eAcute eAcute Dr Paul Sullivan Dr Paul Sullivan Clinical Director of Quality Improvement, Clinical Director of Quality Improvement, Salford Royal Foundation Trust Salford Royal Foundation Trust Senior Quality Improvement Fellow, Senior Quality Improvement Fellow, Centre for Healthcare Improvement Research, Centre for Healthcare Improvement Research, Imperial College, London Imperial College, London
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EAcute Dr Paul Sullivan Clinical Director of Quality Improvement, Salford Royal Foundation Trust Senior Quality Improvement Fellow, Centre for Healthcare.
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eAcuteeAcute
Dr Paul SullivanDr Paul Sullivan
Clinical Director of Quality Improvement,Clinical Director of Quality Improvement,Salford Royal Foundation TrustSalford Royal Foundation Trust
Senior Quality Improvement Fellow,Senior Quality Improvement Fellow,Centre for Healthcare Improvement Research,Centre for Healthcare Improvement Research,
Imperial College, LondonImperial College, London
Risks of hospital stayRisks of hospital stay
Risk of infectionRisk of infection Risk of medical accidentsRisk of medical accidents Medication errorsMedication errors Loss of controlLoss of control Discomfort, sleeplessnessDiscomfort, sleeplessness DisruptionDisruption
Medical Reasons?Medical Reasons?
Treatment only available in hospitalTreatment only available in hospital
MonitoringMonitoring
Risk of rapid deteriorationRisk of rapid deterioration
Temporary increase in care needsTemporary increase in care needs
SurveySurvey
Daily review of general medical inpatients in a Daily review of general medical inpatients in a medical ward– 240 bed daysmedical ward– 240 bed days
Classified into 19 “reasons”Classified into 19 “reasons”
15% of patients did not need to be in hospital15% of patients did not need to be in hospital
Survey of medical wardsSurvey of medical wards
23% of medical in-patients “stable”23% of medical in-patients “stable”
Review of cases by expert panel – 9.6% Review of cases by expert panel – 9.6% could be managed at homecould be managed at home
Of patients delayed for <2 weeks,Of patients delayed for <2 weeks,
43% were due to medic behaviour43% were due to medic behaviour
Survey of medical wardsSurvey of medical wards
Daily visit to medical wards, each team Daily visit to medical wards, each team contactedcontacted
Able to identify that 15% of in-patients Able to identify that 15% of in-patients could be managed in virtual ward systemcould be managed in virtual ward system
Average LOC after identification 10 daysAverage LOC after identification 10 days
Things have moved on since thenThings have moved on since then
Delays in diagnostics removedDelays in diagnostics removed
LOS saved likely to be 1-2 daysLOS saved likely to be 1-2 days
Reasons for delayReasons for delay
Waiting for testWaiting for test Waiting for resultsWaiting for results Waiting for opinionWaiting for opinion Waiting for senior reviewWaiting for senior review
Why?Why?
Medics apprehensive about discharge – Medics apprehensive about discharge – loss to f/u, delay to first OPAloss to f/u, delay to first OPA
Team need to make a decision(s) straight Team need to make a decision(s) straight after the next test(s)after the next test(s)
No knowledge of OP servicesNo knowledge of OP services
Is there a better way of managing these Is there a better way of managing these patients?patients?
Could they be at home?Could they be at home?
Survey on 28 bed EAU 2006Survey on 28 bed EAU 2006
Could this patient be safely and effectively Could this patient be safely and effectively managed at homemanaged at home
Audit on 28 bed AMU Audit on 28 bed AMU
Could this patient be safely and effectively Could this patient be safely and effectively managed at homemanaged at home
2-7 patients each day2-7 patients each day
AlternativesAlternatives
Traditional OPD setting has limitsTraditional OPD setting has limits
Time between available follow up slotsTime between available follow up slots
Patient “visible” only at clinic visitPatient “visible” only at clinic visit
Availability of diagnosticsAvailability of diagnostics
Time to next FOLLOW UP slotTime to next FOLLOW UP slot
Gen med Gen med 2-11 weeks2-11 weeks CardiologyCardiology 17 weeks17 weeks GIGI 8 weeks8 weeks ChestChest 7 weeks7 weeks
AlternativesAlternatives
Priority patients Priority patients cancan be managed at home by be managed at home by individual cliniciansindividual clinicians
Time consuming, no support, numbers limitedTime consuming, no support, numbers limited
Risk of loss to follow upRisk of loss to follow up
eAcuteeAcute
An electronic patient list to which multiple users can add and which can be seen by all members of the Acute Medicine team.
