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 ] [Type the company name] 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. 6 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.

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