Patient Flow Collaborative Learning Session 4

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Patient Flow Collaborative Learning Session 4
Breakout session 1 Room M1 and M2 Tony Snell and
Rochelle Condon
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Breakout session 1Room M1 and M2 9.50 10.35
Improving care for mental health patients
Maria Bubnic and Phyl Halpin Mental Health
Branch Department Human Services 4th May, 2005
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Improving Care for Mental Health Patients in the
ED

• Outline
• Describing the issues
• Key strategies
• Recent initiatives
• Questions

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Pressures on the system

• Increasing number of mental health presentations
  to EDs
• Increasing complexity of mental health
  presentations
• Increasing waits for mental health patients in ED

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Contributing factors

• Greater awareness of mental health problems
  willingness to seek help
• Mainstreaming of mental health acute inpatient
  services with acute health
• Greater visibility accessibility of the ED
  compared to other parts of the service system
• Changes to police practice under section 10 of
  the Mental Health Act
• Co-location of CAT and ECAT services within EDs
• Distribution of acute mental health beds
• Decrease in availability of alternative service
  options

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Research

• Who? How? Why? What happens?
• 5 sites 2 tertiary inner suburban, 2 outer
  suburban, 1 regional
• 5 months all mental health presentations between
  April September 2004
• Retrospective medical file review immediately
  post presentation
• Telephone follow up of a random sample post
  presentation

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Mental Health Presentation

• A primary diagnosis of
• mental illness
• substance abuse
• crisis
• injury assessed as involving intentional self
  harm
• Assigned by the ED clinician

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Research Findings (1)

• 36 actively managed by mental health services
• 41 had prior contact with mental health services
• 26 had been admitted to a mental health ward in
  the previous 12 months and of these 42 required
  admission at the current presentation

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Research Findings (2)

• People who chose to come to ED themselves
• Most considered alternatives but 54 of
  alternatives unavailable as people were seeking
  help in the evening.
• When alternatives were available
• 50 referred onto ED for management
• 31 preferred ED to their usual health care
  provider
• 22 were not prepared to wait for their usual
  health care provider

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Forum

• ED mental health staff
• Also input from drug alcohol, ambulance,
  police, primary care, consumers
• Shared view must do better
• DHS role in developing strategy
• What health services can do

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Key issues

• Most MH presentations occur after hours involve
  emergency services
• gt50 are re-presentations to ED and known clients
  of mental health services
• Increasing number of 24 hour stays for MH
  presentations
• Layout amenity of EDs
• Provision of care within framework of MHA

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Responding to the issues

• upstream to reduce avoidable or inappropriate
  use of EDs
• within ED to improve management in the ED
• downstream to improve access to beds
  continuing community care

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Recent initiatives

• National Suicide Prevention Intervention
  Strategy
• NICS Mental Health Emergency Care Interface
  project
• Victorian Hospital Demand Management (HDM)
  strategy and HARP
• Victorian Patient Flow Collaborative Mental
  Health CLIF projects

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Patient Flow Collaborative Mental Health CLIF
projects
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Mental Health CLIF Projects Areas of focus

• Improve patient flow across acute, subacute
  mental health care
• Link to developments in the patient flow
  collaborative
• Involve consumers

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Mental Health CLIF Projects Funded in 2004-2005

• Western Health involves Western Hospital ED,
  South West AMHS Mid West AMHS
• St Vincents Health involves the ED Mental
  Health Program
• Ballarat Health led by Grampians Psychiatric
  Service

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Western Health CLIF project Needs Analysis

• Limited availability of mental health services
  specialist support
• Limited confidence skill of ED staff to respond
• Variable follow-up post-discharge from ED

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Western Health CLIF project Aims Measures

• Decreased ALOS, particularly for admitted
  recommended subgroups
• Improved access to appropriate alternatives to ED
• Reduction in episodes of aggression, use of
  seclusion specialling
• Improved on-site specialist advice, intervention
  support
• Improved ED staff satisfaction responses to MH
  presentations

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Western Health CLIF project Project Methodology

• Project steering committee coordinator
• Pilot ECAT service model
• Map patient pathways audit practice
• Develop guidelines, policies procedures,
  referral protocols
• Staff education, training support to implement
  changes

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Western Health CLIF project Progress to date

• ECAT model being piloted
• MH ED staff training
• Collaborative assessments
• Weekly team meetings
• Negotiations with police ambulance re
  transport of mental health patients
• IT enhancements

