Emergency Department Task Force. March ED Task Force Report March

Transcription

1 Emergency Department Task Frce March 2015 ED Task Frce Reprt March

2 Table f Cntents Backgrund Cntext Demgraphic cntext Burden f Chrnic Disease... 8 Intrductin Intrductin Critical Determinants f Imprved Perfrmance Standardised Pathways Integrated Care Pathways Frail Elderly Pathway Natinal Oversight and Leadership Pririties identified by the Emergency Department Task Frce 2014/ CAPACITY - Optimising Existing Hspital and Cmmunity Capacity Reducing Delayed Discharges Reduce Length f Stay CAPABILITY - Develping internal capability and Prcess Imprvement Apprpriate admissin avidance Effective management f patients within ED Rapid Access t Inpatient care Access t diagnstics Access t senir decisin making Integrated discharge planning Chrnic Disease Management CONTROL - Leadership, Gvernance, Planning and Oversight Leadership and Gvernance Operatinal Planning and Predictive Mdelling Measurement Oversight Enabling cnsistent imprvement acrss all Hspitals Service Imprvement and Re-design Sharing Learning Patient Engagement and Feedback Summary f Actins References ED Task Frce Reprt March

3 AHD AHP AMU AMAU ANP ALOS CCP CDU CEO CHO CIT CNO COO COPD CUH CT CSAR DOSA ED G.P HCPs HIQA HSE HTA IHRP INMO ICT IT IV LTC MRI NAS NHSS NSP OMNSD PDD PET SDU Senir Clinical Decisin Maker SIPTU SMART SVUH UCHG Acute Hspital Divisin Allied Health Prfessin Acute Medical Unit Acute Medical Assessment Unit Advanced Nurse Practitiner Average Length f Stay Clinical Care Prgramme Clinical Decisin Unit Chief Executive Officer Cmmunity Health Organisatin Cmmunity Interventin Team Chief Nursing Officer, Department f Health Chief Operatins Officer Chrnic Obstructive Pulmnary Disease Crk University Hspital Cmputed Tmgraphy Cmmn Summary Assessment Reprt Day f Surgery Admissin Emergency Department General Practitiner Hme Care Packages Health Infrmatin and Quality Authrity Health Service Executive Health Technlgy Assessment Irish Healthcare Redesign Prgramme Irish Nurses and Midwives Organisatin Infrmatin and Cmmunicatins Technlgy Infrmatin Technlgy Intra Venus Lng Term Care Magnetic Resnance Imaging Natinal Ambulance Service Nursing Hme Supprt Scheme Natinal Service Plan Office f Midwifery & Nursing Service Develpment Predicted Day f Discharge Patient Experience Time Special Delivery Unit Cnsultant, Specialist Registrar r experienced Registrar. May als refer t specific Nursing grades in particular cntext Services Industrial Prfessinal and Technical Unin Specific, Measurable, Attainable, Realistic, Timely St Vincent s University Hspital University Cllege Hspital, Galway ED Task Frce Reprt March

4 Frewrd The Minister, the Department f Health and the HSE wish t thank the members f the ED Task Frce fr their cmmitment and engagement in the deliberatins f the Task Frce and the develpment f the final reprt. The Task Frce brught cnsiderable expertise, experience and insight t the develpment f actins t enable sustained slutins t ED issues at a whle system level. In particular members are t be cmmended fr their fcus n ptimising the use f existing resurces and capacity as well as pinting t the need fr additinal investment in the health system. The excellent and cmmitted wrk f the secretariat that prduced the dcument fr the Task Frce is appreciated. It is recgnised that while members f the Task Frce cntributed actively t its deliberatins they have nt cmmitted their rganisatins, r individual members, and there is a need fr further discussins relating t implementatin. It is als acknwledged that fr thse recmmendatins that are resurce dependent, further interactin will be required with key stakehlders regarding timeframes fr implementatin. The HSE will engage in full discussins at natinal level with each individual representative rganisatin separately with the aim f reaching agreement in relatin t the implementin f the actins in this reprt. ED Task Frce Reprt March

5 Backgrund 1.0 Cntext Research n vercrwding in Emergency Departments (ED) increasingly demnstrates adverse patient utcmes. Prlnged wait times in ED lead t prlnged Inpatient length f stay (Liew et al, 2003), which in turn is nt simply an issue f pr resurce utilisatin but als adversely impacts patient mrtality (Spivulis et al, 2006). Where ED vercrwding persists, nt nly is quality f care cmprmised and utcmes prer but patient mrtality is increased, (Richardsn 2006, Spivulis et al 2006, Richardsn and Muntain 2009). Therefre, Emergency Department crwding is nt just an issue f wrkflw but ne f patient safety. The Emergency Department (ED) Task Frce Reprt, 2006 was published fllwing significant wrk which fcused n addressing prblems manifesting in Emergency Departments. It was recgnised by the Task Frce at that time that Hspitals were perating at clse t 100% capacity while indicating that the ptimum level is apprximately 85%. Recent data frm the OECD, Health at a Glance, 2014 als shws that Ireland is belw the EU average fr the number f practising dctrs per 1,000 ppulatin (Ireland 2.7 against EU rate 3.4) and the number f Hspital beds per 1,000 ppulatin is als belw the EU average (Ireland <4 against EU rate 5.2). The OECD reprt als cnfirms that Irish hspitals are still perating at higher levels f ccupancy than ther OECD cuntries. The recmmendatins f the ED Task Frce, 2006 centred n the fllwing key dmains: Capacity (Optimising access t existing capacity in hspitals and cmmunity) Capability (Patient flw and prcess imprvement) Cntrl (Accuntability, versight, measurement) In recent years, all hspitals are required t develp full year demand and capacity plans, t underpin their respnse t freseeable peaks in demand. Such plans must address escalatin requirements fr dealing with all surge perids and include the prductin f specific plans fr winter mnths, when there is typically an increased demand fr in-patient beds arising frm additinal unscheduled hspital attendances. A key driver fr this planning prcess has been the Special Delivery Unit (SDU). Since 2011, they have required hspitals and cmmunity t: 1. Practively plan fr peak perids, including public hliday perids 2. Adjust planned scheduled care activity, t allw fr higher unscheduled care demands in winter mnths 3. Maximise the efficiency f prcesses that: a. Deflect patients frm admissin e.g. rapid multi-disciplinary team assessment fr frail elderly b. Prvide rapid access t senir decisin makers e.g. intrduce acute medical assessment units c. Minimise admissin delays when an in-patient bed is required e.g. use Visual Hspital systems that facilitate faster identificatin f beds abut t becme available 4. Engage in active discharge planning, including setting predicted dates f discharge, mre frequent ward runds and discharge frm hspital earlier in the wrking day (hme by 11 a.m.), s that beds are available at the ptimal time. 5. Have clear linkages and frmalised an effective wrking relatinships with cmmunity clleagues, particularly fr patients requiring ff-site rehabilitatin r wh require hme supprt services, whether frm HSE health care prfessinals r cntracted agencies which prvide skilled nursing care, e.g. intravenus treatments, r persnal care services frm hme help agencies. Supprted by SDU and as a result f the benefits f the Clinical Prgrammes, Hspitals achieved a significant and sustained reductin in the number f trlley waits during the perid Specifically, there was a ED Task Frce Reprt March

