From Push to Pull
Navigator Supported Triage in Acute Medicine
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From Push to Pull
• Challenge: Acute Medicine Triage
• Why do patients come to hospital?
• Acute Illness vs
Uncertainty vs
Performance Status
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2
Predictors of Death
Comorbidity
Stroke
Diabetes
ECG
Age
Severity Illness
Blood pressure
Pulse
Respiratory rate
Oxygen saturation
Breathlessness
Temperature
Functional Capacity
Level consciousness
Ability to stand
Nursing home residence
Comorbidity
Physiology
Functional Capacity
Pompei P. et al. J. Clin. Epidemiol. 1988;41:275-284.
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Scoring chart
Independent Predictors
>=50 men and >=55 for women and <=75
>75
Points
2
4
A’
Age
A
Airway
Coma (not intoxicated)
Oxygen saturation >=90% and <95%
Oxygen saturation <90%
4
1
2
B
Breathing
Breathlessness
Respiratory rate >20/min and <=30/min
Respiratory rate >30/min
1
1
2
C
Circulation
Systolic blood pressure >80 mmHg and <=100 mmHg
Systolic blood pressure >70 mmHg and <=80 mmHg
Systolic blood pressure <=70 mmHg
Pulse > systolic blood pressure
2
3
4
2
D
Disability
Altered mental status >=50 (not intoxicated)
Stroke
Unable to stand unaided or Nursing Home resident
Prior illness – some part of daytime in bed
Diabetes (Type I or II)
2
3
2
2
1
E
ECG
Abnormal ECG
2
F
Fever
Temperature <35ºC or >= 39ºC
2
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MAELOR vs NENA
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… from PUSH to PULL
Earlier discharge of very low risk patients
Earlier recognition of frail patients
Earlier management of very high risk patients
Benchmarking
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MAELOR Hospital - Wrexham
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Dr C Subbe
C Whitaker
B Hounsone
Dr J Kellett
S Price
J WardJones
Prof A White
L Williams
F Jishi
Dr E Eeles
Dr R Hubbard
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Navigator Assisted Flow
New Admissions
(100%)
Electronic Triage
Simple Clinical Score
&
Clinical Frailty Scale
Very Low Risk
(~ 35%)
Intermediate Risk
(~60%)
Very High Risk
(~ 5%)
Navigator initiated
Senior review &
first line treatment
investigations
Admission Procedure
including
X-rays, ECG
laboratory investigations
Navigator initiated
Senior review &
first line treatment
investigations
significant medical problem
or
very frail
low risk medical problem
and
no frailty
low risk medical problem
intermediate frailty screen
Senior review
including treatment
and discharge planning
Admit
Navigator led
work-up
follow-up
ambulatory care
Navigator led
social assessment
referral frailty team
or intermediate care
Admit
Referral
Critical Care
if appropriate
Admit
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Very Low Risk
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Severity Distribution
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Patients seen
T able 1: P atients seen in control phase (pre navigator) and intervention phase
(not seen and seen) by SCS risk group.
Control vs. Intervention Phase
SCS risk
Pre.
Navigator:
Navigator:
Navigator
not seen
seen
Total
Very low
Count
1276
970
519
2765
Low
Count
675
652
141
1468
Average
Count
545
643
19
1207
High
Count
482
586
11
1079
Very high
Count
106
119
20
245
Count
3084
2970
710
6764
Total
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Length of Stay
Combined Seen
SCS risk
Very low
Low
Average
High
Very High
Pre Navigator
Not Seen
Seen
and Not Seen
2.2
2.5
1.8
2.1
(2.1, 2.4)
(2.3, 2.7)
(1.6, 2.1)
(1.9, 2.4)
5.6
5.6
4.5
5.0
(5.1, 5.6)
(5.1, 6.1)
(3.6, 5.4)
(4.4, 5.6)
8.4
9.9
3.0
5.6
(7.7, 9.3)
(9.1, 10.8)
(1.5, 5.2)
(4.9, 6.3)
10.7
12.0
4.9
7.7
(9.7, 11.8)
(11.0, 13.1)
(2.2, 9.6)
(6.8, 8.8)
9.3
8.6
12.7
10.5
(7.5, 11.5)
(7.0, 10.5)
(7.8, 20.3)
(8.1, 13.5)
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Light Green - $$$
Total all
SCS risk
Total
Not seen
mean cost (se)
Seen
mean cost (se)
Difference
Very low
£1,523 (108)
£1,041 (76)
-£482**
Low
£3,337 (205)
£2,794 (375)
-£543*
Average
£5,631 (292)
£2,002 (694)
-£3,629**
High
£6,429 (297)
£2,619 (895)
-£3,810*
Very high
£4,598 (495)
£5,060 (750)
£462
£3,902 (111)
£1,553 (104)
-£2,349**
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“Gosh, that was quick
I expected to be here all day
waiting..!”.
