1. Valuing Our Patients’ Time - Adult ED Bed Request to Ward Admission
- Children’s ED
26th March 2012
Jane Lees
Joyce Forsyth
Tim Denison
Dr. Richard Aickin 1

2. Auckland City Hospital
Auckland City Hospital opened in It brings together the services of Auckland, Greenlane Clinical Centre and National Women's Health into one building, and links with Starship Children's Health
Capacity of 1063 on nine floors
Tertiary referral hospital with regional and national centre's
Teaching Hospital with close links to the University of Auckland
Our goals are to • Lift the health of people in Auckland City • Lead performance improvement • Live within our means

3. Where We Began… Auckland Q1 2009 70% < 6 Hours
84% < 6 Hrs)
62% < 6 Hrs)
Source: Working Group for Achieving Quality in Emergency Departments Recommendations to Improve Quality and the Measurement of Quality in New Zealand Emergency Departments. Wellington: Ministry of Health.

4. 2008 & 2009 Baseline for Admitted Patients: 44% < 6 Hours
Adult Performance to 6 hour goal to 2012
2008 & 2009 Baseline for Admitted Patients: 44% < 6 Hours

5. Count of Patients with > 6 Hours in ED by Service
For Inpatient Services, the most opportunity for improvement was in General Medicine, followed by General Surgery and Orthopaedics

6. The Problem: Not just in ED

7. “1-Hour” Project – Bed Request to Ward Admission
Admit to Ward
Admit to Ward
Bed Management
Request Bed
Assess Bed Availability
Assign Bed
“Handover” Patient
Move Patient to Ward

8. Baseline – Bed Request to Ward Admission
Average wait to be transferred to an Inpatient Ward = 8 Hours
8 Hours
7% < 1 Hour
Low is Good

9. Many Causes for Delays to LOS
Primary Root Causes
Delays to LOS  Bed Block
Patients wait for decisions, referrals, reviews, diagnostics, documentation, equipment, treatment, etc… prolonging their stay
Weekend care – sometimes treatment not progressed and patients not discharged
Bed Request to Admit Process
Even when a bed is available it could take hours to admit a patient to a ward
Up to 14 individuals involved and over 50 steps in the process
Many Causes for Delays to LOS
Bed Request to Admit Process
14 Roles
57 Steps (++ Variation)

10. Solutions Implemented

11. Daily Rapid Rounds (1 of 2)
Issue: Patients stay longer in hospital as a result of inadequate communication between doctors, nurses, Allied Health and other multidisciplinary team members
Solution: Daily Rapid Rounds - A short daily ward meeting with nurses, doctors, and Allied Health to coordinate their patients’ plan for hospital stay and make that plan visible on a patient-status-at-a-glance board
Benefits: Great team communication, quick referrals, and quick problem solving means patients wait less and are ready to go home earlier
Charge Nurse
Social Worker
Doctors
Physio-therapist
Occupational Therapist
Staff Nurses
System Updated Live
Ward 68 Daily Rapid Round Team

12. Daily Rapid Rounds (2 of 2)
2011 & 2012
0.4 day reduction in Average LOS
Equivalent to 2,100 bed days per year
Orthopaedics also observed a 2,000 bed day per year benefit after Rapid Rounds

13. Nurse Facilitated Discharging (General Medicine)
Issue: Patients may be ready for discharge but have to wait for next medical ward round
Solution: Senior nurses can discharge patients if patient meets criteria set by medical teams – Nurse Facilitated Discharging is initiated by doctors
Benefits: Reduced LOS, increased weekend discharging, earlier in day and after hours discharging
Successful Weekly Nurse Facilitated Discharges
Before
After
NFD per Week
3 / wk

14. Patient Status at a Glance
Issue: System not up to date with Estimated Discharge Dates, plan for patients stay not visible to ward staff, patient information duplicated on white boards
Solution: 42” monitors, redesigned and colour coded patient status – able to eliminate most physical whiteboards
Benefits: Patient Status at a Glance – saves staff time, easy to see patient’s plan for stay, estimated discharge dates kept up-to-date

15. Rapid Improvement Event
Rapid improvement event (RIE) - part of the Lean methodology and provides a mechanism for making radical changes to current processes and activities within very short timescales.
Week long 5 day event at Auckland City Hospital
Goal – Patient transfer to the ward in nine minutes of Bed allocation
Core Group – ED Charge Nurses, Ward Charge Nurses, Clerical staff, Orderlies, Nurse Advisors, Bed Managers.
Advisory Group – Service Managers
Sponsors – Director of Performance, Nurse Director, Clinical Director Emergency Department

16. Transfer of Care
Issue: Patient handovers were a source of frustration for both AED and ward staff. AED staff: “Handover takes too long as the ward staff ask too many questions”. Ward staff: “Handover information is often inaccurate”
Solution: Standardise process for handover using ISOBAR across wards and AED. Review transfer of care form inline with ISOBAR format. Bedside handover using ISOBAR for AED-APU transfers. Education package.
Benefits: Improved quality of handover, reduced time, improved staff satisfaction

17. Communication
Issue: Phone tag for patient handovers, long wait for a nurse to come to the phone for handover (when asked by ward clerk), AED can’t get through to ward due to engaged phones.
Solution: Handover hotline.
Benefits: Dedicated phone for handover and after hours bed management handover. Reduces ‘waiting’ for calls to be answered. Ward RN carries the phone - eliminates the need for ward clerks to search for RN to take handover.

18. Bed Request Confusion
Issue: No standard process for a Doctor to communicate a bed request Solution: All bed requests to “Flow Coordinator”, Flow Coordinator clearly identifiable with new Green scrub top, and Benefits: Easily identifiable in Green top, 1 point of contact. Reduced frustration with not being able to clearly identify who is performing the ‘flow’ role.

