Peter Ward
Senior Physiotherapist
Acute Medicine
Carole Murphy
Senior Occupational Therapist
Emergency Department
Driving Healthcare Change Through HSCP Research
February 28th, 2014
Background
 Historically OT and Social Work providing services
within this setting
 No physiotherapy, SLT or Dietetics services available
 Care pathways established in response to Government
policy and organisational change
Impetus for Change
 Clinical Care Programs, 2010
 Lis Nixon Report, 2011
 Establishment of Special Delivery Unit (SDU), 2011
Service Objectives



Provide rapid access to MDT
assessment for patients in ED,
AMAU and SSU who are
deemed medically fit for D\C
that day
Reduce unnecessary nonmedical admissions to
hospital
If appropriate, support early
discharge from hospital,
improve throughput and
prevent re-admission
Design Phase
 Establishment of a steering group with
representatives from the key HSCP groups
 Responsibility with the clinicians to oversee the
design phase

1.
2.
3.
This included development of:
Care pathway
Single assessment tool
Role of teamlead
Referral to the BRAT service should be considered for patients who are
medically fit to be discharged that day and present with the following:
Frail Elderly
+/- Living Alone
Falls Prevention
Upper/Lower Limb Fractures
Confusion
Exacerbation of Chronic Condition
Does patient present with new difficulties
with transfers/ mobility?
Does the patient present as confused?
Does the patient appear unkempt?
NO
Referral to BRAT not indicated.
Patient at previous functional
status with adequate supports in
place.
YES
Is there a concern regarding
patient’s ability to cope at home?
YES
No
Referral to BRAT not indicated.
Patient at previous functional status
with adequate supports in place.
Contact BRAT Team Lead. Dect: 8457
Team Lead
 Rotational team lead
between Occupational
therapy, Physiotherapy
and MSW
 Responsibilities include
- Morning handover
- Carries BRAT phone
- Screens appropriate patients
- Completes common assessment
form as appropriate
- Contacts relevant profession
Aims of Study
 To establish a profile of the patients referred to the
BRAT service
 To analyse the patient profile of those readmitted to
the hospital within thirty days of BRAT review
 To determine the efficacy of the BRAT service in
relation to cost saving, bed day saving and admission
avoidance
Beaumont Rapid Assessment Team 2012/13
 From February 1st 2012-January 31st 2013
- 280 patients reviewed in 253 working days (1.1
patients\day)
- Average age: 76 years and 9 months; Range 23-102
- 186 females, 94 males (2:1 ratio)
- 46.8% lived alone
- 48% were 80 years old or over
Age Categories
>89
9%
<45
3%
44-65
11%
79-90
39%
<45
44-65
64-80
38%
64-80
79-90
>89
ED Attendances
Age
0-64
65-79
80-89
90+
Total
Total
37,498
Reviewed
39
106
9,324
0.1%
1.1%
109
2.8%
26
4%
3,849
650
51,321
%
280
.54%
Discharge V Admission
Admission,
94, 34%
Discharge,
186, 66%
Gender Distribution of Admissions
200
180
63
160
140
120
Male
100
123
60
40
Female
31
80
63
20
0
Yes
No
Reason for Referral (Total & Discharge)
140
127
Total
120
Discharged
100
90
80
60
40
45
39
31
26
21
21
20
3 2
2 0
0
13.90%
0.70%
Medical
Surgical
45.40%
1.10%
8
7.50%
Falls/Collapse Diff with ADLs Acopia (P\F)
16
5 3
12
5 3
7
1.80%
7.50%
1.80%
4.30%
16.10%
Acopia (SD)
Joint Pain
Confusion
Back Pain
Decreased
Mobility
Onward Destination
63.20%
Home
Interim Care, Rehabilitation, Respite
Ward
33.90%
2.90%
Re-presentations
 44 (23.6%) people of the 186 init1ally discharged
re-presented within 30 days
 Of these 44:
- 75% were deemed medical re-presentation
- 25% were related to ongoing physical/functional issues
 Average time to represent was 11.5 days (Range 130)
Age of re-presenters
>89, 3, 7%
44-65, 5, 11%
64-80, 13, 30%
79-90, 23, 52%
Team Performance
 Average response time: 19 minutes
 44.7% seen within 10 minutes
Cost Savings
 Average Medical LOS was 12.57 days
 770 bed days saved
 Average cost of medical bed is €950 per night
 Saving calculated at €731,500
Challenges to Service Provision
 Medical complications
 Limited access to:
Home Care Packages
 Access to step down facilities:
- rehabilitation
- interim care
- respite
 No Out of Hours Service
Limitations of Study
 Short time frame for research
 Cost estimate is quite conservative
 Difficult to establishing an exact cost saving due to:
- complexity of the group of patients reviewed
- costs are based on hospital averages and therefore do
not address the individual variables which can arise in
the ‘frail elderly’
- Doesn’t take into account those under ED service or
subsequent cost of re-presentations
Positive Service Outcomes
 Coordinated MDT assessment at point of entry to
Beaumont hospital
 Team lead and the common assessment form
enhances communication
 Equipment provision
 Onward referral to both in-house & community
services
 Prioritisation for rehabilitation and discharge planning
Conclusion



Provide rapid access to MDT
assessment for patients in ED,
AMAU and SSU who are
deemed medically fit for D\C
that day
Reduce unnecessary nonmedical admissions to
hospital
If appropriate, support early
discharge from hospital,
improve throughput and
prevent re-admission
Acknowledgements
 Members of BRAT
 HSCP Managers
 Senior Nursing Staff
 Emergency Department Consultants
 Rebecca Mahon – 3rd year Physiotherapy Student RCSI
 Dr. Frances Horgan – Senior Physiotherapy lecturer
RCSI
 Hospital Management
 HSCP Education & Development Advisory Group
QUESTIONS???
References
 Nixon L, Wolford S. Reports into the Emergency Care
Pathways in Beaumont Hospital (2010)
 Beaumont Hospital HIPE Hospital Inpatient Enquiry)
Data, (2012-2013)
 Beaumont Hospital Annual Report 2011
 Report of the unannounced monitoring assessment at
Beaumont Hospital, Dublin. HIQA (2013)