1… CARE … COOPERATE … DELIVER … LEARN …Manaakitanga . Whanaungatanga Rangatiratanga . Kotahitanga . Mohiotanga Wairuatanga

An Overview of a Winter PlanRenee Greven-Garcia, Emergency Physician, Hawkes Bay

Insanity:Insanity:

Doing the same thing Doing the same thing over and over again and over and over again and expecting different results. expecting different results.

Albert Einstein, , (attributed)(attributed)US (German-born) physicist (1879 - 1955)US (German-born) physicist (1879 - 1955)    

3… CARE … COOPERATE … DELIVER … LEARN …Manaakitanga . Whanaungatanga Rangatiratanga . Kotahitanga . Mohiotanga Wairuatanga

Why does it happen?

What can we do about it?

What are the Truths? What are the Myths?

ED Overcrowding

Common MisconceptionsCommon Misconceptions “ “Inappropriate” or “general-practice-type”Inappropriate” or “general-practice-type”

patients cause overcrowdingpatients cause overcrowding

Overcrowding is largely the result of Overcrowding is largely the result of patients being admitted but remaining in the patients being admitted but remaining in the department awaiting suitable beds and/or in department awaiting suitable beds and/or in our case inpatient team reviews/clerkingour case inpatient team reviews/clerking

MJA MJA • Volume 190 Number 7 • 6 April 2009, • Volume 190 Number 7 • 6 April 2009, Drew B Richardson and David Drew B Richardson and David MountainMountain

Myth:Myth:

““Overcrowding is the result of an excess Overcrowding is the result of an excess numbernumber

of patients arriving and waiting to be seen by aof patients arriving and waiting to be seen by aDoctor”Doctor”

Fact:Fact:““Patient attendances at EDs have increased, Patient attendances at EDs have increased,

but the number of patients waiting tobut the number of patients waiting tosee a doctor in Australasian EDs remains see a doctor in Australasian EDs remains

smaller than the number waiting for ansmaller than the number waiting for aninpatient bed”inpatient bed”MJA MJA • Volume 190 Number 7 • 6 April 2009, • Volume 190 Number 7 • 6 April 2009, Drew B Richardson and David MountainDrew B Richardson and David Mountain

Myth:Myth:

“ “The time patients spend in the ED is now The time patients spend in the ED is now excessive because staff take too long in excessive because staff take too long in investigating and treating them”investigating and treating them”

Fact:Fact:“ “ There has been little change in the time taken to There has been little change in the time taken to

assess and treat ED patients, butassess and treat ED patients, butsome increase in waiting time because ED staff and some increase in waiting time because ED staff and

resources are being used to careresources are being used to carefor inpatients, and a large increase in waiting time for inpatients, and a large increase in waiting time

for inpatient beds”for inpatient beds”MJA MJA • Volume 190 Number 7 • 6 April 2009, • Volume 190 Number 7 • 6 April 2009, Drew B Richardson and David MountainDrew B Richardson and David Mountain

Myth:Myth:

““Telephone advice lines and collocated Telephone advice lines and collocated general practitioner services reduce general practitioner services reduce ED attendances”ED attendances”

Fact:Fact: “ “Telephone advice lines and Telephone advice lines and

collocated GP services have little or collocated GP services have little or no effect on ED attendances”no effect on ED attendances”

MJA MJA • Volume 190 Number 7 • 6 April 2009, • Volume 190 Number 7 • 6 April 2009, Drew B Richardson and David MountainDrew B Richardson and David Mountain

Myth:Myth:

““Overcrowding can be reduced by Overcrowding can be reduced by buildingbuilding

larger ED’s”larger ED’s”

Fact:Fact:““Increasing ED size is associated with Increasing ED size is associated with

increased overcrowding”increased overcrowding”MJA MJA • Volume 190 Number 7 • 6 April 2009, • Volume 190 Number 7 • 6 April 2009, Drew B Richardson and David MountainDrew B Richardson and David Mountain

Myth:Myth:

“ “ Overcrowding does not influence patient Overcrowding does not influence patient outcomes” outcomes”

Fact:Fact:““Overcrowding has serious adverse effects Overcrowding has serious adverse effects

on hospital processes, quality of care,on hospital processes, quality of care,and patient outcomes, including mortality”and patient outcomes, including mortality”

MJA MJA • Volume 190 Number 7 • 6 April 2009, • Volume 190 Number 7 • 6 April 2009, Drew B Richardson and David MountainDrew B Richardson and David Mountain

Myth:Myth: “ “The causes of overcrowding lie within The causes of overcrowding lie within

the ED” the ED”

Fact:Fact: “ “The causes and the solutions to The causes and the solutions to

overcrowding lie outside the ED”overcrowding lie outside the ED”

MJA MJA • Volume 190 Number 7 • 6 April 2009, • Volume 190 Number 7 • 6 April 2009, Drew B Richardson and David MountainDrew B Richardson and David Mountain

So how do we turn this:So how do we turn this:

Into This?Into This?

Without Creating This?Without Creating This?

Internal ED StrategiesInternal ED Strategies

Cross training “MEC” team as a Rapid Assessment Cross training “MEC” team as a Rapid Assessment team in WR during times of surge/access block. team in WR during times of surge/access block.

