Long Stay Patients and a Standard Way of Working

1. Long Stay Patients and a Standard Way of Working

2. A STANDARD WAY OF WORKING A standard way of working is one of the essential steps in increasing patient safety, quality and cost- effectiveness “Any project, initiative or intervention is just another band-aid or workaround unless it becomes standard practice” The mantra of a good organisation Health is somewhat odd however in that outliers are seldom managed

3. Long Stay Patients- An Overview • What is a Long Stay Patient ? • Long Stay Case Studies • The extent of the Long Stay Patient Issue • Why is the Long Stay Patient important ? • What do we know about long stay ? • How does one reduce the outliers? • The opportunity and the benefits

4. What is a Long Stay Patient ? The medical record of a long stay patient A long stay patient is an outlier A long stay patient is one where the LOS is considerably greater that the LOS that one would normally expect A current working definition of a long stay patient is one where the LOS=>21 days

5. Long Stay Patients- An Overview • What is a Long Stay Patient ? • Long Stay Case Studies • The extent of the Long Stay Patient Issue • Why is the Long Stay Patient important ? • What do we know about long stay ? • How does one reduce the outliers? • The opportunity and the benefits

6. All DRG Family I03 episodes for six months Sorted by days of stay Flagged at 21 days or more as “Long Stay” Case Studies Case 1 : Hip Replacement St Elsewhere – 6 months episodes

7. The Outliers The Standard chart – focuses attention on average patient Are seldom considered

8. The Bed Day Usage chart – shows that long-stay patients are important The Outliers • 21 days or more : 5% of episodes • 29% of total bed days

9. Our metrics focus on discharged patients, not those still in the hospital Long Stay patients (the LOS=>21 days) are less than 5% of the total They affect the average length of stay by 25%, but this is less than a day when the “normal” LOS is over five days Long Stay Patients are lost in the system

10. 1,900 Episodes 1730 Episodes 5,350 Episodes 24,100 Episodes Case 2 Hospital Alpha, Multi day 2007- 2008 Episodes Length of Stay Bed Days The Long Stay Patient Issue / Opportunity 72,500 Bed Days 21 to 350 Days 14 to < 21 Days 29,500 Bed Days 7 to < 14 Days 52,000 Bed Days Less than 7 Days 66,000 Bed Days 33,080 Episodes 220,000 Bed Days

11. The Long Stay Patient Issue / Opportunity So What ? This is equivalent to 198 beds for a year 72,500 bed days / 365 days =198 beds Or this is equivalent to 6144 patients for a year 72,500 bed days ∕ 11.8 day (LOS) =6144 episodes / patients Given the current emphasis on Emergency targets ,this may be relevant Any way one looks at this ,these figures are non-trivial

12. Long Stay Patients- An Overview • What is a Long Stay Patient ? • Long Stay Case Studies • The extent of the Long Stay Patient Issue • Why is the Long Stay Patient important ? • What do we know about long stay ? • How does one reduce the outliers? • The opportunity and the benefits

13. The extent of the Long Stay Patients Issue An analysis of 2008-2009 data for a cross section of major public hospitals across Australia and NZ, where LOS=>21 days 2.3% of Patients use 32%+ of bed days Minimum :17.5% of Bed Days Maximum :49% of Bed Days Many very poor patient experiences

14. The extent of the Long Stay Patients Issue

15. Long Stay Patients- An Overview • What is a Long Stay Patient ? • Long Stay Case Studies • The extent of the Long Stay Patient Issue • Why is the Long Stay Patient important ? • What do we know about long stay ? • How does one reduce the outliers? • The opportunity and the benefits

16. Q. Why is the Long Stay Patient important ? A. Because it is “The canary in the coal mine” • The long stay patient serves as a sentinel for • Patient Risk Issues • Capacity Issues • Management Issues • Financial Issues The Long stay patient serves as a marker for whole of hospital performance

17. The consequences of a non standard way of working - Patient Risk Issues A Hypothetical

18. Patient Risk Issues • Case Studies indicate many Long Stay patients have a very poor quality experience • When examining these long stay episodes, the focus appears to be on the care system rather than the actual patient experience • Where there is visibility of this experience, it is frequently poor • A long length of stay could be taken as an indicator for poor quality • There needs to be much more focus and information about the impact on the Patient and the quality of the care delivered

19. Capacity Issues : The Crisis??? Hospital boss: We're in crisisArticle from: Courier Mail, Qld . June 2007THE chief of one of Queensland's biggest hospitals has branded the facility "in crisis" and urged staff they must discharge patients quicker.In a damning leaked email, the senior clinical chief executive officer warned staff that the hospital was not coping with demand. "The hospital is in a crisis situation with beds unavailable and emergency department access block,""Could all effort be applied to discharge all clinically suitable patients as rapidly as possible. Such effort is required now and needs to be sustained."

