The Department of Heath estimate that 62% of hospital bed days are occupied by patients over the age of 65. Of these bed days 2.7 million are occupied by patients no longer needing or not requiring acute care in the first place. Of those who are admitted unnecessarily, the Emergency Department (ED) is often where the decision to admit is made. Furthermore, the longer a patient spends in the ED the longer their associated inpatient stay in the hospital will likely be, with the risk of losing up to 5% of their muscle strength per day.
During May and June 2016 the Emergency Care Improvement Programme (ECIP) reviewed Urgent and Emergency Care at Basingstoke and North Hampshire Hospital (BNHH). This was due to reduced ED performance. BNHH did not have an established dedicated Therapy team in ED, despite national evidence and ECIP recommendations. Therapies are well placed in ED to facilitate early patient discharge and help prevent admission of patients who do not require acute hospital care. The project aimed to eliminate avoidable non-medical admissions to inpatient base ward beds in patients over 65 years presenting to ED at BNHH by September 2017.
A multi-disciplinary team (MDT) approach was used to identify issues in ED with Therapy services and non-medical admissions. A combination of Fish-bone analysis and semi-structured interviews and Pareto analysis identified four key themes; Therapy referrals, time of assessment, capacity to conduct assessments, and risk. The MDT group used driver diagrams to generate change ideas. Short trials of these change ideas were implemented using a plan, do, study, act (PDSA) cycle approach. Weekly meetings were used to review and evaluate PDSA cycles and direct future change ideas.
PDSA cycles relating to pro-active, early Therapy screening of patients in ED (e.g. from inbound screens/ ambulance handover), ED based senior decision makers, ring fenced ED Therapists saw a large increase in the number of patients assessed going from 0-5 patients per week to 15-26 patients per week, with discharges home from ED going from 0-4 per week to 10-12 per week. Despite Therapies assessing and discharging more patients in ED (avoiding unnecessary admissions), re- admissions within 7 and 28 days reduced ( < 1 patient per week). Furthermore, inpatient Therapy activity (back door) was not adversely affected by ED activity, as ED and inpatient Therapy resources were shared previously. All metrics were assessed using SPC charts to show that these improvements were directly related to implemented change ideas and did not occur by chance.
Cost and savings
The project did not cost anything to set up as the project focused on how to use current resources differently.
Having a dedicated ring fenced Therapy team in ED with senior decision-makers, and proactive patient screening increased early identification of non-medical patients, expediting assessment and appropriate discharge. Therapy can help prevent unnecessary admission, particularly in patients over 65 years.
By PDSA testing Therapy services in ED, effective changes were translated into practice appropriately and organically as changes were tailored by clinicians to suit service needs. Furthermore, this approach fostered a culture of continuous improvement in relation to the Therapy service in ED.
Top three learning points
Keep PDSA testing small and find out what works well before introducing any change.
It is important to share knowledge and learning with the wider multi-disciplinary team, not only to build relationships but also to understand where activities may facilitate or overlap with your teams’ activities, or to help identify new improvement opportunities.
Co-design is vital. The teams come up with the ideas!
An Individual Quality Improvement Fellowship was provided to Marc Berry by Wessex School of Quality Improvement, funded by Health Education England
This work was presented at Physiotherapy UK 2018.
For further information about this work contact Marc Berry.