AcuteMedicineProgrammeobjectives

Keyobjectives: Quality:Reducetheadmissionrateofmedicalpatientsby10%peryear for3yearspostfullimplementationwithoutincreasing28day readmission,thusenhancingtheglobalpatientexperience. Access: EverymedicalpatientpresentingtotheAMU/AMAU/MAU*will beseenbyaseniormedicaldoctorwithinonehourandwillbe discharged/admittedwithin6hours. Cost:AchieveanationalmedicalpatientmeanALOSof5.8days, generatingtotalbeddaysavingsover3yearsof500,000(1,300beds). Eliminationoftrolleywaits.
(*AcuteMedicalUnit/AcuteMedicalAssessmentUnit/MedicalAssessmentUnit)

AMPkeyfeatures
Streamingofacutemedicalpatientstodefined locusofcare(AMU) EarlyopinionfromSeniorMedicalDoctor Earlydiagnostics(investigatetodischarge NOT admittoinvestigate) ExpeditedSpecialistConsultation FasttrackOPD/procedures Dispositiondecisionwithin6hours(admitor discharge) Dailyward/boardrounds Weekenddischarges

AMPGoals
Betterpatientcare Betterpatient/staffexperience Betterclinicaloutcomes Appropriateclinicalenvironment Reducedelectivewaitingtimesforadmission/daycases,etc. Lesstrolleywaits Improvedefficiency Bettervalueformoney
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AMPModelofCare

Respiratory Unit

StrokeUnit

GP Decision toadmit ED
Critical care Cardiac Unit

Gastro Intestinal Unit Acute Rehabilitation Unit

Acute Bed Pool 2nights

Metabolic Unit

AvLosfor2009,2010,2011
9 9

8.8 8.8 8.6 8.6 AvLOS (days) AvLOS (days) 8.4 8.4 8.2 8.2 8 8

7.8 7.8 7.6 7.6 7.4 7.4

Ja n - Ja n -Ju n Ja n Ja n Ja n - Ja n -Ju n Ja n Ja n Ja n Ja n -Ju n Ja n Ja n Ja n - Ja n -Ju n Ja n Ja n Ja n - Ja n -Ju n Ja n Ja n Ja n Ja n -Ju n Ja n Ja n M ar 09 09 S ep 09 Dec 09 M ar 10 10 S ep 10 Dec 10 M ar 11 11 S ep 11 Dec 11 M ar 09 09 S ep 09 Dec 09 M ar 10 10 S ep 10 Dec 10 M ar 11 11 S ep 11 Dec 11 T i m e P e ri o d T i m e P e ri o d

AMPSummary
Improvesthequalityandthesafetyofcare Reducesinhospitallengthofstay Increasessamedaydischargerates Improvesefficientuseofhospitalresources Greaterpatient,GPandstaffsatisfaction

IrishHospitalsNeedtoReEngineertheProcessof caringformedicalpatients
WhyMedicine? Onethirdofallhospitaladmissionsaremedical Halfofallhospitalbedsareusedbymedicalpatients

How? BenchmarkIrishpracticeagainstaverageEnglishhospitalperformance Target: 25%ofmedicalpatientsassessedandadmissionavoided 31%staylessthan48hoursinhospital 44%staymorethan2days(average10days) Profileandmonitoreachhospitalperformance

MedicalAdmissionsinEnglandduring20092010year:LengthofStay

HospitalA:NumberofAcuteMedicalDischargesbyLengthofStay

3000 3000

2500 2500

N um ber of discharges N um ber of discharges

2000 2000

1500 1500

1000 1000

500 500

10 10

12 12

14 14

LoS LoS

HospitalB:NumberofAcuteMedicalDischargesbyLengthofStay

3000 3000

2500 2500

N u m b e ro fd is c h a rg e s N u m b e ro fd is c h a rg e s

2000 2000

1500 1500

1000 1000

500 500

0 0

> >1 14 4

1 12 2

LoS LoS

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4AreasofIntervention
Assessandavoidadmission ShortStayUnit Efficientprocessingofordinarypatients Appropriatecareanddischargeofcomplexpatients

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ImplementationinProgress
Goodforpatients Goodforservice Goodfortaxpayer

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TheNationalEarlyWarningScore(NEWS)and associated EducationProgramme

Apatientfocused,safetyandqualityinitiative

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Introduction

Aim:Tofacilitateearlydetectionofpatientdeteriorationbycategorisinga

patientsseverityofillnessandpromptingnursingstafftorequesta medicalreview.Thiswilloccuratspecifictriggerpointsutilising structuredcommunicationtoolswhilstfollowingadefinitiveescalation plan. Thisappliestobothmedicalandsurgicalpatients.

