MOHLTC - HSAPD ER/ALC Quarterly Stocktake Report Central West LHIN January, 2010 1 LHIN VIEW: CENTRAL WEST LHIN SYSTEM FOCUS: Reduce time spent in the ER across Ontario Almost 50% of ER visits are made by patients with non-urgent or less urgent needs 1 Reduce ER demand Reducing the number of non-urgent cases that present at the ER will enable emergency clinicians to focus on patients with critical needs Number of ER Unscheduled Visits by quarter per 1000 population (Data Source: MoHLTC Provincial Health Planning Database & CIHI-NACRS) Time spent in the ER is too long: 90% of patients are treated within 9.4 hours from triage to discharge 2 Increase ER capacity/performance Improving triage and admission processes and reducing ambulance offload times will enable emergency clinicians to provide more efficient care Time spent in the ER for high acuity patients (all admitted + non-admitted CTAS I, II, III patients). (Data Source: EDRS) Time spent in the ER for low acuity patients (non-admitted CTAS IV & V patients). (Data Source: EDRS) Time in the ER is five times longer for ER patients admitted to hospital (35 hrs); 75% of their total ER time (26 hrs) is spent waiting for an inpatient bed 3 Improve Bed Utilization Improving bed utilization expedites patient throughput and maximizes hospital capacity Percentage ALC Days (Data Source: CIHI-DAD) Proposed Measure: Number of days from ALC designation to discharge by discharge destination (90th percentile Days) (Data Source: CIHI-DAD) Note: Patients discharged against medical advice and those who died are excluded from analysis. Q2, Q3, Q4 from 08/09 and Q1, Q2 from 09/10 have not been finalized by CIHI. Target TBD. Over the last year (Q1 08/09 to Q1 09/10) growth in ED volume has occurred at a rate of 12% (5150 visits) in the Central West LHIN. The chart above demonstrates a 4 point increase in the number of ER unscheduled visits per 1000 population in the Central West LHIN. This confirms the continued growth. This growth, is in light of the Central West LHIN continuing to have the second lowest utilization rate of ER services across the province. Time spent in the ER for high acuity patients continues to improve in Q2 (09/10) compared to Q1 (09/10). This is a decrease from Q1 09/10 by 18 minutes. From Q4 (08/ 09) to Q2 (09/10) there has been a significant improvement by 96 min (10%). This continued improvement can be attributed to the implementation of the ED P4R strategies directed towards CTAS I, II and III patients. The time spent in the ER for low acuity patients has also decreased by 18 minutes despite an increase in ED volume specifically for CTAS IV and V patients by 1535 visits (10%) In Q2 09/10, the Central West LHIN’s percentage of ALC days remains below the provincial target at 8.91%. The slight increase in the % of ALC days may be attributed to the implementation of the new definition for ALC. The longest wait time to discharge can be seen at 32 days in Long Term Care (LTC) in the Central West LHIN 2 ER/ALC Stocktake Report GUIDE: ER/ALC Interventions within Central West LHIN Interventions Page Aging at Home (AAH) and Urgent Priorities Fund (UPF) Page 7 Pay-for-Results (P4R) Y2 Page 8 Aging at Home (AAH) and Urgent Priorities Fund (UPF) Page 9 Reduce ER demand Increase ER capacity/performance Improve Bed Utilization LEGEND: Interpreting intervention performance Supplementary Measures A set of measures associated with a specific intervention/ strategy that are indirectly linked to one or more overarching goals of the strategy Baseline Target Quarterly Performance Key Considerations Illustrates current performance with respect to the supplementary measure against defined targets. Graphs/charts are inserted by Access to Care. The red, amber and green colour coding of performance results is a visual guide that allows users to easily identify their performance relative to the specified target for a particular indicator; there will be a selected target for each supplementary measure associated with an intervention. Indicators included in the MLAA will be coloured accordingly to the LHIN corridors. Doing Well – In or below Corridor & below LHIN Starting Point The determined baseline The determined target Monitor – In Corridor & above LHIN Starting Point will be inserted here and will be inserted here and will remain the same Attention – Above Corridors, MLAA Performance Variance Report Required will remain the same each quarter each quarter Explains current performance and what proposed changes could be put in place to improve performance. Information is inserted by LHIN. (These are guiding questions only) Additional indicators will be coloured according to the following corridors: Green: performance result meets or exceeds the specified target Amber: performance result is less than or equal to 10% from the specified target Red: performance result is more than 10% from the specified target 3 CENTRAL WEST LHIN Goal: Reduce ER Demand Intervention: Aging at Home (AAH) and Urgent Priorities Fund (UPF) – The Central West LHIN directed funding towards the Nurse Led Long Term Care Outreach Teams, which provides enhanced support to seniors/residents of LTC with the goal of preventing transfers to the Emergency Department (ED). In addition, the Central West LHIN directed funding to the Central West CCAC to further reduce ER demand through focused initiatives: ‘Enhanced End of Life’ and ‘Short Term