19. Documentation
Issue: Doctor would request bed and leave without completing documentation (A/D Plan, 6-Hour Plan, or communicate patient special needs e.g. sideroom) Solution: Flow Coordinator reviews 10-second checklist with doctor at time of bed request Benefits: Patient is ready for handover at time of bed request. No phone-tag and delay to find out special needs or complete docs

20. Global Transparency
Issue: Poor visibility of available beds at a glance. Solution: Developed intranet web page that displays “flight deck” view of bed status Benefits: Anyone, anywhere in hospital has a view of available beds. Saves time. At a glance view of occupancy and expected discharges within 4hrs

21. Change in Practice
Issue: The Bed/Duty manager response to a bed request was often delayed Solution: AED Flow Coordinator views occupancy using bed status board to and schedules Gen Med patients directly to ward without bed request to bed/duty manager Benefits: Saves time / reduces required communication

22. Orderly Requests
Designated space within ED for orderlies to wait for jobs
Issue: Orderlies were requested by placing a file in “toast rack”. No ability to prioritise requests or whether the orderly were aware of a request. No visibility when request was completed. Orderlies did not have a designated place to wait “on the floor” between jobs. Solution: Requests placed in box with motion detector and light trigger. This can be seen in a new orderly bay and nursing staff can see at a glance if an orderly is requested and when request has been actioned (light goes off). Benefits: Quicker response time, able to escalate if no orderly is visible in bay, can see around department if orderly is requested, fewer calls for orderly over intercom = less interruptions for staff
Place clinical notes in box for orderly request
Light goes on when notes are in box

23. Visual Tools
Issue: Patients and families interrupt flow coordinator and other staff with queries – no way for patients & families to establish where to go to ask questions! Solution: Improved visual management on the AED floor. Red feet at reception area to indicate a place to wait for inquiry. Benefits: Reduced staff interruptions, reduced patient frustration

24. Capacity Triggers
Issue: Unclear escalation response when hospital resourced beds are near capacity
Solution: Monday-Friday daily capacity meeting with service managers and 48 hour bed capacity forecasting
Benefits: Improved utilisation of resourced beds across services including use of ‘flexed beds’, advanced notice of impact to elective patients (last resort)

25. Daily Reporting & Review of Breaches
Issue: Daily 6-Hr performance not visible. Difficult to have timely problem solving.
Solution: Automated report of previous day’s patients who spent over 6 hours in ED ed to staff. Key information for each patient visible to support root-cause analysis.
Benefits: Improved visibility of performance, increased urgency with staff, easy to identify corrective actions in a timely manner, reviewed & coded at daily meeting
Overall Performance
Inpatient Services
Patient Referral Reason
Time Stamps: ED Start, Sign-on, Referral, Inpatient Sign-on, Bed Request, BR Complete, ED End

26. Results Sustained: Sub-measure – When Bed is Ready

27. Results Sustained – ED Bed Request to Ward Admission
80% Reduction in the Time Patients Wait
2010 = 14% < 1hr
2009 = 7.2% < 1hr

28. Outcomes
Green tops
Bed request checklist for documentation special needs
Bed status at a glance
ED can book beds in Gen Med directly
Bed availability –
daily rapid rounds,
nurse facilitated discharging,
flex beds in winter, trigger tool, daily capacity review
Bed availability – Electronic whiteboards & EDDs up to date
Phone tag for patient handover = handover hotline
No standard handover process – ISOBAR implemented
Wait for nurse escort / transit nurse – do not use transit nurses, ED nurse escorts patients when nurse escort required’
All handovers face to face in APU

29. Sustaining Change – Business as Usual
Standard work
Daily reporting and analysis of variance
Breach meeting
Weekly target tracking
Audit of standard operating procedures
Visual communication for staff

30. Next Steps – An Example in General Medicine
Opportunity in Patients Referred from 10 p.m. to 8 a.m.
Most breaches on night shift – only 1 Registrar on duty

31. Starship Children’s Emergency Department

32. Child Health approach
Why do seperately/differently within same organisation?
EDs have different structure and function
Children’s ED includes
Functions of the adult admission planning unit
12 hr short stay admission for acute cases
Hospital RMO after hours staffing limited to 1 Paed Medical Registrar
Admission work up and initiation of treatment is by CED clinicians, with handover to inpatient Registrar at time that child is ready for ward
Less emphasis on the “2hr” phase for medical cases, more on “1hr” (for transfer to ward when child’s condition is ready for this)

33. Child ED Performance to 6 hour goal - 2010 to 201233

34. Child ED Triage Performance - 2010 to 201234

35. Children’s Hospital challenges
Smaller total numbers, large daily fluctuations in acute admissions, limited surge capacity
165 beds vs 650 beds in adult services
31,000 CED attendances vs 57,000 AED + 11,000 APU
Historically:
Difficulties in predicting acute volumes
Disconnect with electives planning
High rates of last minute cancellations on day of planned admission
High proportion of child admissions needing isolation
Nursing complexity with increasing skew toward tertiary electives over local secondary paediatric admissions 35

36. Child Health Improvements
Weekly capacity planning meeting
Modelling of short term acute trends
Increasing accuracy as we gain experience with this tool
Usually within +/- 10%
Joined up with elective admission scheduling
Fewer last minute cancellations
Best elective performance during winter months for many years
Improved communication of over-capacity status to Clinicians
Review of criteria for alerts
Text message and early in the day

37. Is this all about bed capacity?

38. Bed capacity Important but not the whole story
Both Adult and Children’s Hospitals are being driven hard
Both have occupancy >90% and not infrequent overcapacity alerts
Both have shown sustained improvement in 6 hour targets
There comes a point where further improvements will be in only small increments and investment in capacity is vital.