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Ward Processes
April 2015 Dr Rachel Bradley& Caroline Daley
Ward Processes Work Stream
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Ward Processes
• Part of Transforming Care Program
• To enable all ward staff to improve quality of care
• Improve patient flow & discharge
• Right Patient, Right Place, Right Time (R3)
• Reduced length of stay
Aims of Ward Processes
Improved patient experience
Improve communication between members of the Multidisciplinary Team, patients & carers
Prioritisation of workload to address safety & flow• Sick, potential early discharges & new patients
Proactive approach towards discharge planning• Identify barriers • Implement actions & escalation
Earlier in the day discharges & use of the Discharge Lounge Increase number of criteria led & weekend discharges Based on LEAN methodology
Benefits
Improve patient safety & experience
Increase throughput & reduced length of stay
Improve Trust 4 hour target performance & trolley waits
Reduce outliers
Reduce elective surgical cancellations
Improved job satisfaction – efficient & effective team working
Patient status at a glance at ward, division and trust level
Improved resource allocation
TTA’s & Discharge Summaries
eHandover
Reverse Triage & EDD
Criteria Led Discharges
Effective Board & Ward Rounds
Goal :To improve earlier in the day discharge to Improve Patient Flow
Ward Processes
Real-TimeMedway
Weekend Plans
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Estimated Date of Discharge: Definition
Estimated Date of Discharge (EDD) is the expected date a patient recovers from their acute illness
and inpatient therapy needs
• EDD may not represent the actual date of discharge but is the ‘best guess’ if all the discharge processes flow smoothly
• It should include two working days for social services to complete their assessments
• It should include time spent at SBCH but NOT other hospitals, interim care homes or rehabilitation settings
• The term EDD should be used rather than PDD
Ward Processes
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Estimated Date of Discharge: Guidance
1. A provisional EDD should be considered on admission, then updated and set by the multidisciplinary team (MDT) within 48 hours
2. The EDD must be recorded on:• The patient status (‘white’) board on the ward• Medway - it will automatically populate the EDD on the e-Handover sheet and the trust operational reports
3. Progress towards achieving EDD should be monitored at the daily board (ward) round reviews • This should be done in conjunction with the Reverse Triage Status• Any blockages to flow must be escalated to senior staff
4. EDD should be used to engage the patient and relatives in proactive discharge planning
5. Changes to EDD should be minimal• Aim to set a realistic achievable date in the first place• Where a change is required, (due to new information or a change in the patient’s clinical condition), this must be
agreed at the daily board (ward) rounds • All changes or reasons for delays must be clearly recorded in the comments box on Medway
Ward Processes
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Terminology used on Board/Ward Rounds
• It is important to that the whole MDT communicates using the same terminology when discussing patient status and EDD
• The statements are relevant to different Reverse Triage Stages
Terminology used at Board/Ward Rounds Comments on Reverse Triage Status
Medically Fit (or optimised) for discharge patients are no longer Red or Amber
Surgically Fit for discharge patients are no longer Red or Amber
Therapy Fit for discharge patients are not light green
Team Fit – refers the UHB ward team patients may be dark green if still awaiting partner agency support
Ward Processes
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TTA’s & Discharge Summaries
eHandover
Reverse Triage & EDD
Criteria Led Discharges
Effective Board & Ward Rounds
Goal :To improve earlier in the day discharge to Improve Patient Flow
Ward Processes
Real-TimeMedway
Weekend Plans
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Reverse Triage Status & EDD
Reverse Triage Status must be used to refine a more
accurate
Estimated date of Discharge
‘Green to Go’
Ward Processes
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The Purpose of Reverse Triage
Ward Processes
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Reverse Triage
Ward Processes Work Stream
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Reverse Triage Operational Reporting
Mrs X
• The Reverse Triage Status entered on e-Handover generates a report used operationally
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Reverse Triage Operational Reporting
• Ward status at a glance visible at Divisional & Trust level
• Useful for trust bed management - especially in escalation• Clinical Site Managers• Hospital Discharge Team• Discharge lounge
• Prioritisation of resource • Diagnostics & Therapy• Social services• CDCC
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TTA’s & Discharge Summaries
eHandover
Reverse Triage & EDD
Criteria Led Discharges
Effective Board & Ward Rounds
Goal :To improve earlier in the day discharge to Improve Patient Flow
Ward Processes
Real-TimeMedway
Weekend Plans
