Fiona Webster, Austin Health: Is it really about Boarder Security?
Post on 07-Dec-2014
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Is it really about Boarder Security?
Getting the patient to the right bed at the right
time
Fiona Webster
Executive Director
Acute Operations
Introduction
• Organisational bed profiling: Bed realignment project undertaken
in conjunction with CSIRO, to guide allocation of new and
existing resources across Austin Health
• Flow strategies: morning beds, PPA, flex, Ready to Go
• Predictive planning activity model used for capacity planning -
Balancing elective & emergency surgical demand
• Surgical Template: Tying theatre bookings to a bed
The problem…
• Ageing population
• Rising community expectations
• Increased ability to treat
• End of life decision making
• Emergency Department as a default for primary care
• Lack of GP treatment for residents of nursing homes
• Growing costs – budget pressure
Background
• Patients requiring admission to Austin Health arrive through a
variety of routes:
• Emergency department
• Elective surgery admissions
• Planned admissions – (Day oncology, endoscopy, sleep studies etc)
• Inter hospital transfers – (tertiary referrals)
• Intra-hospital transfers (Talbot/HRH)
• Direct admissions from the community (unwell patient seen at
outpatients)
• International repatriations
4
Targets • NEAT (National Emergency Access Targets)
• Emergency department four-hour access target for patients in
all triage categories – 80%
• % of Cat 1-5 Patients seen within time – 80%
• NEST (National Elective Surgery Targets)
• 100% of Cat 1 in 30 days
• 88% of Cat 2 treated within 90 days
• 97% of Cat 3 patients treated within 365 days
• Reducing the average waiting time for overdue patients
• Targets don’t cover all activity – so too strong a focus on targets
causes perverse incentives
5
You can’t have your NEST
and NEAT it too...
Balancing demand
Vascular Surgery Neurosurgery Neurology
Cardiology Cardiac Surgery Thoracic Surgery Respiratory Medicine
Colorectal Surgery Gastroenterology Liver Transplant
Orthopaedic Surgery Plastic Surgery Urology Infectious Diseases
General Medicine Renal Medicine
Ophthalmology Oncology Haematology
Acute spinal Paediatrics ICU ENT
Aged care Rehabilitation Awaiting placement
Emergency patients
Elective surgery patients
Direct admissions
Inter hospital transfers
Planned admissions
Intra hospital transfers
• 1000 bed hotel
• Patients arrive without bookings
• Their departure date and time is unknown
• Very few future bookings
• Very specific room requirements
• Always full – people queuing to get in
Why...
• Planned and unplanned patients compete for the same
bed
• Need to match patients to the ‘right’ bed
• Essentially always at 100% occupancy except for
holiday slow downs
• Only funded for a ‘full bed’ that is rapidly turned over
• Emergency demand – 78% of overnight bed days
• Variable, unknown length of stay makes predicting bed
availability difficult
• Acuity of the case will always win (long wait simple cases
bumped)
Why...
• Exit block waiting for patients to be
picked up by other services
• Limited ‘flex’ capacity due to bed
constraints
• Cancelling patients becomes the
pressure release
• Clinician admission decisions is
impacted by bed availability
Patient arrivals by hour
• Patient
discharges do not
match the time of
patients arriving
Our problem…
Bed management and patient flow
- New patients arrive before current patients leave
- Highly specialised services
- Idiosyncratic variation between one clinician and the next
- Person dependant systems and processes
- Lack of flexibility in managing capacity
- Still largely paper based (or have moved to the
spreadsheet!)
- Don’t know what’s coming in the door until its here
- Lack of tools to predict demand
How do we make it better..
