Making it accountable

6th Annual Emergency Department Management Conference

Prof George Braitberg

Professor of Emergency Medicine University of Melbourne and Melbourne Health

Lets Start

Kokoda June 28 to July 7

Emergency Departments have been compared with Air Traffic Control, but are in fact a more complex setting with more complex work.

Unlike airports, patients just “show up” without warning, requiring attention – aeroplanes tend not to do this.

The Perfect Storm • A problem exists that doesn’t go away despite the good

intentions, expended energy and input from a number of talented people

• The problem is known to cause an adverse outcome in the environment in which it exists

• The problem is large enough that it affects people and processes outside its own environment

• The problem is mutifactorial and hence a number of changes must be taken for the problem to be resolved

• The problem expresses itself across a number of domains: – Safety – Morale – Performance – Satisfaction – Personal and Professional beliefs

means every part is accountable

Acute Sub Acute Care

Driving Whole-of-System Reform

Before they arrive …

Telephone Triage is probably not the answer..

Before they arrive …... Call Referral

Paramedic

Locum

Community Nursing Services

Coordinated community care

Linking prehospital care providers to divert patients away from the hospital

Before they come

Hospitals have a role to play

Accountability

• Patient

• Community

• Prehospital Services

Hopefully I haven't “muddied” your understanding

DispositionPresentation &

TriageInpatient Team

Assessment

Emergency

Assessment

Assessment

AmbulanceAmbulance

‘Walk in’‘Walk in’

SpecialistsSpecialists

OtherOther

Other HospitalOther Hospital

Inpatient WardInpatient Ward

Dispatch AreaDispatch Area

Registration

TriageAssessment and

Treatment

Assessment &

Treatment

Pathology

Radiology

Fast Track

Hospital Transfer

Handover

Admission and

transfer to wardResuscitation

HomeHome

Short Stay

Emergency Department Patient Flow

*18% improvement in grant funding from improved admission data

Projected Improvements

*50% saving in letter production

*50% saving of clinician time at Handover

Staff capacity improvement = 10%

Decrease in Adverse Events per annum = 880

Increase in funding per annum = $2.1m *

*10% efficiency improvement across all activities

55% reduction in business risk (Adverse Events)

*$2.1m made up of $2m from Emergency Department DHS Grant; $120k from improvement in Emergency Department 4 hour target performance

Wait 1 Wait 6 Wait 3 Wait 4 Wait 2 Wait 5

Diagnostics

Access Block increases duration of all wait periods

y = 5.5819x + 243.93R2 = 0.1962

0100200300400500600700800

0 5 10 15 20 25 30 35 40

ED

LO

S

Time Elapsed Between Arrival and Tests Being Performed When is the “decision to admit” made?

The Health Service…….

0

100

200

300

400

500

600

2009-8 2009-9 2009-10 2009-11 2009-12 2010-1 2010-2 2010-3 2010-4 2010-5 2010-6 2010-7

Avera

ge L

OS

(m

ins)

Month

Average LOS Admit/Transfer Patients by Month

Welcome to Hotel Austin

What are the metrics of flow failure?

Response of a queuing system in the presence of crowding is non-linear

– As utilisation increases, waits and rejections (queue failure) increase exponentially

qu

eu

e l

en

gth

& f

ail

ures

10 20 30 40 50 60 70 80 90 100

% system utilisation (occupancy)

Overcrowding defines hospital and Emergency Department access block

Consequences

Fatovich DM, Nagree Y and Sprivulis P.Emerg Med J 2005;22:351–354.

