Transcript The Virtual Ward

eAcute
Dr Paul Sullivan
Clinical Director of Quality Improvement,
Salford Royal Foundation Trust
Senior Quality Improvement Fellow,
Centre for Healthcare Improvement Research,
Imperial College, London
Risks of hospital stay
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Risk of infection
Risk of medical accidents
Medication errors
Loss of control
Discomfort, sleeplessness
Disruption
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Medical Reasons?
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Treatment only available in hospital
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Monitoring
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Risk of rapid deterioration
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Temporary increase in care needs
Survey
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Daily review of general medical inpatients in a
medical ward– 240 bed days
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Classified into 19 “reasons”
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15% of patients did not need to be in hospital
Survey of medical wards
 23%
of medical in-patients “stable”
of cases by expert panel – 9.6%
could be managed at home
 Review
 Of
patients delayed for <2 weeks,
43% were due to medic behaviour
Survey of medical wards
 Daily
visit to medical wards, each team
contacted
 Able
to identify that 15% of in-patients
could be managed in virtual ward system
 Average
LOC after identification 10 days
 Things
have moved on since then
 Delays
in diagnostics removed
 LOS
saved likely to be 1-2 days
Reasons for delay
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Waiting for test
 Waiting for results
 Waiting for opinion
 Waiting for senior review
Why?
apprehensive about discharge –
loss to f/u, delay to first OPA
 Medics
 Team
need to make a decision(s) straight
after the next test(s)
 No
knowledge of OP services
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Is there a better way of managing these
patients?
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Could they be at home?
Survey on 28 bed EAU 2006
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Could this patient be safely and effectively
managed at home
Audit on 28 bed AMU
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Could this patient be safely and effectively
managed at home
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2-7 patients each day
Alternatives
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Traditional OPD setting has limits
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Time between available follow up slots
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Patient “visible” only at clinic visit
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Availability of diagnostics
 Time
to next FOLLOW UP slot
Gen med
 Cardiology
 GI
 Chest
2-11 weeks
17 weeks
8 weeks
7 weeks
Alternatives
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Priority patients can be managed at home by
individual clinicians
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Time consuming, no support, numbers limited
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Risk of loss to follow up
eAcute
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An electronic patient list to which multiple users can add and which
can be seen by all members of the Acute Medicine team.
Every weekday at 10am = virtual ward round
This is attended by Acute Medicine consultants, mid grades and FY
doctors and the advanced practitioner nurse on the EAU.
Every patient is discussed every week-day.
Junior staff are available to arrange tests, liaise with diagnostic
depts etc.
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If tests are inappropriately delayed we notice immediately and
rectify
Results are seen immediately and consultant level decisions follow
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Patients can be reviewed as often as needed by telephone
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Patients can be recalled to EAU for bloods or clinical assessment
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We have arrangements with radiology, cardiology and endoscopy so
that virtual ward patients are accorded high priority
eAcute
In-patient
Out-patient (Ambulatory)
Junior staff available to arrange tests, deliver
cards to diagnostics, speak to other services
e.g. radiologists
No staff available
If tests missed for whatever reason (card lost,
patient DNA, test postponed) it is immediately
spotted and rectified
Patient cannot be guaranteed to have test and
clinician may not know if test missed
If further action is indicated by a test result, it
can be taken immediately.
Results generally not reviewed until next
outpatient appointment
Patient has daily review
Reviews limited by time between outpatient
visits
Historically, inpatients have been regarded as
more urgent and have tests done quickly.
There are often longer waits for outpatient
investigations.
This is the eAcute ward
Ideal for
 Time-Critical
investigation
 High
risk if inadvertent delays
 High
risk if DNA
Ideal for
Rapid/serial decisions on test results
Test 2 depends on test 1
Early/frequent communication with pt
Results
160
40
140
35
120
30
100
25
80
20
60
15
40
10
20
5
0
0
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
bed days saved
patients
Results
Low Rockall UGI bleed
?VTE
Other
uss abdo
discuss
review radiology
await result
ett
pos blood cul
monitor bloods
ct brain
24h tape
rv clinically after we
Implementation
 Not
as easy as it seems
Critical features
 Watertight
 Access
– IT solution ideal
24/7, anywhere
 Embedded
in daily work
 Redundancies
– can’t be forgotten
I
know, with absolute certainty, that if I
send a patient home on Sunday, a trusted
consultant will pick up the issues on
Monday.
Critical features
 Prioritisation
Patients are regarded as in-patients by:
 Radiology
 Endoscopy
 Echo, ETT
 How
did we do that?
Our story….
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Developing IT solution
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Making it work in the normal day
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Getting radiology to prioritise
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Getting other departments to prioritise
Sustaining
 Constant
vigilance for fall off in
prioritisation
 Local
ownership
 Keeping
 Just
it team wide
add hot water!
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4096 bed days in 24
months
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5.7 beds free on any
day
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Roll out – estimate
additional 5-10 beds
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23 minutes per day
for 2 consultants and
team
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50 minutes per day
for a JD
Transfer
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Make it watertight – daily case review prevents delays, loss to follow up etc.
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Timetable daily senior case review so it is guaranteed. Several people need
to be involved to ensure that this happens every day, regardless.
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Develop an electronic patient list that is visible to all members of the team
all the time – initial attempts with individual paper lists failed
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Choose an area with high patient throughput so that there are always some
virtual patients to review, otherwise it is difficult to maintain the habit.
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Start with a single investigation, we used CT pulmonary angiogram, and get
clinical directors involved.