Predictive Management - Improving The Patient Experience in ED
Jul 20, 2016 -
Author: Tony McNamara, CEO, Cork University Hospital Group
There is an imperative in the interest of the reputation of the hospital system, to improve patient flow and to address the oft stated observation “I’ll be waiting for days on a trolley”. In public discourse the quality of care in our hospitals is generally very good but access is a significant problem.
The literature is replete with evidence that the longer patients spend on a trolley – usually in the Emergency Department (ED) – the poorer their outcomes. This issue has been a feature of the health service for 15 years and is caused by multiple factors. Of course capacity is one of the key factors but institutional and individual tolerance (often subconscious) of the plight of patients in this situation should also be recognized as a factor.
It therefore behoves executive, clinical and nursing leadership to do everything possible to prioritise the placement of patients to ensure the shortest possible time waiting on a trolley for admission. In addition, there is an imperative in the interest of the reputation of the hospital system, to improve patient flow and to address the oft stated observation “I’ll be waiting for days on a trolley”. In public discourse the quality of care in our hospitals is generally very good but access is a significant problem.
On June 3rd Cork University Hospital commenced an initiative to address the twin challenges of:
(i) Ensuring that no patient waits over 24 hours in the Emergency Department and
(ii) Ensuring that no patient over 75 years of age waits over nine hours for a bed.
Though these have been National targets for some time, we are far more concerned about the clear benefit that this will have to the individual patient. Prolonged waiting is physically detrimental to the patient and associated with a clear erosion of dignity.
Implementing these changes has proven to be interesting in the knowledge that the literature shows that 75% of change initiatives fail and it takes 21 days to change behavior in a way that becomes embedded in the performance of an organization.
The hospital executive initiated an aggressive communication process one week in advance of the commencement date (June 3rd) that was met with a mixture of enthusiasm and cynicism given that these goals have been a priority for the HSE for several years without success. The exemplar leadership given by Bed Management in the hospital was pivotal because they initiated a process of prospectively identifying patients who might breach these targets and made the placement of those patients a priority.
As with any change initiative, implementation was complicated by a number of unpredicted factors;
(a) There were an extraordinarily high number of Orthopaedic trauma patients admitted in mid-June, when there were 30 patients awaiting surgery, requiring the opening of a third trauma theatre;
(b) In the same period, 15 inpatients (an unusually high number), awaited Cardiac Surgery procedures;
(c) The hospital experienced difficulty in transferring patients for post-operative rehabilitation to the South Infirmary University Hospital - a sister hospital in the city;
(d) Pressure on beds resulted in c. 50 patients having their surgery rescheduled in early July;
(e) The perception that the intention was to put trolleys on wards (instead of in ED) gave rise to a level of resistance from some staff.
Patient Experience Time (PET) is the term used to describe the time each patient spends in the ED from the time they are registered in the department to the time they leave (either home or to an inpatient bed). PET is a performance measurement indicator used to evaluate this change initiative and the following data illustrates the outcome to date:
Accepting that this intervention is in its early stages, the evidence thus far gives rise for optimism that this change will significantly improve the experience of patients and their quality of care, but it does give rise to a number of learning points;
- Collective Executive, Clinical and Nursing leadership are critical to the successful stewardship of such change interventions and all must act in unison;
- The success of this change to date is underpinned by many other changes that have each contributed to an improved patient flow and a change culture in the hospital;
- The corporate decision to prioritise both these cohorts of patients is critical but must be supported by a commitment to maintain a level of discharges at c. 73 adult patients per day – the size of a small hospital turning over daily;
- The predictive management of patients who might potentially breach these limits, created much improved control of the management of that cohort of patients;
- Feedback from nurses in ED indicates a change in the dynamic with patients on trolleys because of the assurance that can now be given to patients that they will be placed in beds within the time limits set.
The power of predictive management, whereby control is exerted prospectively by identifying those patients likely to breach, demonstrates what can be achieved in managing what are anticipated activity patterns even in ED where activity is remarkably predictable daily, weekly and monthly.
The learning from the first six weeks has reinforced the benefits of this improvement initiative and illustrated what is needed to maintain the targets at zero breaches or “limits” (suggested as a more appropriate term). The obvious benefits to patients and to the functioning of the ED, reinforces the commitment of the hospital to lower these thresholds over the coming months when the Medical Assessment Unit has commenced working over seven days and the conversion rate reduces at weekends.
As discussion evolves to the perennial question of “Winter Initiatives”, the evidence in Cork University Hospital is that the aggressive implementation of these changes can yield significant improvements in Emergency Departments throughout the country at no cost to the state.
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