Richardson D. MJA 2006; 184 (5): 213-216

Waiting Times increase

Welcome to Hotel Austin

Treatments are delayed

• Time to thrombolysis in myocardial infarction

– (Schull et al Toronto)

– Annals Emerg Med 2004, December

Adverse events occur • SARS

– Schull, Emerg Med J 2003;20:400–401

– Canadian index case

– 18 hour access block

– Infected 128

– Killed 17

• Adverse Events

In a study of 3935 Emergency patients, adverse events in the ED were associated with errors of omission, diagnostic issues and high preventability. 55% of events were judged to be preventable with those resulting in death and disability more likely to be preventable (p < 0.04) Adverse Event Study, Hendrie J, Sammartino L, Silvapulle, M. J. Braitberg G, EMA 2007 (2 papers)

• SA coroner, Vassallo, 2003 – Sent home from ‘blocked ED’ – “good doctors make bad

decisions in bad circumstances”

– DHS & Hospital criticised

• J. Em Med (Canada) 2004 – Child with Toxic Shock – Excessive waiting T – 19 recommendations to the

Ontario Health Ministry

Patients stay longer in the wards……

Welcome to Hotel Austin

Patients die

Hospital Overcrowding increases 7 day mortality

Overcrowding Hazard Scale Multiply hospital occupancy and the ED access block as a combined score

MJA 2006; 184 (5): 208-212

An Overcrowding Hazard Scale score > 2 independently predicted an increased Day 7 mortality rate

Richardson D. MJA 2006; 184 (5): 213-216

There were 7% more presentations and 43% more deaths in the OC cohort compared with the NOC cohort

Access block is Ageist

• Deconditioning • Confusion • Dehydration • Immobility • Constipation • Pressure injury • Falls • Medication error • Delayed allied health

• Delayed discharge planning • Suboptimal nutrition • A trolley is not a ward bed • An ED is not a ward • ED staff are not ward staff • Over 26 % of ED

attendances are elderly (>70)

• This group have twice the average admission rate

Big Picture Causes Workforce Our workforce models have remained unchanged for many years.

There are pockets of innovation and the introduction of Nurse Practitioners, Advanced practice nursing, primary contact physiotherapists have helped orientate the “system” to new ideas. But these innovations are still operating on the fringe in a system heavily reliant on doctors doing doctor thing and nurses doing nursing things. Our future workforce thinking must change.

Social changes The demise of the extended family and changes in the

demographics of marriage and childbearing have led to more elderly people living alone, and with greater feminisation of the workforce fewer people can be carers. The default solution for many partially dependent people is referral to an acute hospital.

Funding models

Payments to hospitals and healthcare providers are rigid and reward

rapid treatment of uncomplicated conditions. In the community

setting, payment is for episodes of care rather than continuity of care.

Complicated emergencies, time-consuming conditions involving

multiple medical specialties, and social issues stretch the time and

financial resources required, and are dealt with piecemeal. Patients

with complex or multiple problems find themselves disproportionality

in a hospital setting heavily focussed on acute medical treatment.

Hospital penicillin is stronger.

We think in terms of hospital beds. We treat, we don’t prevent. We

can be part of the problem and not the solution.

Age and Chronic Disease

Things can seem overwhelming at times

…and then there is us

• Breaking down silos, professional boundaries – moving to care provision by competency not care group or type of degree

• Moving from “patient care revolves around me” to “what can I do to provide the best care for my patient

• Using IT but not relying on IT • Identifying the change agents • Identifying core business roles • Getting rid of waste

Is this the biggest impact of NEAT?

It can be done

Health Services needed to reorganise and re-engage

Southern Health Emergency Core Business Position statement

• Southern Health Emergency endorses and supports Southern Health’s vision, values and purpose in order to plan and deliver safe, effective and people-focused emergency health services.

• Southern Health Emergency recognises that we need to work in partnership with stakeholders to improve health outcomes in our community.

• To achieve a safer and healthier environment patients must spend only that time required to receive appropriate emergency care in the Emergency Department.

• As an organisation, Southern Health will refocus their processes and resources to ensure patients are safely discharged from the Emergency Department at that time.

