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Towards Outstanding Care Royal Hobart Hospital

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Towards Outstanding Care Royal Hobart Hospital Towards Outstanding Care at the Royal Hobart Hospital External Consultation for ED Advisory Panel (EDAP) – A Review of Patient Access at Royal Hobart Hospital 5 August 2019 Professor Harvey Newnham MBBS, FRACP, PhD, GAICD Associate Professor David Hillis MBBS(Hons), MHA, DEd, FRACGP, FRACMA, FRACS(Hon), FCHSE, FAICD Towards Outstanding Care at RHH – Newnham/Hillis TABLE OF CONTENTS EXECUTIVE SUMMARY ........................................................................................................ 3 PREFACE ............................................................................................................................... 7 REPORT FINDINGS ............................................................................................................... 8 1. System and Organisational Enablers ............................................................................... 8 Background and “re-thinking the vision” ...................................................................................... 8 RECOMMENDATION 1.1 ........................................................................................ 9 Lack of Clarity in Governance ...................................................................................................... 9 RECOMMENDATION 1.2 ...................................................................................... 10 RECOMMENDATION 1.3 ...................................................................................... 12 Engagement and Empowerment of staff / clinicians .................................................................. 12 RECOMMENDATION 1.4 ...................................................................................... 14 RECOMMENDATION 1.5 ...................................................................................... 15 Culture ....................................................................................................................................... 15 RECOMMENDATION 1.6 ...................................................................................... 16 Change necessity ...................................................................................................................... 16 RECOMMENDATION 1.7 ...................................................................................... 18 Improve the voice of the consumer ............................................................................................ 18 RECOMMENDATION 1.8 ...................................................................................... 19 Data / Information / IT ................................................................................................................ 19 RECOMMENDATION 1.9 ...................................................................................... 20 RECOMMENDATION 1.10 .................................................................................... 21 2. Understanding patient flow, access block and risk sharing. ........................................... 22 Patient Flow ............................................................................................................................... 22 Sharing of Risk ........................................................................................................................... 23 RECOMMENDATION 2.1 ...................................................................................... 24 What happens when the ‘system” is under serious access stress? ................................ 25 Why are risk and urgency not equally shared across the system? ........................................... 26 3. Improving flow to improve patient access ....................................................................... 27 Non-admitted patients attending the ED .................................................................................... 28 Reducing patient presentations to RHH ED .................................................................... 28 Community-based alternatives to ED attendance or patient admission ..................... 28 RECOMMENDATION 3.1 ...................................................................................... 30 Ambulance assessment, treatment and transport ....................................................... 30 RECOMMENDATION 3.2 ...................................................................................... 31 Relationships with other hospitals ............................................................................... 31 RECOMMENDATION 3.3 ...................................................................................... 32 1 Towards Outstanding Care at RHH – Newnham/Hillis Ambulatory care clinics ............................................................................................... 32 RECOMMENDATION 3.4 ...................................................................................... 32 Improving the progression of care for “non-admitted” patients in the ED ....................... 32 RECOMMENDATION 3.5 ...................................................................................... 34 Improving access and flow for Admitted patients ...................................................................... 34 Patients admitted to the EMU (Emergency Medical Unit) ............................................... 34 RECOMMENDATION 3.6 ...................................................................................... 35 Patients admitted to and discharged directly from the acute ward.................................. 35 RECOMMENDATION 3.7 ...................................................................................... 36 RECOMMENDATION 3.8 ...................................................................................... 39 Patients admitted to the ward who require inpatient subacute care, rehabilitation or limited community-based services. ............................................................................. 39 RECOMMENDATION 3.9 ...................................................................................... 41 Intensive Care Unit at RHH (ICU) .............................................................................................. 41 RECOMMENDATION 3.10 .................................................................................... 42 General Medicine as a case study ............................................................................................. 42 RECOMMENDATION 3.11 .................................................................................... 44 Surgical and Perioperative Services at Royal Hobart Hospital ................................................. 44 RECOMMENDATION 3.12 .................................................................................... 46 Mental Health ............................................................................................................................. 46 RECOMMENDATION 3.13 .................................................................................... 46 Glossary of terms .................................................................................................................. 47 References ............................................................................................................................ 48 Appendix 1. Excerpts from MCAPS 2017 ............................................................................ 51 Appendix 2. Recommendation of previous reviews ............................................................. 56 Appendix 3. Terms of Reference ....................................................................................... 109 2 Towards Outstanding Care at RHH – Newnham/Hillis EXECUTIVE SUMMARY Royal Hobart Hospital (RHH) is the second oldest hospital in Australia. The local community strongly identifies with the hospital and staff are proud to work there, most being happy to recommend their families go there to receive their care. In recent years, however, RHH has been in an almost continuous state of crisis with an ever-present risk of serious adverse patient events resulting from intractable access block(1). The Australian College of Emergency Medicine defines Access Block as ‘the situation where patients who had been admitted and need a hospital bed are delayed from leaving the Emergency Department (ED) because of lack of inpatient bed capacity’(2). An accepted measure is a patient who spends longer than eight hours in ED from time of arrival. The major symptom of access block is ED overcrowding(3) and access block is associated with increased morbidity and mortality(3). Despite the symptoms being most felt in the ED, the cause of access block is a lack of access to inpatient beds, typically through a combination of hospital and system-wide issues involving slow progression of care or “patient flow”(4) both within the hospital and between the hospital and the community. RHH certainly suffers from extreme access block. From January to March 2019 there were more than 150 patients each month who stayed more than 24 hours in the ED: a single occurrence of which is uncommon in most other Australian Hospitals. In the same period almost 40% of all ambulance arrivals were “ramped”, being unable to offload their patients in an acceptable time frame. Indeed, occasionally all of Hobart’s ambulances are simultaneously ramped at the hospital leaving none readily available for emergencies in the community. We also noted that mental health patients seem to bear a disproportionate proportion of the burden of access block; they
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