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St Vincents Health CLIF project Needs Analysis

• Management of information/IT
• Management of communication
• Identification/clarification of need
• Care of patient/carer/family

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St Vincents Health CLIF project Aims Measures

• Identify options for improving patient
  information flow in the ED
• Use of KPIs from NICS project to align efforts
  build on learnings

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St Vincents Health CLIF project Project
Methodology

• Develop IT triage systems to support
  coordinated identification of need
• Weekly liaison meetings
• Staff training
• Revise policies procedures
• Undertake feasibility study of short stay
  facility

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St Vincents Health CLIF project Progress to date

• Improvements to triage system
• Collaborative assessment process tool developed
  to be piloted
• Identification of patient streams
• Exploring use of MH identified beds in ED to fast
  track responses

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Ballarat Health CLIF projectNeeds analysis

• Review of feedback/complaints data
• Further consultation with stakeholders, to be led
  by an Advisory Committee
• Review of triage data
• Process mapping triage responses across inpatient
  community interfaces

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Ballarat Health CLIF projectAims Measures

• Improve access to inpatient and community mental
  health services
• Use of KPIs for
• triage responses
• timeliness of access to inpatient community
  services
• referrer, consumer carer satisfaction

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Ballarat Health CLIF projectProject Methodology

• Possible target areas to improve pathways to
  service access
• Policies procedures, practice guidelines
  referral protocols
• Coordination of information communication
  systems
• Staff education training
• Triage redevelopment

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Ballarat Health CLIF projectProgress to date

• Delayed start - March 2005
• Appointment of project officer
• Establishing Advisory Committee
• Data analysis commenced

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• Questions

?
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Morning Tea

• Meet us back here for
• Intranet theatre booking system
• at 10.55

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Breakout session 2Room M1 and M2 10.55 11.45
Intranet theatre booking system
Robyn Gillies Consultant Anaesthesetist Emergency
Bookings Project Coordinator Clinical Innovations
Funded Program Melbourne Health 5th May, 2005
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Emergency Theatre Booking System (ETBS)
Development of an intranet based emergency
booking system for the Operating Suite at the RMH
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Intranet based Emergency Theatre booking system

• Why?
• How?
• What did we get?
• Did we get what we wanted?
• What will we need to develop further?

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Intranet based Emergency Theatre booking system

• Why?
• How?
• What did we get?
• Did we get what we wanted?
• What will we need to develop further?

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Why Pursue such a project?

• Identification of need

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The booking system prior to February 2005 1
piece of messy paper!
Sometimes these were all that Were filled in
Often data not recorded, lost in translation,
viewed by only the OR in-charge, etc.
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Why Pursue such a project?

• Dissatisfaction with the original system
• Inadequate data collection and lack of ability to
  monitor emergency operations
• Lack of transparency in the original system
• Lack of guidelines for Emergency bookings

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What were we missing?

• Data
• Timeliness of emergency theatre provision
• Times of greatest need for emergency OR
• Impact of changes in the emergency access
• Reliable data on delays and problems in the
  system
• Guidelines
• Any ideas on the rules?

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Intranet based Emergency Theatre booking system

• Why?
• How?
• What did we get?
• Did we get what we wanted?
• What will we need to develop further?

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The ETBSHow did we start?

• Identification of Personnel for discussion and
  implementation
• Project outline with approximate budget
• Application for funding

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The Next Steps

• Project Plan
• including goals and key areas of focus
• Development of Guidelines for Emergency Bookings
• OR executive approved
• Development of Standardised list of priorities
• For each surgical specialty

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Goals for the Project

• Collect data for continuous quality assurance
• Introduce transparency into the theatre booking
• Streamline the process of emergency booking
• Qualify, quantify and improve the current system
  organisation for nursing, equipment etc.
• Develop a reproducible system for use in other
  institutions
• Optimum utilisation of theatre time

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Guidelines for Emergency Bookings

• This also included discussion on
• Communication Issues
• Guidelines for emergency surgery access
• when there is no emergency theatre available.
• A time critical (life or limb threatening)
  emergency
• Access to emergency theatre
• Super-specialty or Complex Surgery
• Dispute Resolution

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Development of Standardised list of priorities

• Surgeons asked to give optimum time frames for
  emergency access
• Asked to estimate times for operations
• Not entered onto the system but available for
  comparison with data collected

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The Next Steps Information Technology

• Plan for IT development
• Recruitment of IT specialist
• Purchase of server
• Process of development allowing review of
  critical areas
• Hardware Decisions
• Mobile hardware for running the floor

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How is this being Implemented?