• ? Open more beds…
• ? Discharge more patients in the morning…
• ? Plan less surgery in Winter
• ? Divert more patients into other programs / services
• HITH
• Transit Lounge
• ED Short Stay
• Acute Assessment
Understand your bed profile
• The current bed allocation at Austin has been in place since
the redevelopment opened in 2005
• We want to be able to place a patient in an appropriate bed
within four hours
• Patients get the best care when they are on their home ward
with a team that is able to manage their care collaboratively
• We needed to profile our beds to take account of work that
would move to our new Surgery Centre, demand for tertiary
services and demand from the Emergency Department
Right patient, right bed, first time
Bed allocation model
14
Beds needed by ED patients
15
ED bed demand
16
Right number of beds
Provide units with the right number of beds to meet demand:
• Moved elective work to The Surgery Centre
• Relocated 8 Urology beds to a new ward
• Will soon relocate Colorectal Unit to a new ward
• Looking at up-skilling staff to flow patients into a neighbouring
ward (building core competencies across ward environments)
Beds at the right time of day • Nov 12 – Admissions
and discharges don’t
balance until 2pm
• Deficit of ~13 beds in
the morning
• Patients wait in ED for
a bed
• How long does it take
to turn over a bed?
• Beds on some units
take longer to come up
Planned patient arrivals (PPA)
We need morning beds
• Every ward should prepare one or two patients who can be
discharged by 8am so that they can accept a patient by 9am
• The afternoon shift identifies the potential patients
• prepares patient for discharge
• organises transport or transit lounge
• seeks a discharge script/early morning medical review
• Sometimes these patients are planned transfers to another
facility
• Helps us start flow early and get patients to the right ward
Morning flex capacity
If we have a deficit of beds in the morning PPAs are not enough!!
• Establish morning flex capacity
• 4 surgical beds that open for the AM shift (ASTU)
• 3 cardiac beds open in the morning (cath lab recovery area)
• 8 Acute Assessment Unit (AAU) beds AM/PM shifts
• Agreement for paediatrics to flex within ratios to take morning
patients
• Beds are closed back as patients are discharged (or by a time deadline)
• Small amount of overnight flex available (four beds)
Greater use of transit lounge
Starting flow early helps
Beds are in balance two hours earlier
Access to beds from ED is better
• Still a long
way to go but
less winter
impact
Decline in boarders
• Fewer
boarders
means
better care
and shorter
LOS
Better communication Ward communication identified early as problem to patient
flow:
• Unable to reach person who makes decision
• ED unable to communicate with ward in-charge
• Bed manager also couldn’t find person responsible for patient flow
decisions
• Tea breaks held up flow because of communication
Introduction of:
• Minimum Deliverables of patient flow standards: ‘In-charge’
responsibilities for patient flow decisions. (Organisationally rolled out)
• Gave each ward a CISCO phone (used only for patient flow)
Ready-to-go? • Discharge Summaries in ED are not being completed in a timely
manner. Resulting in inpatient ward areas unable to :
• Admit the patient on to Medtrak
• Therefore cannot administer medications, order meals, process
pathology
• Cannot be found by relatives via Medtrak and creating safety
concerns
• Confusion regarding suitability for transfer to inpatient wards,
causing rework through additional phone conversations with the ED.
Consequences to this include:
• Decreased motivation by ward staff to expedite admissions
• Wards feeling that data on performance not reflecting true nature
• Increased staff frustration on inability to achieve targets due to delay
of transfers
What we wanted to achieve
a) Clarity when the patient is ready to be transferred to the
ward
b) Standardised communication
c) Less rework
d) Patients transferred out of ED without delay as clinically
appropriate…provide capacity for incoming pts/ ambulance
• ED management 2 hrs
• Bed management allocation 20 mins
• Pull pt to ward 1-2 hrs (decreasing towards 60 mins for wards)
Ready to go criteria…
• Patient needs to be medically stable, not meeting MET criteria
(unless documented/communicated as altered)
• Unit handover has occurred
• Discharge summary completed
• Interim medication and fluid orders completed
Issues that need to be resolved around this are:
Who is responsible for ensuring final ‘sign off’ of the above 4 criteria (process owner)
How are outstanding tasks escalated?
