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Neurosciences Length of Stay Project

Project Added:
1 October 2013
Last updated:
30 September 2014

Neurosciences Length of Stay Project

Helen Tassell and Steven Wood, Prince of Wales Hospital, South Eastern Sydney Local Health District

Summary

The Prince of Wales Hospital (POWH) is a tertiary hospital and a Neurosciences hub, providing specialist Neurology and Neurosurgery services. It was identified that length of stay (LoS) for neurosciences patients at the POWH was above the state benchmark. A multidisciplinary project was undertaken to explore opportunities to optimise the patient journey and improve access to services and reduce LoS.

Poster on the 'Improving the journey for Neuroscietients through a multidisciplinary approach' project

Evaluation reveals impressive results with improved access to beds due to patient flow, enhanced coordination of care more than 20% reduction in length of stay for this patient group, saving 8.4 acute beds.

Presentation to the ACI Sustainability Committee September 2013 (PDF File pdf - 331 KB)

Aim

The aim of the project is to reduce the LoS by 5% for patients admitted under neurosciences at POWH by March 2013.

This will be achieved by:

  • increasing the early identification of risk factors associated with increased LoS
  • reducing procedural and process delays to enable more timely coordination of the patient journey and enhancing effectiveness of discharge planning.

Key issues

Health Roundtable benchmarking data revealed an opportunity to save 2,280 acute bed days (6.3 beds at 100% occupancy) in neurosciences in the 2011/12 financial year if LoS aligned to benchmark.

The diagnostic phase of the project identified five key issues attributed to increasing LoS for Neurosciences patients admitted to POWH.

Communication

  • Commuication of patients goals and expected patient journey to patients, carers and families
  • <20% of long stay patients had a family conference
  • <50% of patients were aware of their discharge plan
  • Frequency and timeliness family conferences to facilitate discharge planning
  • Communication between the multidisciplinary team
  • Family input into goals and discharge planning
  • Resistance to discharge by families

Process delays

  • Cancellation of patient procedures
  • Multiple ways to refer to allied health, creating inefficiencies in follow-up
  • Discharge planning
  • Key staff not attending discharge planning meetings

Post Acute Discharge Planning

  • Difficulties discharging complex patients
  • Patients awaiting admission to rehabilitation units
  • Availability of community resources and equipment particularly those appropriate for neurosciences casemix.

Acute Care Plan Coordination

  • Multiple teams involved in patient care may impact ownership of the patient and discharge decisions
  • Defined management plan for patients
  • Clarity of medical and allied health goals
  • Frequency and timeliness of family conferences
  • Effectiveness and timeliness of discharge planning
  • Clarity of Estimated Date of Discharge (EDD) and destination in discharge planning meetings
  • <20% of patients were set an EDD in discharge planning meeting
  • Patients reviewed over 48 hours after admission to Parkes 8 by some allied health disciplines

Medical Governance

  • Medical decision making at the junior level impacted timeliness of discharge planning
  • Feasibility of definitive Consultant ward rounds

Solutions

Improve Communication

  • Notification of Complex Care Patient (NoCCuP) Tool
    Tool to notify staff that patient is at high risk of long length of stay compared to their admitted diagnosis-related group. This will cover early referrals to relevant parties, follow-up and patient flow and checklists for early discharge planning and improved patient flow.
  • Discharge planning meetings
  • Medical Intern Education
  • Patient expected LoS Guidelines
  • Rehabilitation guidelines

Improve discharge planning

  • Family Conference
    Improve family conference process by having a documented invitation for the family / patient, goals and planning sheet and formal documentation of meeting outcomes including plans, follow-up and major decisions made for in Patients medical files. Introduction of a "Family Conference" sticker for in patient's progress notes to highlight when family conference has occurred.
  • Discharge checklists
  • Setting EDD

Leadership and accountability

  • Complex Care Pathway
    The pathway will build understanding of factors that keep patients in hospital longer than their acute illness and the impact positive impacts on patient care provided a coordinated approach is taken. It will cover early referrals highlighted by the NoCCuP tool, family conference documentation, discharge goals and planning, and checklists for early discharge planning and improved patient flow.
  • Complex Care Coordinator
  • Key Worker

Results

Achievement for year to date May 2013 in comparison to 2011/12:

  • Decreased LoS in Neurology by 23%, equating to 1,796 bed days saved or 4.9 beds at 100% occupancy
  • Decreased LoS in Neurosurgery by 22%, equating to 1,285 bed days saved or 3.5 beds at 100% occupancy

Graph showing over 20% reduction in length of stay
Figure: Comparison of POWH Neurology (NR) and Neurosurgery (NSx) average LoS and number of acute episodes

  • Improved access to acute beds due to improved patient flow
  • Improved communication processes enhancing overall care coordination, evidenced by:
    • more efficient multidisciplinary approach, including understanding of LoS targets and benchmarks
    • timely establishment of estimated date of discharge
    • increased family participation in discharge planning processes, such as family conferences
  • Current strategies in development to further facilitate increased coordination of the patient journey:
    • Recruitment of complex care coordinator
    • Development of a complex care pathway
    • Development of the NoCCuP tool

Conclusion

A multidisciplinary approach has been shown to have a positive impact on improving the patient journey, including decreasing LoS; increasing patient and family participation; and improving staff morale. Working parties will continue to develop and implement evidence based solutions to further enhance coordination of patient care.

Acknowledgements

POWH Parkes 8 Neurosciences team (Medical, Nursing, Allied Health), Dr Patrick Bolton (Director Clinical Services and Sponsor), Allied Health Heads of Departments.

Steering Committee: Dr Jacob Fairhall (Neurosurgeon), Karen Van Cuylenburg (NUM), Angela Evans (CNC), Karena Hayes (CNE), Tracy Kelly (Speech Pathologist), Michelle Hanrahan (Head of Occupational Therapy).

Contacts


Physiotherapist
Prince of Wales Hospital
South Eastern Sydney Local Health District
Phone: 02 9382 2850

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