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Tidying up to be NEAT. Clair Sullivan Princess Alexandra Hospital QuICR. NEAT Team. Dr Judy Flores – Chair, Division of Medicine A/Prof Ian Scott – Director, Internal Medicine Dr Andrew Staib – Deputy Director, Emergency Medicine Dr James Collier – Deputy Director, Emergency Medicine

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Tidying up to be neat

Tidying up to be NEAT

Clair Sullivan

Princess Alexandra Hospital

QuICR


Neat team
NEAT Team

Dr Judy Flores – Chair, Division of Medicine

A/Prof Ian Scott – Director, Internal Medicine

Dr Andrew Staib – Deputy Director, Emergency Medicine

Dr James Collier – Deputy Director, Emergency Medicine

Dr Leena Aggarwal – Director, MAPU

Mr Alan Scanlon - Clinical Data Support, Patient Flow Unit

Dr Georga Cooke - Medical Admin Registrar



What is neat
What is NEAT?

National Emergency Access Target

Aim to have people discharged from hospital or admitted to the ward within 4 hrs of triage

Goal is 77% this year

We started off at 33%....


Wooden spoon
Wooden spoon

Courier Mail

14/12/12

NHPA report

2011-12


Why rush people out of the ed
Why rush people out of the ED?

They can wait in ED till I’m finished clinic

They should stay in ED until all the tests are back: perhaps they will end up under another unit?

It’s nearly time for me to go home, they can go on the list for the after hours reg to admit when they can.



Cautionary tales
Cautionary tales the tests back

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
Harms of ED access block and overcrowding the tests back

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


Harms of ed access block
Harms of ED access block the tests back

Identified as a public health issue similar in magnitude to road toll (Richardson 2012 MJA)


Existing patient journey
Existing Patient Journey the tests back


The patient journey
The Patient Journey the tests back

Mr K 35 year referred from GP with myalgias arthralgias chol 20 trigs 190. He was unable to walk because of the pain. Possible exposure to Dengue

After 1 hour referred to cardiology. Cardiology came to see pt and suggested ID consult. ID over the phone suggested endocrine consult. ED reg made these consults but interrupted by multitrauma, tea break and aggressive patient…

This man spent 6 hrs in ED. No treatment started until endocrine consult. He clearly needed admission at presentation: how can we improve the patient’s experience and our efficiency?






Quick wins
Quick wins Non-compliance

No Bypass

SSW

Gen Ped Rounds

Clinical review committee

Expanding subspec med reg hours

Direct to ward admission form


Direct to ward admission form
Direct to ward admission form Non-compliance

Adopted at MCH RBH


Obviously a complex issue
Obviously a complex issue.. Non-compliance

Problem

Innovations required to improve NEAT performance previously substantially hindered due to differing opinions among clinical areas

Solution

Objective data: enlist a data analyst and a love of graphs


Safety reviews
Safety reviews Non-compliance

  • Weekly NEAT review meetings

    • DOM chair

    • Director of Internal Medicine

    • Director, MAPU

    • Deputy Director, ED

    • Senior medical registrar

    • ADON



So what are the characteristics of those patients who are breaching NEAT?

Can we predict their NEAT risk at triage and expedite their journey? (save time, lives and money)


Pan c study
PAN-C study breaching NEAT?

Princess Alexandra Hospital NEAT Compliance Study

Funded by MACRO Neat


Pan c aim
PAN-C Aim breaching NEAT?

To identify predictors of NEAT non-compliance in patients being admitted to DOM via ED


Pan c methods
PAN-C Methods breaching NEAT?

Real time chart audit

Experienced practising clinician auditing


Pan c results
PAN-C Results breaching NEAT?

38 admissions analysed (full 24hours quota of DOM admissions)

9 of 38 compliant

29 were noncompliant



Pan c results1
PAN-C Results breaching NEAT?

Mean age both groups 65 years

No sig differences (p>0.1) between groups according to age, number of comorbidities, number of drugs, residential care status or mobility impairment


Multiple inpatient referrals
Multiple Inpatient Referrals breaching NEAT?

In NC group: 1 of 9 11%

In NNC group: 7 of 19 37%


Qas and neat compliance
QAS and NEAT Compliance breaching NEAT?

Association with NEAT compliance was significant for arrival by non-QAS means (p=0.04)


Factors causing neat non compliance for admissions1
Factors causing NEAT non-compliance for admissions breaching NEAT?

Preliminary data from PAN-C study chart review

(n=38; 29 non-compliant; 9 compliant)

Mean age both groups 65 years

No sig. differences (p>0.1) between groups according to age, number of co-morbidities, number of drugs, residential care status or mobility impairment


Pan c discussion
PAN-C Discussion breaching NEAT?

Interesting association of multiple inpatient referrals with NNC


Pan c discussion1
PAN-C Discussion breaching NEAT?

Much of this intuitive: if team knows in ED and patient has been referred, likely to have a working diagnosis, have some investigations done and be “fast tracked”

Patients arriving via QAS likely to be complex, unwell and have more limited social supports


Pan c
PAN-C breaching NEAT?

