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STREAMLINING UTIs PROJECT

STREAMLINING UTIs PROJECT. 12 MONTH EVALUATION REPORT November 2010 Anna Rozario Clinical Redesign/Service improvement Unit. TABLE OF CONTENTS. Background...................................................................................................................................Page 3

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STREAMLINING UTIs PROJECT

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  1. STREAMLINING UTIs PROJECT 12 MONTH EVALUATION REPORT November 2010 Anna Rozario Clinical Redesign/Service improvement Unit

  2. TABLE OF CONTENTS Background...................................................................................................................................Page 3 Evaluation Framework..................................................................................................................Page 4 Commentary……………………………………………………………………………...........................Page 5 Executive Summary – Outcomes……………...............................................................................Page 6 Executive Summary – Table …………………………………………………………………………....Page 7 Project KPIs……………………………………………………………………………………………......Page 8 Presentations to ED......................................................................................................................Page 9 Admitted Patients.........................................................................................................................Page 10 Inpatients by Local Government Area…………………………………………………………….….Page 11 Inpatients – LOS...........................................................................................................................Page 12 Inpatients – LOS……………………………………………………………………………………….…Page 13 Inpatients – Average LOS............................................................................................................Page 14 Inpatients – Bed Days (Actual)....................................................................................................Page 15 Inpatients – Bed Days (Extrapolated).........................................................................................Page 16 Bed Days Saved in 12 months since Implementation.…………………………………………….Page 17 Readmissions & Representations..............................................................................................Page 18 Age of Discharged Patients........................................................................................................Page 19 UTI Guidelines.............................................................................................................................Page 20 UTI Fact Sheet.............................................................................................................................Page 21 Conclusions................................................................................................................................Page 22 Next Steps...................................................................................................................................Page 23

  3. BACKGROUND - STREAMLINING UTIs • In 2008 The CHW Executive identified the treatment and management of children with a Urinary Tract Infection as a Diagnostic Related Group (DRG) to undergo a Clinical Redesign Project • The Clinical Redesign program is a NSW State-wide Health initiative that applies the principles and practice of process redesign to healthcare • The Streamlining UTI Project commenced in June 2008 and focused on the patient journeys of children diagnosed with a Typical Urinary Tract Infection

  4. EVALUATION FRAMEWORK • The Streamlining UTIs Project developed a Planned Model of Care for children with a Typical UTI, a major component of this model was the development of the CHW Urinary Tract Infection (typical) Identification and Management Guidelines. These Guidelines were published on 23rd June 2009 at which time the Implementation Phase of the project commenced • This Evaluation Report has been conducted at the 12 month post implementation point so analyses the 6month period from 1st January 2010 – 30th June 2010. • The baseline period used for comparison is 1st July – 31st Dec 2008 which was prior to the Streamlining UTIs Project commencing. • Included in this report is also some information from the previous Evaluation Report which was conducted at the 6 month post implementation point and included 1st July – 31st Dec 2009. • All data evaluated is for DRG - Urinary Tract Infection without Complication, which for baseline and 2009 analysis was DRG L63C however following the introduction of AN-DRG Version 6 is grouped under L63B for the Jan-June 2010 data

  5. COMMENTARY Limitations Diagnosis of UTI can only be confirmed once urine culture results are available. UTI specific treatment can commence prior to availability of the urine culture results, if clinically indicated, and a provisional diagnosis of a suspected UTI can be made because of the presence of signs such as fever, dysuria, positive results for leucocytes &/or nitrites on urinalysis, frequency of micturation etc. However, if no clear focus is initially evident the treatment will be for a PUO and not specifically for a UTI until the urine culture confirms the diagnosis, in these circumstances the LOS may be extended.

