W a Health Royal Perth Hospital Fremantle Hospital Sir Charles Gairdner Hospital Day of Care Surveys

2013

W A Health Royal Perth Hospital Fremantle Hospital Sir Charles Gairdner Hospital Day of care surveys

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1 Introduction 3

Examples of actions from previous surveys 7

Summary 8

How to organise site surveys 10

How the survey was adapted for WA 11

How to do the survey 12

Survey algorithm 16

Top tips for reviewers 17

Chart 1: appropriateness criteria 18

Charts 2, 3 and 4 19

Data collection sheet 20

How are results presented? 21

Results: Royal Perth Hospital 22

Results: Fremantle Hospital 28

Results: Sir Charles Gairdner Hospital 34

Summary 42

Acknowledgements 43

2 Introduction

Why is this topic relevant?

Ensuring emergency access to acute health services is a challenge for many countries.

Emergency access efficiency is commonly measured through emergency department (ED) overcrowding statistics or estimates of patient time spent within EDs. International evidence suggests that lack of timely access to inpatient beds is one of the main reasons for ED overcrowding: this problem has been termed “access block”.

Addressing access block requires improvements in systems and processes for inpatient flows in acute hospitals to create capacity and ensure patients receive timely clinical treatment from appropriate clinical teams in the correct location. Improving inpatient flow is nevertheless a complex issue dependent upon action at many levels within acute, community and social care sectors.

How was this survey developed?

The standard for emergency access in NHS Scotland is that 98% of patients will wait less than four hours from arrival in the ED to admission, discharge or transfer for treatment (95% in

NHS England). At times over the last few years when the percentage of patients in Scotland reported as breaching the standard and waiting more than four hours has shown an increase, it has been found from analysis of “4 hour breaches” that the most frequent cause for this is

”waiting for a bed” .

3 As part of a raft of actions developed at national level in Scotland to support system-level understanding of the nature of delays within acute care, a Day-of-Care Survey (DOCS) method has been developed to identify areas of clinical care or subsets of patients where there might be benefit from alternative service provision or reconfiguration of services.

The method is based on review of medical records against a range of 28 clinical criteria. It identifies patients who do not meet these criteria set for acute hospital care and highlights where delays are occurring across the system. The criteria can be applied at a single point in time, such as a single day, or can be used multiple times on sequential days with the same patients. It is not intended to determine decisions on discharge of individual patients, but to identify problems in the hospital or health system.

Starting from an “Appropriateness Evaluation Protocol” originally developed in the 1980’s a

National Expert Working Group developed the criteria and survey tool for present day hospital care using a variety of methods, including collecting expert opinion, assessing 89 consecutive patients admitted to an acute hospital and measuring them against the criteria on a daily basis, and testing and receiving feedback on the criteria and methodology at four hospitals. This resulted in the development of a set of criteria with 12 “severity of illness” variables, covering derangements in physiological parameters, and 16 “service intensity”, reflecting levels of clinical interventions, prescribed treatments and clinical characteristics according to history, examination and laboratory investigations. These have been tested prospectively in over 2,500 acute hospital in-patients at 5 sites in Scotland and one in

London.

Previous research had found that location of patients outside of the relevant specialty unit

(usually known as “outlying” or, in Scotland, “boarding”) had a significant association with a

4 higher incidence of inappropriate stay. Testing of the criteria in Scotland revealed a similar pattern, with outlying/boarding patients often not meeting the criteria for acute care. This element was therefore added to the data collection methodology. .

Surveying using the criteria is a simple, reproducible process that can be conducted by a combination of clinicians and personnel who are not necessarily directly involved in frontline acute care (non-health care professionals such as social workers and managers). To promote the credibility of results, we recommend that each ward be surveyed by a senior doctor (not responsible for the inpatients surveyed) accompanied either by a nurse, allied health professional (AHP) or manager. Results in older people’s wards are optimised if geriatricians review inpatients with either a senior nurse/AHP with specialist interest in older people’s rehabilitation and, if possible, a senior colleague from social care.

Preparation of staff involved in the survey is crucial, but a 15-minute briefing on the afternoon prior to the survey is normally sufficient. Once prepared and engaged, staff are able to perform surveys on an ongoing basis. The survey process itself is not lengthy, taking up to one hour per ward of 30 beds.

Only one criterion has to be satisfied for the day of care to be deemed “appropriate”: patients who do not meet a single criterion are deemed “inappropriate” for the day of care.

Survey teams have the option of over-riding the protocol in either direction if the objective criteria appeared to give an erroneous or counter-intuitive result.

