Department of Human Services

Patient Flow Collaborative Learning Session 4

Breakout session 1

Room M1 and M2

Tony Snell and Rochelle Condon

Department of Human Services

Breakout session 1Room M1 and M2

9.50 – 10.35

Maria Bubnic and Phyl HalpinMental Health BranchDepartment Human Services

4th May, 2005

Improving care for mental health patients

Improving Care for Improving Care for Mental Health Patients in the EDMental Health Patients in the ED

• Outline:– Describing the issues– Key strategies– Recent initiatives– Questions

Pressures on the systemPressures on the system

• Increasing number of mental health presentations to EDs

• Increasing complexity of mental health presentations

• Increasing waits for mental health patients in ED

Contributing factorsContributing factors

– Greater awareness of mental health problems & willingness to seek help

– Mainstreaming of mental health acute inpatient services with acute health

– Greater visibility & accessibility of the ED compared to other parts of the service system

– Changes to police practice under section 10 of the Mental Health Act

– Co-location of CAT and ECAT services within EDs– Distribution of acute mental health beds– Decrease in availability of alternative service

options

Research Research

• Who? How? Why? What happens? • 5 sites: 2 tertiary inner suburban, 2 outer

suburban, 1 regional• 5 months: all mental health presentations

between April & September 2004• Retrospective medical file review immediately

post presentation• Telephone follow up of a random sample post

presentation

‘‘Mental Health Presentation’Mental Health Presentation’

A primary diagnosis of:• mental illness • substance abuse • crisis• injury assessed as involving ‘intentional

self harm’Assigned by the ED clinician

Research Findings (1)Research Findings (1)

• 36% actively managed by mental health services

• 41% had prior contact with mental health services

• 26% had been admitted to a mental health ward in the previous 12 months and of these 42% required admission at the current presentation

Research Findings (2)Research Findings (2)

• People who chose to come to ED themselves– Most considered alternatives but 54% of

alternatives unavailable as people were seeking help in the evening.

– When alternatives were available:• 50% referred onto ED for management• 31% preferred ED to their usual health care provider• 22% were not prepared to wait for their usual health care

provider

ForumForum

• ED & mental health staff • Also input from drug & alcohol,

ambulance, police, primary care, consumers

• Shared view – must do better– DHS role in developing strategy – What health services can do

Key issuesKey issues

• Most MH presentations occur after hours & involve emergency services

• >50% are re-presentations to ED and known clients of mental health services

• Increasing number of 24 hour+ stays for MH presentations

• Layout & amenity of EDs• Provision of care within framework of MHA

Responding to the issuesResponding to the issues

• ‘upstream’ to reduce avoidable or inappropriate use of EDs

• ‘within ED’ to improve management in the ED

• ‘downstream’ to improve access to beds & continuing community care

Recent initiativesRecent initiatives

• National Suicide Prevention & Intervention Strategy

• NICS Mental Health Emergency Care Interface project

• Victorian Hospital Demand Management (HDM) strategy and HARP

• Victorian Patient Flow Collaborative – Mental Health CLIF projects

Patient Flow Collaborative – Patient Flow Collaborative – Mental Health CLIF projectsMental Health CLIF projects

Mental Health CLIF Projects: Mental Health CLIF Projects: Areas of focusAreas of focus

• Improve patient flow across acute, subacute & mental health care

• Link to developments in the patient flow collaborative

• Involve consumers

Mental Health CLIF Projects: Mental Health CLIF Projects: Funded in 2004-2005Funded in 2004-2005

• Western Health – involves Western Hospital ED, South West AMHS & Mid West AMHS

• St Vincent’s Health – involves the ED & Mental Health Program

• Ballarat Health – led by Grampians Psychiatric Service

Western Health CLIF project: Western Health CLIF project: Needs AnalysisNeeds Analysis

•Limited availability of mental health services & specialist support

•Limited confidence & skill of ED staff to respond

•Variable follow-up post-discharge from ED

Western Health CLIF project: Western Health CLIF project: Aims & MeasuresAims & Measures

