GLADSTONE HOSPITAL

CHALLENGING PATIENT FLOW

GLADSTONE HOSPITAL

GLADSTONE REGION

DEMOGRAPHICS

550km from Brisbane

100Km SE of Rockhampton

180km north of Bundaberg

Population 64000

3.2% Indigenous or Torres Strait Islander

10.3% born overseas

19.8% speak a language other than English at home

Main hospital buildings built in the 1980s

Last Emergency Department redevelopment was in 1998 (17 yrs ago)

SERVICES IN THE HOSPITAL

Emergency

Medicine

Surgery

Paediatrics

Obstetrics/Gynaecology

Palliative care

Physiotherapy

Mental health – NO PSYCHIATRIST – NO ADMISSIONS

Self managed renal dialysis service

3 chemotherapy chairs

EMERGENCY DEPARTMENT

11 beds – 6 monitored

2 Resus bays

1 procedure room

7 consultation rooms

Can only use 3 at a time

X 2 video conference facilities

30,000 PRESENTATION/YR

15-20% Adult Admission rate

20% Paediatric

16-20% Admission rate

Significant trauma challenges

MY CHALLENGE

Appointed Director Nov 2014

2 Week intensive orientation

Took over Leadership.

EMERGENCY DEPARTMENT NOW HAS

SPECIALIST LEADER

DOCTOR Augustus Kigotho, 58, has had somewhat of a

scenic tour from when he started his medical training in

Nairobi, Kenya, until he arrived in Gladstone two weeks

ago.

Dr Kigotho has taken up the role of head of Gladstone

Hospital's emergency department - the first time in

memory that the hospital has had a fully qualified

specialist in emergency medicine as the department's

head.

1. IMMEDIATE CHALLENGE

NO DEPARTMENTAL HANDOVER

2.STAFFING CHALLENGE

Highly locum dependent

Permanent staff – 1.5

Advanced emergency trainee – 1.0

GP on FACRRM training – 0.5

Rest – Locum staff

3. NO DEPARTMENTAL LEADERSHIP

4. DAILY STAFF SHORTAGE OF 2-3 DOCTORS

DATA UTILISATION

Intensive involvement of BADS unit ( Business Analysis Decision Support)

Regular meetings

Its not the data

Its what you do with the data!

24 HOUR PRESENTATIONS:

LOOKING AT THE DATA

STAFFING MODEL CHANGED

Activity driven roster

4 doctors in the morning

4 doctors in the afternoon

ED trainee top heavy as locums

AGGRESSIVE RECRUITMENT DRIVE

Currently

2 permanent FACEM

2 permanent SMO – FACRRM

0.5 FACRRM

1 Advanced ED Trainee

1 NP

Recruitment of 3rd FACEM in process

Markedly reduced locum dependence

CULTURAL CHANGE

MEETING TO DETERMINE WAY FORWARD

GOAL: Engage on Neat

Advantages vs disadvantages

Ensured full understanding

Sort commitment to the course

Triage re-education

Nurse empowerment

Assured of full support from ED Director/NUM/Admin

Given power to follow up patient progress from MO

High emphasis on REVERSE TRIAGE

Documentation by doctors

Patient education by nurses

Nurse initiated investigations

Early involvement of lead SMO

REVERSE TRIAGE

Education prior to discharge

Guarantee treatment complete

Information

Admission not required

Referrals complete

Transport arranged

NURSING MODEL

INCREASED LEADERSHIP PRESENCE AND

VISIBILITY

2 hourly ward round

ED Director/Num

EDDMS invited occasionally

This produced a DRAMATIC CHANGE

Nurses wanted to be on top

Doctors did not want excessive questions from nurses

Outcome: Rapid throughput through ED.

STRUCTURAL CHANGE

Intensive patient centred CUBICLES:

Fully loaded trolley

IV Fluids

Drip stand

3. BARRIER/BOTTLENECKS TO FLOW

Failure to appreciate NEAT importance by senior staff (Locums)

Nurses cannot receive ANY CALLS during ward hand over

Completion of 1st dose Abs in ED prior to transfer.

Resistance to change

Delayed documentation by medical staff, particularly Med Charts.

Limited access to radiology & pathology

Limited MH access

External consultations particularly neurosurgical/cardiology

SOLUTIONS

Immediate staffing model change

Staff re-education / triage

Increased utilization of REVERSE TRIAGE

More ED trainees as locums

AGGRESSIVE RECRUITMENT DRIVE

Ward nurses can take ED handover ANYTIME

Initiation of push Abs and 1st. Dose completion in the wards.

Prolonged radiology availability upto 23:00hrs. CT 24hrs.

Pathology available until 18:00hrs Weekdays. Weekends till 18:00hrs!

MH available until 21:00hrs

Better utilization of NP

FAST TRACK is on track to start in August.

ADMISSION PROCESS

Goal: Smoother admission process

1. DIRECT ADMISSION OF MEDICAL PATIENTS!!!

95% of all hospital diagnosis made by ED physician

ED physician gets the appropriate speciality disposition RIGHT 96% of the time

2. 30 min ward notification to pick up

IMPROVED THROUGHPUT STRATEGY

Early SMO involvement

Determine optimal investigative strategy

Early discussion with other consultants for disposition.

Frequent computer rounds

Appropriate utilisation of SSU

SSU

Opened within 1 month of arrival

High uptake and utilisation

Leading to improved NEAT Performance.

TIME SEEN BY CATEGORY:

CAT 1

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

sept oct nov dec Jan Feb Mar Apr May June July Aug

2013

2014

2015

TIME SEEN BY CATEGORY:CAT 2

TIME SEEN BY CATEGORY:

CAT 3

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

sept oct nov dec Jan Feb Mar Apr May June July Aug

2013

2014

2015

TIME SEEN BY CATEGORY:

CAT 4

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

sept oct nov dec Jan Feb Mar Apr May June July Aug

2013

2014

2015

TIME SEEN BY CATEGORY:CAT 5

80%

82%

84%

86%

88%

90%

92%

94%

96%

98%

100%

sept oct nov dec Jan Feb Mar Apr May June July Aug

201320142015

DID NOT WAIT

ADMITTED NEAT TARGETS:

DISCHARGED NEAT TARGETS:

ONGOING STRATEGIES

Buy in

Set up specific goals – meet target

1. Ensure Executive support

2. Recruitment

3. Whole hospital involvement

4. Regular review of progress

5. Keep troops motivated – regular positive feedback

Reward champions

LEADERSHIP

Performance leadership is key!!

Careful articulation of vision & mission

Know departmental dynamics

Identify

Change agents – Reward

Change resistant group

Cynics vs sceptics

Summary

Data utilisation

Strategies

Cultural change

Leadership

THANK YOU