Whilst the survey in Scotland and England found six of the top-10 reasons for non-discharge were influenced by factors outside the acute hospital (lack of community hospital bed, for instance), four were hospital-related (awaiting AHP assessment or consultant decision and review, for example). This reinforces the understanding that delays to discharge are not

5 exclusively related to factors external to the hospital (as if often assumed), but indicate blockages within hospital systems that need to be addressed.

Why would you do a day of care survey?

The aim of the survey is to generate action to address blockages within acute hospitals through improving internal processes and engaging with partners to reduce delays in accessing community and social care. The hospitals involved in DOCS in Scotland and England have subsequently employed a range of techniques and actions to drive improvement to reduce delays.

Examples of actions generated from DOCS results at UK sites

 Clinicians at one hospital believed that delays for patients waiting for beds was due to

the active need for acute care of all current inpatients. The DOCS results, however,

indicated that 25% of current inpatients were experiencing discharge delays, with

significant numbers waiting for community hospital beds. The hospital used these

data to develop a better understanding of the community capacity required to

provide timely care from the appropriate team.

 The DOCS at another site found delays to completion of AHP treatment plans.

Subsequent AHP investigations revealed that their record-keeping system had not

been making completion of treatment clear, and steps have been taken to rectify this.

 A large teaching hospital used a feedback session with the 50 staff involved in the

DOCS to further develop relationships among acute, community and social care

colleagues.

 A district general hospital now uses the DOCS criteria daily to assess if any patients

with a length of stay of over 14 days requires acute care and, if not, what needs to be

“unblocked” to ensure that the patient pathway of care is seamless and timely.

 Another hospital is using the criteria to engage commissioning partners in providing

appropriate “step-down” care.

7 Summary of day of care methodology

The DOCS provide a snapshot of hospitals’ inpatient status at a particular point in time that enables organisations to identify the sources of delay in inpatient flows and take appropriate action. Experience to date in hospitals in Scotland has shown that the DOCS method:

 offers a simple, easily understandable approach that involves minimal preparation for

staff and can be carried out over short time periods with minimum disruption to

clinical services

 is proving to be valid and reliable

 provides immediate access to core data such as age spread of the hospital population

and length of stay

 creates useful insights, such as recognition that patients who have been in hospital

for 14 days have a high chance of not meeting the DOCS criteria and that criteria are

less likely to be met with increasing patient age

 presents opportunities to improve patient flows by identifying sites of delays and

supporting the development of solutions

 creates local ownership of data and, subsequently, solutions.

DOCS have now been undertaken in acute hospitals of differing size and character in

Scotland and England. Expertise to support future iterations is developing at hospital level and understanding of the reasons for blockages to inpatient flows is increasing locally and nationally. The hospitals are now planning to embark on an iterative process of regular surveys to inform patient-flow management.

8 The process in Scotland has been managed centrally by the Performance Support Team at the Scottish Government, who have worked with participating hospitals to set up, conduct and report on the initial surveys, but the intention now is for Scottish acute hospitals to conduct the surveys independently to a schedule devised to meet local needs.

9 How to organise site surveys

Guidance to Hospitals

 Identify Executive Lead for the Survey to be contact point for receiving final report. (will be undertaken as part of overall feedback on the day and included in final report for all sites in Perth)  Identify a small group to work with the visiting team in validating and finalising the report. This should include the senior clinician and senior manager with responsibility for the site surveyed.  Identify and allocate survey teams to the individual wards  Survey teams preferably should include a consultant or senior doctor with a senior manager/nurse/AHP (in older people wards there may be is benefit in including social work.  Each team can review sixty in-patient beds, with the exception of older people wards which require one team for 30 beds  Consultants should not survey their own wards, and geriatricians should be allocated to survey older people wards  Allocate a central control room on each site and as a gathering point for the survey teams A 30 minute brief on how to complete the data collection will be included with the site briefing visit at your hospital.  On the day of the survey, teams meet at a central location at 7.30am and are provided with a final brief, relevant paperwork and a contact number to call for queries during data collection.  Survey starts at 0800am to ensure minimal interference with clinical work and reduce risk of double counting patients. Most teams should complete the survey within an hour.  The provisional report will be part of the overall feedback on the day  Provide a list of agreed abbreviations for consultant staff  Provide a list of ward numbers/names, bed numbers, designation of beds and consultant ward allocation for each site

Visiting Team

 Provide a verbal brief for the survey teams  Contribute to the data collation  Develop a short presentation of the invalidated data for feedback on the day  Provide a team to work on site with the local team  Develop Graphs and Tables for the report  Provide a narrative for the final report