6 33% reductin in the Irish Nurses and Midwives Organisatin (INMO) natinal trlley cunt in the perid 2011 t The imprvement ver this perid must be viewed against the backdrp f sustained reductins in budget and staffing level and an ageing ppulatin, specifically the fllwing Sustained reductin in HSE budgets 3.3b ver the perid Lss f 12,000 staff during this perid, lss f 5000 nursing staff since 2009 Ageing f the ppulatin (11.7% f ppulatin ver 65, ver 80 s grwing by 4% annually) The resilience fr Health Study (Centre fr Health Plicy and Management, TCD) illustrated these challenges very well (see table 1 belw). Hwever it als highlights significant imprvements in prductivity during the perid with an increase f 10 % in the ttal discharges and 30% in day case activity Table 1: Public Health Staffing, Budget, Ppulatin and Medical Cards Ntwithstanding the achievements ver this perid, it was acknwledged that unacceptable levels fvercrwding still existed in a number f hspitals. It is als agreed that there is scpe fr further imprvements as f length f stay, leadership and gvernance, internal prcess imprvements and cnsistent access t cmmunity supprts including residential care beds in rder t achieve imprved perfrmance n a sustained basis at lcal and natinal level. ED Task Frce Reprt March

7 During 2014, ED perfrmance in terms f trlley waits deterirated and fr the first time in three years, the dwnward trajectry was reversedin September Accrding t INMO figures, the number f trlley waits was 6.5% wrse than it was in This is a matter f serius cncern t the HSE. Key cntributry factrs include: Grwth in the wait time fr NHSS frm 4 weeks in January 2014 t 15 weeks at end f Nvember 2014 Grwth in the ttal number f delayed discharges f the rder f 30% during 2014 cntributed by the grwth in the numbers awaiting NHSS and demand fr sufficient levels f hme care supprt. Significant changes in management structures in hspital and cmmunity services with resulting lss f crprate experience and cntext t drive and versee cnsistent hspital perfrmance Challenges in attracting and retaining senir clinical decisin makers at junir dctr and cnsultant levels ntably in Mdel 3 hspitals The impact f the cnsultant pay cuts and prtracted pay discussins als impacted n Mdel 4 hspitals during 2014 as evidenced by the high vacancy factr at cnsultant level (> 200 Psts). As a result, there has been a grwing reliance n agency prvisin and lss f experienced staff with resulting challenges in terms f admissin rates and discharge f patients. During 2014,medical agency csts grew by mre than 50%, with residual vacancies in a number f key areas ntably acute medicine, emergency medicine and anaesthesia Challenges in recruiting nursing staff as a result f mratrium prvisins with increased reliance n agency staff. Lss f significant numbers f nursing psts due t the mratrium n recruitment and such reliance n agency has direct cnsequences fr effective discharge planning at ward level and cnsistent implementatin f predicted day f discharge, and effective planning f rsters at hspital ward level. Sustained grwth in emergency admissins during 2014 f the rder f 2% with 20% increase in the prprtin f ver 65s admitted n an emergency basis 1.1 Demgraphic cntext The Health Service is already experiencing the impact f a rapidly increasing ageing ppulatin and will cntinue t d s as the trend is expected t cntinue ver the cming years. Currently 11.7% f the general ppulatin are ver 65 years f age. The ver-65 ppulatin is grwing by apprximately 20,000 each year. The ver-80 year s ppulatin, which puts the biggest pressure n health services, is grwing by sme 4% annually. During 2014, almst 22% f all ED attendances were aged 65 r ver, and almst 12.5% were aged 75 r ver. In 2014, the prprtin f ver 65s admitted n an emergency basis increased by 20% frm 32% in January t 38% in December This trend has cntinued int 2015 and will als have an impact n demands fr utpatient services and elective access. Current capacity in cmmunity services is insufficient t meet grwing demands assciated with demgraphic pressures and gives rise t inapprpriate levels f admissin t and delayed discharges frm acute hspitals. There is a real and heightened urgency required t address and alleviate issues facing the prvisin f services t lder peple acrss bth the cmmunity and acute hspital services given that this level f ppulatin ageing is expected t cntinue fr a number f decades. The Prspectus Reprt (2006) highlighted the requirement fr almst 7,000 additinal residential care places fr lder persns t meet expected demgraphic prfile While the target f less than 4% f persns ver 65 in residential care utlined by Prspectus has been achieved it must be brne in mind that ecnmic dwnturn and subsequent high levels f unemplyment were experienced during the perid which led t higher levels f family and carers supprt being available ED Task Frce Reprt March

