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1
2013
]
[Type the company name]
W A Health Royal Perth Hospital
Fremantle Hospital Sir Charles Gairdner Hospital
Day of care surveys
2
Introduction 3
Examples of actions from previous surveys 7
Summary 8
How to organise site surveys 10
How the survey was adapted for WA 11
How to do the survey 12
Survey algorithm 16
Top tips for reviewers 17
Chart 1: appropriateness criteria 18
Charts 2, 3 and 4 19
Data collection sheet 20
How are results presented? 21
Results: Royal Perth Hospital 22
Results: Fremantle Hospital 28
Results: Sir Charles Gairdner Hospital 34
Summary 42
Acknowledgements 43
3
Introduction
Why is this topic relevant?
Ensuring emergency access to acute health services is a challenge for many countries.
Emergency access efficiency is commonly measured through emergency department (ED)
overcrowding statistics or estimates of patient time spent within EDs. International evidence
suggests that lack of timely access to inpatient beds is one of the main reasons for ED
overcrowding: this problem has been termed “access block”.
Addressing access block requires improvements in systems and processes for inpatient flows
in acute hospitals to create capacity and ensure patients receive timely clinical treatment
from appropriate clinical teams in the correct location. Improving inpatient flow is
nevertheless a complex issue dependent upon action at many levels within acute,
community and social care sectors.
How was this survey developed?
The standard for emergency access in NHS Scotland is that 98% of patients will wait less than
four hours from arrival in the ED to admission, discharge or transfer for treatment (95% in
NHS England). At times over the last few years when the percentage of patients in Scotland
reported as breaching the standard and waiting more than four hours has shown an increase,
it has been found from analysis of “4 hour breaches” that the most frequent cause for this is
”waiting for a bed” .
4
As part of a raft of actions developed at national level in Scotland to support system-level
understanding of the nature of delays within acute care, a Day-of-Care Survey (DOCS)
method has been developed to identify areas of clinical care or subsets of patients where
there might be benefit from alternative service provision or reconfiguration of services.
The method is based on review of medical records against a range of 28 clinical criteria. It
identifies patients who do not meet these criteria set for acute hospital care and highlights
where delays are occurring across the system. The criteria can be applied at a single point in
time, such as a single day, or can be used multiple times on sequential days with the same
patients. It is not intended to determine decisions on discharge of individual patients, but to
identify problems in the hospital or health system.
Starting from an “Appropriateness Evaluation Protocol” originally developed in the 1980’s a
National Expert Working Group developed the criteria and survey tool for present day
hospital care using a variety of methods, including collecting expert opinion, assessing 89
consecutive patients admitted to an acute hospital and measuring them against the criteria
on a daily basis, and testing and receiving feedback on the criteria and methodology at four
hospitals. This resulted in the development of a set of criteria with 12 “severity of illness”
variables, covering derangements in physiological parameters, and 16 “service intensity”,
reflecting levels of clinical interventions, prescribed treatments and clinical characteristics
according to history, examination and laboratory investigations. These have been tested
prospectively in over 2,500 acute hospital in-patients at 5 sites in Scotland and one in
London.
Previous research had found that location of patients outside of the relevant specialty unit
(usually known as “outlying” or, in Scotland, “boarding”) had a significant association with a
5
higher incidence of inappropriate stay. Testing of the criteria in Scotland revealed a similar
pattern, with outlying/boarding patients often not meeting the criteria for acute care. This
element was therefore added to the data collection methodology. .
Surveying using the criteria is a simple, reproducible process that can be conducted by a
combination of clinicians and personnel who are not necessarily directly involved in frontline
acute care (non-health care professionals such as social workers and managers). To promote
the credibility of results, we recommend that each ward be surveyed by a senior doctor (not
responsible for the inpatients surveyed) accompanied either by a nurse, allied health
professional (AHP) or manager. Results in older people’s wards are optimised if geriatricians
review inpatients with either a senior nurse/AHP with specialist interest in older people’s
rehabilitation and, if possible, a senior colleague from social care.
Preparation of staff involved in the survey is crucial, but a 15-minute briefing on the
afternoon prior to the survey is normally sufficient. Once prepared and engaged, staff are
able to perform surveys on an ongoing basis. The survey process itself is not lengthy, taking
up to one hour per ward of 30 beds.
Only one criterion has to be satisfied for the day of care to be deemed “appropriate”:
patients who do not meet a single criterion are deemed “inappropriate” for the day of care.
Survey teams have the option of over-riding the protocol in either direction if the objective
criteria appeared to give an erroneous or counter-intuitive result.