10 How was the survey adapted for on-site use in Western Australia?

An original version of the survey documentation was sent to WA health for consideration ahead of the UK team visit. A minor number of changes were discussed and agreed, to take account of general variations in practice and terminology between UK and WA settings. All the documentation and a blank version of the data collection and analysis software were sent to WA Health and distributed to the co-ordinators at the 3 sites. The documentation was then distributed to the local review team members. Short site briefings were made by the UK team at each site as part of the introductory presentation. The surveys were overseen by a physician team member from the UK who chaired a National Working Group in Scotland that developed the DOCS. The UK team provided a data analyst who had used the DOCS in Scotland and additional data entry was done by HSIU staff on site. Results were collected, analysed and presented to participating sites in the course of a single day. Detailed results were included in the UK team final report.

11 How to do the survey

WA HEALTH DAY OF CARE SURVEY August 2013

OVERVIEW

 Section A Guidance on organisation, administration and implementation

 Section B Guidance for survey teams

 Section C Charts and criteria

 Section D Data Collection sheet

12 Section A

Pre Survey

Identify a Hospital Site Coordinator for the Survey This person should be available to coordinate the survey at each hospital as below and will provide advice to the teams and as a communication link to the UK Team for advice Royal Perth Hospital 0730-1200 hrs Thursday 1 August 2013 Fremantle Hospital 0730-1200 hrs Friday 2nd August 2013 Sir Charles Gairdner Hospital 0730 -1200 hrs Monday 5th August 2013

This person should:-  Attend the Site Briefing on Wednesday 31st July as per the schedule for each hospital  Be available at the 0730 briefing on day of audit at each hospital  Remain in the meeting room throughout the survey to liaise with teams and receive completed data collection sheets

Identify the Site Survey Teams prior to Site Briefing on Wednesday 31st July It is important that the survey teams attend these briefings to understand what is required from the case notes review

The Hospital Survey Coordinator should provide the following:- Meeting Point location of UK Team Room to DoH Meeting Point 0730 Briefing and UK Team Room location to Site Survey Teams List of current ward numbers/names/location to Survey Teams and UK Teams

Day of Survey 0730 briefing Meeting The Site Survey Teams should attend the 0730am briefing at [Each Hospital to provide Meeting point/location to DoH} to receive:  Day of Care Survey Charts and Data Collection Sheets for each team  List of ward allocations for Survey Teams  Contact phone number for advice or issues  Receive advice on using the Data Collection Tool  Each survey team should collect a ward list from the ward clerk when they arrive on the ward to ensure they capture all patients in the ward on the day of the survey

0800-0900 A UK Team with one Survey Team (Senior Nurse and Senior Doctor) commence a survey in the Emergency Department followed by one medical ward followed by one surgical ward (wards can be chosen by hospitals)

0800-0900 All hospital survey teams commence survey in all other wards as allocated All Survey Audit Teams return their data collection tools for each ward they have completed to the central meeting room once survey completed. It is important that at least one member of each team is present to give verbal feedback as well as handing in the data sheets.

If teams require advice during the survey they can ring [hospital to provide Ph number or mobile contact number of Hospital Survey Coordinator]

13 Section B:

Guidance for Survey Teams What is the Day of Care Survey?

The Day of Care Survey provides a snapshot in time of the inpatients present within your hospital using a tool based on revision of the Appropriateness Evaluation Protocol (AEP).

Each inpatient is assessed by a consultant and either a senior nurse, a manager, an allied health professional or a social worker through simultaneous review of the patient’s case notes.

You record your assessment on an accompanying Data Collection Sheet as you progress.

Two issues should be uppermost in your mind as you complete the survey:

 the current treatment regime should not be questioned  it is very important to document the patients’ date of admission and date of birth.

How is the Survey carried out?

The survey consists of four charts that provide the criteria against which you review the patients’ notes. It is completed by:

1. having a short discussion with the nurse in charge of the ward 2. reviewing the notes 3. considering the criteria 4. recording observations on the Data Collection Sheet.

How do I use the charts?

Chart 1. Severity of illness and service intensity (to be completed for all patients)

You use this chart to assess the patient’s “appropriateness” as an inpatient.

If the patient is definitely to be discharged today, place a tick in the “discharge today” box and go to Chart 4: Outliers

A patient only needs to meet one of the criteria defined in the chart to be assessed as “appropriate” for inpatient care.