Emergency Department Core Business Statement

Initiate timely assessment and management in order to

• Determine clinical priorities

• Formulate a provisional diagnosis

• Implement initial time critical interventions

• Refer appropriately

To achieve 4 hour EDLOS, Southern Health

Emergency will:

Define „Chunks‟ of

time

Bring the most

appropriate clinician to

“front of house” as

soon as possible

(Primary Contact

Physiotherapist)

Define Core Clinical

Business

Reduction of non

value added time at

Reception and Triage

Define Consultant

in charge PD

Initiation of timely

patient care by the

appropriately

competent clincian

(SONNA)

Define Nurse In

Charge PD

Patient Streaming and

allocation

Develop a Staffing

to Patient Flow

Model

Ambulance off stretcher redesign solutions (Change the currency from cubicle/stretcher to appropriate space)

Introduce Point of

Care testing

Managing the queue

Initiate the

Category 2 doctor

Transfer of care

Admission- ward/ other Transfer/ Transport/Discharge

Interventions/Refer to Unit

Primary Assessment Junior Dr Consults within ½ Hour

Initial Requests Assessment/ Analgesia Procedures

30 min 90 min 120 min 180 min

“Chunks of Time”

The ED side of 4 hours are ours

Emergency Departments needed to become accountable for what they could control

Clinicians need to be accountable

Sacred cows need to be dispelled: – Hospitals wards are for sick people

– Changing a bed card should be easier than selling a Gary Glitter concert ticket

– We are here for the patients

– Everyone should be respected for the work they do

– It is not “us” versus “them”

– We are part of the solution, but not the whole solution

How to improve?

Study of 600 patients presenting to a tertiary ED showed an exceptionally good correlation between ED diagnosis and subsequent discharge diagnosis of 98%

The average time to notification of the inpatient team was 3.07 h after arrival.

Post notification analysis showed the EDLOS on average increased by 55 minutes with IP review overall Processes and impediments in moving patients from the Emergency Department. Pilot Study. Oakley E and Braitberg G. EMA . 2005

If the ED clinical decision was appropriate then the best way to narrow this gap is not to have inpatient review in the ED at all

Admission- ward/ other Transfer/ Transport/Discharge

Interventions/Refer to Unit

Primary Assessment Junior Dr Consults within ½ Hour

Initial Requests Assessment/ Analgesia Procedures

30 min 90 min 120 min

180 min

“Chunks of Time”

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

Jul Aug Sep Oct Nov Dec Jan Feb

% doctor to speciality request within 2 hours

%

Linear (%)

Internal target

NEAT target

70.0%

72.0%

74.0%

76.0%

78.0%

80.0%

82.0%

84.0%

Jul Aug Sep Oct Nov Dec Jan Feb

% of discharge patients with EDLOS < 4 hours

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

50.0%

Jul Aug Sep Oct Nov Dec Jan Feb

% admitted to an IP bed (including Short Stay) within 4

hours

Senior Decision Maker

• Assessment area

• Masters- apprentice

• Patient satisfaction

• Up front diagnostics

• Early referral

• Accountability for ambulance

• “Go to” person

January time components

Individual metrics Dear George,

Please find below graphs which identify how you are performing according to the agreed Emergency Physician KPIs. These KPIs to remind you are:

1. See patients within 30 minutes of arrival (KPI = 80%)

2. Bed Request within 120 minutes of commencing your consultation (KPI = 80%)

3. 360 minutes to get a patient into Short Stay (KPI = 90%)

All SMS will receive this email but only you know which number is yours, everyone else is de-identified. Seeing how one performs in a group of peers is often the best form or feedback.

Please note this data only includes the cases for which you were assigned as the primary clinician, not handovers or where you supervised junior staff. Numbers are dependent on your fractional appointment and whether you have had any period of significant lead – the least number of patients makes the data more susceptible to swings. I have chosen to take 2 months as a “snapshot” and will provide you with data 2 monthly on an ongoing basis. In particular I would urge you to look at trends across data periods.

I hope you find this feedback useful.

You are number x

Individual metrics

Rapid Acceptance Protocol Rapid Acceptance Protocols – General Surgery Right Iliac Fossa Pain/Appendicitis Identity: This is Dr Jane Doe from Dandenong ED Situation: I have a stable patient with right iliac fossa pain and suspected appendicitis. Background: Age Comorbidities History Examination findings: Investigations: Assessment: Appendicitis Request: Will you accept this patient to the ward under the Rapid Acceptance Protocol and is there anything else I need to do?

