In 2013 the CUH Unscheduled Care Governance Group was established and incorporated the Acute Medical Care Programme and Emergency Care Programme governance groups that were already in existence. This enabled a structured work programme to be developed encompassing processes and strategies to be implemented to effect an improvement in the management of the unscheduled care patient pathway. A number of key actions were implemented which resulted in improvements in the patient pathway, namely Acute Medicine Programme, Surgical Care Programme, Lean & Six Sigma Process, The Visual Hospital, Use of Informatics & Data, Investment in Infrasture, Reorganisation of Bed Management Function, Appointment of an Ortho-geriatrician, Improvement in Community Interface. Further information on these already implemented key actions is available in the publication "Unschedule Care Patient Pathway, The Change Programme 2013-2015"
Further Change Initiatives in 2015/2016
The Executive Management Board, cognisant of the need to further develop and build on the strategies in place, have continued to identify further initiatives that will improve the unscheduled care patient pathway and ultimately enhance the patient experience. The clear and absolute focus of the Unscheduled Care Governance Group and wider hospital is to significantly improve the initial experience for patients in the first 24 hours. In addition to the individual change initiatives that are intrinsic to this process, the following is the first of two new initiatives that we believe will make a significant difference to the Hospital's performance and to the experience of patients: Initiative 1 - Ten Point Action Plan & Initiative 2 - Patient Flow Action Cards.
Initiative 1 - Ten Point Action Plan
The average length of stay for patients in CUH compares very favourably with peer hospitals and the achievement of a length of stay of c. 6 days for medical patients is accepted by the SDU as evidence that very many improvements have been made in the internal processes in the Hospital and continued focus on internal initiatives have the capacity to reduce length of stay by very little.
Furthermore it is accepted by the Special Delivery Unit that there is a need to increase bed capacity using the very limited potential that there is to do so in the Hospital presently.
Initiative 1: Reorganise beds in the context of a plan that has been signed off by the EMB to create a 31 bed acute medical ward on a 24/7 basis. This will provide 10 additional beds and will require the transfer of day beds to another ward.
Present Position: New bed plan collated and the recruitment of additional staff is underway
AMU - 7 Day Working
The Acute Medical Assessment Unit has made a very substantial contribution to improved performance since its opening in 2012. For the period January-December 2014, 1,800 patients were admitted to the MSSU, 6,000 patients were assessed and managed in the AMAU and an additional 1,300 patients were assessed at the Review Clinic that would otherwise have presented at ED or through another entry point into the hospital.
Initiative 2: The Acute Medical Assessment Unit currently opens 7.30am to 8.00pm daily and accepts patients up to 4.00pm on the basis that this provides an adequate period of time for patients to be accommodated with a bed thereby minimising the risk of patients having to be re-directed to ED. There is a need to review this policy and the appointment of an additional 2 Acute Physicians will enable a number of changes to be implemented to include:
(a) The AMU Physicians would work a shift system on Saturdays and Sundays from 0800hrs to 1800hrs with the support of the on-call NCHD team. The provision of an additional 2 WTE for nursing staff would allow the opening of the AMAU on Saturdays and Sundays.
(b) The shift from 0800hrs to 1800hrs would aim to round in MSSU and identify discharges Following this, the AM Consultant would attend the ED or AMAU and supervise the on-call take until 1800 pm. The AM consultant would see medical reviews, provide a consult service to the ED and ideally maximise safe patient discharge from the MSSU and ED as well as optimising care. The target would be to reduce conversion rate of medical patients at the weekend from 33% to 30% on Saturday and from 40% to 35% on Sunday.
Present Position: The extended working day to be operational by mid November 2015
A key priority for the EMB is the early establishment of a Discharge Lounge to facilitate the early discharge of patients that is a requirement to facilitate the earliest possible transfer of patients from the ED.
Initiative 3: This will improve the efficiency with which patients can be placed in beds and will improve the 6 and 9 hour significantly. The Discharge lounge will provide a 5 day service from 8.00am to 3.00pm.
Present Position: The Discharge Unit opened on Monday 11th May 2015 and the ultimate aim is to have 40% of inpatients discharged via this unit.
Access To Diagnostics
One of the key difficulties that emerged from the Lean Study into the patient pathway in ED was the delay in accessing diagnostics. The EMB is anxious to prioritise improved resourcing of the Radiology Department on the basis that there will be an improved turnaround time for patients requiring Radiology services. One of the initiatives that will be undertaken immediately is to develop a new protocol for accessing CT services for patients that will improve access and response times.
In addition a number of other supporting interventions will help the flow of patients through the Radiology Department
Initiative 4: Recruit a porter and a health care assistant to improve the throughput of patients in the Radiology Department.
Present Position: Recruitment of staff is progressing. Two public MRI Scanners were commissioned in July and have improved access for patients. We still have some issues to address in particular access to CT services and continues to work with the department of Radiology on maximise capacity.
The appointment of the first Ortho-Geriatrician in CUH in 2014 transformed the patient pathway for elderly patients resulting in a 20% reduction of inpatient orthopaedic patients with the potential for a significant further reduction in length of stay and earlier discharge with a second post. The current appointee has a level of input into the rehabilitation service in SIVUH that could be significantly increased with a second appointment.
Initiative 5: Appoint a second Ortho-Geriatrician to CUH / SIVUH at a cost of €187,191 to be supported by a Registrar and an Administrative Officer at a cost of €291,444.
Present Position: Funding for the additional post has been allocated and the recruitment process is to commence.
Vacant Endoscopy Recovery Area
In July the Endoscopy Department transferred from its existing location and as a consequence an Endoscopy Recovery area suitable for the management of children attending the ED has become available. The development of such a facility will free up space in the ED for use as a Rapid Assessment and Treatment area that will assist in improving the PET times.