• Decreased ALOS, particularly for ‘admitted’ & ‘recommended’ subgroups

• Improved access to appropriate alternatives to ED

• Reduction in episodes of aggression, use of seclusion & specialling

• Improved on-site specialist advice, intervention & support

• Improved ED staff satisfaction & responses to MH presentations

Western Health CLIF project: Western Health CLIF project: Project MethodologyProject Methodology

• Project steering committee & coordinator

• Pilot ECAT service model• Map patient pathways & audit practice• Develop guidelines, policies &

procedures, & referral protocols• Staff education, training & support to

implement changes

Western Health CLIF project: Western Health CLIF project: Progress to dateProgress to date

• ECAT model being piloted• MH & ED staff training• Collaborative assessments • Weekly team meetings• Negotiations with police & ambulance

re: transport of mental health patients• IT enhancements

St Vincent’s Health CLIF project: St Vincent’s Health CLIF project: Needs AnalysisNeeds Analysis

• Management of information/IT• Management of communication• Identification/clarification of need• Care of patient/carer/family

St Vincent’s Health CLIF project: St Vincent’s Health CLIF project: Aims & MeasuresAims & Measures

• Identify options for improving patient & information flow in the ED

• Use of KPIs from NICS project to align efforts & build on learnings

St Vincent’s Health CLIF project: St Vincent’s Health CLIF project: Project MethodologyProject Methodology

• Develop IT & triage systems to support coordinated identification of need

• Weekly liaison meetings• Staff training• Revise policies & procedures• Undertake feasibility study of short stay

facility

St Vincent’s Health CLIF project: St Vincent’s Health CLIF project: Progress to dateProgress to date

• Improvements to triage system• Collaborative assessment process &

tool developed & to be piloted• Identification of patient streams• Exploring use of MH identified beds in

ED to fast track responses

Ballarat Health CLIF project:Ballarat Health CLIF project:Needs analysisNeeds analysis

• Review of feedback/complaints data• Further consultation with stakeholders,

to be led by an Advisory Committee• Review of triage data• Process mapping triage responses

across inpatient & community interfaces

Ballarat Health CLIF project:Ballarat Health CLIF project:Aims & MeasuresAims & Measures

• Improve access to inpatient and community mental health services

• Use of KPIs for:– triage responses– timeliness of access to inpatient &

community services– referrer, consumer & carer satisfaction

Ballarat Health CLIF project:Ballarat Health CLIF project:Project MethodologyProject Methodology

• Possible target areas to improve pathways to service access:– Policies & procedures, practice guidelines &

referral protocols– Coordination of information &

communication systems– Staff education & training– Triage redevelopment

Ballarat Health CLIF project:Ballarat Health CLIF project:Progress to dateProgress to date

• Delayed start - March 2005• Appointment of project officer• Establishing Advisory Committee• Data analysis commenced

Questions

?

Morning TeaMorning Tea

Meet us back here for

Intranet theatre booking system

at 10.55

Department of Human Services

Breakout session 2Room M1 and M2

10.55 – 11.45

Robyn GilliesConsultant AnaesthesetistEmergency Bookings Project CoordinatorClinical Innovations Funded ProgramMelbourne Health

5th May, 2005

Intranet theatre booking system

Department of Human Services

Emergency Theatre Booking System (ETBS)

Development of an intranet based emergency booking system for the Operating Suite at the RMH

Intranet based Emergency Intranet based Emergency Theatre booking systemTheatre booking system

• Why?• How?• What did we get?• Did we get what we wanted?• What will we need to develop further?

Intranet based Emergency Intranet based Emergency Theatre booking systemTheatre booking system

• Why?• How?• What did we get?• Did we get what we wanted?• What will we need to develop further?

Why Pursue such a project?Why Pursue such a project?

• Identification of need

The booking system prior to February 2005 – 1 piece of messy paper!

Often data not recorded, lost in translation, viewed by only the OR in-charge, etc.

Sometimes these were all that Were filled in

Why Pursue such a project?Why Pursue such a project?

• Dissatisfaction with the original system• Inadequate data collection and lack of

ability to monitor emergency operations• Lack of transparency in the original

system • Lack of guidelines for Emergency

bookings

What were we missing?What were we missing?

