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Stepping Home with Cellulitis

Project Added:
4 December 2014
Last updated:
8 December 2014

Stepping Home with Cellulitis

Royal North Shore Hospital, Northern Sydney Local Health District (NSLHD)

Summary

Stepping Home with Cellulitis results in reduced length of stay for patients admitted to Royal North Shore Hospital (RNSH) with Cellulitis through implementation of a clinical pathway.

Download a poster about this project from the Centre for Healthcare Redesign graduation, December 2014.

View a presentation on this project from the Medical Assessment Unit Forum, October 2014.

Aim

To improve access to care and deliver excellent care for patients diagnosed with Cellulitis by providing appropriate, efficient, equitable care which aligns with best clinical practice. To reduce Average Length of Stay for Cellulitis admitted under the general medicine speciality at RNSH from 4.4 days to 2.3 days by December 2015.

Benefits

  • Improved patient outcomes
  • Improved staff and patient satisfaction
  • Reduced risk of adverse events by transferring treatment from the acute care environment to the home environment as soon as possible
  • Improved efficiency, measured by increased throughput thus providing the ability to treat more patients
  • Increased staff capabilities in redesign and project management
  • Royal North Shore Hospital (RNSH) could save 535 bed days annually by moving to an Average Length of Stay (ALoS) of 2.1 days from 4.4 days for General Medicine patients.

Background

In the month of February 2014, RNSH averaged 222 presentations per day to its Emergency Department (ED). ED crowding is not only undesirable because patients have to wait longer, but ED crowding has also been associated with several negative patient-oriented outcomes, including delays in important medications and higher complication rates after ED evaluation, including an increase in mortality2.

The Average Length of Stay (ALoS) for patients with cellulitis at RNSH is 4.1 days (4.4 days for general medicine specialty) which is 77% higher than the 2.3 day ALoS at exemplar sites. The data also demonstrates that the complexity of patients with cellulitis at RNSH is no more so than patients elsewhere.

Literature demonstrates that an increased hospital stay presents risks of infection or adverse events to the patient and this risk increases each day the patient remains in hospital1. Therefore the longer patients stay in hospital; the more likely they are to suffer a range of adverse events considered preventable with optimal care1.

RNSH could save 670 bed days annually by moving to an Relative Stay Index of 75% which is the weighted average of the four exemplar hospitals in the peer group.

Data from the National Health Performance Authority (NHPA) also suggests that NSLHD admits more patients with cellulitis than other areas. It is this data that identified that there are likely opportunities to improve the journey for this patient group by reducing ALoS and improving access to care for patients of NSLHD.

In order to manage demand it is important to maximise health benefits by increasing efficiency. This will ensure delivery of effective, efficient patient-centered care and empower individuals to invest in their own health and wellbeing.

Implementation

A clinical pathway to provide a standardised approach to care for patients with Cellulitis was developed in consultation with clinical staff, stakeholders and patients.

Methods used included literature review, data analysis, process mapping workshops, patient interviews (and thematic analysis) and tagalongs, stakeholder interviews, medical staff surveys, brainstorming, issue prioritization and benchmarking.

  • The drafted Adult Cellulitis Pathway allows for categorisation of patients diagnosed with cellulitis into four categories based on their disease severity
  • This pathway provides a standardised treatment (based on Australian Therapeutic Guidelines), criteria for discharge and follow up requirements for each category
  • The Adult Cellulitis Pathway has been approved by the RNSH Drug Committee and is awaiting approval from the Clinical Forms Committee
Initial implementation is at RNSH Acute Assessment Unit.

Results

During the Implementation Planning phase, while the clinical pathway is awaiting approval from the Clinical Forms Committee, a length of stay reduction of 0.4 days has already been achieved. (ALoS for 2013/14 was 4.1 days compared to ALoS YTD as at September 2014 of 3.7 days). This is thought to be attributed to the communication of best clinical practice for treatment of cellulitis with clinicians.

The Stepping Home with Cellulitis clinical redesign project found clinical variation to be the root cause of the increased ALoS for patients diagnosed with Cellulitis at RNSH.

It is expected the implementation of the Adult Cellulitis Pathway will reduce length of stay for patients admitted to RNSH with Cellulitis through standardisation of treatment and elimination of clinical variation.

Partnerships

The project was undertaken via the Agency for Clinical Innovation’s Centre for Healthcare Redesign program.

Lessons Learnt

  • Sponsorship is key and without it the project will not succeed
  • Communication, communication, communication from and to the right people all of the time
  • Importance of data
  • Underestimated the time it would take for the consultative and approval processes.

References

  1. Hauck K, Zhao X, 2011, How Dangerous is a Day in Hospital? A Model of Adverse Events and Length of Stay for Medical Inpatients, Medical Care, Vol:49, ISSN:0025-7079, Pages:1068-1075
  2. Singer, A, Thode, H, Viccellio, P, Pines,J, 2011, The Association Between Length of Emergency Department Boarding and Mortality, Academic Emergency Medicine, Vol:8, pages:1324-1329

Other Resources

  • The Health Roundtable data 2012/13 Financial Year (FY) - Relative Stay Index (RSI) for Diagnostic Related Group (DRG) family J64 Cellulitis is 111% (benchmark 100%)
  • National Health Performance Authority
  • Australian Therapeutic Guidelines

Contact

Hediyeh Vahdat
Acting Manager Operations NSLHD
Royal North Shore Hospital
Northern Sydney Local Health District
Phone: 02 9463 1112
Email: Hediyeh.vahdat@health.nsw.gov.au

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