More data and multivariate analysis to identify more predicators of NEAT non-compliance

Analysis of those breaching early and those with extended stays

Analysis of large diagnoses groups (chest pain and SOB account for half these patients)

Considering the process of multiple inpatient referrals

Verifying the model

Applying the model



Safety indicators
Safety indicators breaching NEAT?

√ MRSA infection rates unchanged

√ Sentinel events unchanged

? Unplanned transfers to ICU <24 hrs ED admission

√ Did not wait - 6% to 1%



Surely it must be cheaper to spend less time in ed
Surely it must be cheaper to spend less time in ED? breaching NEAT?

Not if you look at funding model for ED

We calculated the cost of an “ED minute” compared to the cost of a “medical ward minute”

$2.51/minute for ED vs 59c/min for ward 5B

Use this novel information to motivate change…


Is neat compliance saving us any money
Is NEAT Compliance saving us any money? breaching NEAT?

Average NEAT savings=NA x NTS x NCS

Mean time July 2012-April 2013

Assumptions: costs stable over that time, mean savings only

NA(number of admissions)

NTS(NEAT time saving):Difference in mean time in ED (648-470=178 mins)

NCS( NEAT cost saving ): ED minute cost-ward minute cost($2.51-$0.62= $1.89)

Mean saving per patient $336.42/patient

Average 30 admissions a day mean saving $10 092.60 /day

Average saving over a year is $3 683 799


Seasonally and Activity Adjusted Calculations breaching NEAT?

ED cost 2.51

5B cost 0.59

Difference 1.92

Average time for April 2011 633.78 minutes

Average time for April 2013 410.34 minutes

Average Patients per day in April 11 26 Patients

Average Patients per day in April 13 31 Patients

ED LOS 2011 (633.78x26) 16478.28 Minutes per day

ED LOS 2011 (410.34x31) 12720.54 Minutes per day

Difference in LOS for 2011 to 2013 3757.74

Cost Savings per day (3757.74 x (2.51 - 0.59) $7,214.86

Cost savings for April $216,445.82

Cost Savings for year $2,597,349.89


Benchmarking
Benchmarking breaching NEAT?

PAH underperforming

Study trip to WA (AAU)

RBH flex bed unit

MCH all medical admissions on ward (low volume admissions)

No one really been able to solve the ED-med reg referral time….


So where to now
So where to now? breaching NEAT?

Three main problems:

1.ED-DOM referral time

2.Occupancy

3.Data


Agreed principles for solution design
Agreed Principles for Solution Design breaching NEAT?

Keep the patient at the centre of our solution

Evidence based

Efficient (training, financial consideration)

Ongoing review and safety monitoring


Data breaching NEAT?

Difficult to access data in meaningful time frame

No dedicated data manager

Hopefully will improve in 3 mths with new software


Occupancy
Occupancy breaching NEAT?

Strategies underway to improve patient discharges

Difficult because of tension between NEAT and NEST

Strategies include:

HITH, public private partnerships, predictive bed management and the “stranded patient” project


Ed dom referral time
ED-DOM referral time breaching NEAT?

Median approx 200mins

This makes med reg review and bed allocation within 240 mins unlikely

Difficult to improve this time without major ED process changes (“process mapped to death at RBH)

MAZE (Medical Admission Zone)


MAZE breaching NEAT?

What?

Patients likely to need ED admission are admitted to MAZE to continue ED review and refer to med reg

PANC data used to help identify early

MAZE cleaved from MAPU

MAZE beds have same priority as ED for bed booking


A recent innovation at RBH is the introduction of flex beds (8 beds 3 trolleys)in an area similar to a transit lounge where patients who have been referred to the medical registrar await admission (under the governance of the inpatient unit). A similar unit at GCH has attracted recent negative media exposure although the true nature of issues there remain unclear.


MAZE (8 beds 3 trolleys)in an area similar to a transit lounge where patients who have been referred to the medical registrar await admission (under the governance of the inpatient unit). A similar unit at GCH has attracted recent negative media exposure although the true nature of issues there remain unclear.

Cost?

Minimal mostly related to increased bed turnover (cleaning etc)


MAZE (8 beds 3 trolleys)in an area similar to a transit lounge where patients who have been referred to the medical registrar await admission (under the governance of the inpatient unit). A similar unit at GCH has attracted recent negative media exposure although the true nature of issues there remain unclear.

How?

Pilot study: convert 4 MAPU beds to MAZE then review after 6 weeks

Priority area (radiology, pathology, beds)

Strict safety monitoring

ED-MAZE vs DOM-MAZE


Ed maze
ED-MAZE (8 beds 3 trolleys)in an area similar to a transit lounge where patients who have been referred to the medical registrar await admission (under the governance of the inpatient unit). A similar unit at GCH has attracted recent negative media exposure although the true nature of issues there remain unclear.

There would be no change in the governance of the patients moved to this unit until seen and accepted by the medical registrar (exactly the same process as now).

The beds would be staffed by MAPU or ED nurses and the patients cared for by the ED medical team until seen by the medical registrar.

