PENINSULA HEALTH
CHEST PAIN STREAMING
Paul Ormrod
Manager Emergency Redesign
Nurse Manager Emergency Short Stay Unit
Frankston Hospital
Peninsula Health
PENINSULA HEALTH
Peninsula Health is the major health care provider serving the metropolitan and rural areas on Victoria’s Mornington Peninsula.
With close to 800 beds Peninsula Health provides a wide range of services from obstetrics to aged care, rehabilitation, emergency and intensive care, oncology, psychiatric services and Hospital in the Home (HITH).
PENINSULA HEALTH
PENINSULA HEALTH
• The region’s population is over 300,000 people
• Seasonal influx of visitors of 100,000. The
• Population is growing at a faster rate than most
other regions
• Predicted growth rate 5.3% higher than
Melbourne
• New freeway expected to increase growth rate
even further
DEMOGRAPHICS OF DEMAND
PENINSULA HEALTH
Frankston Hospital is the major provider of acute secondary
and tertiary hospital services on the Mornington Peninsula.
With 336 beds, it provides general and specialty medical and
surgical services, mental health, maternity, and paediatric
services.
Construction of an additional 90 beds and new Emergency
Department is underway with completion scheduled for 2014
FRANKSTON HOSPITAL
PENINSULA HEALTH
Consistent with the population increase demand on
acute services has also increased over recent years. This
has particularly impacted on the Emergency Department
(ED) at Frankston Hospital.
FRANKSTON HOSPITAL DEMAND
PENINSULA HEALTH
There has been significant growth in ED
presentations to an expected 60,000 this year
PENINSULA HEALTH
0
5,000
10,000
15,000
20,000
25,000
FY 08/09 FY 09/10 FY 10/11 FY 11/12 FY 12/13
Ambulance Victoria Presentations 2008-2009 to 2012-2013
DANDENONG HOSPITAL FRANKSTON HOSPITAL MONASH MEDICAL CENTRE CLAYTON CASEY HOSPITAL
Frankston Hospital Emergency Department receives more patients via Ambulance Service
Victoria than any other hospital in the state
PENINSULA HEALTH
• Length of Stay an Issue across the Board
• Looked at high volume presentations
• Chest Pain identified as potential presentation suitable for streaming of care
National Emergency Access Targets (NEAT)
PENINSULA HEALTH
WHAT WE FOUND
6 Months of data from 2011 showed 1,320 patients presented
with and average LOS for this cohort to be 6hrs and 55 min
80% of these patients were discharged home
Working group established to look at options for this group
(Naomi Winter RN, Sreyus Sreedhar RN, Kishan Ajjampur ED Registrar, Helen Hewitt ED Director)
PENINSULA HEALTH
How could this group be better managed?
• Identify low risk patients early in presentation
• Manage their stay outside the ED
• Develop new pathway for this group
• Decrease waits
PENINSULA HEALTH
OLD PATHWAY FOR THIS GROUP
PENINSULA HEALTH
NEW PATHWAY FOR THIS GROUP
On arrival
moves to
assessment
cubicle
Registration
Moves to
acute
cubicle
Moves to
ESSU
95%
Home
Admit or
Home
PENINSULA HEALTH
Objective of the new
pathway was to identify low
risk chest pain patients and
stream their care early to a
short stay unit managed by
the ED
PENINSULA HEALTH
On arrival
moves to
assessment cubicle
SO HOW DID THIS WORK?
• Key was early assessment
• Hx
• ECG
• Early Decision
ACHIEVED BY
• Dedicated Dr & Nurse (Cat 2)
• Called by Triage
• See, Assess, Send
PENINSULA HEALTH
DID CHANGE ANYTHING?
WE GOT BUSIER & % OF CHEST PAIN PRESENTATIONS INCREASED
PENINSULA HEALTH
50
150
250
350
0
200
400
600
800
Apr
'12
May
'12
Jun
'12
Jul
'12
Aug
'12
Sep
'12
Oct
'12
Nov
'12
Dec '12 Jan
'13
Feb
'13
Mar
'13
No
. o
f p
ati
en
t -
All
pa
tie
nts
No. of admissions to EDS
All transfers to EDS
All transfers to EDS -
previous year
Target population
Target population - previous
year
Potential patients
No
. o
f p
ati
en
ts -
Ta
rge
t p
op
ula
tio
n
90% - 100% occupancy 9 beds
90% - 100% occupancy 8 beds - previous year
41% increasein the number of patients in the target population
being admitted to EDS
SO WHAT DID WE ACHIEVE?
PENINSULA HEALTH
In the previous 12 months April 2012 to April 2013
• 224 patients were streamed directly to EDS
• A further 1,408 went to EDS via an acute ED cubicle
• A further 377 patients presenting with chest pain were
discharged home from the ED
PENINSULA HEALTH
3
4
5
6
7
8
Apr
'12
May
'12
Jun
'12
Jul
'12
Aug
'12
Sep
'12
Oct
'12
Nov
'12
Dec
'12
Jan
'13
Feb
'13
Mar
'13
Ho
urs
Average Length of Stay
All patients
All patients - previous year
Target population
Target population - previous
year
4hr Target
* Target population: Patients presenting with Cat 2&3 chest pain receiving care form emergency physicians
SO DID ANYTHING IMPROVE?
LOS FOR CHEST PAIN GROUP DECREASED
PENINSULA HEALTH
DID WE IDENTIFY PATIENTS APPROPRIATELY?
We expected that less than 5% target of this cohorts of patients would
require admission to an inpatient bed. To date this rate remains below
5%
PENINSULA HEALTH
CHALLENGES
1. Assessment Area (3 cubicles)
The area to be dedicated as an assessment area contained
monitoring equipment.
2. Performing quick assessment
Change of practice to undertake quick assessment and decision
making
3. Standardising work practicesDifferent staff working in different ways
4. Access to EDS beds
EDS bed not available
5. Access block to inpatients
No beds for patients requiring an inpatient bed
PENINSULA HEALTH
STRATEGIES IMPLEMENTED
1. Removed equipment
2. Senior medical staff to undertake this role
3. SOP
4. EDS admission criteria & beds controlled by ED
5. Still working on them
PENINSULA HEALTH
WHERE TO NEXT?
1. Increase in ED Short Stay Beds (15 as June 2013)
2. Working with Mental Health to stream to EDS
3. Identify other presenting groups for streaming
4. A new ED and Short Stay Unit