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eAcute

eAcute. Dr Paul Sullivan Clinical Director of Quality Improvement, Salford Royal Foundation Trust Senior Quality Improvement Fellow, Centre for Healthcare Improvement Research, Imperial College, London. Risks of hospital stay. Risk of infection Risk of medical accidents Medication errors

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eAcute

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  1. eAcute Dr Paul Sullivan Clinical Director of Quality Improvement, Salford Royal Foundation Trust Senior Quality Improvement Fellow, Centre for Healthcare Improvement Research, Imperial College, London

  2. Risks of hospital stay • Risk of infection • Risk of medical accidents • Medication errors • Loss of control • Discomfort, sleeplessness • Disruption

  3. Medical Reasons? • Treatment only available in hospital • Monitoring • Risk of rapid deterioration • Temporary increase in care needs

  4. Survey • Daily review of general medical inpatients in a medical ward– 240 bed days • Classified into 19 “reasons” • 15% of patients did not need to be in hospital

  5. Survey of medical wards • 23% of medical in-patients “stable” • Review of cases by expert panel – 9.6% could be managed at home • Of patients delayed for <2 weeks, 43% were due to medic behaviour

  6. Survey of medical wards • Daily visit to medical wards, each team contacted • Able to identify that 15% of in-patients could be managed in virtual ward system • Average LOC after identification 10 days

  7. Things have moved on since then • Delays in diagnostics removed • LOS saved likely to be 1-2 days

  8. Reasons for delay • Waiting for test • Waiting for results • Waiting for opinion • Waiting for senior review

  9. Why? • Medics apprehensive about discharge – loss to f/u, delay to first OPA • Team need to make a decision(s) straight after the next test(s) • No knowledge of OP services

  10. Is there a better way of managing these patients? • Could they be at home?

  11. Survey on 28 bed EAU 2006 • Could this patient be safely and effectively managed at home

  12. Audit on 28 bed AMU • Could this patient be safely and effectively managed at home • 2-7 patients each day

  13. Alternatives • Traditional OPD setting has limits • Time between available follow up slots • Patient “visible” only at clinic visit • Availability of diagnostics

  14. Time to next FOLLOW UP slotGen med 2-11 weeks • Cardiology 17 weeks • GI 8 weeks • Chest 7 weeks

  15. Alternatives • Priority patients can be managed at home by individual clinicians • Time consuming, no support, numbers limited • Risk of loss to follow up

  16. eAcute

  17. An electronic patient list to which multiple users can add and which can be seen by all members of the Acute Medicine team. • Every weekday at 10am = virtual ward round • This is attended by Acute Medicine consultants, mid grades and FY doctors and the advanced practitioner nurse on the EAU. • Every patient is discussed every week-day. • Junior staff are available to arrange tests, liaise with diagnostic depts etc.

  18. If tests are inappropriately delayed we notice immediately and rectify • Results are seen immediately and consultant level decisions follow • Patients can be reviewed as often as needed by telephone • Patients can be recalled to EAU for bloods or clinical assessment • We have arrangements with radiology, cardiology and endoscopy so that virtual ward patients are accorded high priority

  19. eAcute

  20. This is the eAcute ward

  21. Ideal for • Time-Critical investigation • High risk if inadvertent delays • High risk if DNA

  22. Ideal for Rapid/serial decisions on test results Test 2 depends on test 1 Early/frequent communication with pt

  23. Results

  24. Results

  25. Implementation • Not as easy as it seems

  26. Critical features • Watertight – IT solution ideal • Access 24/7, anywhere • Embedded in daily work • Redundancies – can’t be forgotten

  27. I know, with absolute certainty, that if I send a patient home on Sunday, a trusted consultant will pick up the issues on Monday.

  28. Critical features • PrioritisationPatients are regarded as in-patients by: • Radiology • Endoscopy • Echo, ETT

  29. How did we do that?

  30. Our story…. • Developing IT solution • Making it work in the normal day • Getting radiology to prioritise • Getting other departments to prioritise

  31. Sustaining • Constant vigilance for fall off in prioritisation • Local ownership • Keeping it team wide • Just add hot water!

  32. 4096 bed days in 24 months 5.7 beds free on any day Roll out – estimate additional 5-10 beds 23 minutes per day for 2 consultants and team 50 minutes per day for a JD

  33. Transfer • Make it watertight – daily case review prevents delays, loss to follow up etc. • Timetable daily senior case review so it is guaranteed. Several people need to be involved to ensure that this happens every day, regardless. • Develop an electronic patient list that is visible to all members of the team all the time – initial attempts with individual paper lists failed • Choose an area with high patient throughput so that there are always some virtual patients to review, otherwise it is difficult to maintain the habit. • Start with a single investigation, we used CT pulmonary angiogram, and get clinical directors involved.

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