abdulla – Operational Nurse Manager, SVHS • Sue Cowling – Nurse Unit Manager, ED, St Vincent’s Hospital, Melbourne • Susan O’Shea – Whole of Health Lead, SVHS • Viji Joseph Mathews – Service Improvement and Redesign Manager, SVHS • Vivien Pollnow and Joyce Low – Consumer Representatives, SVHS Conclusion Project findings and solutions can be shared with other local health districts aiming to reduce and eliminate extended stays in their EDs. This project has been the catalyst for other improvement initiatives, including three other teams from SVHS currently attending the Centre for Healthcare Redesign program. Results Progress towards objective There is a downward trend towards achieving the objective of zero patients staying in ED for more than 24 hours as demonstrated in Figure 1. This trend began post-implementation of the Quick wins in August and September 2018. Key area of improvement contributing to progress towards objective Between February and June 2019, only two mental health patients stayed more than 24 hours in ED (as highlighted in Figure 2). This is a Ministry Key Performance indicator (KPI) with a target of zero. 6 Less time in ED: Zero tolerance for patients with extended stays in the Emergency Department (ED) of more than 24 hours Dr Nerida Creswick, Dr Farzad Jazayeri, Anthony Browne RN, Phil Winters CNS, St Vincent’s Hospital Sydney Sustaining change Daily and weekly reporting meetings have provided a mechanism to identify and monitor areas of improvement across the SVHS health service. Continued leadership, transparency and increased accountability in the organisation will result in a sustained organisational focus – no patient will stay in ED greater than 24 hours. At the recent SVHS Annual Safety and Quality Forum, the CEO spoke of the organisation’s priority to have a target of zero patient harm. Meeting our objective will contribute to meeting this target. Contact Name: Dr Nerida Creswick Position: Data Analyst/Project Officer Department: Service Improvement and Redesign Unit, St Vincent’s Hospital, Sydney Email: [email protected] Phone: +61(02) 8382 1723 Solutions design and implementation Initiation Diagnostics Solutions Implementation Planning Evaluation Sustainability The Less Time in ED project’s vision is to achieve a reduced length of stay in ED for all patients presenting to the ED, aligning with St Vincent’s Health Australia’s (SVHA) Mission and Values. Delays in ambulance transfer of care (TOC) result in delays in access to care and ambulances cannot respond to community demand. 4 ED overcrowding has an adverse effect on the ED workforce. 4, 5 Remuneration for increased length of stay hospital acquired complications does not meet the costs incurred caring for these patients. 5 It is a NSW Ministry of Health (Ministry) Improvement Measure that zero patients have extended stays in ED > 24 hours. 6 Goal and vision To achieve nil (zero) patients with an extended stay > 24 hours in ED at St Vincent’s Hospital Sydney by November 2019. Objective Method The Centre for Healthcare Redesign methodology was used for this project, in collaboration with the Agency for Clinical Innovation, the senior hospital executive, clinical staff and consumer representatives at SVHS. Case for change In 2017/18, 745 patients had an extended stay in the St Vincent’s Hospital Sydney (SVHS) Emergency Department (ED) greater than 24 hours. Research clearly demonstrates that these patients are more likely to: • Suffer falls. 1 • Clinically deteriorate. 1,2 • Acquire infections. 2,3,4, • Stay longer in hospital. 2,3,4 • Experience delays in treatment. 3,4 “I spent 52 hours in St Vincent’s Public Hospital Emergency Department without being fed for 18 hours. The staff were amazing and overworked but there were no beds in either private or public wards.” “I spent 52 hours in St Vincent’s Public Hospital Emergency Department without being fed for 18 hours. The staff were amazing and overworked but there were no beds in either private or public wards.” Weekly Patient Case Studies Literature Review 1. The clinical outcomes for patients who stay in ED > 24 hours. 1,2,3,4 2. The possible financial costs to SVHS if a patient breaches 24 hours in ED. 5 3. In support of the 3 solutions, including use of Patient Care Boards in the acute and subacute clinical. setting. Patient and staff safety and experience Timely planning and decision making Better and improved care coordination across the hospital User friendly systems and tools Staff accountability References 1. Samaras N, Chevaley T, Samaras D and Gold G (2010). Older Patients in the Emergency Department: A review. Annals of Emergency Medicine, Volume 56, Issue 3. September 2010. pp 261 – 209). 