Inter-Hospital Transfer Project Standards for transfer

1. Inter-Hospital Transfer ProjectStandards for transfer Bel Macfie Project Manager / Clinical Nurse Director 021 761890 belinda.macfie@waikatodhb.health.nz My name is Belinda Macfie, CND from Waikato DHB, and since March this year I have been seconded to a project about IHTsMy name is Belinda Macfie, CND from Waikato DHB, and since March this year I have been seconded to a project about IHTs

2. Purpose of the IHT project The IHT project commenced in March 2011 and runs until March 2012. The purpose of the project is to improve inter-hospital patient transfers systems by addressing and improving current complex communication systems throughout the chain of referral and transfer processes improving the coordination of transfer processes between hospitals in Midland addressing current uncoordinated transfer systems between Waikato Hospital and Waikato rural hospitals to address workforce issues and inefficiencies, and improve transfer processes identifying benefits of, and make recommendations for a future Midland wide transfer system that will improve efficiencies and patient safety as a whole-of-region approach The project aims to develop and implement a transfer system which addresses and improves communication and lack of coordination between hospitals. Each DHB has an assigned project lead to complete the local transfer work and feed into a preferred Midland wide system The scope is inter-hospital transfers for emergency/trauma/time-critical patients, as well as acute arranged admissions (and consideration of travelling outpatients for Tairawhiti). It is regional and interagency. The project aims to develop and implement a transfer system which addresses and improves communication and lack of coordination between hospitals. Each DHB has an assigned project lead to complete the local transfer work and feed into a preferred Midland wide system The scope is inter-hospital transfers for emergency/trauma/time-critical patients, as well as acute arranged admissions (and consideration of travelling outpatients for Tairawhiti). It is regional and interagency.

3. The current system Referring clinicians making many calls. Poor communication and time delays Inconsistent decision making about when to transfer Hospitals being bypassed inappropriately or not being bypassed when patients need to get to higher level of definitive care Issues with logistical coordination of transfers Inability for some retrieval teams to respond due to staffing Increasing numbers of complaints, incidents and serious events involving transfers Lots of well intentioned tinkering with smaller components of the system but no overall Midland view or approach Lack of standards and agreed processes for all of the above Everyone with all best intentions is working in a complex system which doesnt support efficiencies. Organisations currently experience Unnecessary service and transport costs Considerable waste in resources Poorer patient outcomes Poorer patient and family satisfaction Staff stress and frustrationEveryone with all best intentions is working in a complex system which doesnt support efficiencies. Organisations currently experience Unnecessary service and transport costs Considerable waste in resources Poorer patient outcomes Poorer patient and family satisfaction Staff stress and frustration

4. Process mapping The first activity we completed was inviting specific clinicians and stakeholders in each DHB to map the current transfer process. This is mapping a 60 year old patient who goes to Taumarunui Hospital and needs a CT at Waikato. The scenario is typically characterised by the referring clinician making around 15 phone calls, bouncing between departments to get someone to accept the patientsThe first activity we completed was inviting specific clinicians and stakeholders in each DHB to map the current transfer process. This is mapping a 60 year old patient who goes to Taumarunui Hospital and needs a CT at Waikato. The scenario is typically characterised by the referring clinician making around 15 phone calls, bouncing between departments to get someone to accept the patients

5. Standards for transfer What standards are needed to support an efficient transfer system? Through workshops, consultation and many meetings the following themes arose, which all require a standard to be determined, a process to be written and a measurement to be identified to monitor them

6. Essential standards: Referral The initial clinician to clinician discussion Referral and acceptance SMO to SMO wherever possible NP/Senior clinician to SMO for rural hospitals Gold standard? No! THE standard. The question is how are we going to do it? Hotline for critical care/emergency/trauma cases where advice is needed (instead of or prior to referral and includes access by St John staff)

7. Essential standards Clinical Decision Making The accepting clinician then holds the responsibility to trigger the transfer system. Clinical guidelines needed Bypass � what must bypass 1�- 2�, 2�-3�, 3�-4� Capacity of each hospital Clinical priorities of patient decided Clinician recommends preferred type of transport Capacity is about what level of acuity can be treated at each hospital and what resources/equipment they have. There has been a lot of clinical discussion about escalation to a higher level hospital for clinical convenience, especially after hours, which puts secondary and tertiary staff, facilities and patients under pressure. However, like is the case in Thames, it is possible with excellent team planning to reduce overnight transfers to Waikato so patients can remain in their domicile and can undergo appropriate diagnostics the following day. Capacity is about what level of acuity can be treated at each hospital and what resources/equipment they have. There has been a lot of clinical discussion about escalation to a higher level hospital for clinical convenience, especially after hours, which puts secondary and tertiary staff, facilities and patients under pressure. However, like is the case in Thames, it is possible with excellent team planning to reduce overnight transfers to Waikato so patients can remain in their domicile and can undergo appropriate diagnostics the following day.