Once one criterion has been met, tick the “Chart 1: Met” box in the Data Collection Sheet. If the patient does not meet any of the criteria, tick the “Chart 1: Not Met” box.

You can use your clinical discretion to override the criteria, either way. For instance, a patient might not appear to meet the criteria (in which case, “Chart 1: Not Met” would normally be ticked), but the case note review and your clinical judgment and/or

14 discussion with ward clinicians suggests that the patient is in fact “appropriate” for inpatient care.

In that case, tick the “Override: Appropriate” box. If the override is used, please explain your reasons on the collection tool and note it to the UK Survey Team at the end of the survey.

For patients who met a criterion but were overridden as “inappropriate”, proceed to complete charts 2 and 3.

If you find a patient is appropriate for acute rehabilitation but is located in a specialist bed, tick the “Chart 1: Not met” box, making a note on the Data Collection Sheet as you do so.

If you find a patient is appropriate for acute rehabilitation and is located in a rehabilitation bed, tick the “Chart 1: Met” box and move to the next patient’s notes.

For all patients, complete “Chart 4: Outliers”.

Chart 2: Reason Not Discharged (or transferred) [for patients not meeting any criteria from chart 1, and therefore deemed “inappropriate”]

Use this chart to identify the reason patients who have not met the criteria, or who were overridden as inappropriate, have not been discharged.

If the reason is not on the chart list, please specify the “Other” option (code “T”) and provide the reason. Then move to Chart 3. Chart 3. Alternative place of care Use this chart to identify the most appropriate alternative place of care for patients who have not met the criteria or who were overridden as inappropriate

If you find the most appropriate place is not covered by Options A-C, Select “D” (“Other”) and specify the location. Then move to Chart 4

Chart 4. Outliers (to be completed for all patients) Please identify “outliers” by parent specialty.

If you find the parent specialty is not covered by options “M”, “O” or “S”, please select “A” (“Other”) and specify the parent specialty.

Once you have completed all the Data Collection Sheets for the patients in your allocated ward/s PLEASE RETURN IT TO THE SURVEY COORDINATOR IN THE [hospital to provide location point]

A flowchart summarising the process described above is shown overleaf, followed by some “top tips” to help you complete the survey.

Day of Care Survey algorithm and data collection guide

Start the process again with next patient’s notes

No Clinical override

Start Met used? criteria Yes (Overridden)

Use Chart 1: Is patient being No Does the Use Chart 2 to Use Chart Use Chart discharged patient meet record reason 3 to record 4 to record today? Day of Care not discharged alternative if patient is Criteria? place of an Outlier care

Not met No

criteria Yes Clinical override used?

Yes (Overridden)

Tick discharge today

Move to Chart 4

16 Top tips for day of care survey teams

 Use of an early warning score (such as Modified Early Warning System (MEWS) score) and the patient medicines chart as a quick way to identify severity of illness variables and treatment variables.

 Teams can ask the ward manager or senior nurse to be present during the survey as they often have background information or answers to questions that cannot easily be obtained from the case notes.

 It is quicker to do the survey from the case notes rather than going to individual bed spaces.

 If a ward clerk is available ask them to check the next case note trolley in the sequence to ensure that the notes are present as this will speed up the process.

 Survey teams should resist the temptation to get too interested in the individual clinical condition or in the assessment of whether any particular treatment is appropriate. Concentrate on finding a positive criterion as soon as possible and moving on to the next patient.

 It is not necessary to document how many criteria the patients meet or which ones, just that they have met at least one.

 Patients with no criteria met will take longer to because all the criteria will need to be checked

 Clearly identify patients being discharged on the same day.

 Use your clinical judgment (in pairs) to make decisions about over-riding the criteria when necessary. Some explanation of the clinical over-ride will be needed

 Record the consultant initials to enable analysis about level loading of inpatient workload.

 Recording the date of birth enables analysis of age as a variable. It is not for patient identification.

 It is important to record any beds that are empty or closed. (A patient is not allocated to the bed; not just patients away from their bed for procedures/diagnostics)

 It is very important to survey patients who are not in a recognised bed space, such as those who have been in the emergency department for more than four hours waiting for an inpatient bed and inpatients (over census patients) accommodated in day areas or other areas who would be in an in-patient recognised bed space if available