Every weekday at 10am = virtual ward round
This is attended by Acute Medicine consultants, mid grades and FY doctors and the advanced practitioner nurse on the EAU.
Every patient is discussed every week-day.
Junior staff are available to arrange tests, liaise with diagnostic depts etc.
If tests are inappropriately delayed we notice immediately and rectify
Results are seen immediately and consultant level decisions follow
Patients can be reviewed as often as needed by telephone
Patients can be recalled to EAU for bloods or clinical assessment
We have arrangements with radiology, cardiology and endoscopy so that virtual ward patients are accorded high priority
Junior staff available to arrange tests, deliver Junior staff available to arrange tests, deliver cards to diagnostics, speak to other services cards to diagnostics, speak to other services e.g. radiologistse.g. radiologists
No staff available No staff available
If tests missed for whatever reason (card lost, If tests missed for whatever reason (card lost, patient DNA, test postponed) it is immediately patient DNA, test postponed) it is immediately spotted and rectifiedspotted and rectified
Patient cannot be guaranteed to have test and Patient cannot be guaranteed to have test and clinician may not know if test missedclinician may not know if test missed
If further action is indicated by a test result, it If further action is indicated by a test result, it can be taken immediately.can be taken immediately.
Results generally not reviewed until next Results generally not reviewed until next outpatient appointmentoutpatient appointment
Patient has daily review Patient has daily review Reviews limited by time between outpatient Reviews limited by time between outpatient visitsvisits
Historically, inpatients have been regarded as Historically, inpatients have been regarded as more urgent and have tests done quickly.more urgent and have tests done quickly.
There are often longer waits for outpatient There are often longer waits for outpatient investigations.investigations.
High risk if inadvertent delaysHigh risk if inadvertent delays
High risk if DNAHigh risk if DNA
Ideal forIdeal for
Rapid/serial decisions on test resultsRapid/serial decisions on test results
Test 2 depends on test 1Test 2 depends on test 1
Early/frequent communication with ptEarly/frequent communication with pt
ResultsResults
0
20
40
60
80
100
120
140
160
Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov
0
5
10
15
20
25
30
35
40
bed days saved
patients
ResultsResults
Low Rockall UGI bleed
?VTE
Other
uss abdo
discuss
review radiology
await result
ett
pos blood cul
monitor bloods
ct brain
24h tape
rv clinically after we
ImplementationImplementation
Not as easy as it seemsNot as easy as it seems
Critical featuresCritical features
Watertight – IT solution idealWatertight – IT solution ideal
Access 24/7, anywhereAccess 24/7, anywhere
Embedded in daily workEmbedded in daily work
Redundancies – can’t be forgottenRedundancies – can’t be forgotten
I know, with absolute certainty, that if I I know, with absolute certainty, that if I send a patient home on Sunday, a trusted send a patient home on Sunday, a trusted consultant will pick up the issues on consultant will pick up the issues on Monday.Monday.
Critical featuresCritical features
PrioritisationPrioritisation
Patients are regarded as in-patients by:Patients are regarded as in-patients by: RadiologyRadiology EndoscopyEndoscopy Echo, ETTEcho, ETT
How did we do that?How did we do that?
Our story….Our story….
Developing IT solutionDeveloping IT solution
Making it work in the normal dayMaking it work in the normal day
Getting radiology to prioritiseGetting radiology to prioritise
Getting other departments to prioritiseGetting other departments to prioritise
SustainingSustaining
Constant vigilance for fall off in Constant vigilance for fall off in prioritisationprioritisation
Local ownershipLocal ownership
Keeping it team wideKeeping it team wide
Just add hot water!Just add hot water!
4096 bed days in 24 4096 bed days in 24 monthsmonths
5.7 beds free on any 5.7 beds free on any dayday
Roll out – estimate Roll out – estimate additional 5-10 bedsadditional 5-10 beds
23 minutes per day 23 minutes per day for 2 consultants and for 2 consultants and teamteam
50 minutes per day 50 minutes per day for a JDfor a JD
TransferTransfer Make it watertight – daily case review prevents delays, loss to follow up etc.
Timetable daily senior case review so it is guaranteed. Several people need to be involved to ensure that this happens every day, regardless.
Develop an electronic patient list that is visible to all members of the team all the time – initial attempts with individual paper lists failed
Choose an area with high patient throughput so that there are always some virtual patients to review, otherwise it is difficult to maintain the habit.
Start with a single investigation, we used CT pulmonary angiogram, and get clinical directors involved.