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Tidying up to be NEAT

Tidying up to be NEAT. Clair Sullivan Princess Alexandra Hospital QuICR. NEAT Team. Dr Judy Flores – Chair, Division of Medicine A/Prof Ian Scott – Director, Internal Medicine Dr Andrew Staib – Deputy Director, Emergency Medicine Dr James Collier – Deputy Director, Emergency Medicine

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Tidying up to be NEAT

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  1. Tidying up to be NEAT Clair Sullivan Princess Alexandra Hospital QuICR

  2. NEAT Team Dr Judy Flores – Chair, Division of Medicine A/Prof Ian Scott – Director, Internal Medicine Dr Andrew Staib – Deputy Director, Emergency Medicine Dr James Collier – Deputy Director, Emergency Medicine Dr Leena Aggarwal – Director, MAPU Mr Alan Scanlon - Clinical Data Support, Patient Flow Unit Dr Georga Cooke - Medical Admin Registrar

  3. Background

  4. What is NEAT? National Emergency Access Target Aim to have people discharged from hospital or admitted to the ward within 4 hrs of triage Goal is 77% this year We started off at 33%....

  5. Wooden spoon Courier Mail 14/12/12 NHPA report 2011-12

  6. Why rush people out of the ED? They can wait in ED till I’m finished clinic They should stay in ED until all the tests are back: perhaps they will end up under another unit? It’s nearly time for me to go home, they can go on the list for the after hours reg to admit when they can.

  7. I might miss something if I accept them from ED without all the tests back

  8. Cautionary tales Time to disposition plan <4 h associated with 57% increase in mortality in general medicine patients, corrected for age, gender and triage category No increased risk with ED LOS <8 h Mitra et al Intern Med J 2012 Increase in proportion of admitted GM patients lower triage score (ATS 4) (29.2% vs 21.9%; p<0.001). aged less than 50 years (9.4% vs 7.8%; p=0.01) patients with low triage scores (ATS 4 and 5) increased LOS Adjusted median 6.0 days vs 5.2 days (p=0.008) Nash et al RMH 2013

  9. Harms of ED access block and overcrowding Length of ED stay independently predicts inpatient LOS. Average excess LOS for inpatients: 0.39 days for ED LOS ≤4 hrs; 2.35 days for ED LOS >12 hrs Liew et al Med J Aust 2003 34% increase in risk of death at 10 days among admitted patients presenting during periods of ED overcrowding Richardson Med J Aust 2006 ED overcrowding in Perth’s three tertiary hospitals associated with an estimated excess 120 deaths in 2003 Sprivulis et al Med J Aust 2006 Among patients well enough to leave ED after being seen, longer ED LOS (≥6 hrs) compared to shorter LOS (<1 hr) resulted in 80% increase in death and 100% increase in admission at 7 days in high acuity patients Guttmann et al BMJ 2011 Increased readmissions and ED return visits; inappropriate follow up care (discharge planning) Forero & Hillman, ‘Access block and overcrowding: A literature review’, Prepared for Australasian College of Emergency Medicine Prolonged pain, patient/carer dissatisfaction, violence, ambulance diversions/ramping, reduced efficiency Derlet & Richards Ann Emerg Med 2000

  10. Harms of ED access block Identified as a public health issue similar in magnitude to road toll (Richardson 2012 MJA)

  11. Existing Patient Journey

  12. The Patient Journey Mr K 35 year referred from GP with myalgias arthralgias chol 20 trigs 190. He was unable to walk because of the pain. Possible exposure to Dengue After 1 hour referred to cardiology. Cardiology came to see pt and suggested ID consult. ID over the phone suggested endocrine consult. ED reg made these consults but interrupted by multitrauma, tea break and aggressive patient… This man spent 6 hrs in ED. No treatment started until endocrine consult. He clearly needed admission at presentation: how can we improve the patient’s experience and our efficiency?

  13. Which patient group is dominating ED admissions?

  14. Start with the patient journey

  15. Factors causing NEAT non-compliance for admissions

  16. The POO index: PAH occupancy correlates with NEAT Non-compliance

  17. Quick wins No Bypass SSW Gen Ped Rounds Clinical review committee Expanding subspec med reg hours Direct to ward admission form

  18. Direct to ward admission form Adopted at MCH RBH

  19. Obviously a complex issue.. Problem Innovations required to improve NEAT performance previously substantially hindered due to differing opinions among clinical areas Solution Objective data: enlist a data analyst and a love of graphs

  20. Safety reviews • Weekly NEAT review meetings • DOM chair • Director of Internal Medicine • Director, MAPU • Deputy Director, ED • Senior medical registrar • ADON