Rapid Acceptance Protocols – Gastroenterology Stable Gastrointestinal Bleeding Identify: This is Dr Joe Blogs from Clayton ED Situation: I have a stable patient with a suspected GI bleed (haematemesis &/or melaena) Background: Age Comorbidities History Examination findings: Investigations: Assessment: Stable Gastrointestinal Bleeding Request: Will you accept this patient to the ward under the Rapid Acceptance Protocol and is there anything else I need to do?

1. Stable Gastrointestinal

Bleeding

2. Jaundice

3. Decompensated

Chronic Liver Disease

– Ascites, Jaundice,

Encephalopathy

4. Acute Pancreatitis

(typical pain and

elevated serum lipase)

5. Right Upper Quadrant

Pain/Biliary

Colic/Cholecystitis

6. Sigmoid Diverticulitis

7. Pilonidal/Perianal

Abscess

Owning ambulance transfer times

Call 000

Nearest ambulance ramped at Hospital ED

Ambulance sent from 10km away (most available)

Despatched ambulance arrives at patient, now asystolic

Crit Care Resusc 2006; 8: 321–327

Asystolic patients do not leave hospital alive

Linear relationship between hospital delays and ambulance arrival at scene performance

The detail is in the length of the “tail”.

Ambulance Offload Policy

• In order to adopt a ‘whole of system’ approach and recognise the benefits to the community Melbourne Health will implement a new system for ambulance arrivals.

• Ambulance arrivals that cannot be offloaded to the waiting room will be prioritised to be offloaded into a cubicle before a walk-in patient with the same clinical urgency (ATS), irrespective of waiting time.

• Patients in the waiting room for longer periods should be reassessed to ensure their triage category is unchanged.

Reorganisation of the way we work across the acute sector

Acute Medicine Model of Care

• Flexibility of beds

• ED articulates with APU, RAMU, Ambulatory Care & Community Care

• Community triage lead by teams with consultant supervision: In Reach, Out Reach, HITH, MATS all coordinated by acute care physicians with direct access to Short Stay, MAU, wards and subacute

• Minimal duplication in care improves Quality of care

• Observation Medicine and Shared Management Plans with APU/RAPU

• Cost saving

• Bed day savings

If the right patient is in the right clinical space the benefits are self evident

If the right physician is in the right clinical space the benefits to the patient are self evident

Emergency Physicians

General Physicians

Intensivists ?

ED SOU APU

COMMUNITY

INPATIENT

AMBULATORY CARE/MEDICAL DAY PROCEDURE

Access Floor

XRAY

Clinically lead Community Teams

What we wont see in 5-10 years

• White coats (cant find them now!)

• Ties

• Territorial abysses

• Silos

• Belief that a certificate/Fellowship confers competency (it only recognises the start of the journey)

• We are only accountable to our own clinical practice

• Access Block, Bed Management are no longer someone else’s responsibility or problem

Conclusions

1. Accountability is the key to “ownership”

2. We need to recognise each other’s contribution to the solution and not blaming one another for the problem

3. Not just “whole of hospital”, needs to be “whole of system”.

4. Things are changing

5. Every journey starts with a single step.”

Confucius

Questions?

An ode to Access Block apologies to the

“Hotel California” by the Eagles

In a blocked full department, airconditioned in there

Warm smell of colitis, rising up through the air

Up ahead in the distance, I saw a shimmering light

My head grew heavy and my sight grew dim

I had a patient to admit in sight

As I stood in the doorway….

I heard the code overhead

And I was thinking to myself,

Code Yellow HEWS, it must be 10am

Then as I looked to the heavens to show me the way

There were voices down the corridor,

I thought I heard them say

Welcome to the Public Hospital System

Such a lovely place

Such a lovely face

Plenty of room at the Public Hospital System

Any time of year, you can find a bed here”.