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Effective Board & Ward Rounds
Achieve better results and improve patient flow
Reverse Triage & EDD must be done in combination with an
effective Board (and Ward) Round
Ward Processes
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RCP Effective Board Rounds
Ward Processes
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Effective Board Rounds
Location • Ideally in front of White Board. Why? • MDT focus all in one place• Patient status at a glance• Allows real-time update of information on white board• Top Tip: Open eHandover on computer and allocate someone
to update this real-time during the board round
Key members/representatives of the ward multidisciplinary team should be present • This should include a senior doctor & nursing staff, therapists, member
of Hospital Discharge Team and Social Worker
Timings• Always Start on time – don’t wait for late comers• Duration <1.5 min per patient• Approximately 15-30mins for 18 patients
Information• Nursing and medical staff must know their patients• Use eHandover as a means of joint MDT communication & update
regularly
Ward Processes
Discuss each patients key issues:
• Current main medical or surgical problems • Social background• Current functional ability on the ward• Rehabilitation potential and agreed goals• Potential care needs• EDD• Barriers to discharge/flow• Actions to address these
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Effective Board Rounds
Documentation• Key issues and clear action plans for each patient should be documented• This can be done in the medical records (gold standard) and/or on ehandover • Update Reverse Triage status and EDD on ehandover asap as this is used for
operational reporting
Mini Board Rounds• These can occur later in the day, noon & 3-4pm• Usually <15mins • Ward doctor and nursing staff minimum• Useful to update and clarify decisions from ward rounds, identify potential transfers
off the ward or prepare discharges for the next morning
Leadership• The best Board Rounds occur with good clear leadership• A designated leader should:
• Ensure that the BR keeps to time and the key issues covered • Highlight barriers to discharge • Agree action plans to tackle these• Identifies patients for transfer off ward or NOT to transfer and remain on speciality ward
• It is useful to summarise the priority tasks at the end • Ward round to review sick patients 1st , then potential early discharges and new patients• Examples of tasks; urgent TTOs, escalation of an outstanding investigation, complete section 2 or CM7, priority physio review
Ward Processes
Note:
• Board Rounds ensure better communication, patient safety and flow
• Board rounds also provide an opportunity for a Safety Brief, update on key ward issues etc.
• One size may not fit all across the trust
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TTA’s & Discharge Summaries
eHandover
Reverse Triage & EDD
Criteria Led Discharges
Effective Board & Ward Rounds
Goal :To improve earlier in the day discharge to Improve Patient Flow
Ward Processes
Real-TimeMedway
Weekend Plans
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Timely TTOS & Discharge Summaries
• Reverse Triage & EDD should predict which patients require TTOs & D/Cs
• Effective Board/Ward Rounds ensure that a proactive decision are made to prepare TTOs & D/Cs in advance of the EDD
• These must be completed before patients are able to transfer to the Discharge Lounge
• Dossette Boxes require 24hours notice
• ALL Medically/Surgically Fit patients, Light/Dark GREEN or ?HOME<24hrs Reverse Triage Status should have completed TTOs and D/Cs
• Minor adjustments can be made nearer the EDD• Update D/Cs & TTO status on eHandover
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TTA’s & Discharge Summaries
eHandover
Reverse Triage & EDD
Criteria Led Discharges
Effective Board & Ward Rounds
Goal :To improve earlier in the day discharge to Improve Patient Flow
Ward Processes
Real-TimeMedway
Weekend Plans
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Criteria Led Discharge CLD & Weekend Plans
• Some patients may be suitable for Criteria Led Discharge• Examples include if post transfusion Hb >8, after Echo, if manages stairs practice with physio
• Use the © magnet on the patient status at a glance ‘white’ board
• Update CLD status on eHandover
• Weekend Management Plan • Sticker placed in Medical Notes Friday afternoon• Useful summary of key issues• Escalation plans• Highlights potential Weekend & CLD patients
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Ward Processes Project Work 2013-2014Criteria Led Discharge CLD
• CLD under utilised at weekends • Should include Nurse Led Discharges & DC to Care Homes (supported by Brisdoc
GP weekend reviews)
• Medicine Division • Little scope to improve CLD Mon-Friday on wards in new model of care• Applied to some Day Cases such as Endoscopy
• Surgical Division • Some application already exists in Enhanced Recovery Pathways• Further potential in Day Cases & Elective Admissions
• Specialised Services • Lots of potential in cardiology• Particularly in ACS, STEMI, NSTEMI pathways
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GP Weekend Reviews
Would your patient benefit from a GP weekend review to support their discharge at the weekend?
