Anda di halaman 1dari 43

2013

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

] [Type the company name]

Introduction Examples of actions from previous surveys Summary How to organise site surveys How the survey was adapted for WA How to do the survey Survey algorithm Top tips for reviewers Chart 1: appropriateness criteria Charts 2, 3 and 4 Data collection sheet How are results presented? Results: Royal Perth Hospital Results: Fremantle Hospital Results: Sir Charles Gairdner Hospital Summary Acknowledgements

3 7 8 10 11 12 16 17 18 19 20 21 22 28 34 42 43

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 .

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 1980s 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 1 6 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

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 peoples wards are optimised if geriatricians review inpatients with either a senior nurse/AHP with specialist interest in older peoples 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

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.

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.

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.

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 patients 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 patients 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 patients 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.

15

Day of Care Survey algorithm and data collection guide


Start the process again with next patients notes
No Clinical override used?

Start

Met criteria Use Chart 1: Does the patient meet Day of Care Criteria?

Yes (Overridden)

Is patient being discharged today?

No

Use Chart 2 to record reason not discharged

Use Chart 3 to record alternative place of care

Use Chart 4 to record if patient is an Outlier

Yes

Not met criteria

No 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 in- patient 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 <35 or >38 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 2 Therapy Therapy Requires IV, IM or subcutaneous medication (that cannot be delivered at home/in the community) Receiving treatment or new/experimental treatment requiring frequent dose adjustments or medical monitoring under direct medical supervision Surgical procedure today that is not suitable for day case Invasive procedure not suitable for day case (e.g. some interventional radiology, some guided biopsies, etc.) Vital sign monitoring every hour or more frequently Chemotherapy requiring constant supervision Requires accurate input/output fluid balance measurement Requires continuous oxygen, non-invasive ventilation or intensive nebuliser therapy that cannot be delivered at home To establish complex nutritional support, including enteral feeding Requires intravenous fluids (that cannot be delivered at home/in the community 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) Requires multiple investigations for urgent diagnosis

3 4 5 6 7 8 9 10 11

Procedure Procedure Monitoring Monitoring Monitoring Respiratory Fluid/nutrition Fluid/nutrition Recovery

12

Investigation

18

Chart 2. Reason not discharged


A B C D E F G H I J L M N S T Awaiting Social work allocation/Assessment/Completion of Assessment Awaiting Alterations home modification to equipment/housing Waiting for Home Care Support/ community services(HACC 1 MOW2) TCP3 Awaiting place in Care in Residential Aged Care Bed Awaiting General Hospital Bed Awaiting/planned repatriation to other hospital- Rural Health Region Awaiting care in another Tertiary Hospital (Single Service 4) Vacancy available in a aged care residence of choice/discharge planning in progress Awaiting final multi-disciplinary decision Awaiting procedure/investigation/results and not meeting criteria for acute care Awaiting Consultant decision/review Delay due to relatives Delay due to transport Waiting Allied Health Assessment/treatment specify which Allied Health Service Other Please specify

Chart 3. Alternative place of care


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

Chart 4. Outliers
N M O S A Not an outlier Medical Orthopaedic Surgical Other please specify

1 2

Home and Community Care Services 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 Ward Date Total Number of patients Beds Closed (empty and cannot be used) Number of Outliers

Chart 1
Date of Birth Date of Discharge Met Admission Today Not met

Clinical Override
Inappropriate Appropriate

Chart 2
Reason not discharged

Chart 3
Alternative Place of Care

Chart 4
Outlier

Consultant Initials

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 selfexplanatory. 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 Ward RPH Ward Name Total beds Active beds Inactive beds Senior Nurses Senior Doctor/Registrar

3K 4F CTUP 10A 10C 5A 5B 5E 5G 5H 6A 6G 6H

3K GERIATRIC/GEM UNIT 4F CARDIOLOGY CARDIAC TELEMETRY UNIT 10A MEDICAL ONCOLOGY 10C IMMUNOLOGY 5A IMU TEAM 1 AND TEAM 3 - Internal medicine 5B IMU TEAM 2 AND TEAM 3 - Internal medicine 5E IMU TEAM 4 AND TEAM 5 - Internal medicine 5G ORTHOPAEDIC 5H ORTHOPAEDIC/NEUROSURGERY 6A NEPHROLOGY 6G CARDIOTHORACIC/VASCULAR 6H PLASTICS/ENT

17 20 5 30 10 21 21 26 30 30 21 31 30

17 20 5 30 10 21 21 26 30 30 21 31 30

0 0 0 0 0 0 0 0 0 0 0 0 0

Glenda Jacoby Carl Donaghue Carl Donaghue Sala Nanthakumar Trevor Cherry Sam Morgan Vanessa o'Connell Dave Hughes Sharon Birchenough Kathy Young Kathy Sims Kerry Stokes Mel Murrell