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 Very High Risk
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Critical Illness –
ICU admissions
• 85/3084 (2.8%) vs 62/3680 (2.0%)
• First 2 days: 54% vs 35% .
– Chi-square = 5.78, df=2, p = .055
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 Frail Patients
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Intermediate Care
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“The EPOC of the frail patient”
Using the Clinical Frailty Scale in Acute Medicine
RN performs triage
using the tools t o
assess severity of
illness and frailty.
Subbe CP, Price S, Ward-Jones J, White A, Waudby C, Kellett J, Hubbard
R, Eeles E, Jishi F
If int er-current illness is
mild, rehabilitation &
home support might be
suitable for some
patients
Aim
•
Electronic Triage
Simple Clinical Score
&
Clinical Frailty Scale
We aimed to quantify the likely workload for an intermediate care
team dealing with low-mortality-risk patients with frailty admitted
to Acute Medicine using a simple triage tool.
Methods
•
New Admissions
(100%)
significant medical problem
or
very frail
Non-cardiac admissions to Acute Medicine Unit (AMU) were triaged
using a PC based system (Electronic Point of Care, EPOC) and a
measure of disease severity [1] to trigger senior review in very high
and very low risk patients and since March of 2011 a measure of
frailty [2] (Figure) to trigger early support by intermediate care
specialists in patients classified as “vulnerable”, “mildly frail” and
“moderately frail”.
Admit
Very Low Risk
(~ 35%)
Intermediate Risk
(~60%)
Very High Risk
(~ 5%)
Navigator initiated
Senior review &
first line treatment
investigations
Admission Procedure
including
X-rays, ECG
laboratory investigations
Navigator initiated
Senior review &
first line treatment
investigations
low risk medical problem
and
no frailty
low risk medical problem
intermediate frailty screen
Navigator led
work-up
follow-up
ambulatory care
Navigator led
social assessment
referral frailty team
or intermediate care
Referral
Critical Care
if appropriate
Senior review
including treatment
and discharge planning
Admit
Admit
Acute Nurse P ractitioner
coordinates treatment
including sepsis-6 & times
transfer t o critical care
where needed.
Acute Nurse P ractitioner
arranges investigations &
follows patients for up to 72
hours, if need in the HotClinic on MAU.
Results
Between October 2010 and May 2011 we saw 3955 patients (range per
month from 437 to 522). Mean age of patients was 65 (+/-21) years,
median SCS 4 [IQR 2-7].
The intermediate care target group of patients with intermediate frailty
and very low or low risk in the SCS was 37 – 64 per month. Frailty did
influence length of stay independent of SCS (p<0.000) with patients in the
“Well” group staying a mean of 3 (SD 6) days and those with “moderate”
frailty 14 (SD 16) days. Patients with worse frailty (classified as
“vulnerable” or greater frailty) had fewer 0 or 1-day admissions (p<0.000).
References
[1] Kellett J et al.The Simple Clinical Score predicts mortality for 30 days after
admission to an acute medical unit. Q J Med 2006; 99:771–781.
[2] Rockwood K et al. A global clinical measure of fitness and frailty in elderly
people. CMAJ 2005;173(5):489-95.
Clinical Frailty Scale
Month March
(2011) April
May
Total
No data
171
33
27
231
Very Fit
40
65
65
170
Well
65
108
109
282
Managing
Well
67
118
100
285
Vulnerable Mildly Frail
40
36
71
43
66
41
177
120
Conclusions
The CFS is a feasible fast assessment
of patients on the AMU. We are
currently piloting an intervention that
uses the information to enhance flow
in these patient groups.
This project is part of a service
improvement grant by the Health
Foundation.
Wrexham Maelor Hospital, Wrexham, Croesnewdd Road, Wrexham, LL13 6TD
01978-291100, csubbe@hotmail.com
Moderately
Frail
42
38
54
134
Severely
Frail
39
50
46
135
Very Sev.
Frail
2
10
10
22
Term n
i ally
Ill
1
5
4
10
Total
503
541
522
1566
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Challenges …
 Patients with Very Low Risk
– Capacity of AMU
– Consistency between teams
 Patients with Very High Risk
 Frail patients
– Variability between areas
– Funding for intermediate care
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Challenges …. & Solutions
 Patients with Very Low Risk
– Virtual Short-stay ward
 Patients with Very High Risk
– High dependency area in AMU
 Frail patients
– Negotiation by Navigator
– Patient assisted CGA
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Thank You Shine!!!
& Richard Edgeworth
From Push to Pull
Navigator Supported Triage in Acute Medicine
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39
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Simple Clinical Score
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