Whilst the survey in Scotland and England found six of the top-10 reasons for non-discharge
were influenced by factors outside the acute hospital (lack of community hospital bed, for
instance), four were hospital-related (awaiting AHP assessment or consultant decision and
review, for example). This reinforces the understanding that delays to discharge are not
6
exclusively related to factors external to the hospital (as if often assumed), but indicate
blockages within hospital systems that need to be addressed.
Why would you do a day of care survey?
The aim of the survey is to generate action to address blockages within acute hospitals through
improving internal processes and engaging with partners to reduce delays in accessing community
and social care. The hospitals involved in DOCS in Scotland and England have subsequently employed
a range of techniques and actions to drive improvement to reduce delays.
7
Examples of actions generated from DOCS results at UK sites
Clinicians at one hospital believed that delays for patients waiting for beds was due to
the active need for acute care of all current inpatients. The DOCS results, however,
indicated that 25% of current inpatients were experiencing discharge delays, with
significant numbers waiting for community hospital beds. The hospital used these
data to develop a better understanding of the community capacity required to
provide timely care from the appropriate team.
The DOCS at another site found delays to completion of AHP treatment plans.
Subsequent AHP investigations revealed that their record-keeping system had not
been making completion of treatment clear, and steps have been taken to rectify this.
A large teaching hospital used a feedback session with the 50 staff involved in the
DOCS to further develop relationships among acute, community and social care
colleagues.
A district general hospital now uses the DOCS criteria daily to assess if any patients
with a length of stay of over 14 days requires acute care and, if not, what needs to be
“unblocked” to ensure that the patient pathway of care is seamless and timely.
Another hospital is using the criteria to engage commissioning partners in providing
appropriate “step-down” care.
8
Summary of day of care methodology
The DOCS provide a snapshot of hospitals’ inpatient status at a particular point in time that
enables organisations to identify the sources of delay in inpatient flows and take appropriate
action. Experience to date in hospitals in Scotland has shown that the DOCS method:
offers a simple, easily understandable approach that involves minimal preparation for
staff and can be carried out over short time periods with minimum disruption to
clinical services
is proving to be valid and reliable
provides immediate access to core data such as age spread of the hospital population
and length of stay
creates useful insights, such as recognition that patients who have been in hospital
for 14 days have a high chance of not meeting the DOCS criteria and that criteria are
less likely to be met with increasing patient age
presents opportunities to improve patient flows by identifying sites of delays and
supporting the development of solutions
creates local ownership of data and, subsequently, solutions.
DOCS have now been undertaken in acute hospitals of differing size and character in
Scotland and England. Expertise to support future iterations is developing at hospital level
and understanding of the reasons for blockages to inpatient flows is increasing locally and
nationally. The hospitals are now planning to embark on an iterative process of regular
surveys to inform patient-flow management.
9
The process in Scotland has been managed centrally by the Performance Support Team at
the Scottish Government, who have worked with participating hospitals to set up, conduct
and report on the initial surveys, but the intention now is for Scottish acute hospitals to
conduct the surveys independently to a schedule devised to meet local needs.
10
How to organise site surveys
Guidance to Hospitals
Identify Executive Lead for the Survey to be contact point for receiving final report. (will be undertaken as part of overall feedback on the day and included in final report for all sites in Perth)
Identify a small group to work with the visiting team in validating and finalising the report. This should include the senior clinician and senior manager with responsibility for the site surveyed.
Identify and allocate survey teams to the individual wards
Survey teams preferably should include a consultant or senior doctor with a senior manager/nurse/AHP (in older people wards there may be is benefit in including social work.
Each team can review sixty in-patient beds, with the exception of older people wards which require one team for 30 beds
Consultants should not survey their own wards, and geriatricians should be allocated to survey older people wards
Allocate a central control room on each site and as a gathering point for the survey teams A 30 minute brief on how to complete the data collection will be included with the site briefing visit at your hospital.
On the day of the survey, teams meet at a central location at 7.30am and are provided with a final brief, relevant paperwork and a contact number to call for queries during data collection.
Survey starts at 0800am to ensure minimal interference with clinical work and reduce risk of double counting patients. Most teams should complete the survey within an hour.
The provisional report will be part of the overall feedback on the day
Provide a list of agreed abbreviations for consultant staff
Provide a list of ward numbers/names, bed numbers, designation of beds and consultant ward allocation for each site
Visiting Team
Provide a verbal brief for the survey teams
Contribute to the data collation
Develop a short presentation of the invalidated data for feedback on the day
Provide a team to work on site with the local team
Develop Graphs and Tables for the report
Provide a narrative for the final report
11
How was the survey adapted for on-site use in Western Australia?