It is imperative that beds booked from MAZE have precedence for allocation or the proposal will fail. It is anticipated most patients will remain in MAZE for 2-3 hours


Risks of ed maze
Risks of ED-MAZE (8 beds 3 trolleys)in an area similar to a transit lounge where patients who have been referred to the medical registrar await admission (under the governance of the inpatient unit). A similar unit at GCH has attracted recent negative media exposure although the true nature of issues there remain unclear.

Loss of MAPU beds for other purposes (although 84% occupancy much of the time currently)

Bed block in MAZE

Need to be clear about governance


Benefits of ed maze
Benefits of ED-MAZE (8 beds 3 trolleys)in an area similar to a transit lounge where patients who have been referred to the medical registrar await admission (under the governance of the inpatient unit). A similar unit at GCH has attracted recent negative media exposure although the true nature of issues there remain unclear.

Improved time-motion for admitting after hours med reg

Improved medical inpatient NEAT performance


Dom maze
DOM-MAZE (8 beds 3 trolleys)in an area similar to a transit lounge where patients who have been referred to the medical registrar await admission (under the governance of the inpatient unit). A similar unit at GCH has attracted recent negative media exposure although the true nature of issues there remain unclear.

In this model the MAPU will be converted to an Acute Admitting Unit similar to those we have reviewed in WA. ED would decide that a patient is likely to need medical admission and transfer to DOM-MAZE. It is likely only basic investigations would be undertaken in ED prior to transfer to DOM-MAZE.


Dom maze1
DOM-MAZE (8 beds 3 trolleys)in an area similar to a transit lounge where patients who have been referred to the medical registrar await admission (under the governance of the inpatient unit). A similar unit at GCH has attracted recent negative media exposure although the true nature of issues there remain unclear.

Part time or full time?

Once transferred to DOM-MAZE, the patients would become the responsibility of DOM. This would require an increase in DOM resources.


Risks of dom maze
Risks of DOM-MAZE (8 beds 3 trolleys)in an area similar to a transit lounge where patients who have been referred to the medical registrar await admission (under the governance of the inpatient unit). A similar unit at GCH has attracted recent negative media exposure although the true nature of issues there remain unclear.

Loss of MAPU beds for other purposes (although 84% occupancy much of the time currently)

Bed block in DOM- MAZE

Need to be clear about governance

Loss of continuity for patients admitted by one registrar than cared for by another (although this is usual currently for those admitted outside business hours). This could be minimised by calling subspec registrars for admissions to their unit to be done in DOM-MAZE or the patient being transferred from DOM-MAZE to the appropriate inpatient ward.

Potential confusion regarding subspecialty vs gen med admission for some patients

Very sick or non-medical patients being transferred to DOM-MAZE by ED


Benefits of dom maze
Benefits of DOM-MAZE (8 beds 3 trolleys)in an area similar to a transit lounge where patients who have been referred to the medical registrar await admission (under the governance of the inpatient unit). A similar unit at GCH has attracted recent negative media exposure although the true nature of issues there remain unclear.

Patients receive DOM care earlier

Improved time-motion for admitting after hours med reg

Improved medical inpatient NEAT performance

New resources for DOM

Research and teaching opportunities for DOM


Critical success factors
Critical Success Factors (8 beds 3 trolleys)in an area similar to a transit lounge where patients who have been referred to the medical registrar await admission (under the governance of the inpatient unit). A similar unit at GCH has attracted recent negative media exposure although the true nature of issues there remain unclear.

Support from team

Support from exec

Maintaining patient safety

Budget

Remaining patient focussed

Good communication and engagement with our team


Potential problems
Potential Problems (8 beds 3 trolleys)in an area similar to a transit lounge where patients who have been referred to the medical registrar await admission (under the governance of the inpatient unit). A similar unit at GCH has attracted recent negative media exposure although the true nature of issues there remain unclear.

Understand a complex problem and reaching consensus for action

Budget (our cost benefit analysis may help here)

Accessible and timely data to assess performance

Initiating and maintaining change


Next steps
Next Steps (8 beds 3 trolleys)in an area similar to a transit lounge where patients who have been referred to the medical registrar await admission (under the governance of the inpatient unit). A similar unit at GCH has attracted recent negative media exposure although the true nature of issues there remain unclear.

PANC risk generation engine

MAZE pilot

Data management

Occupancy strategies

Patient experiences

Ongoing weekly review safety and costs analysis


The patient journey1
The Patient Journey (8 beds 3 trolleys)in an area similar to a transit lounge where patients who have been referred to the medical registrar await admission (under the governance of the inpatient unit). A similar unit at GCH has attracted recent negative media exposure although the true nature of issues there remain unclear.

Mr K 35 year referred from GP with myalgias arthralgias chol 20 trigs 190. He was unable to walk because of the pain. Possible exposure to Dengue

After 1 hour and basic bloods the decision made by ED that he will likely need admission.

Discharged to MAZE and med reg reviews within 2 hours and treatment commenced.


Onwards and Upwards… (8 beds 3 trolleys)in an area similar to a transit lounge where patients who have been referred to the medical registrar await admission (under the governance of the inpatient unit). A similar unit at GCH has attracted recent negative media exposure although the true nature of issues there remain unclear.


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