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TTA’s & Discharge Summaries
eHandover
Reverse Triage & EDD
Criteria Led Discharges
Effective Board & Ward Rounds
Goal :To improve earlier in the day discharge to Improve Patient Flow
Ward Processes
Real-TimeMedway
Weekend Plans
Real Time Medway
Target to update <15mins on admission & discharge from Wards
Supports eHandover, bed management & reports
Reduces ED trolley waits as identifies availability of beds for admissions
Ensures correct patient location and consultant is recorded real time
More efficient Ward Rounds
Assist in better outlier management by site managers and clinical teams
Improves patient safety
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Real Time Medway
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TTA’s & Discharge Summaries
eHandover
Reverse Triage & EDD
Criteria Led Discharges
Effective Board & Ward Rounds
Goal :To improve earlier in the day discharge to Improve Patient Flow
Ward Processes
Real-TimeMedway
Weekend Plans
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E-Handover
What is it?• Electronic handover system used by ward multidisciplinary team• Separate Nursing & Medical print versions available• This should replace separate patient lists
Why should we use it?• Improves communication at ward level between all members of the multidisciplinary team• Improves efficiency - avoids duplication as auto populates patient details
• Links to eLogger used for Complex Discharges - Used by ward staff, Hospital DC Team, CDCC & Social Services
• Links to Reverse Triage Operational Report
How do I access it?• ‘Top 10’ list on the right hand side of the trust homepage• Avon Portal account username and password • Patient information needs to be updated electronically by all members of ward team
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eHandover print out
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Does Embedding Ward Processes Make a
Difference ?
Background
• Reverse Triage • One of seven Trust wide Patient Flow Projects (phase 1) • February -September 2013
• Ward Processes • A phase 2 Patient Flow project building on RT phase 1 and broadening the remit to include several
key ward processes• October 2013 – June 2014
• Breaking The Cycle Together (BTCT)• Ward processes underpins many components of the Breaking The Cycle Together Project and
SAFER Bundles• May 2014
Patient Flow Project
Projects in programme – Phase II
An additional 7 projects have been prioritised for phase II of the patient flow programme.
The project teams are in the process of mobilising the individual projects.
Each project will be run in line with the project methodology and will be overseen by the R3 : Patient Flow Project Steering Group.
Whilst a number of these projects focus on internal improvements in our patient flow, there is a higher proportion of projects that focus on improvements with partner organisations in the second phase.
Project Objectives
1. Ambulatory care • Maximise the use of ambulatory care pathways for ambulatory care conditions to reduce emergency admissions
2.Ward Processes – Including Reverse Triage, eHandover Criteria Led discharge, TTA’s & Discharge Summaries
• Proactive approach to discharge planning• Increase in number of patients discharged before midday• Increase TTAs and discharge summaries prepared day before discharge• Increase number of discharges at weekend
3. ITU - pathways
• Reduced the number of patients transferred to wards out of hours• Reduce the number of Elective operation cancellations due to ITU
availability • Tertiary referrals are repatriated to referring location within agreed
timeframes
4. Care homes• 7 day transfers to care homes• Improved timeliness from referral to transfer to care homes (including
assessment
5. Improved work with partners• Improve information sharing and joint working to smooth pathways for
patients across partner organisations • Reduce the amount of time patients are delayed in an acute hospital
setting
6. Out of hospital care• Better utilisation of community beds available for rehabilitation• Clarify the care needs of beds to support patients discharged from
hospital into community beds
7. MAU• Ensure specialty ownership of management of patients within MAU• Early supported discharge from MAU either via outpatients or Ambulatory
Care.