  6. EXECUTIVE SUMMARY - OUTCOMES Despite a 23% increase in the number of DRG L63B presentations to the ED in the 2010 Jan - Jun period compared to the 2008 July – Dec baseline period the following outcomes were achieved: • 7% Reduction in the number of patients admitted for DRG – L63B • 25% Reduction in Average LOS for DRG – L63B • 80% of inpatients were discharged within 2 days, an improvement of 24% • 25% Reduction in Bed days used for DRG L63B • 38 Actual Bed days saved in the 6 month 2010 period • 76 Extrapolated Bed days saved in the 6 month 2010 period • An increase of 973 hits on the website for viewing of the UTI Fact Sheet in the 6 month 2010 period

  7. EXECUTIVE SUMMARY - TABLE 12 month Evaluation point 6 month Evaluation point

  8. PROJECT KPIs Initial targets set at the Project Initiation Phase Reduction in LOS for DRG - L63C patients by 30% Reduced admissions for DRG - L63C patients by 30% Demonstrated improvement in the patient experience for those patients with a typical UTI Commentary Though the Streamlining UTIs project has not met the KPI targets set it has delivered significant gains for the hospital. It is recognised that 30% reductions in number of admissions and LOS were stretch targets. Also recognised that any reduction seen in number of admissions would mean that those still requiring admission would be of a higher acuity resulting in less capacity to reduce their LOS. However, it is noted that this 12 month Evaluation identifies a 25% reduction in average LOS, close to the stretch target of 30%

  9. UTI PRESENTATIONS to ED In the Jan – June 2010 evaluation period there was a 23% increase in the number of children presenting to the ED with a typical UTI (DRG L63B) compared to the 2008 Baseline period. Source: Health-e-Care provided by CHW Emergency Department

  10. ADMITTED PATIENTS Analysis shows that despite the 23% increase in the number of children presenting and requiring treatment for UTI in the 2010 period, the percentage of children admitted with a typical UTI was 7% lower than in the 2008 baseline period. 7% Reduction in the number of patients admitted in 2010 period Source: Health-e-Care data provided by CHW Emergency Department, HIE Data provided by MSAU

  11. INPATIENTS BY LOCAL GOVERNMENT AREA (LGA) Source: HIE Data provided by MSAU Admitted Patients as per LGA for 2010 period

  12. INPATIENTS – LOS The Streamlining UTIs project implemented an evidence based change of practice that was published within theCHW Urinary Tract Infection (typical) Identification and Management Guidelines on June 23, 2009. The Guidelines contained inpatient and outpatient management including a Planned Model of Care flow chart to guide the patients journey at key clinical decision making points. The graph below shows the number of patients for each LOS for the baseline, 6 month and 12 month evaluation periods. The trend line continues to move towards the left demonstrating reducing LOS following the implementation of the Guidelines. 25% Reduction in Average LOS in 2010 period Source: HIE Data provided by MSAU

  13. INPATIENTS – LOS Significant improvements have been seen in LOS for the 2010 period, with reductions in the 3 – 5 days categories resulting in 95% of patients being discharged within 3 days compared with 80% of patients in the baseline period. Significantly 80% of patients are now discharged within 2 days compared with only 56% of admissions in the 2008 baseline period. 80% of patients now discharged within 2 days – a 24% improvement Source: HIE Data provided by MSAU

  14. INPATIENTS - AVERAGE LOS 25% Reduction in Average LOS in 2010 period Source: HIE Data provided by MSAU

  15. INPATIENTS – Bed Days(Actual) Despite a 23% increase in the number of children presenting to the ED for treatment of a UTI in the Jan – June 2010 period, the combination of a 7% reduction in percentage of children admitted and a 25% reduction in average LOS resulted in a 25% reduction in bed days used. This equates to 38 bed days in the 6 month period. 25% Reduction in Bed days used – (38 bed days) in 2010 period Source: Health-e-Care data provided by CHW Emergency Department, HIE Data provided by MSAU

  16. INPATIENTS - Bed Days (Extrapolated) If you applied the 2008 trends to the increased number of ED presentations in the 2010 period, it can be extrapolated that if a Planned Model of Care had not been implemented the number of bed days used would have been 191, however, as a result of the changes in clinical practice the actual bed days used was 115, a difference of 76 bed days. 76 Extrapolated Bed days saved in the 6 month Jan – June 2010 period Source: Health-e-Care data provided by CHW Emergency Department, HIE Data provided by MSAU