  21. Analysis of Key Issues and Causes

  22. So what are the characteristics of those patients who are breaching NEAT? Can we predict their NEAT risk at triage and expedite their journey? (save time, lives and money)

  23. PAN-C study Princess Alexandra Hospital NEAT Compliance Study Funded by MACRO Neat

  24. PAN-C Aim To identify predictors of NEAT non-compliance in patients being admitted to DOM via ED

  25. PAN-C Methods Real time chart audit Experienced practising clinician auditing

  26. PAN-C Results 38 admissions analysed (full 24hours quota of DOM admissions) 9 of 38 compliant 29 were noncompliant

  27. chest pain and SOB account for half these patients

  28. PAN-C Results Mean age both groups 65 years No sig differences (p>0.1) between groups according to age, number of comorbidities, number of drugs, residential care status or mobility impairment

  29. Multiple Inpatient Referrals In NC group: 1 of 9 11% In NNC group: 7 of 19 37%

  30. QAS and NEAT Compliance Association with NEAT compliance was significant for arrival by non-QAS means (p=0.04)

  31. Factors causing NEAT non-compliance for admissions Preliminary data from PAN-C study chart review (n=38; 29 non-compliant; 9 compliant) Mean age both groups 65 years No sig. differences (p>0.1) between groups according to age, number of co-morbidities, number of drugs, residential care status or mobility impairment

  32. PAN-C Discussion Interesting association of multiple inpatient referrals with NNC

  33. PAN-C Discussion Much of this intuitive: if team knows in ED and patient has been referred, likely to have a working diagnosis, have some investigations done and be “fast tracked” Patients arriving via QAS likely to be complex, unwell and have more limited social supports

  34. PAN-C More data and multivariate analysis to identify more predicators of NEAT non-compliance Analysis of those breaching early and those with extended stays Analysis of large diagnoses groups (chest pain and SOB account for half these patients) Considering the process of multiple inpatient referrals Verifying the model Applying the model

  35. Have our quick wins been safe?

  36. Safety indicators √ MRSA infection rates unchanged √ Sentinel events unchanged ? Unplanned transfers to ICU <24 hrs ED admission √ Did not wait - 6% to 1%

  37. Have our quick wins saved us any money?

  38. Surely it must be cheaper to spend less time in ED? Not if you look at funding model for ED We calculated the cost of an “ED minute” compared to the cost of a “medical ward minute” $2.51/minute for ED vs 59c/min for ward 5B Use this novel information to motivate change…

  39. Is NEAT Compliance saving us any money? Average NEAT savings=NA x NTS x NCS Mean time July 2012-April 2013 Assumptions: costs stable over that time, mean savings only NA(number of admissions) NTS(NEAT time saving):Difference in mean time in ED (648-470=178 mins) NCS( NEAT cost saving ): ED minute cost-ward minute cost($2.51-$0.62= $1.89) Mean saving per patient $336.42/patient Average 30 admissions a day mean saving $10 092.60 /day Average saving over a year is $3 683 799

  40. Seasonally and Activity Adjusted Calculations ED cost 2.51 5B cost 0.59 Difference 1.92 Average time for April 2011 633.78 minutes Average time for April 2013 410.34 minutes Average Patients per day in April 11 26 Patients Average Patients per day in April 13 31 Patients ED LOS 2011 (633.78x26) 16478.28 Minutes per day ED LOS 2011 (410.34x31) 12720.54 Minutes per day Difference in LOS for 2011 to 2013 3757.74 Cost Savings per day (3757.74 x (2.51 - 0.59) $7,214.86 Cost savings for April $216,445.82 Cost Savings for year $2,597,349.89

  41. Benchmarking PAH underperforming Study trip to WA (AAU) RBH flex bed unit MCH all medical admissions on ward (low volume admissions) No one really been able to solve the ED-med reg referral time….

  42. So where to now? Three main problems: 1.ED-DOM referral time 2.Occupancy 3.Data

  43. Agreed Principles for Solution Design Keep the patient at the centre of our solution Evidence based Efficient (training, financial consideration) Ongoing review and safety monitoring

  44. Data Difficult to access data in meaningful time frame No dedicated data manager Hopefully will improve in 3 mths with new software

  45. Occupancy Strategies underway to improve patient discharges Difficult because of tension between NEAT and NEST Strategies include: HITH, public private partnerships, predictive bed management and the “stranded patient” project

  46. ED-DOM referral time Median approx 200mins This makes med reg review and bed allocation within 240 mins unlikely Difficult to improve this time without major ED process changes (“process mapped to death at RBH) MAZE (Medical Admission Zone)

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