17 Section C Day of Care Survey Charts and Criteria

If patient is definitely for discharge today, record this and go to chart 4 “Outliers” Chart 1: “Appropriateness” Charts Code Descriptor Clinical Criterion No 1 Acute or ongoing deterioration in conscious level 2 Acute or ongoing new confusion 3 Acute neurological deficit, including stroke within 72 hours 4 Acute coronary syndrome confirmed or suspected 5 Acute dysrhythmia with haemodynamic disturbance 6 Pulse rate <50 or >100 7 BP systolic <90 8 Phase IV hypertension 9 Active bleeding 10 Transfusion due to blood loss 11 Temperature <35º or >38º 12 Arterial pH <7.3 or pH >7.45 13 Na <123 or >150 14 K <2.5 or >6.0 15 Acute kidney injury (renal impairment) 16 Post-operative ileus

Service intensity that requires access to acute hospital 1 Therapy Requires IV, IM or subcutaneous medication (that cannot be delivered at home/in the community) 2 Therapy Receiving treatment or new/experimental treatment requiring frequent dose adjustments or medical monitoring under direct medical supervision 3 Procedure Surgical procedure today that is not suitable for day case 4 Procedure Invasive procedure not suitable for day case (e.g. some interventional radiology, some guided biopsies, etc.) 5 Monitoring Vital sign monitoring every hour or more frequently 6 Monitoring Chemotherapy requiring constant supervision 7 Monitoring Requires accurate input/output fluid balance measurement 8 Respiratory Requires continuous oxygen, non-invasive ventilation or intensive nebuliser therapy that cannot be delivered at home 9 Fluid/nutrition To establish complex nutritional support, including enteral feeding Requires intravenous fluids (that cannot be delivered at home/in 10 Fluid/nutrition the community 11 Recovery Immediate post-operative recovery phase from therapy/procedure covered in 2 and 3 (above), including need for complex dressings/wound drainage (that cannot be delivered in the community/at home) 12 Investigation Requires multiple investigations for urgent diagnosis

18 Chart 2. Reason not discharged

A Awaiting Social work allocation/Assessment/Completion of Assessment B Awaiting Alterations home modification to equipment/housing C Waiting for Home Care Support/ community services(HACC1 MOW2) TCP3 D Awaiting place in Care in Residential Aged Care Bed E Awaiting General Hospital Bed F Awaiting/planned repatriation to other hospital- Rural Health Region G Awaiting care in another Tertiary Hospital (Single Service4) H Vacancy available in a aged care residence of choice/discharge planning in progress I Awaiting final multi-disciplinary decision J Awaiting procedure/investigation/results and not meeting criteria for acute care L Awaiting Consultant decision/review M Delay due to relatives N Delay due to transport S Waiting Allied Health Assessment/treatment – specify which Allied Health Service T Other – Please specify

Chart 3. Alternative place of care A At home - HITH, RITH, Post Acute Care Community Care B Outpatients follow up C Non acute area of care (Over Census Patient Area) D Other – Please specify

Chart 4. Outliers

N Not an outlier M Medical O Orthopaedic S Surgical A Other – please specify

1 Home and Community Care Services 2 Meals on Wheels 3 Transition Care Package 4 Tertiary care provided in only one of the adult tertiary hospitals

19 Section D

Data Collection Sheet

Total Number of Bed Beds Closed (empty Ward and cannot be used) Total Number of Number of Outliers Date patients

Chart 1 Clinical Chart 2 Chart 3 Chart 4 Override

Date of Date of Discharge Met Not Reason not Alternative Outlier

Birth Admission Today met discharged Place of Care

Consultant Initials Appropriate Inappropriate

20 How are the results presented?

Results for each of the 3 WA hospital sites are presented separately in the order in which the surveys were carried out. Locally provided information of ward lists, bed complement and reviewer allocation precedes each set of results.

Raw data is not included but has been retained in case any further reconciliation is needed. Summary charts are presented for key variables such as age and length of stay. These are presented in the same order in each set of results. Chart labelling should be self- explanatory.

Patients identified for definite discharge are excluded from further analysis with the exception of chart 4 (outliers). Ward specific charts are displayed as both actual numbers of patients and as proportions for comparison. Note that some wards/areas have small numbers of patients.

The only location identified as a rehabilitation area was ward 3K at Royal Perth. In the UK we record patients in such a facility as being “appropriate” if they are receiving rehabilitation, regardless of whether they meet the acute care criteria. In other words in the UK, we would “over-ride” a “not met criteria” patient as “appropriate”. As we were not aware that ward 3K was a defined rehabilitation facility in advance of the survey, the results should not be used for comparison with other wards.