2. Singer AJ, Thode HC Jr, Vicello P and Pines JM (2011) The Association Between Length of Emergency Department Boarding and Mortality. Academic Emergency Medicine, Volume 18, issue 12, pp. 1324 – 1329. 3. Pines JM and Hollander JE. Emergency Department crowding is associated with poor care for patients in severe pain. Annals of Emergency medicine. 2008. Jan; 51(1), pp. 1-5. 4. Forero R, Hillman K, McCarthy S, Fatovich D, Joseph A and Richardson DW. Access block and emergency department overcrowding. Emergency Medicine Australasia. 2010. 22, pp. 119-135. 5. Duckett S, Jorm C, Moran G, and Parsonage H. (2018). Safer care saves money: how to improve patient care and save public money at the same time. Grattan Institute. 6. NSW Health. 2018-19 KPI and Improvement Measure Data Supplement. Emergency Department Extended Stays: Presentations staying in ED > 24 hours, pp 321 – 322. Accessed 8/1/2019. 7. Australian Commission on Safety and Quality in Health Care. National Safety and Quality Health Service Standards (NSQHS): ed. 2 2017. Standard 2: Partnering with Consumers. Decreased falls and clinical deterioration Patient centred care and discharge planning Decreased hospital acquired infections Improved patient and staff satisfaction Solution / Initiative Area Solution 1 Solution 2 Solution 3 Nov Dec Jan Sep Oct Feb May Jun 2019 2020 Jul Design, test and implement a patient disposition tool to aid medical decision making when deciding if a patient is safe for discharge or requiring admission to hospital. Escalation of patients in ED > 12 hours and > 20 hours as part of the Hospital Demand and Capacity Escalation plan Bedside patient care boards need to be updated daily by the MDT in full consultation with patients and their families. 7 Aug Development Development Communication and Education Communication and Education Refinement Refinement Roll out to all Roll out to all Implementation Implementation Development of measurement system Development of measurement system Evaluation Evaluation Evaluation Evaluation Evaluation Evaluation Consultation Consultation Exec Approval Exec Approval Final version Final version Implementation Implementation Consultation Consultation Consultation Consultation Development Development Develop measurement system Develop measurement system Phase I Implementation Phase I Implementation Roll out to all Roll out to all Literature review of tools Literature review of tools Design and testing of tool Design and testing of tool Project milestones to date • August 2018 Weekly reporting at Tier 3 Performance Board • September 2018 “Mary campaign” across the hospital • July 2019 Bedside patient care board use commenced in three wards • August 2019 Demand and Capacity Escalation plan (Solution 1) approved by Executive for implementation 60 68 38 43 54 59 69 91 59 63 50 134 124 88 31 45 44 32 14 29 19 4 16 33 0 20 40 60 80 100 120 140 160 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Pts in ED > 24 hrs Target: 0 11 13 6 8 11 13 14 5 3 10 5 1 7 1 00 1 0 0 2 4 6 8 10 12 14 16 Mental Health Pts >24 hrs in ED Target: 0 (as per NSW MOH Service Level Agreement 18/19) In the last five months, only two mental health patients stayed more than 24 hours Figure 1. Number of patients who stayed in St Vincent’s Hospital Sydney ED for more than 24 hours Figure 2. Mental Health patients who stayed in SVHS ED > 24 hours Figure 3. Patient care board completion rate Quick win 2: Launch of “Mary” campaign by CEO Bedside Patient Care Board use commenced in three wards Quick win 1: Weekly performance board reporting began Process improvement Patient care boards completion improved by 66%-points (Figure 3). When asked by a consumer representative what the multi- disciplinary team (MDT) had discussed when writing on your Patient Care Board, a Gorman Unit patient commented: “I was asked about my goals – a good thing, especially as I am detoxing.” Week 2 = 86% Week 1 = 69% 25 out of 30 Falls Risk & Mobility were completed 18 out of 30 Diets were recorded 26 out of 30 PCBs had at least one goal recorded had the correct date and names of the patient and nurse recorded 26 out of 30 PCBs 17 out of 30 Rehabilitation Unit had an EDD
Transcript of the Emergency Department (ED) of more than 24 …...Between February and June 2019, only two mental...