• 4 Planned Phases
• Education
• Data Collection
• System modification based feedback and quality of
  data collected
• Data Distribution to close the loop
• 5th Phase
• Modifications based on learnings

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Intranet based Emergency Theatre booking system

• Why?
• How?
• What did we get?
• Did we get what we wanted?
• What will we need to develop further?

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What does it look like??

• A visual of the ETBS as it exists in its not
  quite final form

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The Actual System

• ETBS
• Adding a booking
• Priority of booking
• Organising the bookings
• Confirmation/completion and cancellation of
  bookings
• Data collection

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This is the site looked up on internet explorer
Users click here to add a booking
This is what can be seen on networked computers
after a password has been entered
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Check is clicked when the UR number has been
entered this serves to check if the correct
patient has been entered and does not allow
patients outside the hospital to be booked.
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Drop down box of specialty units
When submit is clicked an on screen prompt
appears reminding the person booking to contact
the OR anaesthetist in charge to confirm the
booking
If not available all hours then outline
availability
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CIC clicks here to administrate
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Patients name and UR will appear here
Details of the case for discussion will appear
here. A case can only be confirmed when a
priority has been assigned to it in the
administration window (after discussion)
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At this point the priority is set by the surgeon
and anaesthetist as part of the discussion about
the patient.
The booking is confirmed and automatically added
in order of priority to the list
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(No Transcript)
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Click on the for details
Person making comment
Click to add comment
All interested units and ward nursing staff can
then view the list and see details of each
patient. Comments can be made by all users.
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When a booking is completed (we define this as
the beginning of an intervention in the OR, the
Anaesthetist Or nurse in charge completes the
booking thereby taking it off the screen Delay
details must be entered in order to complete the
booking
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Colour changes to prompt action or discussion
with surgeons
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Intranet based Emergency Theatre booking system

• Why?
• How?
• What did we get?
• Did we get what we wanted?
• What will we need to develop further?

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Did We get What we Wanted?

• Yes
• Transparent/visible
• More organised
• Able to collect reliable data
• We have guidelines!
• Booking process was streamlined
• We will be able to close the loop with the data
  we now have

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Did We get What we Wanted?

• No
• Optimum theatre utilisation will require more
  work with elective system

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What Do the Users think?

• Surgical Staff
• Registrars approve of system, unhappy with IT
  down times
• Consultants surprised by new guidelines
  highlighted some communication issues in some
  surgical units
• Nursing staff
• happy with increased transparency but sometimes
  frustrated about poor communication with
  Anaesthetist in Charge

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What Do the Users think?

• Anaesthetists
• Most are happy
• Some struggle with new technology
• Some struggled with motivation

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What Do the Users think?

• Anaesthetists
• Most are happy
• Some struggle with new technology
• Some struggled with motivation

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Intranet based Emergency Theatre booking system

• Why?
• How?
• What did we get?
• Did we get what we wanted?
• What will we need to develop further?

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Ongoing Development

• Modifications to help in OR organisation
• Modifications for increasingly relevant data
  collection
• Modifications to work towards meeting priority
  times
• Improving closing the loop data feedback and
  monitoring changes over time.

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Future Opportunities

• Modify elective booking system to integrate with
  the emergency bookings system.
• Introduce ETBS to other institutions
• What do you think?

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Summary

• Ambitious project
• Good results
• Highlighted other areas in need of modification
• Its not just about the technology
• A good start .

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Thank You for your time.

• Questions

?
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Lunch

• Meet us back here for
• Team tabletop presentations
• at 12.45

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Team Presentations12.45 3.15

• Rochelle Condon Room M1 and M2
• Austin Health
• Ballarat Health
• Royal Womens Hospital
• Angliss Hospital
• Northeast Health Wangaratta
• Peter MacCallum Cancer Center

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Tabletop presentations

• The aim of this session is to
• Promote discussion
• Share peer to peer practical experiences of
  innovation
• Increase energy for change and shared learning
• Spread ideas between teams

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Session format

• 2 teams per table
• Team A has 15 minutes to share experiences with
  team B
• Whistle blows
• Team B has 15 minutes to share experiences with
  team A
• Rotation 1
• Continued.
• Working afternoon tea is available

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Session format
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Session format
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• Meet us back in the plenary for
• Team planning time
• at 3.20