Identification icon activated via medtrak to announce patient ready to move
Identification of ED need for PSA assistance for transfer from ward areas
Identifying who is responsible for ensuring the discharge summary completed
0
10
20
30
40
50
60
70
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
RTG Compliance - last 30 days
% Admitted to ward with RTG Patients Admitted To Ward
What percentage of pts have a RTG?
Improved to 62%
Before November - All Wards
Now - All Wards
Improved
13.2%
85% Patients
transferred to
wards within
2 hours
Better bed management
Split elective and emergency streams
• The Surgery Centre is not impacted by emergency demand
• Provides more beds for Emergency Demand
Increased flex capacity
• Having the ability to open extra beds at short notice at marginal cost
Better bed management
• Predictive planning
• Demand projections
• Booking templates
Bed Management
information
Direct Admission/
Interhospital transfer
ERC
Ps
Level 8 electives
tota
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ard
(av
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/day
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tota
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EC
SAEC 8E SAEC 8W SAEC 8N SAEC
Monday 1 0 3 0 0 5 1 5 6 11 5
WEE
K 1
Tuesday 1 3 1 2 1 6 1 11 6 17 4
Wednesday 1 5 1 2 0 4 1 11 6 17 3
Thursday 0 3 1 2 0 3 2 8 6 14 3
Friday 1 3 1 1 1 4 0 8 6 14 3
Monday 1 4 3 2 0 3 0 9 6 15 4
WEE
K 2
Tuesday 1 4 3 2 1 5 0 11 6 17 5
Wedensday 1 4 2 1 0 5 0 10 6 16 3
Thursday 0 3 1 4 1 4 1 11 6 17 3
Friday 1 3 1 2 1 3 0 8 6 14 3
Monday 1 6 2 1 0 5 0 12 6 18 3
WEE
K 3
Tuesday 1 5 0 1 0 6 2 12 6 18 3
Wednesday 1 4 0 2 1 5 0 11 6 17 2
Thursday 0 4 0 1 1 3 0 8 6 14 1
Friday 1 3 1 1 1 5 1 9 6 15 4
Monday 1 4 2 1 1 4 0 9 6 15 4
WEE
K 4
Tuesday 1 6 0 2 1 5 3 12 6 18 5
Wednesday 1 3 1 1 1 4 2 8 6 14 5
Thursday 0 3 0 2 2 5 1 10 6 16 3
Friday 1 4 0 0 2 4 0 8 6 14 3
Elective
Admission
Template
Day surgical
procedures: SAEC
Day medical
procedures: AAU,
ACC
Further
medical
assessment AAU
Step down medical bed: Ward 10, rehabilitation bed
Overnight surgical I/P
Extended
Stay: ACC /MH
High acuity
admission ICU/HDU
6W HDU
CCU
Respiratory
State-wide services/ Trauma
agreements: Spinal, vertebral column, LTUx
Psychiatric services
Single room/ Isolation
requirements
Standard day… 1500-1600 Planning for next day
• Review EDDs, ETBS capacity to finish the day,
• Consultation with wards & external stakeholders where required
• Send alerts to liaison nurse/ ESAM role & medical (surgical) teams for assistance
in extreme bed access situations
• Reorder tomorrow’s lists, defer work where appropriate
• Review direct admissions list and ensure plan for transferring patients.
1930hrs
• Ensure patients in AAU have bed plans for closure
• daily operational shift reporting
• Ensure capacity is at optimal level (additional beds open etc)
2030hrs finish and handover to AHSM
Standard day... 0700…
• accept Night activity handover
• Allocate patients in ED to opening capacity (AAU/ASTU etc)
• Early discharge confirmation & Allocation of PPAs
• Placement of long waiting patients
• Early assessment, triage of theatre flow & beds balanced against competing
areas of demand (ICU, other hospitals, emergency department, other)
0800-1200: Surgical flow position
• Establish & coordination/management of issues (reorder list, alternative post
op destination, change to day procedure, cancel etc )
• Confirm movement and placement of patients
• Ensure minimisation of HIPs and boarders management
• Facilitate discharge planning assistance to wards
• Assist ETBS (Emergency Theatre) with treating patients in time & access to
OR
48 I/P ED admissions
25-30 elective admits
@12+ direct admissions
+/- OPD, Failed D/c, ACC
admissions etc
37
Performance
Alert
Additional demand
Organisational Awareness
Forecasting the activity ahead...