Yuen Leow Aref Arjomand Aref Arjomand Ash Gurumurthi Patricia Martinez Hassan Kamalddin Rita Malik Mark Donaldson Ivan Lau Trishna Bhalla Ricki Arenson Kate Kloza Chris West Cecilia Wee/Jose CidFernandez Manreet Randhawa Sherman Picardo Shelina Mahbub Richard Warren Stephen Wright Nicola Sandler Nicola Sandler Cecilia Wee/Jose CidFernandez

7A 8A 9A 9B 9C AAU STU STUA

7A GENERAL SURGERY 8A NEUROLOGY / STROKE 9A DGM 9B DGM 9C RENAL/RESPIRATORY ACUTE ASSESSMENT UNIT 3G STATE MAJOR TRAUMA UNIT 3G STATE MAJOR TRAUMA UNIT HIGH ACUITY

34 38 19 19 30 33 26 4

34 38 19 19 30 33 26 4

0 0 0 0 0 0 0 0

Brycelynn White Annita House Gillian Watt Isabelle Brewer Noela Pascoe Andrea McFaull Donna Coutts-Smith Donna Coutts-Smith

AGSU Grand Total ED

7A/AGSU ACUTE GENERAL SURGERY UNIT

8 503

8 503

0 0

Brycelynn White

Inpatient and breach patients

Tim Leen

Carolyn Wilson

23

Summary: Royal Perth Hospital Bed occupancy Number of beds in survey (allocated beds) In-patients surveyed Beds closed Patients being discharged today AEP criteria for day of care not met Criteria not met, alternative "home" Criteria not met, alternative "non-acute bed" Criteria not met: L.O.S. 7 days > 7 days Bed numbers Total beds in survey Bed closed Beds empty Admitted greater than 24hrs before day of audit Admitted less than 24hrs before audit Missing admission dates Total Discharges Patients being discharged today AEP Criteria for day-of-care Met and not over-ridden Not met but over-ridden (appropriate stay) Missing (assumed met) Sub-total (met) Not met and not over-ridden Met but over-ridden (inappropriate stay) Sub-total (not met) Total Not met criteria All inpatients excluding discharges Criteria not met % (excluding discharges) Outliers Total Percent

97.7% 512 500 12 48 99 24 31 51 48

512 12 9 364 136 0 500

48

348 5 0 353 99 0 99 452

452 21.9% 44 8.8%

24

AEP met by ward


40

Excludes patients being discharged today.

35

30

Number of patients

25

20

15

10

0
4F CTUP
AAU

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

% of AEP met by ward


100% 90% 80%

Excludes patients being discharged today.

70%
60% 50% 40% 30% 20% 10% 0% AAU 6G AGSU 6A EMW 7A 9B 6H 9C 5H 5A 10A STU 5G 5B 4F CTUP 10C 9A 8A ED 5E 3K

% of AEP MET

% of NOT MET

Royal Perth Hospital

25

AGSU

EMW

STU

10A

10C

ED

3K

5A

5B

5E

6A

7A

8A

9A

5H

6H

9B

5G

6G

9C

Age profile of patients in survey


100 90 80 70

Excludes patients being discharged today.

Number of patients

60 50 40 30 20 10 0 0-9 10-19 20-29 30-39 40-49 50-59 Age band


Sum of NOT MET TOTAL

60-69

70-79

80-89

90+

Sum of AEP MET TOTAL

Sum of missing AEP

Length of stay for all patients


250

Excludes patients being discharged today.

200

Number of patients

150

100

50

0 0 days 1-3 days 4-7 days Length of stay (days)


Sum of NOT MET TOTAL

8-14 days

15+ days

Sum of AEP MET TOTAL

Sum of missing AEP

Royal Perth Hospital

26

Alternative place of care for patients not meeting AEP


50%
Excludes patients being discharged today.

45%
40%

35%
Percentage of patients
30% 25% 20% 15% 10% 5% 0% At home Non acute area of care Other please specify Outpatients follow up Alternative place of care #N/A

Royal Perth Hospital

27

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

28

Beds on multiday wards at FH


Hosp FH

14 Jul 2013 snapshot

Row Labels Aged Care/Rehab GEM V5 Critical Care B8N General ASU B7N B7S B8S B9N B9S CDU MAU SSSUO