8 The Viability Study n the Future f Residential Care, finalised in 2012, highlights nging deficits in residential care at natinal level and in particular in the greater Dublin area with Dublin Nrth East having ne f the mst significant deficits. In the shrt term, the challenge f meeting HIQA registratin requirements in terms f physical infrastructure has resulted in a lss f lng term capacity in a number f areas ntably in Dublin Nrth East which already has a deficit f lng stay capacity. This has als resulted in cmpeting demands in terms f capital cst f meeting additinal requirements and replacement f existing stck. It is estimated that as a result f reduced funding and increased reliance n private prvisin in the past 10 years, there has been a lss f 2,000 public beds. While there has been a significant increase in private prvisin t supprt the 22,361 patients under the Fair Deal Scheme, the lss f public beds pses particular challenges in terms f placement f cmplex patients. 1.2 Burden f Chrnic Disease Over ne third f the Irish ppulatin reprt having a chrnic illness, including heart disease, respiratry disease, cancer, and diabetes. Over half f Irish peple ver 50 have 2 r mre chrnic diseases (see table 2 belw) The prprtin f the ppulatin reprting a chrnic illness increases with age. The mst cmmn acute illnesses fr inpatients in Irish hspitals are circulatry disease, respiratry disease, cancer, and diseases f the digestive system. Hspital use increases with age. Table 2: Chrnic Cnditins by Age and SES The healthcare csts in Ireland are five times higher fr patients with fur r mre cnditins. These patients have n average: 11 GP visits per year 3 OPD visits ED Task Frce Reprt March

9 3.5 admissins Much f the burden f chrnic and acute disease in ur ppulatin can be reduced by lifestyle changes, lifestyle chices such as vaccinatin, and risk factr mdificatin. Where disease des ccur, the burden can be reduced by receiving timely, accessible, evidence based treatment and fllw-up. It is estimated that there is significant ptential thrugh fcus n chrnic disease management t reduce the burden f chrnic disease n the health service. Chrnic disease pathway develpment within the public health services is an area which must be significantly develped t fcus n delivery f care as clse t the patient as pssible. The rle f CNS and ANP nursing services, as seen in ther jurisdictins are in ther areas f healthcare in Ireland have a key rle t play in delivering cst effective care. Cmmunity Healthcare Organisatins ptentially have the ability t reduce the burden n the acute hspital system with particular emphasis n the 5% f patients with chrnic disease wh currently cnsume 40% f in-patient bed days (HSE 2008). ED Task Frce Reprt March

10 Intrductin 2.0 Intrductin In December 2014, the Minister fr Health, Mr. Le Varadkar T.D., cnvened an Emergency Department Task Frce t fcus n the deterirating perfrmance in the health system manifesting in Emergency Departments. It is acknwledged that the main symptms f sub-ptimal Unscheduled Care services, which manifest as significant vercrwding and unacceptable trlley waits fr patients, are nt simply attributable t the functining f an Emergency Department itself. Rather these symptms are caused by a series f factrs acrss the whle health system The bjectives f the Task Frce are: T establish a cmmunicatin and exchange platfrm between the HSE and relevant stakehlder grups, regarding n-ging wrk and specific initiatives at whle system level t enable sustained imprvements in Unscheduled Care perfrmance. T infrm, drive and supprt the HSE Acute Hspital Divisin s Implementatin Plan fr Unscheduled Care. This plan will identify specific actins t address demand capacity management, effective patient flw, integrated care pathways and discharge planning. T identify cllabrative wrking arrangements between the Acute Hspitals, their Cmmunity cunterparts and ther relevant stakehlders, t ensure the mst efficient and effective implementatin f management actins, including system redesign as well as wrk practice and staffing prfile changes where apprpriate. T anticipate ptential prblems r issues and t ensure apprpriate structures, prcesses and cntrls are in place t manage these befre they escalate T infrm plicy develpment in key areas by acting as a discussin frum n plicy matters between the HSE, DOH and relevant stakehlders n key issues The Task Frce is chaired jintly by the HSE, Natinal Directr f Acute Hspitals and a nminated Unin Representative. At the time f publicatin f the reprt the jint Chairs were Mr. Liam Wds, HSE, Natinal Directr Acute Hspitals and Mr. Liam Dran, INMO. A cre principle underpinning the wrk and pririties f the Task Frce is that it is inapprpriate fr any patient t wait n a trlley after a decisin t admit has been made and that there must be a whle system apprach t addressing the causal factrs and the agreed natinal hspital and cmmunity targets must reflect this principle. In this cntext, the eliminatin f lng wait times was identified as an immediate pririty fr the Task Frce. The agreed natinal target f 95% cmpliance with 6 hurs Patient Experience time was re-stated; with the recgnitin f an interim target f n patient waiting mre than 9 hurs fr admissin set fr A zer tlerance t breach f 24 hurs fr Patient Experience was reinfrced with requirement t invke special measures t address such events. Membership f the grup includes representatin as fllws: Natinal Directr, Acute Hspitals Acute Hspitals Natinal Clinical Directr Natinal Directr Quality and Patient Safety Natinal Directr Clinical Prgrammes ED Task Frce Reprt March