An original version of the survey documentation was sent to WA health for consideration
ahead of the UK team visit. A minor number of changes were discussed and agreed, to take
account of general variations in practice and terminology between UK and WA settings. All
the documentation and a blank version of the data collection and analysis software were
sent to WA Health and distributed to the co-ordinators at the 3 sites. The documentation
was then distributed to the local review team members. Short site briefings were made by
the UK team at each site as part of the introductory presentation. The surveys were overseen
by a physician team member from the UK who chaired a National Working Group in Scotland
that developed the DOCS. The UK team provided a data analyst who had used the DOCS in
Scotland and additional data entry was done by HSIU staff on site. Results were collected,
analysed and presented to participating sites in the course of a single day. Detailed results
were included in the UK team final report.
12
How to do the survey
WA HEALTH
DAY OF CARE SURVEY
August 2013
OVERVIEW
Section A Guidance on organisation, administration and implementation
Section B Guidance for survey teams
Section C Charts and criteria
Section D Data Collection sheet
13
Section A
Pre Survey
Identify a Hospital Site Coordinator for the Survey This person should be available to coordinate the survey at each hospital as below and will provide advice to the teams and as a communication link to the UK Team for advice Royal Perth Hospital 0730-1200 hrs Thursday 1 August 2013 Fremantle Hospital 0730-1200 hrs Friday 2nd August 2013 Sir Charles Gairdner Hospital 0730 -1200 hrs Monday 5th August 2013 This person should:-
Attend the Site Briefing on Wednesday 31st July as per the schedule for each hospital
Be available at the 0730 briefing on day of audit at each hospital
Remain in the meeting room throughout the survey to liaise with teams and receive completed data collection sheets
Identify the Site Survey Teams prior to Site Briefing on Wednesday 31st July It is important that the survey teams attend these briefings to understand what is required from the case notes review
The Hospital Survey Coordinator should provide the following:- Meeting Point location of UK Team Room to DoH Meeting Point 0730 Briefing and UK Team Room location to Site Survey Teams List of current ward numbers/names/location to Survey Teams and UK Teams
Day of Survey 0730 briefing Meeting
The Site Survey Teams should attend the 0730am briefing at [Each Hospital to provide Meeting point/location to DoH} to receive:
Day of Care Survey Charts and Data Collection Sheets for each team
List of ward allocations for Survey Teams
Contact phone number for advice or issues
Receive advice on using the Data Collection Tool
Each survey team should collect a ward list from the ward clerk when they arrive on the ward to ensure they capture all patients in the ward on the day of the survey
0800-0900
A UK Team with one Survey Team (Senior Nurse and Senior Doctor) commence a survey in the Emergency Department followed by one medical ward followed by one surgical ward (wards can be chosen by hospitals) 0800-0900
All hospital survey teams commence survey in all other wards as allocated All Survey Audit Teams return their data collection tools for each ward they have completed to the central meeting room once survey completed. It is important that at least one member of each team is present to give verbal feedback as well as handing in the data sheets.
If teams require advice during the survey they can ring [hospital to provide Ph number or mobile contact number of Hospital Survey Coordinator]
14
Section B:
Guidance for Survey Teams
What is the Day of Care Survey?
The Day of Care Survey provides a snapshot in time of the inpatients present within your hospital using a tool based on revision of the Appropriateness Evaluation Protocol (AEP).
Each inpatient is assessed by a consultant and either a senior nurse, a manager, an allied health professional or a social worker through simultaneous review of the patient’s case notes.
You record your assessment on an accompanying Data Collection Sheet as you progress.
Two issues should be uppermost in your mind as you complete the survey:
the current treatment regime should not be questioned it is very important to document the patients’ date of
admission and date of birth.
How is the Survey carried out? The survey consists of four charts that provide the criteria against which you review the patients’ notes. It is completed by:
1. having a short discussion with the nurse in charge of the ward 2. reviewing the notes 3. considering the criteria 4. recording observations on the Data Collection Sheet.
How do I use the charts? Chart 1. Severity of illness and service intensity (to be completed for all patients)
You use this chart to assess the patient’s “appropriateness” as an inpatient.
If the patient is definitely to be discharged today, place a tick in the “discharge today” box and go to Chart 4: Outliers A patient only needs to meet one of the criteria defined in the chart to be assessed as “appropriate” for inpatient care. Once one criterion has been met, tick the “Chart 1: Met” box in the Data Collection Sheet. If the patient does not meet any of the criteria, tick the “Chart 1: Not Met” box. You can use your clinical discretion to override the criteria, either way. For instance, a patient might not appear to meet the criteria (in which case, “Chart 1: Not Met” would normally be ticked), but the case note review and your clinical judgment and/or
15
discussion with ward clinicians suggests that the patient is in fact “appropriate” for inpatient care. In that case, tick the “Override: Appropriate” box. If the override is used, please explain your reasons on the collection tool and note it to the UK Survey Team at the end of the survey.