• Data:– Timeliness of emergency theatre provision– Times of greatest need for emergency OR– Impact of changes in the emergency access– Reliable data on delays and problems in the

system

• Guidelines– Any ideas on the rules?

Intranet based Emergency Intranet based Emergency Theatre booking systemTheatre booking system

• Why?• How?• What did we get?• Did we get what we wanted?• What will we need to develop further?

The ETBS:How did we start?The ETBS:How did we start?

• Identification of Personnel – for discussion and implementation

• Project outline with approximate budget• Application for funding

The Next StepsThe Next Steps

• Project Plan– including goals and key areas of focus

• Development of Guidelines for Emergency Bookings – OR executive approved

• Development of Standardised list of priorities – For each surgical specialty

Goals for the ProjectGoals for the Project

• Collect data for continuous quality assurance • Introduce transparency into the theatre

booking • Streamline the process of emergency booking • Qualify, quantify and improve the current

system organisation for nursing, equipment etc.

• Develop a reproducible system for use in other institutions

• Optimum utilisation of theatre time

Guidelines for Emergency Guidelines for Emergency BookingsBookings

This also included discussion on: • Communication Issues• Guidelines for emergency surgery access

– when there is no emergency theatre available. – A time critical (life or limb threatening) emergency– Access to emergency theatre

• Super-specialty or Complex Surgery • Dispute Resolution

Development of Development of Standardised list of prioritiesStandardised list of priorities

• Surgeons asked to give “optimum time frames” for emergency access– Asked to estimate times for operations– Not entered onto the system but available

for comparison with data collected

The Next Steps – Information The Next Steps – Information TechnologyTechnology

• Plan for IT development – Recruitment of IT specialist– Purchase of server– Process of development allowing review of

critical areas

• Hardware Decisions – Mobile hardware for “running the floor”

How is this being How is this being Implemented?Implemented?

• 4 Planned Phases – Education – Data Collection – System modification based feedback and

quality of data collected– Data Distribution to “close the loop”

• 5th Phase– Modifications based on learnings

Intranet based Emergency Intranet based Emergency Theatre booking systemTheatre booking system

• Why?• How?• What did we get?• Did we get what we wanted?• What will we need to develop further?

Department of Human Services

What does it look like??

A visual of the ETBS as it exists in its not quite final form

The Actual SystemThe Actual System

• ETBS– Adding a booking– Priority of booking– Organising the bookings– Confirmation/completion and cancellation

of bookings– Data collection

This is what can be seen on networked computers after a password has been entered

Users click here to add a booking

This is the site looked up on internet explorer

Check is clicked when the UR number has been entered – this serves to check if the correct patient has been entered and does not allow patients outside the hospital to be booked.

If not available all hours then outline availability

Drop down box of specialty units

When submit is clicked an on screen prompt appears reminding the person booking to contact the OR anaesthetist in charge to confirm the booking

CIC clicks here to administrate

Patients name and UR will appear here Details of the case for discussion will

appear here. A case can only be confirmed when a priority has been assigned to it in the administration window (after discussion)

At this point the priority is set by the surgeon and anaesthetist as part of the discussion about the patient.

The booking is confirmed and automatically added in order of priority to the list

Person making comment

Click on the “+” for details

Click to add comment

All interested units and ward nursing staff can then view the list and see details of each patient. Comments can be made by all users.

When a booking is completed (we define this as the beginning of an intervention in the OR, the Anaesthetist Or nurse in charge completes the booking thereby taking it off the screen

Delay details must be entered in order to complete the booking

Colour changes to prompt action or discussion with surgeons

Intranet based Emergency Intranet based Emergency Theatre booking systemTheatre booking system

• Why?• How?• What did we get?• Did we get what we wanted?• What will we need to develop further?

Did We get What we Did We get What we Wanted?Wanted?

• Yes– Transparent/visible– More organised– Able to collect reliable data– We have guidelines!– Booking process was streamlined– We will be able to “close the loop” with the

data we now have

Did We get What we Did We get What we Wanted?Wanted?