11 HSE Scial Care HSE Scial Care Clinical Lead HSE Primary Care HSE Emergency Medicine Prgramme HSE Acute Medicine Prgramme HSE G.P. Lead Special Delivery Unit Irish Assciatin fr Emergency Medicine Irish Medical Organisatin Irish Nursing and Midwifes Organisatin Irish Hspital Cnsultants Assciatin IMPACT SIPTU Natinal Ambulance Service Deputy Directr and Head f Operatins, HSE AHD Patient Representative Hspital Grup CEO Nminated Hspital Manager HSE, Mental Health Divisin HSE, OMNSD Department f Health Secretariat HSE Acute Hspitals Divisin 2.1 Critical Determinants f Imprved Perfrmance The ED Task Frce Reprt, 2006 identified that the key causes f delay fr patients in ED are variatins in the hspitals and cmmunity s capacity, capability and cntrl prcesses, specifically in: management f available bed capacity the level and availability f clinical decisin making the availability f diagnstics, senir in-huse specialty assessment and ther ED supprts ED internal cntrl prcesses cmmunity and cntinuing care capacity prcesses The ED Task Frce, 2006 key findings fcused n individual hspital and system wide measures t imprve perfrmance in Emergency Departments. The findings were stratified acrss three areas: Capacity Fcused n ensuring that Hspitals and Cmmunity have defined the vlume f capacity required t manage activity levels and the requirement t ensure that existing capacity is ptimised. Capability Apprpriate systems and prcesses in place in hspitals and cmmunity t enable and supprt apprpriate ED avidance, Effective Management f Patients in ED, Senir Decisin Making, Access t Diagnstics, Effective Discharge Planning, Effective management f specific patient chrts Cntrl Apprpriate cntrl prcesses - in place acrss Hspitals and Cmmunity including clear lines f accuntability with apprpriate measurement systems in place t supprt decisin making. The cncept f peratinal grip has been used mre recently by the SDU t elucidate the requirements in relatin t cntrl, including clinical and crprate leadership, accuntability and measurement. The SDU experience, in line with evidence frm ther jurisdictins mirrred the key findings frm the ED Task Frce in The next sectin sets ut the high level critical determinants f imprvements and the recmmendatins in the cllective experience f the SDU and best practice: ED Task Frce Reprt March

12 Dmain Leadership and Gvernance Key Features Perfrmance is wned by lcal leaders, with a clearly identified Unscheduled Care Lead. Supprted by the SDU and the Clinical Care Prgrammes, this lcal wnership is a critical prerequisite t unscheduled care imprvement. It must be embedded int every lcal peratinal structure and delivered within a cherent hspital / grup gvernance mdel. Every site that has achieved sustained imprvement has created a brad internal leadership calitin f managerial, nursing and medical leaders, changing the internal rganisatinal narrative and reinfrcing the mral bligatin t prevent high trlley cunts and reduce PET times in ED. Prcess Imprvement Prcess Imprvement Integrated Planning Patient assessment Key features f perfrming sites are: The develpment f a well-functining patient pathway which cmprises: acute assessment by senir clinical decisin makers, well-structured shrt stay facility supprted by timely diagnstics and Prtected streaming including ANPs, especially in high vlume mdel 4 hspitals. Develpment f frail elderly pathways underpinned by strng clinical gvernance and clear linkages between geriatric medicine and emergency medicine can effect reductins in length f stay Use f rapid access assessment mdels fr geriatric medicine and chrnic disease are enabling hspital avidance and re admissin. Geriatric teams in all sites shuld seek t create an immediate access elderly assessment and treatment service fr elderly patients therwise requiring ED assessment. As extensive perating hurs as pssible will be sught Patient pathways and prcesses Critical determinant f success are: Systematised apprach t patient flw where each pint f the patient jurney is mapped and understd Use f demand/capacity mdelling and prcess imprvement techniques. Standards arund ALS, driven by a navigatinal hub/visual hspital functin, - meaningful use f predicted date f discharge (care planning fr each patient), Specialty wards cnfiguratin and a fcus n weekend discharging. Systems and prcesses in relatin t patient flw and prcessing reflective f 7 day business f hspital services t avid the queue build up ver weekends and ut f hurs, giving rise t high trlley numbers and cngestin in the early days f each week. Cntinuus fcus n 7 day discharges with agreed daily review f predicted discharges that take accunt f demand capacity requirements (hspital t set daily target based n average daily admissins fr that day) 7 day wrking f AMAUs planned weekend handvers f discharges (e.g. CUH, Tallaght, Kerry) Integrated discharge planning Dependencies n stakehlders external t the hspital, particularly fr cmplex discharge ED Task Frce Reprt March

13 Data and Infrmatin needs must be clearly understd and managed practively. This is especially imprtant in efficient mdel three hspitals, where egress blcks have a disprprtinate impact n peratinal efficiency. Bttlenecks at any stage f patient flw will result in queues acrss the system. Every hspital has a tlerance level fr limitatins n access. With specific reference t delayed discharges 10% f acute beds, in any ne hspital, are cnsidered t be an inflexin pint beynd which efficiency markedly deterirates and subptimal care is delivered. Hwever it is als acknwledged that even at 5-10%, it pses challenges in a system that is perating cnsistently at 100% ccupancy Hspitals and their cmmunity partners must integrate their planning and understand their demand fr efficient egress flws. The required resurces must be delivered in a timely, efficient and cntinuus manner. The flws are predictable, with hspitals able t quantify the numbers f hme care packages and transitinal care beds required n a weekly basis t maintain equilibrium Gd use f Infrmatin and Cmmunicatin Technlgy implemented t supprt frnt line service delivery will enhance transparency and accuntability imprving delivery prcesses and management s peratinal grip. Apprpriate data systems are imprtant fr success. The system must value and explit the ptential f web-based timely, accurate, visual data systems in prviding business intelligence. Organisatins can then understand, plan and respnd in an apprpriate manner t demand and capacity prfiles Use f SDU Standardised Unscheduled Care Assessment Tl t measure perfrmance Use f standardised templates by hspitals t develp imprvement plans these can then be measured bjectively t determine effectiveness Use f systems with prven ptential t prvide real time versight and business intelligence t deliver smarter, mre respnsive care. TrlleyGar, the SDU Emergency Care Perfrmance Imprver web-site and the HSE Cmpstat are all wrthy f further develpment. Use f demand and capacity spreadsheets fr lcal use in hspitals with less develped IT systems. 2.2 Standardised Pathways Integrated Care Pathways The Patient Flw Integrated Care Pathway (ICP) seeks t ensure that peple can access the care they need in a timely manner. An essential cmpnent f Patient Care ICP is that that are structures and prcesses in place t enable effective flw acrss hspital and cmmunity settings. This is a key cmpnent f prviding safe and high quality healthcare. The Integrated Care Prgrammes are being develped within the plicy cntext f Future health and Healthy Ireland. Five pririty integrated care prgrammes have been identified, t be implemented n a phased basis. These are: Integrated Care Prgramme fr Patient Flw Integrated Care Prgramme fr Older Peple Integrated Care Prgramme fr Chrnic Disease Preventin and Management ED Task Frce Reprt March