For patients who met a criterion but were overridden as “inappropriate”, proceed to complete charts 2 and 3. If you find a patient is appropriate for acute rehabilitation but is located in a specialist bed, tick the “Chart 1: Not met” box, making a note on the Data Collection Sheet as you do so. If you find a patient is appropriate for acute rehabilitation and is located in a rehabilitation bed, tick the “Chart 1: Met” box and move to the next patient’s notes. For all patients, complete “Chart 4: Outliers”.
Chart 2: Reason Not Discharged (or transferred) [for patients not meeting any criteria from chart 1, and therefore deemed “inappropriate”] Use this chart to identify the reason patients who have not met the criteria, or who were overridden as inappropriate, have not been discharged. If the reason is not on the chart list, please specify the “Other” option (code “T”) and provide the reason. Then move to Chart 3.
Chart 3. Alternative place of care Use this chart to identify the most appropriate alternative place of care for patients who have not met the criteria or who were overridden as inappropriate If you find the most appropriate place is not covered by Options A-C, Select “D” (“Other”) and specify the location. Then move to Chart 4
Chart 4. Outliers (to be completed for all patients) Please identify “outliers” by parent specialty. If you find the parent specialty is not covered by options “M”, “O” or “S”, please select “A” (“Other”) and specify the parent specialty.
Once you have completed all the Data Collection Sheets for the patients in your allocated ward/s PLEASE RETURN IT TO THE SURVEY COORDINATOR IN THE [hospital to provide location point]
A flowchart summarising the process described above is shown overleaf, followed by some “top tips” to help you complete the survey.
16
Day of Care Survey algorithm and data collection guide
Start the process again with next patient’s notes
Start
Met criteria
Clinical override used?
No
Yes (Overridden)
Is patient being No discharged
today?
Use Chart 1: Does the
patient meet Day of Care
Criteria?
Use Chart 2 to record reason not discharged
Use Chart 3 to record alternative place of
care
Use Chart 4 to record if patient is an Outlier
Yes
Not met criteria
Clinical override used?
No
Yes (Overridden)
Tick discharge today
Move to Chart 4
17
Top tips for day of care survey teams
Use of an early warning score (such as Modified Early Warning System (MEWS) score) and the patient medicines chart as a quick way to identify severity of illness variables and treatment variables.
Teams can ask the ward manager or senior nurse to be present during the survey as they
often have background information or answers to questions that cannot easily be obtained from the case notes.
It is quicker to do the survey from the case notes rather than going to individual bed spaces.
If a ward clerk is available ask them to check the next case note trolley in the sequence to
ensure that the notes are present as this will speed up the process.
Survey teams should resist the temptation to get too interested in the individual clinical condition or in the assessment of whether any particular treatment is appropriate. Concentrate on finding a positive criterion as soon as possible and moving on to the next patient.
It is not necessary to document how many criteria the patients meet or which ones, just that
they have met at least one.
Patients with no criteria met will take longer to because all the criteria will need to be checked
Clearly identify patients being discharged on the same day.
Use your clinical judgment (in pairs) to make decisions about over-riding the criteria when
necessary. Some explanation of the clinical over-ride will be needed
Record the consultant initials to enable analysis about level loading of in- patient workload.
Recording the date of birth enables analysis of age as a variable. It is not for patient identification.
It is important to record any beds that are empty or closed. (A patient is not allocated to the
bed; not just patients away from their bed for procedures/diagnostics)
It is very important to survey patients who are not in a recognised bed space, such as those who have been in the emergency department for more than four hours waiting for an in-patient bed and inpatients (over census patients) accommodated in day areas or other areas who would be in an in-patient recognised bed space if available
18
Section C Day of Care Survey Charts and Criteria
If patient is definitely for discharge today, record this and go to chart 4 “Outliers”
Chart 1: “Appropriateness” Charts
Code No
Descriptor Clinical Criterion
1 Acute or ongoing deterioration in conscious level
2 Acute or ongoing new confusion
3 Acute neurological deficit, including stroke within 72 hours
4 Acute coronary syndrome confirmed or suspected
5 Acute dysrhythmia with haemodynamic disturbance
6 Pulse rate <50 or >100
7 BP systolic <90
8 Phase IV hypertension
9 Active bleeding
10 Transfusion due to blood loss
11 Temperature <35º or >38º
12 Arterial pH <7.3 or pH >7.45
13 Na <123 or >150
14 K <2.5 or >6.0
15 Acute kidney injury (renal impairment)
16 Post-operative ileus
Service intensity that requires access to acute hospital
1 Therapy Requires IV, IM or subcutaneous medication (that cannot be
delivered at home/in the community)
2 Therapy Receiving treatment or new/experimental treatment requiring
frequent dose adjustments or medical monitoring under direct medical supervision
3 Procedure Surgical procedure today that is not suitable for day case
4 Procedure Invasive procedure not suitable for day case (e.g. some
interventional radiology, some guided biopsies, etc.)