WardNme

Total beds 36 10 26 22 22 252 15 31 31 31 27 31 10 24 14

Active beds 36 10 26 21 21 252 15 31 31 31 27 31 10 24 14

Inactive beds 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0

Geriatric Evaluation V5 Restorative Rehab B8N Cardiothoracic ASU Acute Surg Unit B7N - Surgical Specs Plastics, ENT, Oral surgery, Colorectal, Gastro B7S - Orthopaedics B8S - General Surgical and Vascular B9N - Haematology/ Oncology and General Med B9S - General Medical and Renal ED CDU Clin Dec Unit MAU Medical Assess Short Stay Overnight V6 - General Medical

V6 Grand Total

38 310

38 309

0 1

29

Summary Figures: Fremantle Hospital


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

Bed numbers Total beds in survey Bed closed Beds empty Patients not allocated beds (on trolleys) Admitted greater than 24hrs before day of audit Admitted less than 24hrs before audit Missing admission dates Total
Discharges Patients being discharged today AEP Criteria for day-of-care Met and not over-ridden Not met but over-ridden (appropriate stay) Missing (assumed met) Sub-total (met) Not met and not over-ridden Met but over-ridden (inappropriate stay) Sub-total (not met) Total Not met criteria All inpatients excluding discharges Criteria not met % (excluding discharges) Outliers Total Outliers % of patients outlying

350 0 13 12 271 75 0 346

39

225 18 1 244 54 10 64 308

307 20.8%

45 13.0%

30

AEP met by ward


35

Excludes patients being discharged today.

30

25

Number of patients

20

15

10

0
V5 B8S B7N B8N B9N B9S

B7S

ED

ENDEAVOUR

ASU

AMITY

MAU

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

% of AEP met by ward


100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
ASU B9N B8N CDU

Excludes patients being discharged today.

B7N

B7S

B8S

ED

SSSUO

CDU

GAGI

GEM

ENDEAVOUR

B9S

% of AEP MET

SSSUO

% of AEP NOT MET

Fremantle Hospital

31

AMITY

GAGI

V5

MAU

GEM

V6

V6

Age profile of patients in survey


80

Excludes patients being discharged today.

70

60

Number of patients

50

40

30

20

10

0 10-19 20-29 30-39 40-49 50-59 Age band 60-69 70-79 80-89 90+

Sum of AEP MET TOTAL

Sum of NOT MET TOTAL

Sum of missing AEP

Length of stay for all patients


140

Excludes patients being discharged today.

120

100

Number of patients

80

60

40

20

0 0 days 1-3 days 4-7 days Length of stay (days)


Sum of NOT MET TOTAL

8-14 days

15+ days

Sum of AEP MET TOTAL

Sum of missing AEP

Fremantle Hospital

32

Reason not discharged in patients

Excludes patients being discharged today.

Waiting for AHP assessment / treatment

Reason not discharged

Awaiting consultant decision/review

Home care support availability / funding

Making choices / awaiting place of availability in care home

10

12

Number of patients

Alternative place of care for patients not meeting AEP


50%
Excludes patients being discharged today.

45%
40%

35%
Percentage of patients
30% 25% 20% 15% 10% 5% 0% At home Non acute area of care Other please specify Outpatients follow up Alternative place of care #N/A

Fremantle Hospital

33

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

34

Beds on multiday wards at SCGH


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

14 Jul 2013 snapshot

Inactive beds 0 0 0 3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 3

35

Summary: Sir Charles Gairdner Bed occupancy Number of beds in survey (allocated beds) In-patients surveyed Beds closed Patients being discharged today AEP criteria for day of care not met Criteria not met, alternative "home" Criteria not met, alternative "non-acute bed" Criteria not met: L.O.S. 7 days > 7 days Bed numbers Total beds in survey Bed closed Beds empty Admitted greater than 24hrs before day of audit Admitted less than 24hrs before audit Missing admission dates Total Discharges Patients being discharged today AEP Criteria for day-of-care Met and not over-ridden Not met but over-ridden (appropriate stay) Missing (assumed met) Sub-total (met) Not met and not over-ridden Met but over-ridden (inappropriate stay) Sub-total (not met) Total Not met criteria All inpatients excluding discharges Criteria not met % (excluding discharges) Outliers Total Outliers % of patients outlying

104.0% 430 447 1 48 108 35 12 49 59

430 1 9 361 86 0 447

48

289 2 1 292 99 10 109 401

399 27.3%

88 19.7%

36

Sir Charles Gairdner Hospital

37

Sir Charles Gairdner Hospital

38

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 surveyed [n]

Occupancy [%]

Patients not Patients meeting outlying [%] acute care criteria [%]

Royal Perth 500

98 99 104

22 21 27

9 13 20

Fremantle

346 447

Sir Charles Gairdner

Reasons for not discharged in patients not meeting criteria


Hospital site Royal Perth Fremantle Sir Charles Gairdner Within site control [%] Out of site control [%] Mixed/other [%]

48 42 48

21 36 29

31 22 23

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

43