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Improving Management of Long Stay Patients

Project Added:
8 July 2015
Last updated:
4 November 2015

Improving Management of Long Stay Patients

Summary

Liverpool Hospital implemented a sustainable process for monitoring, management and early escalation of long stay patients. The goal was to provide a structure for helping clinical teams develop appropriate and high-quality patient management plans. 

This project was a finalist in the 2015 NSW Health Awards, Collaborative Team category.
Watch a video on this project.

Aim

To reduce the number of long stay patients in emergency department (ED) accessible beds and total long stay patient bed days by 20% within six months.

Benefits

  • Improves patient safety and clinical outcomes by reducing unnecessary long stays in hospital, associated with increased morbidity and mortality.
  • Embeds a sustainable escalation and monitoring process for patients with length of stay greater than 28 days.
  • Reduces risk of complications or adverse events associated with long length of stay (LoS), including:
    • hospital-acquired infections
    • falls and pressure injuries
    • de-conditioning and functional decline
    • psychological effects including loss of confidence and independence.
  • Improves access and efficiency through decreased bed day use and reduced LoS.
  • Improves patient and carer experience.
  • Reduces incidence of potentially avoidable or unnecessary clinical interventions.
  • Improves team communication, care planning and care coordination processes.

Project status

Project started: 1 May 2014.

Project status: Sustained - the project has been implemented, is sustained in standard business.

Partnership: Clinical Excellence Commission Clinical Leadership Program.

Background

  • A process for monitoring, management and early escalation of long stay patients was not in place.
  • Executive involvement in care planning was often considered punitive or counterproductive.
  • Teams often described feeling ill-equipped to identify solutions and adequately plan and resolve complex discharge issues without guidance and assistance.
  • From May to June 2014, the project team identified a significant cluster of long stay patients in ED-accessible beds at Liverpool Hospital:
    • 70 patients with a LoS greater than 30 days
    • 14 patients with a LoS greater than 100 days
    • 4 patients with a LoS greater than 200 days
    • longest patient LoS greater than 450 days.
  • Case reviews on 14 extreme long stay patients (more than 100 days) identified:
    • 87% required input from more than one team
    • 28% had a supported management plan
    • 93% had experienced team delays in escalation.
  • Other long stay factors were identified, including:
    • a lack of understanding of discharge options for complex discharges
    • admitting medical officer (AMO) and specialty variation in discharge planning practices and LoS
    • variable levels of clinical experience within teams
    • a lack of multidisciplinary communication
    • a lack of clear responsibility for discharge and care planning.

Implementation

  • Targeted case review and development of management plans with multidisciplinary input for all patients with a LoS greater than 100 days.
  • A ward reporting template was developed from the Patient Flow Portal to detail long stay patient management plans. This was completed weekly by nursing unit managers (NUMs) with input from the AMO and multidisciplinary team.
  • Weekly review of all patients with a LoS greater than 28 days.
  • Active support from executive and clinical teams for complex discharges.
  • NUM and multidisciplinary team education and feedback on management plans.
  • Ward visits to support and enable teams, promoting problem solving.
  • Weekly review of monitoring and escalation process.
  • Identified issues and discharge barriers were monitored and logged. 

Results

As at February 2015: 

  • Decrease in patients with LoS greater than 100 days, from 14 to 4 (70%).
  • Decrease in patients in ED-accessible beds with LoS greater than 30 days from 70 to 50 (29%).
  • 82% of weekly patient care management plans now supported, up from 28%.
  • Longest stay patient over 450 days in May 2014 and longest stay in February 2015 was 137 days.
  • Targeted case management increased the number of long stay patient discharges by 20% during July and August 2014.
  • Cumulative bed days for patients with LoS greater than 30 bed days reduced from 4328 to 2536 days. This achieved the initial target of less than 3000 bed days.
  • Top specialty reduced number of long stay patient numbers from 16 to 6.
  • The Patient Flow Portal tool was used to monitor long stay patient numbers and report on current patient management plans.
  • The Long Stay Review Committee was established, with a sustainable process implemented. 

Long stay patient reductions have since been maintained through to June 2015, supporting an overall reduction in hospital LoS. The process continues to evolve with ongoing monitoring of patient numbers greater than 14 and 28 days. The project is also informing strategies developed as part of the NSW Whole of Health Program.

Number of patients >100 days. Decline from 14 at 5 May 2014 to 4 at 5 Jan 2015

Cumulative bed days LoS >30 day, pre 4328, post 2536

Number of patients >30 days. Decline from 70 at 5 May 2014 to 55 at 5 Jan 2015

Lessons learnt

  • Must engage clinicians and empower team-based planning without adding to workload and burden. Teams must see value in the project to support engagement.
  • Input from multidisciplinary senior clinicians is required.
  • Embedding a weekly monitoring process is critical to maintain momentum.
  • Developing a culture of escalation with consistent follow up response, support and action is vital to ongoing success.
  • Ongoing team education and constructive feedback on patient management plans is required.
  • Patient care teams should be encouraged to learn from the process.
  • Fostering a culture of increased accountability and responsibility is important.
  • Long stay patient monitoring must be incorporated into ward processes.

References

Contact

Matt Jennings
Director Allied Health, Liverpool Hospital
South Western Sydney Local Health District
Phone : 02 8738 6301
Email: matthew.jennings@sswahs.nsw.gov.au 

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