20. Long Stay Patients- An Overview • What is a Long Stay Patient ? • Long Stay Case Studies • The extent of the Long Stay Patient Issue • Why is the Long Stay Patient important ? • What do we know about long stay ? • How does one reduce the outliers? • The opportunity and the benefits

21. What do we currently know about Long Stay?. . . • Long Stay is a big issue and not high on anyone's radar. • One hears a lot about Bed Blockers, but little about causes of long stay • Long Stay patients are where the non standard ways of working all converge • The Data is poor • Because it has not been looked at previously • Statistical Discharges are a nightmare . The number of long stay patients can be understated by 50% • There is no case record • Scope can be vague • Normalisation is a large problem. Problems and issues become accepted • Consequently a patient can be in for 500+ days. • Long Stay not age or sex dependent

22. What do we currently know about Long Stay?. . . • A large number of problems appear to be facility specific • - organisation problems – e.g. theatre access • - clinical problems – e.g. adverse events, poor management of delirium • Omission appears to be as large a problem as commission • Patients can become stranded • Causes not picked up in Medical Records • The best predictor of length of stay appears to be the current length of stay • Hospitals are dangerous places

23. Long Stay Patients- An Overview • What is a Long Stay Patient ? • Long Stay Case Studies • The extent of the Long Stay Patient Issue • Why is the Long Stay Patient important ? • What do we know about long stay ? • How does one reduce the outliers? • The opportunity and the benefits

24. How does one reduce these outliers ? Management Plan : Recognition of problem Ownership of problem Support for owner A phased professional programme Diagnosis : Understand what causes Long Stay at a specific facility : Prevention: Identify the problems (rocks) and remove . Adopt standard ways of working Identify potential high risk patients at an early stage. Identify long stay patients and manage where appropriate Rescue Identify Patients at risk and rescue where appropriate

25. The Management Plan • Recognition of problem • Senior management and clinical staff must understand that the Long Stay patient is a major issue . • The issue is the same magnitude as emergency patients, elective patients etc • Ownership of problem • Accountability for Long Stay patients must reside at the 2nd organisational level for the facility e.g. Director of Clinical Services • Everyone owns the problem • Phased professional programme • There is no golden bullet solution • One needs to commence a phased professional program to address the issue

26. Diagnosis, Diagnosis, Diagnosis Identifying the causes of long stay • Real Time • Identify Long Stay Patients on a daily basis • Detailed investigation and review of new Long Stay patients • History • Understand the base line situation (Long Stay Patients 2008/2009 ) • Causes not symptoms • Determine and understand the causes of Long Stay • There are common issues and site specific issues

27. Prevention Identify the problems and remove them The Major Problems The lack of awareness of the long stay patient problem The length of time patients are in the hospital • The best predictor of length of stay appears to be the current length of stay • Hospitals are dangerous places

28. Prevention…2 Identify the problems and remove • Waiting, Waiting, Waiting • PICC • CT • Cath Lab • OT • Rehabilitation Assessment • Clinical Decision (House Surgeon, Registrar ,Consultant) • Complications from adverse events • Infections • Lack of clear management plan • Lack of clear discharge plan • Referrals not followed up or actioned • Poor to nil discharge planning • Discharge meetings do not include medical staff • Unclear entry criteria for facilities and programs patients referred to • New Staff

29. Prevention …3 Identify those patients at high risk, early and manage • Patient admitted / transferred and nothing occurs for 7-14 days • Patient over 80 and major surgery • Patient lives in supported accommodation and has a major event • Patient has a significant adverse event • No clear clinical management plan • No clear discharge plan

30. Rescue Identify long stay patients and manage where appropriate Identify stranded and long stay patients via the monitoring system and review • Rescue stranded patients • Actively manage all stranded patients • Develop and implement an agreed rescue process • Clear management plan and accountabilities • Clear discharge plan and accountabilities • Monitor and follow up

31. Long Stay Patients- An Overview • What is a Long Stay Patient ? • Long Stay Case Studies • The extent of the Long Stay Patient Issue • Why is the Long Stay Patient important ? • What do we know about long stay ? • How does one reduce the outliers? • The opportunity and the benefits

32. The Opportunity Few patients result in many bed days, therefore manage the few, to achieve significant benefits The Benefits • Significantly improved patient care • Significantly improved patient experience • Reduced ALOS and bed requirements • Improved bed availability, if surplus beds remain open • Significant financial savings, if surplus beds are closed

33. 2010 SAFER Patient Care Collaborative Program :Reducing harm from hospitalisation OR Long Stay Patients

34. Thank you and Any Questions ?

35. Case 3 : Illustrative Data for St Elsewhere’s Hospital