14 Integrated Care Prgramme fr Children Integrated Care Prgramme fr Maternal Health Within these ICPs, specific wrk streams are being identified e.g. Urgent & Emergency Care (within Patient Flw), integrated frail elderly care pathway (jint wrkstream lder persns and patient flw) The Integrated Care Prgramme fr Patient Flw seeks t ensure that peple can access the care they need in a timely manner. An essential cmpnent f Patient Care ICP is that there are structures and prcesses in place t enable effective flw acrss hspital and cmmunity settings. This is a key cmpnent f prviding safe and high quality healthcare. The Integrated Care Prgramme fr Patient Flw is underpinned by practive management f interfaces between stakehlders t reduce barriers t integratin and allws fr chesive care prvisin acrss a cntinuum f services. The patient flw ICP is currently in the design phase with an evidence review underway and the utput frm a benefits realisatin wrkshp with key stakehlders cmplete. Visin and benefits: Critical success factrs Integrated Care Prgrammes: Investment in cntinuing t build n a fundatin f expertise in data capture analysis and management and in the infrmatin systems t enable data t be captured in an efficient way. Access t prfund evidenced based quality imprvement methdlgies. Clear priritisatin f this wrk by senir figures Engagement f all key stakehlders Applicatin f prject management methdlgies Accuntability and stewardship at senir clinical and management levels ED Task Frce Reprt March

15 2.2.2 Frail Elderly Pathway A particular fcus is needed n frail elderly pathways, due t the ptential fr significant gains fr bth patients and hspitals. A number f initiatives have been prpsed r develped in this regard: A recent elderly pathway initiative pilted in the ED in UCHG achieved a tw day reductin in length f stay. Geriatric teams in all sites shuld seek t create an immediate access elderly assessment and treatment service fr elderly patients therwise requiring ED assessment The develpment f Rapid Access services that are underpinned by strng clinical gvernance and apprpriate pathways between geriatric medicine and emergency medicine. A Rapid Assessment Team established in the MMUH in May 2012, as part f the implementatin f the Natinal Acute Medicine, Emergency Medicine and the Care f Older Peple Natinal Clinical Prgrammes has resulted in 61% f frail elderly patients with reduced mbility/falls risks and cncerns regarding cping at hme aviding unnecessary admissin Cmmunity Case Management Initiative (CCMI) - targeted at meeting the needs f frail elderly peple particularly thse with multiple medical c-mrbidities. The case management mdel is prpsed t drive the integratin f care f lder peple with cmplex needs acrss traditinal hspital and cmmunity bundaries. Frail elderly peple with cmplex needs are identified in a timely manner by a Case Manager, wrking with a Cnsultant Geriatrician acrss the hspitalcmmunity interface, and are actively managed using a variety f settings ther than Emergency Departments. Such a mdel f care has been develped in Cnnlly Hspital in the Dublin area and has demnstrated a reductin in admissins frm nursing hmes by up t 40%. The bjectives f the CCMI develpment are: T prvide a timely, efficient and well-c-rdinated service fr lder peple. T anticipate ptential crisis situatins and assist patients and their families in planning fr same; this may include planning fr increased hme supprts, planned transitin t lngterm care and / r cntinued decline in health requiring higher level health and scial care supprts e.g. twards end f life in the cmmunity T minimise ptentially avidable acute hspital admissin T facilitate apprpriate timely supprted discharge T prevent premature placement in lng-term care Where lng-term care is required, t ensure it can be expedited frm the cmmunity thereby aviding an unnecessary acute hspital admissin. A cmprehensive integrated care prgramme fr lder peple will be develped which will supprt service prvisin acrss hspital and cmmunity targeting thse mst at risk f hspital admissin and ensuring that Primary Care, Scial Care and Acute hspital services are delivered in an integrated way. This requires a lcal gvernance structure t ensure integrated wrking acrss fur peratinal divisins Primary Care, Scial Care, Acute Hspital services and Mental Health. This is central t the CCMI and necessary fr any measures invlving frail lder peple. 2.3 Natinal Oversight and Leadership While the lcus f cntrl fr change must rest with the lcal health system (Hspital and Cmmunity Health Organisatin), this must be supprted by the Natinal system wrking with the SDU and the Natinal Clinical Prgrammes. There is als a need fr develping structures and prcesses that enable imprvement measurement and versight within and acrss the fur Divisins and facilitate integrated wrking and care prvisin. ED Task Frce Reprt March