5 Monitoring Vital sign monitoring every hour or more frequently
6 Monitoring Chemotherapy requiring constant supervision
7 Monitoring Requires accurate input/output fluid balance measurement
8 Respiratory Requires continuous oxygen, non-invasive ventilation or intensive nebuliser therapy that cannot be delivered at home
9 Fluid/nutrition To establish complex nutritional support, including enteral feeding
10 Fluid/nutrition Requires intravenous fluids (that cannot be delivered at home/in the community
11 Recovery Immediate post-operative recovery phase from therapy/procedure covered in 2 and 3 (above), including need for complex dressings/wound drainage (that cannot be delivered in the community/at home)
12 Investigation Requires multiple investigations for urgent diagnosis
19
Chart 2. Reason not discharged
A Awaiting Social work allocation/Assessment/Completion of Assessment
B Awaiting Alterations home modification to equipment/housing
C Waiting for Home Care Support/ community services(HACC1 MOW2) TCP3
D Awaiting place in Care in Residential Aged Care Bed
E Awaiting General Hospital Bed
F Awaiting/planned repatriation to other hospital- Rural Health Region
G Awaiting care in another Tertiary Hospital (Single Service4)
H Vacancy available in a aged care residence of choice/discharge planning in progress
I Awaiting final multi-disciplinary decision
J Awaiting procedure/investigation/results and not meeting criteria for acute care
L Awaiting Consultant decision/review
M Delay due to relatives
N Delay due to transport
S Waiting Allied Health Assessment/treatment – specify which Allied Health Service
T Other – Please specify
Chart 3. Alternative place of care
A At home - HITH, RITH, Post Acute Care Community Care
B Outpatients follow up
C Non acute area of care (Over Census Patient Area)
D Other – Please specify
Chart 4. Outliers
N Not an outlier
M Medical
O Orthopaedic
S Surgical
A Other – please specify
1 Home and Community Care Services
2 Meals on Wheels
3 Transition Care Package
4 Tertiary care provided in only one of the adult tertiary hospitals
20
Section D
Data Collection Sheet
Ward
Total Number of Bed Beds Closed (empty and cannot be used)
Date
Total Number of patients
Number of Outliers
Chart 1 Clinical Override
Chart 2 Chart 3 Chart 4
Date of Birth
Co
nsu
ltan
t
Init
ials
Date of Admission
Discharge Today
Met Not met
Ap
pro
pri
ate
Inap
pro
pri
ate
Reason not discharged
Alternative Place of Care
Outlier
21
How are the results presented?
Results for each of the 3 WA hospital sites are presented separately in the order in which
the surveys were carried out. Locally provided information of ward lists, bed complement
and reviewer allocation precedes each set of results.
Raw data is not included but has been retained in case any further reconciliation is needed.
Summary charts are presented for key variables such as age and length of stay. These are
presented in the same order in each set of results. Chart labelling should be self-
explanatory.
Patients identified for definite discharge are excluded from further analysis with the
exception of chart 4 (outliers). Ward specific charts are displayed as both actual numbers of
patients and as proportions for comparison. Note that some wards/areas have small
numbers of patients.
The only location identified as a rehabilitation area was ward 3K at Royal Perth. In the UK
we record patients in such a facility as being “appropriate” if they are receiving
rehabilitation, regardless of whether they meet the acute care criteria. In other words in the
UK, we would “over-ride” a “not met criteria” patient as “appropriate”. As we were not
aware that ward 3K was a defined rehabilitation facility in advance of the survey, the results
should not be used for comparison with other wards.