• No– Optimum theatre utilisation will require

more work with elective system

What Do the Users think?What Do the Users think?

• Surgical Staff– Registrars – approve of system, unhappy with IT

down times– Consultants – surprised by new guidelines:

highlighted some communication issues in some surgical units

• Nursing staff– happy with increased transparency but sometimes

frustrated about poor communication with Anaesthetist in Charge

What Do the Users think?What Do the Users think?

• Anaesthetists– Most are happy– Some struggle with new technology– Some struggled with motivation

What Do the Users think?What Do the Users think?

• Anaesthetists– Most are happy– Some struggle with new technology– Some struggled with motivation

Intranet based Emergency Intranet based Emergency Theatre booking systemTheatre booking system

• Why?• How?• What did we get?• Did we get what we wanted?• What will we need to develop further?

Ongoing DevelopmentOngoing Development

• Modifications to help in OR organisation • Modifications for increasingly relevant

data collection • Modifications to work towards meeting

priority times• Improving “ closing the loop” data

feedback and monitoring changes over time.

Future OpportunitiesFuture Opportunities

• Modify elective booking system to integrate with the emergency bookings system.

• Introduce ETBS to other institutions• What do you think?

SummarySummary

• Ambitious project• Good results• Highlighted other areas in need of

modification• It’s not just about the technology• A good start ….

Questions

?Thank You for your time.Thank You for your time.

LunchLunch

Meet us back here for

Team tabletop presentations

at 12.45

Team Presentations12.45– 3.15

Rochelle Condon Room M1 and M2

•Austin Health

•Ballarat Health

•Royal Women’s Hospital

•Angliss Hospital

•Northeast Health – Wangaratta

•Peter MacCallum Cancer Center

Tabletop presentationsTabletop presentations

The aim of this session is to;• Promote discussion• Share “peer to peer” practical

experiences of innovation• Increase energy for change and shared

learning• Spread ideas between teams

Session formatSession format

• 2 teams per table• Team A has 15 minutes to share experiences

with team B• Whistle blows• Team B has 15 minutes to share experiences

with team A• Rotation 1• Continued….• Working afternoon tea is available

Session formatSession format

Time Activity Rotation

1.00 – 1.15 15 minutes

Austin Health presents to Ballarat Health Royal Women’s Hospital presents to Angliss HospitalNortheast Health - Wangaratta presents to Peter MacCallum Cancer Center

1.15 –1.30

15 minutes

Ballarat Health presents to Austin HealthAngliss Hospital presents to Northeast Health - Royal Women’s Hospital Peter MacCallum Cancer Center presents to Wangaratta

1.35 – 1.50

15 minutes

Austin Health presents to Peter MacCallum Cancer Center

Royal Women’s Hospital presents to Ballarat Health

Northeast Health – Wangaratta presents to Angliss Hospital

Rotation 1

1.50– 2.05

15 minutes

Peter MacCallum Cancer Center presents to Austin Health

Ballarat Health presents to Royal Women’s Hospital

Angliss Hospital presents to Northeast Health – Wangaratta

Session formatSession format

Time Activity Rotation

2.10 – 2.25 15 minutes

Austin Health presents to Angliss HospitalBallarat Health presents to Peter MacCallum Cancer CenterNortheast Health – Wangaratta presents to Royal Women’s Hospital

Rotation 2

2.25 –2.40

15 minutes

Angliss Hospital presents to Austin HealthPeter MacCallum Cancer Center presents to Ballarat Health Royal Women’s Hospital presents to Northeast Health – Wangaratta

2.45 – 3.00

15 minutes

Austin Health presents to Northeast Health – Wangaratta

Ballarat Health presents to Angliss Hospital

Peter MacCallum Cancer Center presents to Royal Women’s Hospital

Rotation 3

3.00 – 3.15

15 minutes

Northeast Health – Wangaratta presents to Austin Health

Angliss Hospital presents to Ballarat Health

Royal Women’s Hospital presents to Peter MacCallum Cancer Center

Meet us back in the plenary for

Team planning time

at 3.20