21 Results of day of care survey

Royal Perth Hospital Thursday 1 August 2013

22 List of Wards and Beds RPH for Day of Care Audit - UK Survey as of 01 August 2013

Time : 0730-0800 - Audit debrief

0800-1000 - Audit Hospital RPH Total Active Inactive Ward Ward Name beds beds beds Senior Nurses Senior Doctor/Registrar

3K 3K GERIATRIC/GEM UNIT 17 17 0 Glenda Jacoby Yuen Leow

4F 4F CARDIOLOGY 20 20 0 Carl Donaghue Aref Arjomand

CTUP CARDIAC TELEMETRY UNIT 5 5 0 Carl Donaghue Aref Arjomand

10A 10A MEDICAL ONCOLOGY 30 30 0 Sala Nanthakumar Ash Gurumurthi

10C 10C IMMUNOLOGY 10 10 0 Trevor Cherry Patricia Martinez

5A 5A IMU TEAM 1 AND TEAM 3 - Internal medicine 21 21 0 Sam Morgan Hassan Kamalddin

5B 5B IMU TEAM 2 AND TEAM 3 - Internal medicine 21 21 0 Vanessa o'Connell Rita Malik

5E 5E IMU TEAM 4 AND TEAM 5 - Internal medicine 26 26 0 Dave Hughes Mark Donaldson

5G 5G ORTHOPAEDIC 30 30 0 Sharon Birchenough Ivan Lau

5H 5H ORTHOPAEDIC/NEUROSURGERY 30 30 0 Kathy Young Trishna Bhalla

6A 6A NEPHROLOGY 21 21 0 Kathy Sims Ricki Arenson

6G 6G CARDIOTHORACIC/VASCULAR 31 31 0 Kerry Stokes Kate Kloza

6H 6H PLASTICS/ENT 30 30 0 Mel Murrell Chris West

Cecilia Wee/Jose Cid- 7A 7A GENERAL SURGERY 34 34 0 Brycelynn White Fernandez

8A 8A NEUROLOGY / STROKE 38 38 0 Annita House Manreet Randhawa

9A 9A DGM 19 19 0 Gillian Watt Sherman Picardo

9B 9B DGM 19 19 0 Isabelle Brewer Shelina Mahbub

9C 9C RENAL/RESPIRATORY 30 30 0 Noela Pascoe Richard Warren

AAU ACUTE ASSESSMENT UNIT 33 33 0 Andrea McFaull Stephen Wright

STU 3G STATE MAJOR TRAUMA UNIT 26 26 0 Donna Coutts-Smith Nicola Sandler

STUA 3G STATE MAJOR TRAUMA UNIT HIGH ACUITY 4 4 0 Donna Coutts-Smith Nicola Sandler

Cecilia Wee/Jose Cid- AGSU 7A/AGSU ACUTE GENERAL SURGERY UNIT 8 8 0 Brycelynn White Fernandez

Grand Total 503 503 0

ED Inpatient and breach patients Tim Leen Carolyn Wilson

23 Summary: Royal Perth Hospital Bed occupancy 97.7% Number of beds in survey (allocated beds) 512 In-patients surveyed 500 Beds closed 12 Patients being discharged today 48 AEP criteria for day of care not met 99

Criteria not met, alternative "home" 24 Criteria not met, alternative "non-acute bed" 31 Criteria not met: L.O.S.  7 days 51 > 7 days 48  Bed numbers Total beds in survey 512 Bed closed 12 Beds empty 9

Admitted greater than 24hrs before day of audit 364 Admitted less than 24hrs before audit 136 Missing admission dates 0 Total 500

Discharges Patients being discharged today 48

AEP Criteria for day-of-care Met and not over-ridden 348 Not met but over-ridden (appropriate stay) 5 Missing (assumed met) 0 Sub-total (met) 353

Not met and not over-ridden 99 Met but over-ridden (inappropriate stay) 0 Sub-total (not met) 99 Total 452

Not met criteria All inpatients excluding discharges 452 Criteria not met % (excluding discharges) 21.9%

Outliers Total 44 Percent 8.8%

24 AEP met by ward Excludes patients being discharged today. 40

15 Number of patients of Number

3K 5A 5B 5E 6A 7A 8A 9A 9B

5H 6H 9C

5G 6G

10A

10C

STU

AAU

EMW

AGSU 4F CTUP 4F Ward Sum of AEP MET TOTAL Sum of NOT MET TOTAL Sum of missing AEP

% of AEP met by ward Excludes patients being discharged today.