8. Essential standards Responsibility Regional coordination functions/role Takes call from accepting clinician about the clinical priorities for the patient and preferred transport methods Takes full responsibility for logistical coordination and operational placement of patient Calls back the referring hospital with transfer details Is the main contact person for NorthComm, St John, Air ambulance Two options emerging � regional coordinator - clinician or nurse To be fully regionalised this requires access to all relevant Midland DHB systems and bed management processes or to have a named coordinator 24/7 in each DHB

9. Essential standards Communication Shared systems and real time feedback e.g. St John communicates any road ambulance delays to the regional coordinator point and hospitals communicate delays to St John Key NorthComm role liaises with key Midland wide coordination role Handover standards

10. Essential standards Timely access to care Retrieval teams and patient escort/transit staff (DHB, road and air ambulance) Sub group is looking at centralised stand-alone model (Midland transport team) as a preference, operating from one or two distinct localities Prompt arrival of road/air vehicles with seamless interface (Optima St John) Contingencies (especially for weather or high demand) Expected time for team to be assembled and in the air � 15, 20 or 30 mins? Road transfer standard - to match staff type with patient acuity and vehicle selection. Road transfer systems need reviewing e.g. Some current St John contracts state that RN must escort when journey is over an hour but distance should not be the determinant here. BOP have a policy that states all patients experience the same level of care during interhospital transfers as they do hospital All DHBs have to work together to enable timely access to the most appropriate care. Tertiary ICU clinical directors, even when they have reached bed capacity, believe that they can have beds available within an hour for higher acuity patients, through efficient discharge processes that allow patients to be discharged to HDU or back to their domicile hospital following acute tertiary care episodes Air retrieval teams must also comply with health and safety act 1992 and air standards/flight nurse standards (including training/competence, orientation, clothing/equipment, wellbeing monitoring)Road transfer systems need reviewing e.g. Some current St John contracts state that RN must escort when journey is over an hour but distance should not be the determinant here. BOP have a policy that states all patients experience the same level of care during interhospital transfers as they do hospital All DHBs have to work together to enable timely access to the most appropriate care. Tertiary ICU clinical directors, even when they have reached bed capacity, believe that they can have beds available within an hour for higher acuity patients, through efficient discharge processes that allow patients to be discharged to HDU or back to their domicile hospital following acute tertiary care episodes Air retrieval teams must also comply with health and safety act 1992 and air standards/flight nurse standards (including training/competence, orientation, clothing/equipment, wellbeing monitoring)

11. Essential standards Repatriation Referring hospital kept informed daily of patient progress, EDD Regional coordination centre has a regional/rural link person as a contact as with key accountability for seamless, well-communicated discharge, and improving efficiencies in back loading of vehicles for inter-hospital transfers Use of Optima (St John) to minimise costs of repatriation Referring (regional/rural) hospital ensures planning occurs for bed to be available if patient is returning Referring hospitals must keep track of patients and must aim to take them back as soon as possible �Must take them back� vs. �Don�t have any beds� Discharging hospital has checklist to assist patient if being discharged home directly to another region Discharge quality, timeliness and communication is arguably one of the most inconsistent and uncoordinated activities in health. While this transfer system is trying to ensure that rural and regional patients experience care within the same timeframes as local patients, secondary and tertiary hospitals cannot readily keep taking patients in without having some pretty slick processes to prevent bottlenecks and bed block at the discharge end. Furthermore discharge processes for rural and regional patients need to be improved so that the regional context, discharge timeframes and patient needs are considered e.g. not just given a script when patient will not get home until 9pm on a Friday with no chance of getting medications over the weekendDischarge quality, timeliness and communication is arguably one of the most inconsistent and uncoordinated activities in health. While this transfer system is trying to ensure that rural and regional patients experience care within the same timeframes as local patients, secondary and tertiary hospitals cannot readily keep taking patients in without having some pretty slick processes to prevent bottlenecks and bed block at the discharge end. Furthermore discharge processes for rural and regional patients need to be improved so that the regional context, discharge timeframes and patient needs are considered e.g. not just given a script when patient will not get home until 9pm on a Friday with no chance of getting medications over the weekend

12. Essential standards System monitoring Regional KPIs needed To monitor effectiveness, efficiency, patient safety and reduce waste. To identify pressure points, gaps and where inefficiencies still lie Monitor standards; timeliness to definitive care, time until take off (for retrieval teams), timeframes for patients to receive testing and diagnostics, % of time when confirmation of booking transport occurs, % of time when there is communication about delays (from hospital or transport provider), % of time when discharge cannot occur due to lack of bed availability at referring hospital In some cases it is going to take a philosophical shift from the reactive system we have at present, and more openness, collaboration and transparency between Midland DHBs to truly realise the efficiencies and improvements in patient safety that can be made. An options analysis paper will be developed by the end of the month, outlining details about the components of a preferred system and the implications of each. The plan is to pilot a new system of transfer with Waikato, Lakes and Tairawhiti by the end of the year.In some cases it is going to take a philosophical shift from the reactive system we have at present, and more openness, collaboration and transparency between Midland DHBs to truly realise the efficiencies and improvements in patient safety that can be made. An options analysis paper will be developed by the end of the month, outlining details about the components of a preferred system and the implications of each. The plan is to pilot a new system of transfer with Waikato, Lakes and Tairawhiti by the end of the year.