Long Stay Patient Project
“Stranded Patients”
08 April 2013
Presented by Andrew Davies
Project Leaders: Alicia Sutton, Charlotte Porter
1
ADHB %<6 Hour Performance
100%
2008
2009
2011
2010
2013
2012
90%
80%
70%
60%
50%
% < 6 Hours Overall
Baseline % < 6 Hour Overall
Goal
% < 6 Hours ED Discharge
Baseline % < 6 Hour ED Disch
Mar
Jan
Nov
Sep
Jul
May
Mar
Jan
Nov
Sep
Jul
May
Mar
Jan
Nov
Sep
Jul
May
Mar
Jan
Nov
Sep
Jul
May
Mar
Jan
Nov
Sep
Jul
May
30%
Mar
40%
Jan
% < 6 Hour Emergency Department Stay
Overall - AED & CED Combined Performance
% < 6 Hours Admitted to Ward
Baseline % < 6 Hour Admit to Ward
2
The Problem: Not just in ED
Project Scope: Hospital-wide initiative involving all parts of the hospital
6 Hour Goal (Key Metric)
2 hours
1 hour
Inpatient
Specialist
Admit to ward
3 hours
Patient
presents to ED
ED Specialist
Assessment
Also In Scope
Bed
Management
ED Performance
is Primary
Influencer
Discharge
Discharge
Ward Performance
is Primary
Influencer
Other Key Performance Influencers
Diagnostic Services
(Labs, Radiology, etc.)
Allied
Health
Elective
Scheduling
Primary Care
Facilities
3
Why Focus on Long Stay Patients?
 Voice of staff
 Recommended next steps from other
acute flow projects (e.g. Daily Rapid
Rounds)
 Literature Review
– Healthcare Advisory Board –
Maximizing Hospital Capacity
(2002)
4
ADHB General Medicine – Evaluating the Opportunity
Patients with Over 10 Day Length of Stay
LOS > 10 Days
LOS > 10 Days
Patients with Over 21 Day Length of Stay
LOS > 21 Days
LOS > 21 Days
ADHB General Medicine Discharges from July 2004 to March 2013
5
The Project
 Initiated Long-Stay Patient Project in General Medicine – April 2012
 Clinical note review conducted of all > 21 day patients discharged from
December 2010 to December 2011
 Implemented first improvements from July 2012 to December 2012
 Leveraged results and actions to other service areas
6
Causes for Delay - Over 21 Day Patients
Pareto of Days Waiting - Gen Med Long Stay Patients over 21 days
Dec 2010 to Dec 2011 (n=121 patients)
300
250
Total Wait Days
240
Number of Patients who Waited
189
200
188
175
146
150
128
101
100
78
Reha+ Bed…
PT R/V
OT R/V
OPH R/V
P/H Placement
SW R/V
2
PPPR
0
27
14
17
OPH bed…
13
36
2
8
2
2
Rehab+ R/V
24
49
47
Tikura Trust
56
55
50
NASC R/V
250
R/H Placement
Days Waiting OR Patients who Waited
Top Causes
 Rest Home /
Private Hospital
Placement
 PPPR
 Social Work
Input
 Older Peoples
Health Review &
Placement
7
Other Observations During Audit
 Significant variation in practice of how the plan for the stay is managed
 No standard Admission to Discharge process followed for 1st time Rest Home /
Private Hospital patients
 No escalation criteria to involve Service Manager, Nurse Advisor & Clinical
Director.
