An Overview of a Winter Plan Renee Greven-Garcia, Emergency Physician, Hawkes Bay

1. An Overview of a Winter PlanRenee Greven-Garcia, Emergency Physician, Hawkes Bay

2. Insanity: Doing the same thing over and over again and expecting different results. Albert Einstein, (attributed)US (German-born) physicist (1879 - 1955)

3. ED Overcrowding Why does it happen? What can we do about it? What are the Truths? What are the Myths?

4. Common Misconceptions • “Inappropriate” or “general-practice-type” patients cause overcrowding • Overcrowding is largely the result of patients being admitted but remaining in the department awaiting suitable beds and/or in our case inpatient team reviews/clerking • MJA • Volume 190 Number 7 • 6 April 2009, Drew B Richardson and David Mountain

5. Myth: “Overcrowding is the result of an excess number of patients arriving and waiting to be seen by a Doctor” Fact: “Patient attendances at EDs have increased, but the number of patients waiting to see a doctor in Australasian EDs remains smaller than the number waiting for an inpatient bed” MJA • Volume 190 Number 7 • 6 April 2009, Drew B Richardson and David Mountain

6. Myth: “The time patients spend in the ED is now excessive because staff take too long in investigating and treating them” Fact: “ There has been little change in the time taken to assess and treat ED patients, but some increase in waiting time because ED staff and resources are being used to care for inpatients, and a large increase in waiting time for inpatient beds” MJA • Volume 190 Number 7 • 6 April 2009, Drew B Richardson and David Mountain

7. Myth: “Telephone advice lines and collocated general practitioner services reduce ED attendances” Fact: “Telephone advice lines and collocated GP services have little or no effect on ED attendances” MJA • Volume 190 Number 7 • 6 April 2009, Drew B Richardson and David Mountain

8. Myth: “Overcrowding can be reduced by building larger ED’s” Fact: “Increasing ED size is associated with increased overcrowding” MJA • Volume 190 Number 7 • 6 April 2009, Drew B Richardson and David Mountain

9. Myth: “ Overcrowding does not influence patient outcomes” Fact: “Overcrowding has serious adverse effects on hospital processes, quality of care, and patient outcomes, including mortality” • MJA • Volume 190 Number 7 • 6 April 2009, Drew B Richardson and David Mountain

10. Myth: “The causes of overcrowding lie within the ED” Fact: “The causes and the solutions to overcrowding lie outside the ED” MJA • Volume 190 Number 7 • 6 April 2009, Drew B Richardson and David Mountain

11. So how do we turn this:

12. Into This?

13. Without Creating This?

14. Internal ED Strategies • Cross training “MEC” team as a Rapid Assessment team in WR during times of surge/access block. • Creating a holding area in a side room for referred inpatients in evenings-nursing resource-$ • Staffing evenings and weekends at least as robustly as weekdays with RMO’s to meet demand • Created Business Case for increased numbers of ED consultants to improve weekend/afterhours cover- Stalled  $$ • INVOLVE WHOLE OF HOSPITAL IN MOH ED TARGET AND ED FLOW ISSUES AS PRIORITY FOR WINTER AND ALWAYS. . ..

15. WORK WITH OUR ALLIES, EMPOWER AND ENGAGE WHOLE OF HOSPITAL HEROS • Medicine • Nursing • Allied Health • Elder Persons • COO, CMO • Integrated care and service managers • Ancillary Support Managers

16. External ED Strategies-Identifying the Issues in our DHB for ownership/advocacy in the wider group • Admission Avoidance: AAU, COPD, Chest Pain, “CPO pathways” Cellulitis, DVT etc. . .Liase with GP’s • Streaming of Acutes • Inpatient Efficiency • Matching Demand

17. Winter Planning Malcolm Arnold Gastroenterologist/Physician CD Dept Medicine HBDHB

19. The Problem(s)

20. Factors at play in general… • Shrinking numbers of beds • Pressure from Ministry to meet targets • MONEY!!!! • Ageing population staying (or being kept) well for longer, then getting older then getting more and more degenerative and neoplastic diseases • Primary care constraints

21. Factors at play in general… • Soft admissions – social issues, easier to admit and sort than do so on outpatient basis. Better/easier access to specialist as inpatient than going on OP waiting list • Delayed discharges – social issues, delays in specialist review, diagnostics • Over investigating of non urgent incidental findings

22. (Winter) Planning issues • Bed Block • Inappropriate presentations to ED • Office Hours - 45/168 (in fact exclude 73% of actual hours in the week) • Availability of diagnostics, diagnosticians, operators, nurses, doers and thinkers • Least experienced people available to do the job at some critical times (except ED!), and often busy sorting out one issue whilst others flooding in the doors

23. Factors at play in winter • Viral illnesses exacerbating pre-existing problems • Staff illness • Cost of GP visits – defer seeking medical input, get sicker, come to ED

24. Considered approaches • Do things better, more efficiently and effectively • Reduce ALOS • Look for simple fixes if possible • Keep people well and out of hospital, or alternatively don’t let them in….

25. Measures discussed in HBDHB • Predicted Date of Discharge (PDD) • Use of a medical patient admission proforma • Swing Ward • ICU Reg Outreach for Surgical • Discharge Lounge • Outpatient Capacity for Acute/Urgent referrals

26. Measures discussed in HBDHB • Surgical Response to ED • Rest home acceptance after 2pm and at weekends • Implement low risk chest pain pathway • Additional medical registrar for winter • Weekends and after hours

27. Measures discussed in HBDHB • Communication ED or GP • Pre-Admission work-up and pathway adherence for OrthopaedicsElective procedure cancellation • AT&R • Hospital Handover PM Meeting • Electronic Whiteboards

28. The Answer…. • Whisky, honey, lemon and hot water (ratios dependent on relative merits of each)