16 Natinal Hspital Level A key requirments are t: Supprt and develp systems t enable frntline delivery f services in an integrated manner with gd interfaces between these systems. They must als prvide key metrics in a transparent, timely, visible, understandable and relevant frmat, as a means f driving imprved perfrmance acrss the whle system. Examples include: TrlleyGAR, including >9 hur Trlley Waits eliminatin f PET times greater than 24 hurs Define agreed escalatin pints in ensuring that breaches are averted and apprpriate interventins at each pint Eliminatin f >9 hur PET times fr patients aged 75+. Supprt thse sites where there are validated capability issues via: Natinal wrkshps t share infrmatin n successful prcess change Reginal wrkshps n ptimal patient flw Seeking prfessinal bdy endrsement fr facilitated discharge planning and high impact practices, such as, daily runding, Mandatry Operatinal Management training fr new managers and fr existing managers as apprpriate. Supprt thse sites where there are capacity issues, thrugh: Systematic and bjective review f current bed numbers Clearly priritised plans fr additinal system capacityrecgnise, reward and spread gd practice. Reward prven successful implementatin f prductive change. Ensure that any additinal resurce allcatin, be that fr service develpments, educatin r training, takes int accunt imprved perfrmance. Fr thse sites that are persistently under-perfrming, it is imprtant that the perfrmance diagnstic examines capacity, internal cntrl and capability issues s that apprpriate and targeted interventins are undertaken. In wrking clsely with sites, their executive teams and cmmunity partners, the SDU has used structured evidence based framewrks. The SDU analysis bradly discerns three distinct chrts f hspital, requiring different types f respnses and engagement. The peratinalisatin f the ED Task Frce plan must recgnise these chrts s that there is apprpriate targeting f actin and measurement f impact. 1. Hspitals with gd capability but requiring n-ging supprt t imprve clinical pathways, peratinal management and t maintain egress flws. 2. Well-perfrming Mdel 3 hspitals needing particular supprt with recruitment and patient egress. 3. Hspitals needing fundamental capacity and capability building in peratinal leadership and gvernance, in additin t a range f mre cmprehensive prcess re-design f key patient pathways. The Irish Healthcare Redesign Prgramme (IHRP), currently being pilted in Tallaght, will be explited t help such sites identify the pririty actins that must be prgressed. ED Task Frce Reprt March

17 Primary Care, Scial Care and Mental Health Develp apprpriate metrics t enable effective measurement f primary, scial care and mental health services aimed at supprting hspital avidance and effective integrated discharge. T include: Respnse times fr primary care ut f hurs services t supprt effective admissin avidance Measurement f impact f Cmmunity Interventin Team (CIT) n admissin avidance and early discharge Measurement f wait time fr apprval and release f hme care package funding Measurement f wait times fr NHSS apprvals Average number f hurs per hme care package Whle System Respnse Requirement t develpment apprpriate structures t enable effective wrking acrss primary, acute, scial, mental health and cmmunity services (Natinal Directrs, AHD) The Irish Hspital Re-design Prgramme (IRHP) will require leadership and cllabratin acrss primary, acute and scial care services t ensure integrated appraches t the management f unscheduled care (Natinal Directrs, AHD) The rle f the clinical prgrammes in wrking cllabratively t develp a shared view f what cnstitutes best practice. The Irish Hspital Re-design Prgramme (IHRP) pilt study has enabled such cllabratin; the implementatin f sustained change in unscheduled care demands clear and cnsistent messages frm the prfessinal bdies abut best practice in patient flw and management (Natinal Directrs, AHD) Develpment f apprpriate metrics t enable effective measurement and evaluatin f integratin between acute, primary, scial care and mental health services(natinal Directrs, AHD) ED Task Frce Reprt March

18 3.0 Pririties identified by the Emergency Department Task Frce 2014/5 Many f the prpsals identified in this reprt mirrr thse made in previus wrk and experience in this area. The ED Task Frce Reprt, 2006, Special Delivery Unit (SDU) Unscheduled Care Strategic Plan, 2013, Natinal Acute Medicine Reprt and Natinal Emergency Medicine Prgramme Reprt have set ut recmmendatins, guidance and prcesses that are evidence based and are therefre still relevant in terms f prviding sustained slutins. Identified belw are key areas fr fcus by the HSE and Department f Health that will prvide a basis fr reslving the ED vercrwding issue at a systemic level. It is recgnised the ED Task Frce has nt engaged directly with hspitals t diagnse specific lcal issues that may be relevant at lcal Hspital level hwever the Strategic Plan fr the SDU has been infrmed by internatinal evidence and als SDU s direct engagement with hspitals ver a fur year perid in implementing imprvement plans aimed at delivering sustainable change. It is imprtant t state that the Task Frce des nt accept that it is apprpriate fr any patient t wait n a trlley after a decisin t admit has been made. It is intended that the actins utlined in this reprt can prvide sustainable slutins twards achievement f this gal, hwever, it is recgnised that there are structural issues that will nt be reslved in shrt term which may impede delivery f this gal. Key issues identified by the ED Task Frce 2014 are summarised belw: Requirement t develp sustainable slutins t the issues f delayed discharges s that existing hspital capacity can be ptimised. Specifically the wait times fr Fair Deal must be 4 weeks if patient flw and egress issues are t be addressed The number f delayed discharges must be reduced n a cntinuus basis such that it des nt exceed 500. The current situatin whereby it is rutinely in excess f 730 means that in the majrity f hspitals have in excess f 15% f the beds are blcked n an nging basis and in a number f sites the figure is as high as 25% Requirement t drive prcess imprvements s that hspital length f stay is reduced. There is variatin in ALS between Mdel 4 hspitals, in particular, even when adjustments are made fr the prprtin f beds blcked as a result f delayed discharge. The SDU has identified that it wuld be pssible t free up t 60 beds in a single Mdel 4 hspital if length f stay was reduced in line with the Natinal Target. Pririties in this regard include: Applicatin f predicted date f discharge n a pan hspital basis- immediate target fr this activity is 80 % Discharge frm hspital the first discharge frm each ward start n later than 9.30 am n the day f discharge t align with times f maximum bed demand fr newly admitted patients. A whle hspital system apprach is required t achieve this including cmmunicatin with families and develpment f apprpriate waiting areas fr discharged patients ( e.g. discharge lunges) t ensure that there is apprpriate clinical versight f bth discharged and newly admitted patients 7 day discharges The cre principle is that the hspital understands its demand capacity requirements and that its discharges are apprpriately aligned with its demand requirements ED Task Frce Reprt March