Predictive planning & templating
Issues:
• No consistency in number of electives booked requiring IP beds
• Level of acuity on each day would exceed ICU/HDU capacity, or ward ability to
manage complexity
• Waste ++- Theatre cancellations, staff present but not able to work and poor
customer service/ focus
• Lack of accountability and fairness (some units able to access theatre/ beds
more than others)
Solution:
• All surgical activity operate from a template, Clinical wards operate off Predictive
planning to manage their daily/ weekly demand
• CSIRO ward bed profiling information used for wards to plan for both NEST & NEAT
Scheduling Activity; SAEC: TOTAL 8E 8N 8W
7N/
3N 6 S TOTAL
UGI x 2, Plastics x 1 OMFS x 1 ENT x2, 1 x ERCP, 1x radiology, 8 Urol 2x6S, Ortho 2x 8N (trauma), Ortho x 3 8N, Plastic 1x8N, UGI 1 x 8E 1 6 0 0 2 9
CRS4 x 1, UGI x1, Orthox1, HPB x2, ERCP x1, Radiology x1, Cardiology
x1, 8 Urol 1x6S, CRS4 2x8E, UGI 1x8E, HPB 2x8W, Ortho 4x8N( 1 Trauma), plast 1 x8N3 5 2 0 1
11
UGI x1, HPB x2, UROLO x 1 ENT x1 , ERCP x1, Radiology x2, 8 Urol 3x6S, UGI 1x8E, CRS4x1 HPB 2x8W Ortho x 2 ( trauma) 2 2 2 0 3 9
HPB x1, Ortho x1 ( truama), ENT x2, Radiology x2, Vascular x2 8 Urol 2x6S, CRS4 1x8E, HPB 2x8W, Ortho 3x8N ( 1x trauma) UGI 1x8E 2 3 2 0 2 9
Urol x1, HPB x1, Plastic x1, CRS4 x1, ERCP x1, Radiology x1, Vascular x1, 7 Urol 2x 6S, CRS4 1x8E, HPB 1x8W, Ortho 4x8N ( 1x Truama), Plas 1x8N, 1 5 1 0 2 9
UGI x1, Ortho x 2 ( Trauma), 1x ERCP, 1x radiology 5 Urol 3x6S, UGI 1x8E, HPB 2x8W, Ortho 2x8N, Plastics x1 8N 1 3 2 0 3 9
Urolx1, 1x ERCP, 2x radiology, 1x Cardiology, ENT x1 7 Urol 2x6S, CRS4 2x8E, UGI 1x8E, ortho 3x8N ( 2xT), plastic Quad hand l i s t ( 3N) 3 3 0 1 2 9
UGI x1, plas x1, urol x 1 ENT x2, 2x radiology, 1x ERCP, 8 Urol 2x6S, UGI 2x8E, Ortho 3x8N, plas 1x8N 2 4 0 0 2 8HPB x2 (1 for tenkoff), Urolx1, 1x radiology, 1 x cardiology, 2 x Vascular,
ENT x 1 8 Urol 2x6S, CRS4 x1 8E, UGIx1, HPB 2x8W(IM 1x8E &7N)ortho 2x8N, ( 1X truama)3 3 2 1 2 11
Urol x1, HPB x1, Plastic x2, Ortho x1( Truama), UGI x1, ERCP x1, Radiology
x1, OMFS x1 9 Urol 3x6S, CRS4 x1 8E, UGI 1x8E, HPB 1x8W, Ortho 3x8N, plas 1x8N2 4 1 0 3
10
UGI x1, ENT x2, 1x ERCP, 1 xradiology, plastics x 1, OMFS x 1 7 Urol 1x6S, UGI 2x8E, HPB 1x8W, Ortho 3x8N( 1x Truama), Plas 1x8N 2 5 1 0 1 9