 Poor visibility of current long-stay patients leading to variation in management
8
Increase Visibility in Service of Long Stay Patients
 Daily Long Stay Patient report automated, reviewed by Nurse Specialists &
Charge Nurses (July – 2012)
Current Gen Med Patients as at 11/12/2012 00:00:00,
staying 10 days or longer
NHI
Family Name
Event No
Admit Date Time
LOS Days
Ward Code Ward Stay Type
ABC1234
Pitt
3902162 02/10/2012 12:21
69.6
65
Ward stay
ABC1235
Ford
3927162 14/11/2012 14:09
26.5
68
Ward stay
ABC1236
Holden
3930640 20/11/2012 12:14
20.6
65
Ward stay
ABC1237
Mitsubishi
3931019 21/11/2012 02:12
20.0
68
Ward stay
ABC1238
Nissan
3931592 21/11/2012 18:59
19.3
68
Ward stay
ABC1239
Millner
3932454 23/11/2012 01:29
18.0
66
Ward stay
ABC1240
Osbaldiston
3934113 26/11/2012 11:29
14.6
67
Ward stay
ABC1241
McGregor
3934241 26/11/2012 13:53
14.5
66
Ward stay
ABC1242
Denison
3934331 26/11/2012 15:39
14.5
65
Ward stay
ABC1243
Griffin
3934450 26/11/2012 18:51
14.3
65
Ward stay
ABC1244
Sutton
3935235 27/11/2012 21:44
13.2
66
Ward stay
ABC1245
Meyrick
3935539 28/11/2012 14:18
12.5
68
Ward stay
ABC1246
Reeves
3935616 28/11/2012 14:52
12.5
65
Ward stay
ABC1247
Devaliant
3936436 29/11/2012 17:04
11.4
65
Ward stay
9
Increase Visibility in Service of Long Stay Patients
 Long Stay Patient Report reviewed and discussed weekly at General Medicine
Production Meeting (October 2012)
– Issues escalated to Service Manager, Nurse Advisor & Clinical Director
– Charge Nurses, Nurse Specialists & Nurse Educators also attend
10
Increase Visibility in Service of Long Stay Patients
 Include LOS on Patient Status at a Glance whiteboards on Wards 65, 66, 67, 68
(January 2013)
 Visible in Nursing Station and can be flagged at Daily Rapid Rounds
Current LOS
Added to
Whiteboards
11
Results: Proportion of Over 10 Day LOS Patients
Lowest Proportion of > 10 Day Patients Ever @ 6.1% (January to March 2013)
Quarterly Proportion of > 10 Day LOS Patients since July 2007
Proportion of Gen Med Discharges Over 10 Day LOS
0.10
2
1
1
3
4
1
UCL=0.09504
_
P=0.07974
0.08
0.07
LCL=0.06443
0.06
2012/2013 FQ3
2012/2013 FQ2
2012/2013 FQ1
2011/2012 FQ4
2011/2012 FQ3
2011/2012 FQ2
2011/2012 FQ1
2010/2011 FQ4
2010/2011 FQ3
2010/2011 FQ2
2010/2011 FQ1
2009/2010 FQ4
2009/2010 FQ3
2009/2010 FQ2
2009/2010 FQ1
2008/2009 FQ4
2008/2009 FQ3
2008/2009 FQ2
2008/2009 FQ1
2007/2008 FQ4
2007/2008 FQ3
DxFyear
1
2007/2008 FQ2
Fquarter
2007/2008 FQ1
Proportion
0.09
Key Projects
1 Daily Rapid Rounds
implemented (Feb 2010)
2 New medical model of
care implemented (Dec
2011)
– Split Acute (APU) &
Inpatient Ward
– 4-8 p.m. on-call
consultant on-site
– Additional weekend
medical staff
3 Long Stay Project
Commenced (Apr 2012)
4 Long Stay Patient Visibility
and Standard Escalation
Practices implemented
(Sep-Dec 2012)
12
Results: General Medicine Average Length of Stay
Shortest Quarterly Average Length of Stay Ever @ 2.97 (January to March 2013)
Quarterly Average LOS Patients since July 2004
General Medicine Average LOS All Discharges (incl non-WIES)
4.0
3.9
3.8
1
1
1
1
1
1
2 3 4
UCL=3.837
5
3.7
_
_
X=3.577
3.5
3.4
6
LCL=3.317
3.3
3.2
3.1
3.0
2.9
DxCalQ
DxYear
1
1
1
1
1
2004 Q3
2004 Q4
2005 Q1
2005 Q2
2005 Q3
2005 Q4
2006 Q1
2006 Q2