Creating a holding area in a side room for referred Creating a holding area in a side room for referred inpatients in evenings-nursing resource-$inpatients in evenings-nursing resource-$

Staffing evenings and weekends Staffing evenings and weekends at leastat least as robustly as robustly as weekdays with RMO’s to meet demandas weekdays with RMO’s to meet demand

Created Business Case for increased numbers of Created Business Case for increased numbers of ED consultants to improve weekend/afterhours ED consultants to improve weekend/afterhours cover- Stalled cover- Stalled $$ $$

INVOLVE WHOLE OF HOSPITAL IN MOH ED INVOLVE WHOLE OF HOSPITAL IN MOH ED TARGET AND ED FLOW ISSUES AS PRIORITY TARGET AND ED FLOW ISSUES AS PRIORITY FOR WINTER AND ALWAYS. . .. FOR WINTER AND ALWAYS. . ..

MedicineMedicine NursingNursing Allied HealthAllied Health Elder Persons Elder Persons COO, CMOCOO, CMO Integrated care and service Integrated care and service

managersmanagers Ancillary Support ManagersAncillary Support Managers

WORK WITH OUR ALLIES,

EMPOWER AND ENGAGE WHOLE OF HOSPITAL HEROS

External ED External ED Strategies-Strategies-Identifying the Identifying the Issues in our DHB Issues in our DHB for for ownership/advocacy ownership/advocacy in the wider groupin the wider group Admission Avoidance:Admission Avoidance:

AAU, COPD, Chest Pain, “CPO pathways” AAU, COPD, Chest Pain, “CPO pathways” Cellulitis, DVT etc. . .Liase with GP’sCellulitis, DVT etc. . .Liase with GP’s

Streaming of AcutesStreaming of Acutes Inpatient EfficiencyInpatient Efficiency Matching DemandMatching Demand

Winter PlanningWinter Planning

Malcolm ArnoldMalcolm ArnoldGastroenterologist/PhysicianGastroenterologist/Physician

CD Dept Medicine HBDHBCD Dept Medicine HBDHB

The Problem(s)The Problem(s)

Factors at play in Factors at play in general…general…

Shrinking numbers of bedsShrinking numbers of beds Pressure from Ministry to meet targetsPressure from Ministry to meet targets MONEY!!!!MONEY!!!! Ageing population staying (or being kept) Ageing population staying (or being kept)

well for longer, then getting older then well for longer, then getting older then getting more and more degenerative and getting more and more degenerative and neoplastic diseasesneoplastic diseases

Primary care constraintsPrimary care constraints

Factors at play in Factors at play in general…general…

Soft admissions – social issues, easier to Soft admissions – social issues, easier to admit and sort than do so on outpatient admit and sort than do so on outpatient basis. Better/easier access to specialist basis. Better/easier access to specialist as inpatient than going on OP waiting listas inpatient than going on OP waiting list

Delayed discharges – social issues, Delayed discharges – social issues, delays in specialist review, diagnosticsdelays in specialist review, diagnostics

Over investigating of non urgent Over investigating of non urgent incidental findingsincidental findings

(Winter) Planning issues(Winter) Planning issues

Bed BlockBed Block Inappropriate presentations to EDInappropriate presentations to ED Office Hours - 45/168 (in fact exclude 73% of Office Hours - 45/168 (in fact exclude 73% of

actual hours in the week)actual hours in the week) Availability of diagnostics, diagnosticians, Availability of diagnostics, diagnosticians,

operators, nurses, doers and thinkersoperators, nurses, doers and thinkers Least experienced people available to do the Least experienced people available to do the

job at some critical times (except ED!), and job at some critical times (except ED!), and often busy sorting out one issue whilst others often busy sorting out one issue whilst others flooding in the doorsflooding in the doors

Factors at play in winterFactors at play in winter

Viral illnesses exacerbating pre-existing Viral illnesses exacerbating pre-existing problemsproblems

Staff illnessStaff illness Cost of GP visits – defer seeking medical Cost of GP visits – defer seeking medical

input, get sicker, come to EDinput, get sicker, come to ED

Considered approachesConsidered approaches

Do things better, more efficiently and Do things better, more efficiently and effectivelyeffectively

Reduce ALOSReduce ALOS Look for simple fixes if possibleLook for simple fixes if possible Keep people well and out of hospital, or Keep people well and out of hospital, or

alternatively don’t let them in….alternatively don’t let them in….

Measures discussed in Measures discussed in HBDHBHBDHB

Predicted Date of Discharge (PDD)Predicted Date of Discharge (PDD) Use of a medical patient admission Use of a medical patient admission

proforma proforma Swing WardSwing Ward ICU Reg Outreach for SurgicalICU Reg Outreach for Surgical Discharge LoungeDischarge Lounge Outpatient Capacity for Acute/Urgent Outpatient Capacity for Acute/Urgent

referralsreferrals

Measures discussed in Measures discussed in HBDHBHBDHB

Surgical Response to EDSurgical Response to ED Rest home acceptance after 2pm and at Rest home acceptance after 2pm and at

weekendsweekends Implement low risk chest pain pathwayImplement low risk chest pain pathway Additional medical registrar for winterAdditional medical registrar for winter Weekends and after hoursWeekends and after hours

Measures discussed in Measures discussed in HBDHBHBDHB

Communication ED or GPCommunication ED or GP Pre-Admission work-up and pathway Pre-Admission work-up and pathway

adherence for Orthopaedicsadherence for Orthopaedics Elective Elective procedure cancellationprocedure cancellation

AT&RAT&R Hospital Handover PM MeetingHospital Handover PM Meeting Electronic WhiteboardsElectronic Whiteboards

The Answer….The Answer….

Whisky, honey, lemon and hot Whisky, honey, lemon and hot water (ratios dependent on water (ratios dependent on

relative merits of each)relative merits of each)