22
Results of day of care survey
Royal Perth Hospital
Thursday 1 August 2013
23
List of Wards and Beds RPH for Day of Care Audit - UK Survey as of 01 August 2013
Time : 0730-0800 - Audit debrief
0800-1000 - Audit Hospital RPH
Ward Ward Name Total beds
Active beds
Inactive beds Senior Nurses Senior Doctor/Registrar
3K 3K GERIATRIC/GEM UNIT 17 17 0 Glenda Jacoby Yuen Leow
4F 4F CARDIOLOGY 20 20 0 Carl Donaghue Aref Arjomand
CTUP CARDIAC TELEMETRY UNIT 5 5 0 Carl Donaghue Aref Arjomand
10A 10A MEDICAL ONCOLOGY 30 30 0 Sala Nanthakumar Ash Gurumurthi
10C 10C IMMUNOLOGY 10 10 0 Trevor Cherry Patricia Martinez
5A 5A IMU TEAM 1 AND TEAM 3 - Internal medicine 21 21 0 Sam Morgan Hassan Kamalddin
5B 5B IMU TEAM 2 AND TEAM 3 - Internal medicine 21 21 0 Vanessa o'Connell Rita Malik
5E 5E IMU TEAM 4 AND TEAM 5 - Internal medicine 26 26 0 Dave Hughes Mark Donaldson
5G 5G ORTHOPAEDIC 30 30 0 Sharon Birchenough Ivan Lau
5H 5H ORTHOPAEDIC/NEUROSURGERY 30 30 0 Kathy Young Trishna Bhalla
6A 6A NEPHROLOGY 21 21 0 Kathy Sims Ricki Arenson
6G 6G CARDIOTHORACIC/VASCULAR 31 31 0 Kerry Stokes Kate Kloza
6H 6H PLASTICS/ENT 30 30 0 Mel Murrell Chris West
7A 7A GENERAL SURGERY 34 34 0 Brycelynn White Cecilia Wee/Jose Cid-Fernandez
8A 8A NEUROLOGY / STROKE 38 38 0 Annita House Manreet Randhawa
9A 9A DGM 19 19 0 Gillian Watt Sherman Picardo
9B 9B DGM 19 19 0 Isabelle Brewer Shelina Mahbub
9C 9C RENAL/RESPIRATORY 30 30 0 Noela Pascoe Richard Warren
AAU ACUTE ASSESSMENT UNIT 33 33 0 Andrea McFaull Stephen Wright
STU 3G STATE MAJOR TRAUMA UNIT 26 26 0 Donna Coutts-Smith Nicola Sandler
STUA 3G STATE MAJOR TRAUMA UNIT HIGH ACUITY 4 4 0 Donna Coutts-Smith Nicola Sandler
AGSU 7A/AGSU ACUTE GENERAL SURGERY UNIT 8 8 0 Brycelynn White Cecilia Wee/Jose Cid-Fernandez
Grand Total 503 503 0
ED Inpatient and breach patients Tim Leen Carolyn Wilson
24
Summary: Royal Perth Hospital
Bed occupancy 97.7%
Number of beds in survey (allocated beds) 512
In-patients surveyed 500
Beds closed 12
Patients being discharged today 48
AEP criteria for day of care not met 99
Criteria not met, alternative "home" 24
Criteria not met, alternative "non-acute bed" 31
Criteria not met: L.O.S. 7 days 51
> 7 days 48
Bed numbers
Total beds in survey 512
Bed closed 12
Beds empty 9
Admitted greater than 24hrs before day of audit 364
Admitted less than 24hrs before audit 136
Missing admission dates 0
Total 500
Discharges
Patients being discharged today 48
AEP Criteria for day-of-care
Met and not over-ridden 348
Not met but over-ridden (appropriate stay) 5
Missing (assumed met) 0
Sub-total (met) 353
Not met and not over-ridden 99
Met but over-ridden (inappropriate stay) 0
Sub-total (not met) 99
Total 452
Not met criteria
All inpatients excluding discharges 452
Criteria not met % (excluding discharges) 21.9%
Outliers Total 44
Percent 8.8%
25
0
5
10
15
20
25
30
35
40
3K
4F
CT
UP
5A
5B
5E
5G
5H
6A
6G
6H
7A
8A
9A
9B
9C
10
A
10
C
AA
U
AG
SU
ED
EM
W
ST
U
Nu
mb
er
of
pa
tien
ts
Ward
AEP met by ward
Sum of AEP MET TOTAL Sum of NOT MET TOTAL Sum of missing AEP
Excludes patients being discharged today.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
AAU 6G AGSU 6A EMW 7A 9B 6H 9C 5H 5A 10A STU 5G 5B 4FCTUP
10C 9A 8A ED 5E 3K
% of AEP MET % of NOT MET
Excludes patients being discharged today. % of AEP met by ward
Royal Perth Hospital
26
0
10
20
30
40
50
60
70
80
90
100
0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90+
Nu
mb
er
of
pa
tien
ts
Age band
Age profile of patients in survey
Sum of AEP MET TOTAL Sum of NOT MET TOTAL Sum of missing AEP
Excludes patients being discharged today.
