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Irish National Acute Medicine Programme Patient Flow Model O’Reilly O, Courtney G, Casey A* Problem Patients requiring urgent care experienced long delays. The National Acute Medicine Programme established a new model of care streaming acutely unwell medical patients away from ED into Acute Medical Assessment Units in all 33 Irish hospitals. Aims Quality and Safety – patients to be seen by a Nurse within 20 minutes and Senior Doctor within 1 hour of arrival. Access – the patient journey through the urgent care pathway not to exceed 6 hours and eliminate trolleys waits for medical patients. Cost and Value – change processes; increase ambulatory care, reduce overnight admissions and shorten length of stay, resulting in bed day savings. Flow Model Patients are now referred directly for admission from GPs to the Acute Medical Assessment Unit, self referring patients present to ED and have rapid nurse triage. Medical patients in triage category 2 and 3 are referred promptly to the AMAU, shortening the patient experience time. This has decongested ED and radically reduced medical trolley waits. Demand Capacity Modelling The Planning number (PN) is calculated at 84 th centile of daily weekday demand. The number of assessment beds calculated at PN/3, number of short stay beds and ward beds calculated by applying target demand benchmarks and lengths of stay. KPIs Mirror Pathway – 4 Areas of Intervention 1. Assess and Avoid Admission - target 25% Interventions; adequate assessment area, senior decision makers, access to rapid diagnostics. All patients have Early Warning Score within 20 minutes. Close liaison with discharge planner, clear pathways to frail elderly service, stroke unit, CCU, community supports. 2. Short Stay – target 31% to have a length of stay less than 48 hours. Interventions include; adequately sized short stay unit, all patients to be seen by Consultant within 12 hours of transfer from assessment, twice daily Consultant ward rounds, priority for diagnostics, white boards with visible data, regular team “huddle” to determine progress. 3. processing of ordinary patients – target less than 44% of patients to have a length of stay greater than 48 hours. Interventions include; daily ward rounds, weekend nurse enabled discharges, active discharge planning, liaison with carers and community supports, transport. 4. Appropriate Care and Discharge of Complex Patients – target less than 11% of patients to have an LOS greater than 14 days. Interventions; early assessment and identification of complex patients, streaming to geriatric service. Proactive discharge planning, liaison with funding agencies for community placements and supports. The acute medicine pathway has helped the health service manage this demand, despite 21% overall increase in medical discharges, the pathway resulted in 15% increase in avoided medical admissions and only a 6% increase in overnight admissions. The overnight length of stay decreased by 6% and hence no additional beds were required. Key Messages National and local clinical and managerial leadership coalition. Explicit flow model, with quantified demand and capacity calculations for each hospital National monthly monitoring of standard KPIs mirroring pathway performance and feedback Demonstration of the power of data to clinicians and managers to change practice Capacity of assessment and short stay wards to be sized for expected demand, short stay unit as a buffer zone, patients to be pulled first from short stay. Buy in from hospital physician groups, identifying win win scenarios 33% decrease in 30 day rolling average for trolley waits Contact Dr. Orlaith O’Reilly – *Acute Medicine Programme Team; Prof G. Courtney, Dr. O O’Reilly, Ms A Casey, Ms. AM Keown, Ms. E Data Source: HIPE, ESRI © Acute Medicine Programme Ireland RESULTS There has been an increased demand for unscheduled care services; an 11% increase in emergency admissions to all specialties between 2006 and 2013 and a 4% increase in ED attendances.
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