Beaumont Rapid Assessment Team (BRAT) Service R\V 1 st February 2012-31 st January 2013

1. Beaumont Rapid Assessment Team (BRAT) Service R\V1st February 2012-31st January 2013 Peter Ward Senior Physiotherapist Acute Medicine Driving Healthcare Change Through HSCP Research February 28th, 2014 Carole Murphy Senior Occupational Therapist Emergency Department

2. 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

3. Impetus for Change • Clinical Care Programs, 2010 • Lis Nixon Report, 2011 • Establishment of Special Delivery Unit (SDU), 2011

4. 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 non-medical admissions to hospital • If appropriate, support early discharge from hospital, improve throughput and prevent re-admission

5. Design Phase • Establishment of a steering group with representatives from the key HSCP groups • Responsibility with the clinicians to oversee the design phase • This included development of: • Care pathway • Single assessment tool • Role of teamlead

6. 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? No Referral to BRAT not indicated. Patient at previous functional status with adequate supports in place. YES Contact BRAT Team Lead. Dect: 8457

7. 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

8. 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

9. 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

10. Age Categories

11. ED Attendances

12. Discharge V Admission

13. Gender Distribution of Admissions

14. Reason for Referral (Total & Discharge)

15. Onward Destination

16. 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 1-30)

17. Age of re-presenters

18. Team Performance • Average response time: 19 minutes • 44.7% seen within 10 minutes

19. 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

20. 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

21. 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

22. 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

23. 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 non-medical admissions to hospital • If appropriate, support early discharge from hospital, improve throughput and prevent re-admission

24. 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

25. QUESTIONS???

26. 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)