0
50
100
150
200
250
0 days 1-3 days 4-7 days 8-14 days 15+ days
Nu
mb
er
of
pa
tien
ts
Length of stay (days)
Length of stay for all patients
Sum of AEP MET TOTAL Sum of NOT MET TOTAL Sum of missing AEP
Excludes patients being discharged today.
Royal Perth Hospital
27
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
At home Non acute area of care Other – please specify Outpatients follow up #N/A
Pe
rce
nta
ge o
f p
ati
en
ts
Alternative place of care
Alternative place of care for patients not meeting AEPExcludes patients being discharged today.
Royal Perth Hospital
28
Results of day of care survey
Fremantle Hospital
Friday 2 August 2013
29
Beds on multiday wards at FH 14 Jul 2013
snapshot
Hosp FH
Row Labels WardNme Total beds Active beds Inactive
beds
Aged Care/Rehab 36 36 0
GEM Geriatric Evaluation 10 10 0
V5 V5 Restorative Rehab 26 26 0
Critical Care 22 21 1
B8N B8N Cardiothoracic 22 21 1
General 252 252 0
ASU ASU Acute Surg Unit 15 15 0
B7N B7N - Surgical Specs – Plastics, ENT, Oral surgery, Colorectal, Gastro
31 31 0
B7S B7S - Orthopaedics 31 31 0
B8S B8S - General Surgical and Vascular 31 31 0
B9N B9N - Haematology/ Oncology and General Med 27 27 0
B9S B9S - General Medical and Renal 31 31 0
CDU ED CDU Clin Dec Unit 10 10 0
MAU MAU Medical Assess 24 24 0
SSSUO Short Stay Overnight 14 14 0
V6
V6 - General Medical
38 38 0
Grand Total 310 309 1
30
Bed occupancy 98.9%
Number of beds in survey (allocated beds) 350
In-patients surveyed 346
Beds closed 0
Patients being discharged today 39
AEP criteria for day of care not met 78
Criteria not met, alternative "home" 35
Criteria not met, alternative "non-acute bed" 9
Criteria not met: L.O.S. 7 days 24
> 7 days 55
Bed numbers
Total beds in survey 350
Bed closed 0
Beds empty 13
Patients not allocated beds (on trolleys) 12
Admitted greater than 24hrs before day of audit 271
Admitted less than 24hrs before audit 75
Missing admission dates 0
Total 346
Discharges
Patients being discharged today 39
AEP Criteria for day-of-care
Met and not over-ridden 225
Not met but over-ridden (appropriate stay) 18
Missing (assumed met) 1
Sub-total (met) 244
Not met and not over-ridden 54
Met but over-ridden (inappropriate stay) 10
Sub-total (not met) 64
Total 308
Not met criteria
All inpatients excluding discharges 307
Criteria not met % (excluding discharges) 20.8%
Outliers
Total Outliers 45
% of patients outlying 13.0%
Summary Figures: Fremantle Hospital
31
0
5
10
15
20
25
30
35
AM
ITY
AS
U
B7N
B7S
B8N
B8S
B9N
B9S
CD
U
ED
EN
DE
AV
OU
R
GA
GI
GE
M
MA
U
SS
SU
O V5
V6
Nu
mb
er
of
pa
tien
ts
Ward
AEP met by ward
Sum of AEP MET TOTAL Sum of NOT MET TOTAL Sum of missing AEP
Excludes patients being discharged today.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
CD
U
END
EAV
OU
R
GA
GI
MA
U
ASU
SSSU
O
B7
S
GEM B9
N V5
B8
N
B8
S
ED
B7
N V6
B9
S
AM
ITY
% of AEP MET % of AEP NOT MET
Excludes patients being discharged today. % of AEP met by ward
Fremantle Hospital
32
0
10
20
30
40
50
60
70
80
10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90+
Nu
mb
er
of
pa
tien
ts
Age band
Age profile of patients in survey
Sum of AEP MET TOTAL Sum of NOT MET TOTAL Sum of missing AEP
Excludes patients being discharged today.
0
20
40
60
80
100
120
140
0 days 1-3 days 4-7 days 8-14 days 15+ days
Nu
mb
er
of
pa
tien
ts
Length of stay (days)
Length of stay for all patients
Sum of AEP MET TOTAL Sum of NOT MET TOTAL Sum of missing AEP
Excludes patients being discharged today.
Fremantle Hospital
33
0 2 4 6 8 10 12
Making choices / awaiting place of availability in care home
Home care support availability / funding
Awaiting consultant decision/review
Waiting for AHP assessment / treatment
Number of patients
Rea
so
n n
ot
dis
ch
arg
ed
Reason not discharged in patientsExcludes patients being discharged today.