UGI x1, plastic x1, HPB x1, CRS4 x1, ortho x 2 ERCP x1, Radiology x1, 8 Urol 1x6S, CRS4 x2 8E, UGI 1x8E, HPB 2x8W, Plast 1x8N, ortho 3x8N (1xtruama) 3 4 2 0 1 10
HPB x2,, ENTx2, radiology x2, ERCP x1, 7 Urol 2x6S, UGI 1x8E, CRS4 1x8E, HPB 2x8W, Ortho (2x truama) 2 2 2 0 2 8
UGI x1,Ortho x1 vascular x2 , 2x radiology, 1x Cardiology, ENT x1 8 Urol 2x6S, CRS4 1x8E, UGI 1x8E, HPB 2x8W, Ortho 5x8N 2 5 2 0 2 11
CRS4 x2, Plas x1, urol x1, HPB x1, 1 xradiology, 1 xERCP, Vascular x1, 8 urol 3x6S, CRS4 1x8E, HPB 1x8W, Ortho 3x8N (8N x1 Truama), Plas 1x8N1 4 1 0 3 9
HPB x1, Urol x 1, UGI x 1, plastic x1, ortho x1, radiology x1, ERCP x1 7 Urol 3x6S, UGI 1x8E, HPB 1x8W, plas 1x8N, Ortho 2x 8N (+2x 8N Truama) 1 4 1 0 3 9
Urology x 1, HPB/T x 2 UGI x1, plastic x1, ERCP x1, Radiology x2, 8 Urol 2x6S, CRS4 2x8E, HPB/T x 2 8W, UGI 1x8E, Ortho 1x8N, plastic 1x 8N 3 2 2 0 2 9
UGI x1, HPB x1, radiology x2, ERCP x1, ENTx1 6 Urol 2x6S, UGI 2x8E, HPB 1x8W, Ortho 3x8N, plas x1 8N 2 4 1 0 2 9
HPB x2 ( 1 for tenchoff), 1 x Ortho ENT x1, Vasc x1, radiology x1,1 x
cardiology 7 urol 2x6S, HPB 2x8W (IM 2x7N), Ortho 2x8N (8N x1 trauma) 0 3 2 2 2
9
HPB x1, plastic x2, Ortho x1, radiology x1, ERCP x1, 1 x cardiology, Vascular
x1, 8 Urol 3x6S, CRS4 1x8E, HPB 1x8W, Plas 1x8N, Ortho 3x8N1 4 1 0 3
9
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Matching operating units each day with # of
beds, holding each unit accountable
Predictable Surgical elective bed numbers, also
assists with booking appropriately balanced lists
Predictive Planning (individual ward example)
Ward 7 South Date:
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Admissions
Elective admissions booked 3 4 2 3 2 0 0
ED Admissions: 2 1 2 2 1 2 1
Intensive Care admissions 1 0 0 2 1 1 0
Urgent direct admissions 1 1 1 * * * *
Other:
Admissions Total: 7 6 8 7 3 3 1
Discharges Projected: 6 7 3 7 5 4 4
Balance/ Plan: 1 1 -5 0 2 1 3
# of external referrals still
waiting:
Planning Patient Flow: Weekly projection
Additional Issues:
1 22
1 x Complex Pt +
2 awiting
subacute
transfers
Plan; postpone X,
Priority d/w Dr B,
for A+C to be
admitted
Ward taking
responsibility for
balancing demand
Medical unit
engagement
Organisational view…
42
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