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Embedding Ward Processes
• Ward Processes Pilot work in 2013 • Medical wards – more embedded especially EAU & care of the elderly• Upper GI Surgery – variable results• T&O wards – ongoing focussed work becoming embedded• Cardiology – excellent results in pilot but not sustained• Children Hospital – successful RT pilot in admissions
• Lots of Communications to all staff members
• Change happens gradually and often over several steps
• Divisional & Trust support • Operational plans• Link to SAFER bundles & breaking the Cycle together
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Embedding Ward Processes
• Ward Processes have been embedded into the EAU/OPAU models of care• MDT working as standard• Gold standard Board Rounds• Prioritisation on Ward Rounds – sick, potential discharges then new patients• New OPAU opened Nov 2014• Average length of stay in Care of the Elderly has fallen from 10 in 2013 to <4 days in 2015• Positive feedback from ward staff
• Ward Processes Pilot work in Children’s Hospital Admission Unit 2013 • Increased number of discharges seen• Increased number of discharges earlier in the day• Positive staff feedback
• Ward Processes becoming embedded in new T&O Wards 2014• New Ward 602 & 604 opened Sept 2014• Increased bed base & direct admissions• Full MDT Board Rounds since November 2014
Ward Processes Project Work 2013
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New Discharge Lounge Opened
Focused Ward Process work on wards
51 & 53
New Discharge Lounge Opened
Ward Process work on EAU & COE wards
• Focussed Ward Processes work on • Elderly Admissions Unit (EAU) & Care of the Elderly (COE) wards• Cardiology wards 51&53
BCH Reverse Triage Pilot Oct 2013Discharges Before Midday
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Staff Feedback Regarding Reverse Triage, White Board Pilot on Paediatric Admission Unit Jan 2014
Q How would you rate Reverse Triage as a tool to assist with discharge planning ?0 Excellent
11 Good
8 Fair
0 Poor
Reasons stated below:
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Trauma & Orthopaedic Length of Stay
• Full daily MDT Board Rounds part of new T&O ward model of care• 30 bedded ward 14 now 2 wards 602 & 604• Small expansion in bed base permitting more direct admissions
New T&O Wards 602 & 604 opened
Full MDT Daily Board Rounds
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Ward Processes, S.A.F.E.R. and Breaking The Cycle Together
Ward Processes underpins the
S.A.F.E.R. quality standards
The S.A.F.E.R. bundles formed part
of the 2014
Breaking the Cycle Together Exercise
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FLOW at UHB
• Problems with FLOW was identified as the number one issue for UHB to address following the 2014 CQC inspection
Feb 2015 Poster Campaign
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Use of the Discharge Lounge
• Open Monday to Friday 08:30 – 20:00• 8 reclining chairs• 24 Chairs – some pressure relieving chairs• Hot food available end of April• Pharmacist on site
Voluntary Services – Home from Hospital Support
• Home From Hospital Service Launched on 1st April 2015
• Collaboration between RVS and RedCross & UHB
• Identify patients at Board/Ward Round who would benefit from this support – Integrated Discharge Hub (IDH) team member will make referral
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Ward Process work on EAU & COE wards
New Discharge Lounge Opened
Matrons Pilot ‘3 at 3’
embedding Ward
Processes
Medicine: 2013 to Current Performance Data % of Total DCs <12pm
New MAU & OPAU models of
Care
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New Discharge Lounge Opened
Surgery 2013 to Current Performance Data
New Surgical wards &
model of care
50
Cardiology & Cardiac Surgery BHI 2013 to Current Performance Data
New Discharge Lounge Opened
Focussed work on
promoting DC LoungeFocused
Ward Process work on wards
51 & 53
51
BRI & BHI 2013 to CurrentPerformance Data
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Change Management
• Some initiatives can show improvements in the short term
• However, in order to provide quality improvements that lasts improvement processes must be:
