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Updates on the ACU pilot and the Medical Surveillance Unit

29-Jul-2016

Accountable Care Unit update

This month, we would like to continue to highlight an important metric that contributes to the pilot’s overall assessment: Patient length of stay (LOS).

The traditional health care model can have physicians distributed throughout multiple hospital units and hospitals. This practice can create an environment where physicians are required to travel between units daily, providing them with less time for each patient and decreased availability for the care teams. Staff on 4A found this model challenging as they had less time to communicate with the physician about the patient’s plan of care, resulting in fragmented communication and a challenge for consistency of care, at times resulting in an extended length of stay for the patient. The transformation that ACU has brought to 4A has created an environment where a team of physicians works on one designated unit with a designated care team. This shift from the traditional design has enabled cohesiveness, communication, timeliness and face to face problem solving. Based on the previous research conducted by Dr. Stein, the ACU model had a significant impact on patient care and a length of stay reduction was observed. Based on the same referral volumes, the length of stay at Emory University Hospital in Atlanta Georgia reduced from 5.0 days to 4.5 days—a 10% length of stay reduction which the ACU team hopes to achieve after the six-month pilot has been completed. The reduction in length of stay will, in turn, positively impact patient flow within RQHR, allowing for faster turnover of beds and movement from the ER into acute inpatient beds and discharges out into the community.
 
Another major impact on the patient’s length of stay pertains to the patient’s dietary intake and malnutrition. Food is medicine. Data indicates that patients who consume 50% or less of their meal tray will have a longer hospital stay and increased risk of mortality.
 

 

Medical Surveillance Unit

Executive Summary:

In the spring of 2015, the Senior Leadership Team agreed to the creation of a medical intermediate care unit at the Pasqua Hospital in conjunction with the amalgamation of the cardiac program at the Regina General Hospital. The Critical Care/Cardiosciences program then set out to review patient characteristics, medical management and levels of nursing expertise to create a non-interventional cardiac monitoring unit which would provide enhanced patient care to medically complex patients.

Over one year later, a compelling case is made with data, which has been collated at the unit level, highlighting the work of this team as well as the positive patient and staff outcomes. The team has demonstrated improvement in all three areas of the Region’s focus in quality and safety, access and patient flow and system sustainability.

Background:

Following the Cardiosciences program realignment at the RGH in October of 2014, the Medical Surveillance Unit (MSU) functioned as a general medicine unit with telemetry capabilities. In the fall of 2015, an agreement was reached related to the medical model of care which would see a Hospitalist run unit with support from General Internal Medicine physicians as consultants.

A unit leadership dyad relationship was formed with Dr. Kish Lyster and Marlee Cossette as physician and unit manager co-leads. Implementation plans were developed through the creation of a MSU Transition Committee with oversight from Dr. David McCutcheon and Lori Garchinski. While formal work was ongoing related to the Accountable Care Pilot on 4A, the frontline leadership team in MSU quietly adopted key concepts of the ACU model which included Structured Interdisciplinary Bedside Rounding (SIBR), team huddles, geographic protection of beds, as well as bedside shift to shift nursing handover.

The incorporation of an Early Assessment and Response System (EARS) aided staff in managing more complex patient needs and provide a formal communication mechanism between physician and nursing teams to highlight important changes in the patient’s clinical condition. An aggressive 13 week integrated timeline was created to ensure the January 15, 2016 go live would be achieved. This timeline included creating our admission criteria, admission algorithms, SIBR training and ground rules development, shift to shift at the bedside roll out plans, consent forms, work standards, team huddle guidelines, and education days among other activities.

Prior to go live date in January, the co-leads realized the need for an evidenced-based method to evaluate and demonstrate the effectiveness of this new model of care. An Excel dashboard was developed by the Manager, Marlee Cossette, which captures unit based metrics on a daily basis. The dashboard has been designed in a manner in which its statistics simultaneously populate charts and graphs when unit staff, physicians and the manager enter data into the workbook. While we can demonstrate pre and post benchmarking within MSU, there is a need to review the outcomes as they compare to similar units nationally. 

Results:

The dashboard of results captures 20 patient flow/demographic specific data points, 6 quality and safety metrics, 6 system sustainability metrics, and 4 physician related data points. The team uses this data to make real time, unit based, data driven decisions for resource planning, education, and needs assessments. Data to date supports the need for a medical intermediate care unit within RQHR at the Pasqua Hospital as 88% of patients admitted to MSU meet the admission criteria.

A research study has been approved and data collection is underway to formally evaluate intermediate care provisions on MSU. Specifically, patient outcomes such as morbidity, mortality and readmission rates to provide a robust and evidence based review to support ongoing development of intermediate care in the RQHR.

While there are many metrics that highlight the improvements in patient flow and quality of care, the success of the program can also be seen in both the decrease in staff churn, overtime rates and absenteeism. The leadership of MSU believes that this is a testament to the importance of the work and the engagement of the frontline staff. The unit went through a number of changes in their scope of practice as it related to being part of the Cardiosciences team and an initial lack of clear direction in late 2014 through early 2015.

This should not be underestimated in terms of staff morale and engagement. The current metrics clearly highlight the satisfaction of the staff working this model. When the leadership of MSU shared that there was a presentation occurring to SLT about the unit changes, 6 staff at a daily huddle volunteered to come on their own time to share their experiences and support for this model of care.

As work continues with frontline manager success, the time spent on data collection must transition to other resources so that the manager can be freed up to allow for other initiatives and work that she is accountable for. Formalizing the research component of daily metrics through other avenues will allow more robust measurements and mechanisms to feed the data back to staff and physicians in a timely manner.

More detailed information is available from the dyad team of Dr. Kish Lyster kishmd@gmail.com and Unit Manager Marlee Cossette Marlee.Cossette@rqhealth.ca.