Dr A Dorward - Shifting the Balance of Care

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The Admitted Patient
Specialty Ward
Dr Alistair Dorward
Consultant Respiratory Physician
Royal Alexandra Hospital
Paisley
ACUTE MEDICINE
Surgery
CCU
Acute
General
Ward
Acute
General
Ward
Acute
General
Ward
Acute
General
Ward
Acute Admissions
Acute
General
Ward
Patient Flow
Acute Admissions
CCU
Respiratory
Acute
Admission
Unit
Cardiology
Diabetes &
Endo
Home
Home
GI/Haem
Stroke &
rehab
Specialty Wards
 Chronic/complex patients seen by appropriate
specialist
Before
After
Cardiology
34%
58%
Respiratory
53%
67%
Asthma
44%
93%
Hanlon, Beck, Robertson, Henderson, Capewell, Dorward . Coping with the Inexorable Rise in Medical
Admissions: Evaluating a Radical Reorganisation of Acute Medical care in a Scottish District Hospital. Health
Bulletin 55 (3) 1997
Speciality Ward Flow
Admission
• Patient
selection
• Elective
patients
• Infection
control
• Geography
• Bed
Management
Ward flow
• Nursing
• Medical
• Physiotherapy
• Pulm
physiology
• Timely
investigations
• Mobility
• Morbidity
Discharge
• Discharge
planning
• AHPs
• SWD
• Home care
• Pharmacy
• Respiratory
support
• O2
Barriers to Patient Flow
•
•
•
Medical
– Unwell
– Dying
– Symptom control
– Requiring O2
– Poor mobility
Medical Administration
– Waiting ward round
– Waiting consultant
– Waiting specialist / Geriatrician
opinion
Waiting
– Social work
– AHP
– Transport
– Long term care
•
•
•
Other waits
– Radiology
– Endoscopy
– Bronchoscopy
– Pulmonary function
– Transport
– Other investigations
Refusing home
– Patient
– Relatives
Patient Boarding
RAH Respiratory Unit
8
7
7
6
6
6
5
5
4
4
4
3
3
2
2
1
1
0
0
0
41-45
46-50
51-55
56-60
61-65
39 beds – 1 empty
66-70 71-75
Age range
76-80
81-85
85-90
91-95
RAH Respiratory Unit
• 19 male
• 1 day case
• 1 elective admission
12
10
COPD
Other
8
6
4
Pneumonia
Lung Cancer
Non resp diagnosis
VTE
TB
2
0
Asthma
RAH Respiratory Unit
Unwell
Waiting Social work
Waiting specialist
Waiting LT care
Radiology
Waiting consultant wd Rd
Other investigations
Awaiting dom O2
Symptom control
Dying
Confusion
0
5
10
15
20
25
COPD
Current discharge procedures in UK hospitals
• Only 53% of patients were seen by a respiratory physician before discharge;:
69% were seen by a specialist nurse
• Only 32% of hospitals use a formal discharge check list
• Only 22% of hospitals have a COPD discharge pack for Patients
• Only 25% felt ready to leave hospital
• Only 26% felt able to cope at home
• Only 37% felt reassured that good support was available at home
• Only 34% felt informed about their COPD and reasons for admission
• Only 52% of hospitals refer patients directly to pulmonary
• rehabilitation
• Only 63% of hospitals refer patients to their smoking cessation
• service
Re
ha
b
M
Di isc
ab
de etes
Ha me
em nti
ox ato a
ic
co logy
nf
us
ion
Em O
pt /D
yb
ed
s
GI
di
ac
Ch
es
St t
ro
ke
Ca
r
Bed occupancy by illness
80
70
60
50
40
30
20
10
0
Jan-98
Jan-00
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