Acknowledgements• Todd McEwan – Director of Acute Care Services, SVHS – Project Executive Sponsor• Agency for Clinical Innovation, NSW Ministry of Health• Anna Thornton – Director of Nursing, SVHS – Project Authorising Sponsor• A/Prof Anthony Schembri – CEO, SVHS• ED Governance Steering Committee, SVHS• Hospital Staff, SVHS• Dr Emily Stone – Staff Specialist, Thoracic Medicine, SVHS – Project clinical lead• Erin Hudswell – Nurse Manager – Patient Flow, SVHS• Kathryn Zeitz – Interim Director, Medicine Stream, SVHS (2017-2018)• Jessica Moran – Manager Clinical Redesign at Gosford Hospital, CCLHD• Dr Mark Benzimra – Staff Specialist, Thoracic Medicine, SVHS• Dr Nicholas Babidge – Director of Mental Health, Head of Psychiatry, SVHS – Project clinical lead• Dr Allan Cameron – Consultant Physician, NHS Greater Glasgow and Clyde, UK• A/Prof Sandy Beveridge – Staff Specialist, Director of Gerontology, SVHS – Project clinical lead• Saarte Berendsen Russell – Nurse Researcher, RPAH ED, SLHD• Shiraz Abdulla – Operational Nurse Manager, SVHS• Sue Cowling – Nurse Unit Manager, ED, St Vincent’s Hospital, Melbourne• Susan O’Shea – Whole of Health Lead, SVHS• Viji Joseph Mathews – Service Improvement and Redesign Manager, SVHS• Vivien Pollnow and Joyce Low – Consumer Representatives, SVHS
Conclusion Project findings and solutions can be shared with other local health districts aiming to reduce and eliminate extended stays in their EDs. This project has been the catalyst for other improvement initiatives, including three other teams from SVHS currently attending the Centre for Healthcare Redesign program.
ResultsProgress towards objective
There is a downward trend towards achieving the objective of zero patients staying in ED for more than 24 hours as demonstrated in Figure 1. This trend began post-implementation of the Quick wins in August and September 2018.
Key area of improvement contributing to progresstowards objective
Between February and June 2019, only two mental healthpatients stayed more than 24 hours in ED (as highlighted inFigure 2). This is a Ministry Key Performance indicator(KPI) with a target of zero.6
Less time in ED:Zero tolerance for patients with extended stays in
the Emergency Department (ED) of more than 24 hoursDr Nerida Creswick, Dr Farzad Jazayeri, Anthony Browne RN, Phil Winters CNS, St Vincent’s Hospital Sydney
Sustaining change Daily and weekly reporting meetings have provided a mechanism to identify and monitor areas of improvement across the SVHS health service. Continued leadership, transparency and increased accountability in the organisation will result in a sustained organisational focus – no patient will stay in ED greater than 24 hours. At the recent SVHS Annual Safety and Quality Forum, the CEO spoke of the organisation’s priority to have a target of zero patient harm. Meeting our objective will contribute to meeting this target.
ContactName: Dr Nerida CreswickPosition: Data Analyst/Project OfficerDepartment: Service Improvement and Redesign Unit, St Vincent’s Hospital, Sydney
Email: [email protected]
Phone: +61(02) 8382 1723
Solutions design and implementation
Initiation Diagnostics Solutions Implementation Planning
EvaluationSustainability
The Less Time in ED project’s vision is to achieve a reduced length of stay in ED for all patients presenting to the ED, aligning with St Vincent’s Health Australia’s (SVHA) Mission and Values.
Delays in ambulance transfer of care (TOC) result in delays in access to care and ambulances cannot respond to community demand.4ED overcrowding has an adverse effect on the ED workforce.4, 5
Remuneration for increased length of stay hospital acquired complications does not meet the costs incurred caring for these patients.5It is a NSW Ministry of Health (Ministry) Improvement Measure that zero patients have extended stays in ED > 24 hours.6
Goal and vision
To achieve nil (zero) patients with an extended stay > 24 hours in ED at St Vincent’s Hospital Sydney by November 2019.
Objective
MethodThe Centre for Healthcare Redesign methodology was used for this project, in collaboration with the Agency for Clinical Innovation, the senior hospital executive, clinical staff and consumer representatives at SVHS.
Case for changeIn 2017/18, 745 patients had an extended stay in the St Vincent’s Hospital Sydney (SVHS) Emergency Department (ED) greater than 24 hours. Research clearly demonstrates that these patients are more likely to:• Suffer falls.1• Clinically deteriorate. 1,2
• Acquire infections. 2,3,4,
• Stay longer in hospital. 2,3,4
• Experience delays in treatment. 3,4
“I spent 52 hours in St Vincent’s Public Hospital Emergency Department without being fed for 18 hours. The staff were
amazing and overworked but there were no beds in either private or public wards.”
“I spent 52 hours in St Vincent’s Public Hospital Emergency Department without being fed for 18 hours. The staff were
amazing and overworked but there were no beds in either private or public wards.”
