Shorter Stays in the ED forum 26 and 27 March, 2012.

Shorter Stays in the ED forum

26 and 27 March, 2012

Opening and overview of national picture

Mike Ardagh

Welcome

Programme – Day 1

• Opening and overview• Sessions

1. CDHB – CREST/Preload

2. NMDHB – data analysis

3. MCDHB – MAPU

4. ADHB – process improvement from decision to admit

5. CCDHB – creating momentum

6. BOP – Ops centre set up and operation

• Wrap up then drinks/nibbles (about 4.30)

Programme – Day 29am start

• Panel – challenges and promising initiatives• Bob Lloyd

1. The science of improvement

2. The quality measurement journey

3. Building capacity and capability

• Close – about 4pm.

The top ten challenges facing NZ DHBs in their target work

Ardagh, Tonkin and Possenniskie. NZMJ 14 October 2011, Vol 124 No 1344; ISSN 1175 8716

1. Access to hospital beds

2. Access to diagnostics (particularly CT and US)

3. Inpatient registrar delays

4. Increased patient presentations

5. ED too small/poor layout

6. ED staff deficiencies

7. Discharge delays on the wards

8. Clinical staff not engaging in change

9. Can’t get elderly inpatients into aged care facilities

10. Nights and weekends more difficult

Special bedshttp://www.hiirc.org.nz/page/18737/guidance-statement-ed-obervation-and-inpatient/?section=9088&contentType=451&tab=822

Creation of ED observation units and inpatient assessment units so that patients with a particular need, for example further observation or treatment by ED staff to achieve discharge or ‘work up’ by inpatient teams, have that need fulfilled in a space well suited to that purpose.

Hospital Operations Planning Dedicated and sophisticated daily hospital operations planning to enhance the use of the human and physical resource, and to improve patient flow between the ED and inpatient wards.

Discharge planning Good discharge planning, beginning early with multidisciplinary input and as a particular focus of daily activities to reduce unnecessary patient waits and free hospital capacity.

Access to imaging Guidelines and pathways for accessing imaging and a responsive service for the provision of both images and expert interpretation.

Responsive acute services Separation of acute and elective medical roster conflicts so that inpatient specialties provide a responsive acute service.

Pathways for acute patients Pathways or agreements so that patients with common and relatively straightforward presentations, for example fractured neck of femur, can be transferred to the ward promptly rather than having to wait in the ED for an inpatient registrar assessment.

Acute demand mitigation Analysis of the drivers of increased demand for acute services and interventions to mitigate this demand.

Enhanced ED layout Layout of EDs to enhance function, including ‘streaming’ of patients and good ‘command and control’.

Enhanced ED senior staffing A greater senior staff presence to enhance decision making and overview of department activities.

Engagement of staff Engagement of all staff by ‘marketing’ changes with an appropriate whole of system and patient focused emphasis.

Promising initiatives

The panel• The panellists

» Vanessa Thornton» Mike Hunter» Tim Parke» Paul Watson

• Questions1. What are the top challenges?

2. What are the promising initiatives?

(What do we need to do?)

How are we doing so far?

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q22009/10 2010/11 2011/12

70%

75%

80%

85%

90%

95%

100%

80%

83%

86% 87%86%

88% 89%

91%90%

92%

National Performance Trend Over QuartersP

erf

orm

an

ce

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q22009/10 2010/11 2011/12

150000

175000

200000

225000

250000

74%

76%

78%

80%

82%

84%

86%

88%

90%

92%

94%

Trend of National Performance and Presentations

Presentations Performance

Pre

sen

tati

on

s

Per

form

ance

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q22009/10 2010/11 2011/12

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

ALL DHBsWest Coast DHB

How are we really doing?

What about NZ?

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q22009/10 2010/11 2011/12

70%

75%

80%

85%

90%

95%

100%

80%

83%

86% 87%86%

88% 89%

91%90%

92%

National Performance Trend Over QuartersP

erf

orm

an

ce

Are we kicking people out just before 6 hours?

DT_Diff

Pe

rce

nt o

f To

tal

0

5

10

15

Triage Level 1

2 4 6 8 10

Triage Level 2 Triage Level 3

2 4 6 8 10

Triage Level 4

0

5

10

15

Triage Level 5

Are more people re-presenting to ED?(within 24 hours)

2008-2009 2009-2010 2010-20111.0%

1.1%

1.2%

1.3%

300000

310000

320000

330000

340000

350000

360000

370000

380000

390000

400000

Repeat % Presentations

Are we admitting more patients?1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6

2007 2008 2009 2010 2011

0

5000

10000

15000

20000

25000

30000

35000

40000

45000

50000

Are we admitting less worthy patients?( reducing average IP LOS)

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

2007 2008 2009 2010 2011

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

2001 2002 2003 2004 2005 2006 2007 2008 2009 20101.0%

1.2%

1.4%

1.6%

1.8%

2.0%

10-year mortality rate

Are more people dying?

Soft data• A better winter last year

– Problems, but a more responsive system

• Significant interest in ED’s lot• Dedicated DHB activity to relieve ED

overcrowding• New conversations• Unexpected advocates• Control

So

• We are doing well against the target• We are probably doing well against more

meaningful measures• All the signals are positive, (although the

data isn’t great)• Let’s keep doing it

But

• It’s getting harder– Demand is increasing– The easy things have been done

That’s why we’re here

Programme – Day 1

• Opening and overview• Sessions

1. CDHB – CREST/Preload

2. NMDHB – data analysis

3. MCDHB – MAPU

4. ADHB – process improvement from decision to admit

5. CCDHB – creating momentum

6. BOP – Ops centre set up and operation

• Wrap up then drinks/nibbles (about 4.30)