  17. BED DAYS SAVED over 12 months Evaluation of the impact of the Streamlining UTIs Project has now been done at the 6 month and 12 month point following the implementation of the projects Planned Model of Care for children with a Typical UTI. The Table at right indicates the Actual and Extrapolated Bed day savings for the 6 month and 12 month Evaluation periods. 68 - Actual Bed Days saved over 12 months 148 - Extrapolated Bed Days saved over 12 months

  18. READMISSIONS & REPRESENTATIONS Implementation of the UTI Planned Model of Care has not resulted in an increase in the number of admissions or readmissions There was an increase in the number of children representing to ED with a Typical UTI in the evaluation periods, a medical record audit on these representations to ED identified that in each case the clinical management applied was in accordance with the CHW Urinary Tract Infection (typical) Identification and Management Guidelines. Of the 6 children in 2010 who represented to ED with a UTI none went on to require inpatient admission, they were managed and discharged from ED within an average of 3hrs from time of representation.

  19. AGE OF DISCHARGED PATIENTS Throughout the Streamlining UTIs project it was acknowledged that the 3 month – 2yr age group were the most likely to present to ED with a typical UTI, as well as the most likely to require admission due to clinical needs such as fever, risk of dehydration, vomiting, not tolerating oral antibiotics etc. However, an increase in the number of discharges from ED within this age group is noted in both the 6 and 12 month evaluation periods, indicating the Planned Model of Care is able to be applied to this age group without an increase in their representations or readmissions. DRG-L63C/L63B Source: Health-e-Care data provided by CHW Emergency Department,

  20. UTI GUIDELINES Guidelines Published Source: CHW Policy and Procedure Metadata The new UTI Guidelines were published on the 23rd June 2009, the graph above indicates a significant increase in the number of occasions the new Guidelines were accessed following their publication. Sustained viewing of the new Guidelines by CHW staff is believed to be due to the Guidelines now containing inpatient and outpatient management and a Planned Model of Care Flow Chart to guide clinicians at key clinical decision making points throughout the patients journey.

  21. UTI FACT SHEET Source: Kids Health @ CHW The UTI Fact sheet, in consultation with the co-authors at Sydney Children’s Hospital and Kaleidoscope, was modified to reflect the change in clinical practice contained within the new UTI Guidelines. The chart above reflects an increase in number of hits from 3456 in the 2008 baseline period to 4429 in the 2010 evaluation period, equating to approximately 6 more hits a day on the UTI Fact sheet.

  22. CONCLUSIONS The Streamlining UTIs Project implementation has led to sustained positive outcomes for patients, their carers/parents as a result of: • Executive Sponsorship • Commitment and involvement of all CHW clinicians during each phase of the project, especially clinicians from the Emergency and General Medicine Departments • An Implementation and Communication Plan to inform and educate clinicians • Patient and carer focus throughout the project • Development of a Planned Model of Care for children with a UTI • Availability of Evidence based research to support the newly developed Planned Model of Care • Development of the CHW Urinary Tract Infection (typical) Identification and Management Guidelines which includes evidence based guidance for diagnostic , inpatient and discharge management • CHW Urinary Tract Infection (typical) Identification and Management Guidelines available as an electronic global document and includes a Flow Chart of the patient journey along with links to discharge documents • Development of a GP Letter and Fact Sheet

  23. NEXT STEPS As per 6 month Evaluation Report the following should occur: • Patient Survey to evaluate the impact of the Streamlining UTIs Project on the patient and carers journey. Survey is currently being conducted by Anna Rozario and Joyce Murphy • Further discussions on capacity of CAPAC to be utilised for patients currently being admitted • As patients with a typical UTI generally do not require management in a tertiary facility such as CHW, further discussions to occur regarding transferring of patients to their local government area hospital rather than admit to CHW • Further evaluation will occur at 6 monthly intervals to ensure sustainability, this will be undertaken by Clinical Redesign staff whilst Clinical Redesign funding exists (current Wave 2 funding expires on June 30th 2011)

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