2006 Q3
2006 Q4
2007 Q1
2007 Q2
2007 Q3
2007 Q4
2008 Q1
2008 Q2
2008 Q3
2008 Q4
2009 Q1
2009 Q2
2009 Q3
2009 Q4
2010 Q1
2010 Q2
2010 Q3
2010 Q4
2011 Q1
2011 Q2
2011 Q3
2011 Q4
2012 Q1
2012 Q2
2012 Q3
2012 Q4
2013 Q1
Days
3.6
Key Projects
1 Daily Rapid Rounds
implemented (Feb 2010)
2 New medical model of
care implemented (Dec
2011)
– Split Acute (APU) &
Inpatient Ward
– 4-8 p.m. on-call
consultant on-site
– Additional weekend
medical staff
3 Long Stay Project
Commenced (Apr 2012)
4 Long Stay Patient Visibility
and Standard Escalation
Practices implemented
(Sep-Dec 2012)
13
Results: General Medicine Average Length of Stay
Quarterly Average LOS Patients since July 2004
General Medicine Average LOS All Discharges (incl non-WIES)
4.0
3.9
3.8
1
1
1
1
1
1
4
2
UCL=3.837
5
3.7
_
_
X=3.577
3.5
3.4
6
LCL=3.317
3.3
3.2
3.1
3.0
2.9
DxCalQ
DxYear
1
1
1
0.5 day reduction
in Average LOS
~ 6,000 bed days/yr
1
1
2004 Q3
2004 Q4
2005 Q1
2005 Q2
2005 Q3
2005 Q4
2006 Q1
2006 Q2
2006 Q3
2006 Q4
2007 Q1
2007 Q2
2007 Q3
2007 Q4
2008 Q1
2008 Q2
2008 Q3
2008 Q4
2009 Q1
2009 Q2
2009 Q3
2009 Q4
2010 Q1
2010 Q2
2010 Q3
2010 Q4
2011 Q1
2011 Q2
2011 Q3
2011 Q4
2012 Q1
2012 Q2
2012 Q3
2012 Q4
2013 Q1
Days
3.6
14
What Next - We need to focus on the whole system
with initiatives on each part of the journey
Other
DHBs / 5
Private
Provider
1
5
9
1
9
Medical
2
0
APU
Radiology
1
8
WARD
1
7
Operating
Rooms
CLINIC
8
7
12
1
1
9
GP
3
7
ED
1
8
DCCM
Hospice
1
5
6
REHAB
1
8
Community (Home)
Community (Home)
2
1
6
Follow
-up
Clinic
Surgical
13
3
4
7
Residential
Care
Residential
Care
1
4
Patient Transit
Supply Chain
Labs
Pharmacy
Therapies
1
4
IMTS
Hospital Ops
Demand Management
1
0
Flow Improvement
1
1
15
15
Initiatives to reduce acute demand to secondary
facilities
Other
DHBs / 5
Private
Provider
Hospice
7
9
2
9
GP
CLINIC
3
7
APU
8
6
4
Residential
Care
1
DCCM
1.
Avoidable presentations
from
Medical
ARRC
2. Reduce the % of St John
Radiology
transports for statusWARD
3 and 4
patients
3. Use of the
GAIHN predictive
Operating
Surgical
risk algorithm
Rooms
4. Cluster model for ARRC
5. Gen Med Acute clinics
6. Advance Care plan
(Implementation)
Patient Transit
Supply clinic
Chain
7. Acute
pathways
Labs
8. Reducing Readmissions
REHAB
Community (Home)
Community (Home)
ED
Follow
-up
Clinic
3
7
Residential
Care
4
Pharmacy
Therapies
IMTS
Hospital Ops
Demand Management
16
16
Initiatives to improve the flow within secondary
facilities
Other
DHBs /
Private
Provider
1
5
GP
ED
1
1
APU
DCCM
1
9
Medical
12
2
0
Radiology
1
8
WARD
1
7
Operating
Rooms
CLINIC
Surgical
13
Residential
Care
Patient Transit
Supply Chain
Labs
Pharmacy
Therapies
1
4
IMTS
Hospital Ops
Flow Improvement
1
0
1
1
10. Integrated
Ops centre
Hospice
11. Management of escalation
practices
12. Improved utilization of bed
capacity at GSU
13. Elimination
of duplicated
Follow
REHAB
-up
documentation
between
1
Clinic
8 and IP specialties
AED
14. National shared care plan
15. Matching medical
resources to demand
16. Coordination
between AED
Residential
Care
and IP
17. Stranded Patients
18. Proactive discharging
19. Medical HDU and
enhanced DCCM admission
criteria
20. Ward based flow
improvement initiatives
Community (Home)
Community (Home)
1
8
1
6
1
5
17
17