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
At home Non acute area of care Other – please specify Outpatients follow up #N/A
Pe
rce
nta
ge o
f p
ati
en
ts
Alternative place of care
Alternative place of care for patients not meeting AEPExcludes patients being discharged today.
Fremantle Hospital
34
Results of day of care survey
Sir Charles Gairdner Hospital
Monday 5 August 2013
35
Beds on multiday wards at SCGH 14 Jul 2013 snapshot Hosp SCGH
Values
Row Labels WardNme Total beds Active beds Inactive beds
Aged Care/Rehab 35 35 0
C17 GERIATRIC EVALUATION AND MANAGEMENT UNIT 14 14 0
GRU GMED 6 21 21 0
General 409 406 3
C16 GMED 8 & 9 30 30 0
G41 CARDIOLOGY 14 14 0
G51 ORTH/NEUROLOGY 30 30 0
G52 NEUROSURGERY 27 27 0
G53 ORTHO/RHEUMATOLOGY 30 30 0
G54 RESP MED / PULM PHYS 28 28 0
G61 GMED 1,3&5/DRAC 30 30 0
G62 CARDIOTHORACIC/VASC 24 24 0
G63 RENAL/GSUR 5/GAST/TRANSPLANT 30 30 0
G64 ENT/OPHT/PLAS 18 18 0
G66 NEUROSURGERY/PAIN/ORAL 18 18 0
G71 DERM/ENDO/RAD0/PALL/GMED 4/IMMU/GS4 30 30 0
G72 GMED 7 30 30 0
G73 ONCO/HAEM 30 30 0
G74 UROL/NUC GSUR2-3/SAU GMED1 40 37 3
Grand Total 444 441 3
36
Summary: Sir Charles Gairdner
Bed occupancy 104.0%
Number of beds in survey (allocated beds) 430
In-patients surveyed 447
Beds closed 1
Patients being discharged today 48
AEP criteria for day of care not met 108
Criteria not met, alternative "home" 35
Criteria not met, alternative "non-acute bed" 12
Criteria not met: L.O.S. 7 days 49
> 7 days 59
Bed numbers
Total beds in survey 430
Bed closed 1
Beds empty 9
Admitted greater than 24hrs before day of audit 361
Admitted less than 24hrs before audit 86
Missing admission dates 0
Total 447
Discharges
Patients being discharged today 48
AEP Criteria for day-of-care
Met and not over-ridden 289
Not met but over-ridden (appropriate stay) 2
Missing (assumed met) 1
Sub-total (met) 292
Not met and not over-ridden 99
Met but over-ridden (inappropriate stay) 10
Sub-total (not met) 109
Total 401
Not met criteria
All inpatients excluding discharges 399
Criteria not met % (excluding discharges) 27.3%
Outliers
Total Outliers 88
% of patients outlying 19.7%
37
Sir Charles Gairdner Hospital
38
Sir Charles Gairdner Hospital
39
Sir Charles Gairdner Hospital
40
Sir Charles Gairdner Hospital
41
All hospital sites: aggregate data
Top 4 reasons for “reason not discharged” for patients not meeting
acute care criteria
42
Summary
A total of 1293 in-patients were reviewed by hospital staff using an agreed survey method
on 3 sites on a Thursday, Friday and Monday. Bed occupancy was between 98 and 104%.
Between 21 and 27% of patients in the survey did not meet any of the 28 criteria for
appropriateness of acute care. There was marked ward to ward variation in the proportion
of patients not meeting the criteria.Outlying was common and varied between 9 and 20%.
Analysis of the reasons that patients not meeting criteria had not been discharged showed
that about half such factors would be those considered to be under hospital control.
Hospital Patients surveyed [n]
Occupancy [%]
Patients not meeting acute care criteria [%]
Patients outlying [%]
Royal Perth 500 98 22 9
Fremantle 346 99 21 13
Sir Charles Gairdner
447 104 27 20
Reasons for not discharged in patients not meeting criteria
Hospital site Within site control [%]
Out of site control [%]
Mixed/other[%]
Royal Perth 48 21 31
Fremantle 42 36 22
Sir Charles Gairdner
48 29 23
43
Acknowledgements
The UK visiting team wish to thank Marea Gent for co-ordinating the survey in
Perth, and the site co-ordinators and reviewers who gave up their time to
conduct the survey.
UK team
Prof. Derek Bell
Shaun Danielli
Dr.Veronica Devlin
Patrice Donnelly
Bas Gough
Kenny Grant
Martin Hopkins
Katie Horrell
Chris McNicholas
Dr. Simon Watkin (DOC lead)
Dr. Tom Woodcock