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0% AAU 6G AGSU 6A EMW 7A 9B 6H 9C 5H 5A 10A STU 5G 5B 4F 10C 9A 8A ED 5E 3K CTUP % of AEP MET % of NOT MET Royal Perth Hospital

Age profile of patients in survey Excludes patients being discharged today. 100

40 Number of patients of Number 30

0 0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90+ Age band Sum of AEP MET TOTAL Sum of NOT MET TOTAL Sum of missing AEP

Length of stay for all patients Excludes patients being discharged today. 250

200

150

100 Number of patients of Number

0 0 days 1-3 days 4-7 days 8-14 days 15+ days Length of stay (days) Sum of AEP MET TOTAL Sum of NOT MET TOTAL Sum of missing AEP Royal Perth Hospital

Alternative place of care for patients not meeting AEP Excludes patients being discharged today. 50%

45%

40%

35%

30%

25%

20% Percentage of patients of Percentage 15%

10%

0% At home Non acute area of care Other – please specify Outpatients follow up #N/A Alternative place of care Royal Perth Hospital

Results of day of care survey Fremantle Hospital Friday 2 August 2013

28 14 Jul 2013 Beds on multiday wards at FH snapshot

Hosp FH

Inactive Row Labels WardNme Total beds Active beds beds Aged Care/Rehab 36 36 0 GEM Geriatric Evaluation 10 10 0 V5 V5 Restorative Rehab 26 26 0 Critical Care 22 21 1 B8N B8N Cardiothoracic 22 21 1 General 252 252 0 ASU ASU Acute Surg Unit 15 15 0 B7N B7N - Surgical Specs – Plastics, ENT, Oral 31 31 0 surgery, Colorectal, Gastro B7S B7S - Orthopaedics 31 31 0 B8S B8S - General Surgical and Vascular 31 31 0 B9N - Haematology/ Oncology and General B9N Med 27 27 0 B9S B9S - General Medical and Renal 31 31 0 CDU ED CDU Clin Dec Unit 10 10 0 MAU MAU Medical Assess 24 24 0 SSSUO Short Stay Overnight 14 14 0 V6 - General Medical

V6 38 38 0 Grand Total 310 309 1

Summary Figures: Fremantle Hospital

Bed occupancy 98.9% Number of beds in survey (allocated beds) 350 In-patients surveyed 346 Beds closed 0 Patients being discharged today 39 AEP criteria for day of care not met 78 Criteria not met, alternative "home" 35 Criteria not met, alternative "non-acute bed" 9 Criteria not met: L.O.S. 7 days 24 > 7 days 55

Bed numbers Total beds in survey 350 Bed closed 0 Beds empty 13 Patients not allocated beds (on trolleys) 12 Admitted greater than 24hrs before day of audit 271 Admitted less than 24hrs before audit 75 Missing admission dates 0 Total 346

Discharges Patients being discharged today 39

AEP Criteria for day-of-care Met and not over-ridden 225 Not met but over-ridden (appropriate stay) 18 Missing (assumed met) 1 Sub-total (met) 244

Not met and not over-ridden 54 Met but over-ridden (inappropriate stay) 10 Sub-total (not met) 64 Total 308

Not met criteria All inpatients excluding discharges 307 Criteria not met % (excluding discharges) 20.8%

Outliers Total Outliers 45 % of patients outlying 13.0%

30 AEP met by ward Excludes patients being discharged today. 35

15 Number of patients of Number 10

V5 V6

B7S B8S B9S

B7N B8N B9N

ASU

CDU

MAU

GEM

GAGI

AMITY

SSSUO ENDEAVOUR Ward Sum of AEP MET TOTAL Sum of NOT MET TOTAL Sum of missing AEP

% of AEP met by ward Excludes patients being discharged today.

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

V5 V6

B7S B8S B9S

ASU

B9N B8N B7N

CDU

GEM

MAU

GAGI

AMITY

SSSUO ENDEAVOUR % of AEP MET % of AEP NOT MET Fremantle Hospital

Age profile of patients in survey Excludes patients being discharged today. 80

30 Number of patients of Number

0 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90+ Age band Sum of AEP MET TOTAL Sum of NOT MET TOTAL Sum of missing AEP

Length of stay for all patients Excludes patients being discharged today. 140

120

100

60 Number of patients of Number 40

0 0 days 1-3 days 4-7 days 8-14 days 15+ days Length of stay (days) Sum of AEP MET TOTAL Sum of NOT MET TOTAL Sum of missing AEP Fremantle Hospital

Reason not discharged in patients Excludes patients being discharged today.