19 including at weekends s that patient flw is managed effectively. Review f SDU data suggests that hspitals discharges are nt sufficient t meet the capacity requirements resulting in queuing. Accrdingly hspitals need t set a daily site specific target which is based n the average number f admissins by day f the week. Each hspital will be required t determine with assistance f the SDU, the average admissin requirement fr each f the week. This will indicate the discharges required by the hspital each day. Hspitals will be expected t reprt against this target. Optimisatin f Mdel 2 hspitals t manage unscheduled demand effectively. The recent initiatives in UL and Suth/Suth West in terms f directing patients t Mdel 2 hspitals needs t be replicated, having regard t the fact that there is variatin in the capacity and capability f small hspitals in different hspital Grups. Therefre there is a need fr tailred slutins and requirement fr sme targeted investment t enable bi directinal flw cnsistently acrss grups. This includes the apprpriate level f clinical gvernance including expanding rles f nursing and ther prfessinal grups. Leadership and gvernance issues thse hspitals that have delivered sustained imprvements in Hspital perfrmance typically have strng clinical and managerial leadership that supprt the cnsistent priritisatin f unscheduled care. This is als reflected in strng centralised peratinal prcesses and cntrls that enable an peratinal grip n the issues Access t senir clinical decisin making is critical in terms f addressing admissin and discharge issues. A number f hspitals have a huge reliance n agency prvisin at cnsultant and NCHD level. The issue is mst acute in Mdel 3 hspitals hwever in the past year; the issues f vacancies at cnsultant level in Mdel 4 hspitals are als evident. This vacancy factr must be viewed in the cntext that verall numbers f practising dctrs are lwer than the EU average. OECD analysis highlights that Ireland has 2.7 dctrs per 1,000 ppulatins while the average is 3.4. It is recgnised that cnsistent delivery f senir decisin making requires targeted investment in additinal cnsultant, NCHD and ther prfessinal grups (nursing & AHP). With specific reference t Mdel 3 hspitals there is als a need t tackle the structural challenges that militate against recruitment and retentin f dctrs As an immediate pririty, there is a requirement t tackle the structural issues that are driving cntinued reliance n agency in these hspitals. This will require targeted actin at Hspital Grup level and shuld cnsider apprpriate structuring f appintments at cnsultant level. In relatin t NCHDs there is a requirement t engage with pstgraduate medical training bdies t enable apprpriate rtatin. The rle f Advanced Nurse Practitiner shuld be examined in terms f fulfilling senir decisin making rles within apprpriate setting and agreed criteria. Delegated discharge The implementatin f delegated discharge and agreement f apprpriate criteria must be dne in cnjunctin with the cnsultant representative bdies, having regard t the nging clinical respnsibility f the cnsultant fr their patients. The use f criteria-led, delegated discharge by senir nurses is an imprtant cmpnent f enabling imprved senir decisin making. The CNM2 rle is central t the implementatin f delegated discharge. Crss team discharging crss- team discharging is already in peratin in a small number f sites and has prven t be effective in enabling 7 day discharging. This needs t be extended acrss all hspitals within agreed criteria t ensure safe and apprpriate discharge ED Task Frce Reprt March

20 Standardised care pathways- there are a number f examples f where implementing standardised care pathways fr frail elderly can enable hspital avidance; reduce length f stay and prevent readmissin. Of particular nte in this cntext are the Rapid Access Mdels and the Cmmunity Case Management Mdels. A key requirement is t share the learning frm these initiatives and seek t mainstream as part f the verall respnse t unscheduled care. Oversight and Measurement- there is a requirement fr effective management and cntrl structures at hspital level that include effective demand capacity management, clear lines f accuntability fr bed managment and discharge plicy, rbust whle system escalatin measures and prcesses The detailed actins t address the abve issues are set ut in the fllwing sectins f this reprt. 3.1 CAPACITY - Optimising Existing Hspital and Cmmunity Capacity The 2006 ED Task Frce Reprt identified delayed discharges as a majr structural challenge fr hspitals as it militated against effective use f existing capacity. The publicatin f the Task Frce Reprt in 2007 acted as an imprtant catalyst t the intrductin f the Nursing Hme Supprt Scheme (NHSS) in an effrt t prvide a sustainable slutin t the requirements in relatin t lng term care. Since 2013, due t financial cnstraints, the ageing ppulatin, and reductin f public nursing hme beds, it has nt been pssible t prvide adequately fr the lng term and cntinuing care requirements f the ppulatin. In 2014, we have seen an increase f 26% in the numbers f delayed discharges with between 15-20% f available beds blcked in many hspitals Reducing Delayed Discharges A key requirement identified by the Minister is the reductin in the wait time fr NHSS t 4 weeks and t set a maximum number f 500 delayed discharges by end These requirements can nly be achieved thrugh additinal investment in the Fair Deal Scheme, HCPs and shrt stay beds. There is als a recgnised capacity deficit in terms f lng term care capacity and this has been exacerbated by HIQA requirements in relatin t physical infrastructure which has resulted in the lss f ver 2000 public beds, ntably in thse areas that have histrically been challenged in terms f public capacity. Prspectus, 2006 identified a capacity requirement f almst 7,000 new residential care beds by 2016 and the HSE Viability Study n the Future f Residential Care cntinued t highlight capacity deficits in this area. Objective: Reduce delayed discharges t a maximum level f 500 by end 2015 in rder t achieve and sustain reductin in delayed discharges t this level. it is recgnised that there is need fr investment in a range f areas including NHSS, Transitinal Care and Hme Care services, in cnjunctin with imprvements in acute hspital prcesses, cmmunity service, hspital avidance measures and with an integrated mdel f care, fully functinal acrss service prvisin. (This target has been set in recgnitin that there will always be number f discharges which are delayed fr practical and lgistical reasns and that there are recgnised physical r available manpwer capacity cnstraints that may be difficult t vercme in the shrt term) Shrt term actins Agree what is meant by a delayed discharge s that it can be apprpriately measured and targeted at hspital and cmmunity level (HSE AHD, Scial Care ) Set and maintain NHSS wait time f 4 weeks thrugh the prvisin f adequate funding in 2015 (HSE, Scial Care Q2 2015) Enfrce regulatry guidelines fr submissin f financial and CSAR infrmatin t NHSS (HSE, Scial Care in cnjunctin with AHD - ) ED Task Frce Reprt March

