Primary Care - Hospital Interface 'Acute unselected medical admissions' Is there a better way?

1. “acute unselected medical
admissions”
Is there a better way ?

2.  ? Help for HSE 374 million budget overrun

3. LEVERS FOR CHANGE
• National Policy and Reconfiguration
• Year on Year ED – Trolley crisis
• Numbers of older more complex acute medical
illness presenting to hosp
• Renewed focus on Acute Medical Care
• 6hr Emergency access targets

5.  Irelands only level 1 trauma centre
 850 bed hospital
 40 + specialties
 250,000 patient episodes annually
 9,000 births per year
 180,000 out-patient attendances per year
 3,250 multi-professional staff
 €250m capital development programme
 Large change programme being implemented

6. AMU - Cork University Hospital
 January 2011 opened with 23 acute medical beds
 Direct GP referrals from February 2011
 Direct transfers from ED / Trolleys
 Consultant Physician continuous presence on the unit
 Up skilling of nursing staff
 Culture shared team approach promoting high quality
care with proactive rapid assessment and discharge
planning

7.  48 hour Length of Stay
 Same day Diagnostics
 Senior decision maker on the floor
 Daily specialist in each service
 CIT daily to facilitate discharge and
handover in the community

8. AIM:
 Improve access for patients to prompt medical
assessment by a senior clinical decision maker
 Uncouple the necessity for overnight admission for a
procedure or investigation is a key paradigm shift
 Improve patient flow and reduce wait for in-patient
bed.

9.  2400 acute medical patients admitted
 2,065 medical patient discharges
 48% discharged in 48 hours
 25% in 24 hours
 Average length of stay 61.29 hrs
 Length of Stay for General Acute Medicine in
hospital reduced from 10.4 - 6.5 days for first 6
months 2011

10.  1.5 WTE Consultant Physician
 Weekly rotation NCHD team
 3 . WTE Nursing Staff
 1 . WTE Care Assistant – Radiology
 Reconfiguration of General Ward 35 beds to 23 short
stay unit
Capital Infra structure rebuild 1.5 million
including equipment

11. AvLOS 2010 = 9.07 days
V
AvLOS 2011 = 7.07 days
Reduction overall = 2 days
Bed days Saved = 20,512 (equivalent to 56
beds)
Cost savings significant if allow 1100 euros per bed

12.  Initially phased opening Mon-Fri (0800hrs-2000hrs)
 Continuous Consultant Physician presence
 Same – Day Diagnostics
 AMU review Clinics to support same day discharge
strategy

13.  2 further WTE Consultant Physician posts
 3 NCHD posts ( Transfers 1 ED –CUH 2 - SIVUH )
 Transfer Nursing Staff from ED /MSSU
 8 trolleys for 13 bay assessment area.

15.  Transfer of Cardiology services end Nov ’11
 Closure ED SIVUH 8pm – 8am end Nov ’11
 Change in pathway for trauma rehabilitation to SIVUH – Dec
’11
 Increased acute General Medical Activity 13%
 Full closure of SIVUH ED – July ’12
 Transfer emergency surgery ex SIVUH - July ’12
 Not a steady state at any stage in 2012

16. Number of Patients Admitted to MSSU ( other sources) 676
Number of Patients Assessed in AMAU ( 981 MSSU) 3726
Number of Patients Assessed in AMU Review Clinic 1158
Total Number of Patients Assessed in AMU 5560

17. AM AU Discharge Outcomes
250
238
234
200 199
188 185 187
182
177
173
150 150
Di scharge d Same Day
Month
Admi tte d to MSSU
115 Admi tte d to CUH
104 107 107 Transfe rre d to Othe r Hospi tal
100 103
98
94 93
90 88 90 88
80 83
79
58 60
50
23 24
11
4 6 5 4
0 0 1 2 0 1 1
Jan-12 Fe b-12 Mar- Apr-12 May- Jun- Jul-12 Aug-12 Se p-12 Oct-12
12 12 12
Number of Patients

18. AvLOS 2011 = 7.07 day
V
AvLOS 2012 = 6.2 days
Reduction overall = approx 3 days (24+beds)

20.  Better patient care
 Better patient/staff experience
 Improved access for primary care
 Better clinical outcomes
 Appropriate clinical environment
 Reduced elective waiting times for admission/day
cases, etc.
 Less trolley waits
 Improved efficiency
 Better value for money

21.  Team approach - Patient focused
 Continuous presence of senior
clinicians on the floor
 Priority access to Diagnostics
 Partnership with Primary Care with
improved access /communication

22.  Daily Consultant ward rounds 8am, 5pm and “Hot “
review Mid-day
 AMU Physician continual presence, no other fixed
commitments
 AMU Physician for unit provides phone advice for
primary care

23.  AMU’S improve the quality and the safety of care
 Reduce in-hospital length of stay
 Increased direct discharge rates
 Improved efficiency of hospital resources
 Greater patient and staff satisfaction

24.  Good for patients
 Good for service
 Good for tax payer

25. Success is not final, failure
is not fatal: It is the courage
to continue that counts.
Winston Churchill