Weekly Patient Case Studies
Literature Review1. The clinical outcomes for patients
who stay in ED > 24 hours.1,2,3,4
2. The possible financial costs to SVHS if a patient breaches 24 hours in ED.5
3. In support of the 3 solutions, including use of Patient Care Boards in the acute and subacute clinical. setting.
Patient and staff safety and experience
Timely planning and decision
making
Better and improved care coordination
across the hospital
User friendly systems and
tools
Staff accountability
References1. Samaras N, Chevaley T, Samaras D and Gold G (2010). Older Patients in the Emergency Department: A
review. Annals of Emergency Medicine, Volume 56, Issue 3. September 2010. pp 261 – 209).2. Singer AJ, Thode HC Jr, Vicello P and Pines JM (2011) The Association Between Length of Emergency
Department Boarding and Mortality. Academic Emergency Medicine, Volume 18, issue 12, pp. 1324 – 1329.3. Pines JM and Hollander JE. Emergency Department crowding is associated with poor care for patients in severe
pain. Annals of Emergency medicine. 2008. Jan; 51(1), pp. 1-5. 4. Forero R, Hillman K, McCarthy S, Fatovich D, Joseph A and Richardson DW. Access block and emergency
department overcrowding. Emergency Medicine Australasia. 2010. 22, pp. 119-135. 5. Duckett S, Jorm C, Moran G, and Parsonage H. (2018). Safer care saves money: how to improve patient care
and save public money at the same time. Grattan Institute. 6. NSW Health. 2018-19 KPI and Improvement Measure Data Supplement. Emergency Department Extended
Stays: Presentations staying in ED > 24 hours, pp 321 – 322. Accessed 8/1/2019. 7. Australian Commission on Safety and Quality in Health Care. National Safety and Quality Health Service
Standards (NSQHS): ed. 2 2017. Standard 2: Partnering with Consumers.
Decreased falls and clinical deterioration
Patient centred care and discharge planning
Decreased hospital acquired infections
Improved patient and staff satisfaction
Solution / InitiativeArea
Solutio
n 1
Solutio
n 2
Solutio
n 3
Nov Dec JanSep Oct FebMay Jun2019 2020
Jul
Design, test and implement a patient disposition tool to aid medical decision making when deciding if a patient is safe for discharge or requiring admission to hospital.
Escalation of patients in ED > 12 hours and > 20 hours as part of the Hospital Demand and Capacity Escalation plan
Bedside patient care boards need to be updated daily by the MDT in full consultation with patients and their families. 7
Aug
DevelopmentDevelopmentCommunication and EducationCommunication and Education
RefinementRefinement
Roll out to allRoll out to all
ImplementationImplementation
Development of measurement systemDevelopment of measurement system
EvaluationEvaluation
EvaluationEvaluation
EvaluationEvaluation
ConsultationConsultation
Exec ApprovalExec Approval
Final versionFinal version
ImplementationImplementation
ConsultationConsultation
ConsultationConsultationDevelopmentDevelopment
Develop measurement system
Develop measurement system
Phase I ImplementationPhase I ImplementationRoll out to allRoll out to all
Literature review of toolsLiterature review of tools
Design and testing of toolDesign and testing of tool
Project milestones to date• August 2018 Weekly reporting at Tier 3 Performance Board
• September 2018 “Mary campaign” across the hospital
• July 2019 Bedside patient care board use commenced in three wards
• August 2019 Demand and Capacity Escalation plan (Solution 1) approved by Executive for implementation
60 68
38
4354 59 69
91
59
63
50
134 124
88
31
45 4432
14
29 194
1633
0
20
40
60
80
100
120
140
160
Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19Mar-19 Apr-19 May-19 Jun-19
Pts in ED > 24 hrs Target: 0
1113
68
111314
53
10
5
1
7
1 0 0 1 00
2
4
6
8
10
12
14
16
Mental Health Pts >24 hrs in ED Target: 0 (as per NSW MOH Service Level Agreement 18/19)
In the last five months, only two mental health patients stayed more than 24 hours
Figure 1. Number of patients who stayed in St Vincent’s Hospital Sydney ED for more than 24 hours
Figure 2. Mental Health patients who stayed in SVHS ED > 24 hours Figure 3. Patient care board completion rate
Quick win 2: Launch of “Mary”campaign by CEO
Bedside Patient Care Board usecommenced in three wards
Quick win 1: Weekly performanceboard reporting began
Process improvement
Patient care boards completion improved by 66%-points (Figure 3). When asked by a consumer representative what the multi-disciplinary team (MDT) had discussed when writing on your Patient Care Board, a Gorman Unit patient commented: “I was asked about my goals – a good thing, especially as I am detoxing.”
Week 2 = 86%Week 1 = 69%
25 out of 30Falls Risk & Mobility were completed
18 out of 30Diets were recorded
26 out of 30 PCBshad at least one goal recorded
had the correct date and names of the patient and nurse recorded
26 out of 30 PCBs
17 out of 30
Rehabilitation Unit
had an EDD