21 Set and enfrce timelines fr prcessing f financial infrmatin by Nursing Hme Sectin (HSE, Scial Care - ) Set and versee individual Hspital targets t ensure that the ttal number f Delayed Discharges des nt exceed 500 in 2015 and that n hspitals delayed discharges are in excess f 10% f its available beds. This shuld include individual Hspital weekly discharge targets fr Scial/Primary Care as identified by the SDU. (HSE Scial Care/Primary Care in cnjunctin with AHD ) Set targets, by Hspital, fr delivery f Hme Supprt services t ensure minimum delay fr patients in Hspitals accessing apprpriate supprts. It is recgnised that hme supprt is nt a demand led scheme but is budget capped and must meet the requirements f thse in hspital and in the cmmunity.(hse, Scial Care ) Define and implement a menu f apprpriate clinical pathways using the infrmatin that is already available i.e. 27 Clinical Prgrammes each f which describe in detail an evidence based clinical pathway (See Appendix 1 fr list). (HSE AHD/CCP/Scial Care Q4 2015) Define Cmmunity/Acute Hspital Catchment Areas fr lder persn s services specifically (HSE AHD/Scial Care Q2 2015) Develp and implement agreed metrics t ensure that agreed targets fr delayed discharges are being met cnsistently at natinal and hspital level (HSE AHD/Scial Care/Primary Care Q2 2015) Medium term actins Develp Integrated care pathways acrss the acute hspitals/cmmunity interface in the cntext f the newly created Divisinal structures (HSE AHD/CCP Q4 2015) In cnjunctin with the DOH, cntinue t define the requirement fr additinal residential care capacity bth in terms f lng stay and shrt stay t supprt the cntinuum f care requirements and in particular in key lcatins where there is an identified shrtfall in such capacity, bth currently and ver the cming years. Determine requirements in nursing and ther staffing grups which will allw identified patient care needs t be met. (HSE Scial Care 2016/2017) Wrk with the DOH and HIQA t find slutins t the current regulatry requirements s as t prtect public bed capacity which is vital t supprt the acute hspital system. (HSE Scial Care 2015/2016) Wrk with the DOH t develp apprpriate public lng term capacity s that cmplex patient needs can be met cnsistently (HSE Scial Care 2016) Develp and establish a rbust lcal clinical gvernance mdel with clear links t the discharging hspital and existing cmmunity services (HSE Scial Care 2015) The DOH t lead n apprpriate wrkfrce planning t ensure safe and agreed nursing staffing levels and nursing clinical gvernance systems are in place t accept discharged patients (DOH/ HSE 2016) Develp ring-fenced funding streams fr certain patient grups (HSE/ DOH 2016), specifically: Older peple ED Task Frce Reprt March

22 Thse with chrnic illness Yung peple with chrnic neurlgical cnditins e.g. acquired brain injury, multiple sclersis, mtr neurne disease etc. Jint wnership f peple that require a flexible netwrk f care prvided by Primary, Scial, Acute Hspital and Mental Health Services. An apprpriate ICT system t supprt all f the abve. Develp a framewrk t plan practively fr the ageing ppulatin having regard t the prjectins fr the next 6 years (HSE AHD/ Scial Care/ Primary Care Q4 2015) Reduce Length f Stay The ptimisatin f existing capacity is nt dependent slely n tackling the delayed discharges issue. The wrk f the Surgical and Acute Medicine Prgrammes has highlighted the need t target length f stay t ptimise the available capacity. The target fr length f stay fr medical patients, adjusted t exclude inpatients with ver 30 days stay is 4.2 days. At this stage, the majrity f mdel 4 hspitals are in excess f this target with the Dublin teaching hspitals perating well beynd this target in terms f medical patients. The ptimisatin f existing capacity thrugh earlier discharge requires expansin f services in the cmmunity with regard t hw the nging care needs f patients are managed. It is accepted that CIT s, with clear gvernance by and linked with existing scial and primary care services, can be effective in reducing length f stay and enabling hspital avidance, There is a need t evaluate the different mdels f CIT t determine their effectiveness and impact n admissin avidance and early discharge with the aim f delivering seamless care acrss the cntinuum. T enable sustained imprvements in length f stay t be achieved, cmmunity services will need t be resurced in rder t accept early discharge f patients. This will require additinal nursing, HCA supprt and AHPs. Objective: Reduce LOS in line with target set in 2015 HSE Natinal Service Plan (Medical 5.8; Surgical 5.1, LOS All 5.0; llos adjusted 4.3) Optimise Existing Hspital Capacity Surgical Beds Shrt Term Actins: Increase DOSA rates t natinal verall target f 70% in 2015 with each hspital having a target set by the Natinal Surgical Prgramme. Current perfrmance is circa 65% hwever there is significant variatin by site. Further develpment f rbust pre-assessment mdels f care thrugh investment in CNS s in pre-assessment is critical in this regard. (HSE AHD/Hspital Grup CEO s, ) Increase surgical rates and reduce vernight stays initial target set fr Laparscpic Chlecystectmy (> 60%) (HSE AHD/ Hspital Grup CEO s, ) % f bed utilisatin by acute surgical admissins that d nt have a surgical primary prcedure reductin f 5 % in 2015 (HSE AHD/ Hspital Grup CEO s, ) Define targets fr shift f inapprpriate day-case wrklad t utpatient settings (HSE AHD/CCP Surgical, ) Medium term Actins: ED Task Frce Reprt March