Initiative 6: Transfer Paediatric ED services from the main ED to the Endoscopy Recovery area to create additional treatment space in the ED assisting in improving PET times.
Present Position: The department has identified a plan that will allow for the transfer of the paediatric service to the separate location and in addition provide enhanced accommodation for the Rapid Assessment and Treatment service. Refurbishment of the accommodation will commence in the 4th quarter 2015.
Bed Management Structure
The Bed Management function has become ever more central and critical to the efficient functioning of the Hospital and it is vital that it is staffed with specialists in that area of the highest caliber. The implementation of the Visual Hospital coupled with the department having responsibility now for both Unscheduled Care and Scheduled Care has emphasised further the need for expertise in bed management.
In due course as the SSW Hospital Group evolves we must proceed to have a Group (at least in Cork City and County) structure to manage beds with real-time transparency on the status of beds. In the meantime we need to support the Bed Management function in CUH and initiate discussions on the establishment of a Group structure possibly to be managed from CUH.
Initiative 7: Appoint a CNM 3 Bed Manager to increase the expertise in the function of bed management.
Present Position: This post has been approved by the EMB and the paperwork has been submitted to the NRS for advertising.
Utilise OPD at weekends
The Out Patients Department is located immediately adjacent to the ED and is available for use as an assessment / treatment area from 5 pm Friday to 8 am Monday. This would allow the rapid assessment and treatment of those patients (66%) who will not require admission thereby improving PET times.
Initiative 8: Use the OPD at key times over weekends for assessment /treatment of patients. This would facilitate the use of the OPD from 6.00pm to 8am Monday to Friday and from 2.00pm to 8.00pm on Saturday and Sunday. This would yield a resultant improvement in the PET for those patients who will not require admission.
Present Position: This initiative requires the recruitment of additional nursing staff and this is currently under review.
An extensive recruitment programme is underway to recruit nursing staff to fill the vacant posts throughout the hospital. The process of recruiting nurses which has impeded these developments heretofore is continuing but for the first time this year the number of staff nurses commencing exceeds the number of nurses leaving the service and we have much to do in order to fill the 40 vacancies that we have currently. Of the 52 nurses graduating this year 47 have agreed to continue their nursing career in CUH and we continue to recruit nurses through various recruitment campaigns.
In due course as the SSW Group evolves we must move to devolve recruitment of staff including nursing staff to address the significant impediment that exists as a result of delays in the appointment of staff.
Initiative 9: Expedite the filling of vacant nursing posts as a matter of extreme urgency.
Present Position: Continue to recruit the additional nursing staff require utilising all recruitment processes available
Step Down Beds
A good deal of attention has been given to reducing the number of delayed discharges and funding in support of this initiative has been very welcome.
A key challenge and significant impediment to the efficient throughput of patients is the paucity in step-down beds and a resolution to this will need to be found before Q4 in 2015.
Initiative 10: Open Step-Down Unit. Funding has been secured to open a Step-down unit. Following advice from procurement we have used the framework which exists and sought tenders from 3 companies who are listed on the framework.
We have asked that they provide a solution that would provide the necessary nursing and care assistant staff required to open the additional beds by mid-November bridging the time frame when the permanent recruitment process has been completed.
Present Position: One of the companies has tendered on the basis that they can provide these resources to enable us to implement this initiative within that timeframe
Initiative 2 - Patient Flow Action Cards
The hospital is challenged with providing capacity to deal with the daily demand for inpatient beds on a daily basis. It is clear that the most significant factor in this problem is appropriate number of inpatient beds. The tangible effects for patients can include prolonged wait times in the Emergency Department, prolonged wait for inpatient bed and at times cancellation of planned elective activity.
To deal with the capacity issue there is an extensive plan produced by the Unscheduled Care Governance Group and EMB (open physical beds, HDU beds, 7/7 working of AMU, Discharge Unit, and Access to Diagnostics). In addition the hospital functions extremely favourably when compared with our peer hospital regarding activity and length of stay.
To optimise and capture how we run the hospital on a daily basis in the face of these demands, the Unscheduled Care Governance group have developed a number of simple action cards focussed on a number of key areas which will be implemented from 5th October 2015.
The overarching goal is:
(i) To reduce the need for admitted patients to remain in the Emergency Department and access an inpatient bed as quickly as possible.
(ii) By association, freeing up space, to allow patients be seen faster in a safer Emergency Department.
Action Card 1 (> 28 Day stay Cohort of Patients)
This is a small percentage (3%) of our total inpatients but by the nature of their prolonged stay utilise 34% of available bed days per year. Of course there are multiple reasons for this but Action Card 1 will bring a focus to this group.
|Action Card 2 (The Discharge Process)|
This action card encapsulates the principles of Plan for Every Patient and use of PDD (Predicted Discharge Date) In addition particular attention to the Medical and Surgical teams should be paid to Mandatory Discharge Meeting (Point 6), which takes daily in the Hub of CRC. Duration of attendance is approximately 2-3 minutes and any one fully briefed member of each department/team must attend. Teams will differ but it is best to assign that role to one person for any one week.
|Action Card 3 (Discharge Unit)|
This Unit is operational since Q1 2015 and the target is that 40% of discharges are through that unit.
|Action Card 4 (Standard Daily Operation Process)|
This card outlines the exact operation process and predominantly involves Bed Management, DON, ADON, Clinical Directors and Night sisters.
|Action Card 5 (Bi-directional Flow)|
There is daily movement of patients between CUH and all other hospitals in the South- South West Group. This card formalises those movements and contact details.
|Action Card 6 (Full Capacity Protocol)|
This card addresses the operation of surge capacity and how and where we do it to.
Publication "Unschedule Care Patient Pathway, The Change Programme 2013-2015"