Waiting for AHP assessment / treatment

Awaiting consultant decision/review

Home care support availability / funding Reason not discharged not Reason

Making choices / awaiting place of availability in care home

0 2 4 6 8 10 12 Number of patients

Alternative place of care for patients not meeting AEP Excludes patients being discharged today. 50%

45%

40%

35%

30%

25%

20% Percentage of patients of Percentage 15%

10%

0% At home Non acute area of care Other – please specify Outpatients follow up #N/A Alternative place of care Fremantle Hospital

Results of day of care survey Sir Charles Gairdner Hospital Monday 5 August 2013

34 Beds on multiday wards at SCGH 14 Jul 2013 snapshot

Hosp SCGH

Values

Row Labels WardNme Total beds Active beds Inactive beds Aged Care/Rehab 35 35 0 C17 GERIATRIC EVALUATION AND MANAGEMENT UNIT 14 14 0 GRU GMED 6 21 21 0 General 409 406 3 C16 GMED 8 & 9 30 30 0 G41 CARDIOLOGY 14 14 0 G51 ORTH/NEUROLOGY 30 30 0 G52 NEUROSURGERY 27 27 0 G53 ORTHO/RHEUMATOLOGY 30 30 0 G54 RESP MED / PULM PHYS 28 28 0 G61 GMED 1,3&5/DRAC 30 30 0 G62 CARDIOTHORACIC/VASC 24 24 0 G63 RENAL/GSUR 5/GAST/TRANSPLANT 30 30 0 G64 ENT/OPHT/PLAS 18 18 0 G66 NEUROSURGERY/PAIN/ORAL 18 18 0 G71 DERM/ENDO/RAD0/PALL/GMED 4/IMMU/GS4 30 30 0 G72 GMED 7 30 30 0 G73 ONCO/HAEM 30 30 0 G74 UROL/NUC GSUR2-3/SAU GMED1 40 37 3 Grand Total 444 441 3

35 Summary: Sir Charles Gairdner Bed occupancy 104.0% Number of beds in survey (allocated beds) 430 In-patients surveyed 447 Beds closed 1 Patients being discharged today 48 AEP criteria for day of care not met 108

Criteria not met, alternative "home" 35 Criteria not met, alternative "non-acute bed" 12 Criteria not met: L.O.S.  7 days 49 > 7 days 59   Bed numbers Total beds in survey 430 Bed closed 1 Beds empty 9

Admitted greater than 24hrs before day of audit 361 Admitted less than 24hrs before audit 86 Missing admission dates 0 Total 447

Discharges Patients being discharged today 48

AEP Criteria for day-of-care Met and not over-ridden 289 Not met but over-ridden (appropriate stay) 2 Missing (assumed met) 1 Sub-total (met) 292

Not met and not over-ridden 99 Met but over-ridden (inappropriate stay) 10 Sub-total (not met) 109 Total 401

Not met criteria All inpatients excluding discharges 399 Criteria not met % (excluding discharges) 27.3%

Outliers Total Outliers 88 % of patients outlying 19.7%

36 Sir Charles Gairdner Hospital

Sir Charles Gairdner Hospital

39 Sir Charles Gairdner Hospital

40 All hospital sites: aggregate data

Top 4 reasons for “reason not discharged” for patients not meeting acute care criteria

41 Summary

A total of 1293 in-patients were reviewed by hospital staff using an agreed survey method on 3 sites on a Thursday, Friday and Monday. Bed occupancy was between 98 and 104%.

Between 21 and 27% of patients in the survey did not meet any of the 28 criteria for appropriateness of acute care. There was marked ward to ward variation in the proportion of patients not meeting the criteria.Outlying was common and varied between 9 and 20%.

Analysis of the reasons that patients not meeting criteria had not been discharged showed that about half such factors would be those considered to be under hospital control.

Hospital Patients Occupancy Patients not Patients surveyed [%] meeting outlying [%] [n] acute care criteria [%] Royal Perth 500 98 22 9

Fremantle 346 99 21 13

Sir Charles 447 104 27 20 Gairdner

Reasons for not discharged in patients not meeting criteria

Hospital site Within site Out of site Mixed/other control [%] control [%] [%] Royal Perth 48 21 31

Fremantle 42 36 22

Sir Charles 48 29 23 Gairdner

42 Acknowledgements

The UK visiting team wish to thank Marea Gent for co-ordinating the survey in Perth, and the site co-ordinators and reviewers who gave up their time to conduct the survey.

UK team

Prof. Derek Bell

Shaun Danielli

Dr.Veronica Devlin

Patrice Donnelly

Bas Gough

Kenny Grant

Martin Hopkins

Katie Horrell

Chris McNicholas

Dr. Simon Watkin (DOC lead)

Dr. Tom Woodcock