• Embedded at ward level • Supported at Divisional & Executive levels
• Important to audit performance and feedback outcome measures to all staff
• Particularly positive feedback
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Ward Performance Book
Total Discharges before 10
Total Discharges before 12
Total Discharges to the Discharge Lounge before 10:00
Total Discharges to the Discharge Lounge before 12:00
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Week Commencing Target 30
/03
/20
15
06
/04
/20
15
13
/04
/20
15
20
/04
/20
15
27
/04
/20
15
04
/05
/20
15
11
/05
/20
15
18
/05
/20
15
25
/05
/20
15
01
/06
/20
15
SLA 378 378 378 378 378 378 378 378 378 365Actual 406 97 - - - - - - - -Average LOS 5.1 5.7 3.8 - - - - - - - -Discharges before 10am 48 20 1 - - - - - - - -Discharges before 12am 33% 18.5% 17.0% - - - - - - - -Transfers to Discharge Lounge before 10am 2 1 - - - - - - - -Transfers to Discharge Lounge before 12am 19 4 - - - - - - - -BRI ED SLA 1284 1333 1304 1316 1208 1297 1237 1302 1245 1285BRI ED Attendances 997 396 - - - - - - - -BRI 4 hour performance 95% 95.9% 96.0% - - - - - - - -BRI ESC 1&2 performance 98% 98.6% 98.4% - - - - - - - -BRI ESC 3 performance 80% 86.2% 87.7% - - - - - - - -
Average LOS 1 1.1 0.9 - - - - - - - -Total Discharges 66 18 - - - - - - - -Discharges before 10am 9 1 - - - - - - - -Discharges before 12am 16 5 - - - - - - - -Transfers to Discharge Lounge before 10am 1 1 - - - - - - - -Transfers to Discharge Lounge before 12am 7 3 - - - - - - - -
Average LOS 3 3.4 2.7 - - - - - - - -Total Discharges 2 - - - - - - - - -Discharges before 10am 2 0 - - - - - - - -Discharges before 12am 3 0 - - - - - - - -Transfers to Discharge Lounge before 10am 0 0 - - - - - - - -Transfers to Discharge Lounge before 12am 1 0 - - - - - - - -
Average LOS 5 5.5 4.2 - - - - - - - -Total Discharges 5 - - - - - - - - -Discharges before 10am 2 0 - - - - - - - -Discharges before 12am 3 0 - - - - - - - -Transfers to Discharge Lounge before 10am 0 0 - - - - - - - -Transfers to Discharge Lounge before 12am 2 0 - - - - - - - -
Average LOS 5.6 5.9 4.6 - - - - - - - -Total Discharges 1 - - - - - - - - -Discharges before 10am 0 0 - - - - - - - -Discharges before 12am 2 0 - - - - - - - -Transfers to Discharge Lounge before 10am 0 - - - - - - - - -Transfers to Discharge Lounge before 12am 2 - - - - - - - - -
Average LOS 12 10.0 8.5 - - - - - - - -Total Discharges 2 - - - - - - - - -Discharges before 10am 0 0 - - - - - - - -Discharges before 12am 1 0 - - - - - - - -Transfers to Discharge Lounge before 10am 0 0 - - - - - - - -Transfers to Discharge Lounge before 12am 1 0 - - - - - - - -
Average LOS 4 4.8 4.0 - - - - - - - -Total Discharges 9 - - - - - - - - -Discharges before 10am 3 0 - - - - - - - -Discharges before 12am 3 1 - - - - - - - -Transfers to Discharge Lounge before 10am 0 0 - - - - - - - -Transfers to Discharge Lounge before 12am 1 0 - - - - - - - -
Average LOS 13.9 11.1 8.8 - - - - - - - -Total Discharges 0 - - - - - - - - -Discharges before 10am 1 0 - - - - - - - -Discharges before 12am 2 - - - - - - - - -Transfers to Discharge Lounge before 10am 0 - - - - - - - - -Transfers to Discharge Lounge before 12am 1 - - - - - - - - -
A900
B301
B501
B404
A400
Divisional Position
A515
A300
Medicine Ward KPI’s
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Summary
Aims of Ward Processes
Improved patient experience
Improve communication between members of the Multidisciplinary Team, patients & carers
Prioritisation of workload to address safety & flow• Sick, potential early discharges & new patients
Proactive approach towards discharge planning• Identify barriers • Implement actions & escalation
Earlier in the day discharges & use of the Discharge Lounge Increase number of criteria led & weekend discharges Based on LEAN methodology
57
Conclusion
There is no single component that improves Flow
A combination of different improvement processes can increase efficiency and effectiveness
Different wards have different strengths and weaknesses
It is important for the ward team to identify the key challenges in need of improvement
A toolkit of Ward Processes available
Key outcome measures
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Any Questions?
Any Questions?