Why:Asignificantnumberofcardiacarrestsandunplannedadmissions to

ICUdemonstratedeteriorationinpatientsvitalsigns upto24hoursprior tocardiacarrest.Insomecases,theremaybeafailuretorecogniseor respondearlyenoughtothedeterioratingpatient.

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Patientsvitalsignsarerecordede.g.BloodPressure,Pulse Eachvitalsignisscoredfrom0to3. ThesescoresareaddedtogethertogivetheEarlyWarningScore Ifthescoreisat3orabovetheescalationprotocolorgradedresponseisinitiated

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Background
ANationalGovernanceGroupwassetupsupportedbyaNational AdvisoryGroup HIQArecommendedanationallyagreedEarlyWarningScore NICEClinicalGuideline50recommendstheuseofaphysiological track andtrigger systemstomonitoralladultpatientsinacutehospital settings IrelandwasthefirstknowncountrytoagreeaNationalEarlyWarning Score(NEWS) Thescoringsystemissupportedbyaninterdisciplinaryeducation programme,COMPASS,sharedwithusbyourAustraliancolleagues

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Background(contd.)
Programmeissupportedby,amongothers:RCPI,RCSI,Officeofthe NursingandMidwiferyServicesDirector(ONMSD),Patients RepresentativeGroups,theIrishAssociationofDirectorsofNursingand Midwifery(IADNAM),theClinicalIndemnityScheme(CIS)andtheIrish NursesandMidwivesOrganisation(INMO),TheNursingandMidwifery BoardgrantedCategory1approval(6credits)fortheprogramme ItisnotedthataNEWSsystemdoesnotreplaceclinicaljudgementof experiencedstaff,butisveryimportantinprovidinganobjectivepatient assessmenttosupportclinicaldecisionmaking Thefullprogrammeisavailableonthewebsiteasfollows: www.hse.ie/go/nationalearlywarningscore/

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Planfor2012
IntroducetheNationalEarlyWarningScore(NEWS)andassociated EducationProgrammeintoeveryacutehospitalinthecountry. Consistencyacrosstheentireacutehospitalserviceincategorising patients severityofillnessandpromptingappropriateaction. AuditandEvaluation Progresstodate: 1300stafftrained Medicalinternsarebeingtrainedupnationallyonthe programme (compulsorypartoftheinternsEducationandTraining contract) Allsiteshavecommencedworkonthisandweexpectallsites operationalbyendofyear

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TheNationalEarlyWarningScore isgoodNEWSforpatients and willsavelives

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AcuteMedicineProgramme CorkUniversityHospital March2012

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Cultureiscrucialandleaderswithcoreskills forclinicaldriveandorganisationalchange willsettheclimateforpositive transformation

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KeyReasonsforSuccess!
Teamapproach Patientfocused Continuouspresenceofsenior cliniciansonthefloor PriorityaccesstoDiagnostics

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CUH AcuteMedicalUnitopenedJan10th 2011

TotalAdmissions,DischargesandtransfersfromJan10th toDecember2011

Admissions=2,410 Discharges=2,065 25%homewithin24hours 48%homewithin48hours

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LengthofStay TotalMedicine

AvLOS 2009=8.97days V AvLOS 2011=7.16days Reductionoverall=1.8days Beddayssaved=20,512(equivalentto56beds)

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Phase2AMAUJan11th2012
11/01/2012 12/03/2012

NumberofPatientsAdmittedtoMSSU NumberofPatientsAssessedinAMAU NumberofPatientsSeeninAMUReviewClinic TotalNumberofPatientsAttendancesinAMU

406 528 269 1,203

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AMAU Data
600 528 500

400

303 300

200

178

100 40 7 0 Assessed Discharged Same Day Admitted to MSSU Admitted to CUH Transferred to Other Hospital

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AMAU Discharge Outcomes

7.6%

1.3%

33.7% 57.4%

Discharged Same Day

Admitted to MSSU

Admitted to CUH

Transferred to Other Hospital

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KeyChallenges
TogenerateaculturewherewesayNO totrolleysandfind alternativesolutionsasawholehospitalworkingtogether ratherthanassinglesilos TointegratethehospitalservicewithGPsandthe communityasaseamlessservicethatiseasilyaccessible appropriateandefficient Toprovidesufficientlongtermcarebedcapacityforpatients whorequiresuchcare

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TheAMPwilldeliver,providedallteams worktogetherandaresupportedbyclinical andmanagerialleadershipthathasthe Patientatthecentreofthisprocess

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