Extraordinary Circumstances initiative' (STEC). Further funding was directed through the Aging at Home initiatives which included: Integrated Service Teams for High Risk Seniors, Seniors Mental Health Intensive Case Management, Supportive Housing and the Regional Geriatrics Services. Supplementary Measures Number of ER Unscheduled Visits by quarter per 1000 population Baseline TBD NA Target TBD NA Current Performance Quarterly Performance 61 (Data Source: MoHLTC Provincial Health Planning Database & CIHI-NACRS) Key Considerations Past: The Central West LHIN remains at the second lowest number in the province in terms of ER utilization.. Further analysis reveals the Localization Index for Q1 09/10 has been remained constant. The Nurse led outreach teams have provided enhanced support for residents in LTC homes. This program aims to reduce avoidable transfers to the ED from LTC homes. The total number of clients served in Q1 (09/10) in LTC homes were 148 clients which has potentially averted admissions and visits to the ED. The Enhanced End of Life(EEOL) initiative provides enhanced services to enable palliative end of life clients to stay at home rather than be admitted to the hospital. In Q1 this initiative served 60 clients and saved an estimated 140 bed days The STEC initiative enable clients to stay at home when a change in circumstance might precipitate a trip to the ED. In Q1 a total of 176 clients were admitted to this service and saved an estimated 40 bed days saved.. The EEOL and STEC initiatives estimated bed days saved were estimated by the Central West CCAC, on the assumption that 1 hospital day is equivalent to 6 days of home care. Current: In Q1 09/10 the number of unscheduled visits increased by 4 per 1000 population in the Central West LHIN. In the Central West LHIN there continues to be an increase in overall ED growth from Q4 (08/09) to Q1 (09/10) 6.8% growth in ED visits in the Central West LHIN. The Central West LHIN has the lowest number of General Practitioners per population of any LHIN in the province. This lack of primary care adds to the demand on the Emergency Department. Future: In an effort to further reduce ER demand the following Aging at Home Year 2 initiatives have been directed at reducing ER Demand: Integrated Service Teams for High Risk Seniors- this initiative will identify, engage and promote the well being of high risk seniors, and prevent early and unnecessary admittance to the ED and inpatient hospital unit. The target for this initiative is 46 clients in the community. Early indication shows this target will be reached by year end. Seniors Mental Health Intensive Case Management – will impact on reducing ER demand by providing early assistance to seniors with serious mental health issues or complex concerns who are being discharged from hospital. This initiative plans to support 21 individuals in the community. Supportive Housing – this initiative will provide services for seniors, in Etobicoke, assisting them to live in their own home by navigating the health care system, with a focus on disease prevention. The target for this initiative is 16 clients. This initiative is projected to be on target by end of fiscal year Regional Geriatrics Service – there are plans to implement an Outreach Transition team as the community based component of this initiative. This will serve seniors in the community who are at high risk of presenting to the ED. Furthermore, current gaps in the continuum of care for seniors will be identified and addressed through this service. There are plans for this service to be operational in early 2010. Ambulatory Nursing Clinic- the Central West CCAC implemented a Nursing Clinic in Q4 2009/10. This clinic was implemented in support of findings from the ED Notification system . Findings identified a high volume of patients presenting to the ED who required IV and wound therapy. These patients will now be seen in the Ambulatory Nursing Clinic. 4 CENTRAL WEST LHIN Goal: Increase ER Capacity/Performance Year 2 ED Pay for Results funding was specifically targeted towards several key initiatives to improve ED LOS. These initiatives include the continuation of the following Year 1 initiatives: Redesign of triage and registration, reallocation of hours for the Urgent Care Clinic , continuation of the Clinical Decision Unit, and the Medical Lab Assistant role. In Q2 2009/10, the following new initiatives were implemented: Expansion of the Rapid Assessment Zone (RAZ), and the implementation of the Ambulatory Treatment Centre (ATC). The RAZ will address the CTAS III patients as well as the CTAS IV and V patients during the hours the Urgent Care Clinic is not in operation. The expansion of hours of the RAZ or Fast Track area will support CTAS III, IV and V patients with the addition of 5 stretchers. It is anticipated the ED LOS for these patients will decrease. Similarly, the Ambulatory Treatment Centre processes have been reviewed through a Lean day with front line staff and physicians. Through this process, it is anticipated to improve patient access and flow. Other initiatives in Year 2 include Improved Access to Diagnostic Imaging which is anticipated to decrease the length of time patients wait for results, by the expansion of hours of operation, until 1000 pm. The Case Finding initiative involves CCAC Case Managers in the ED working to identify potential patients who can be cared for in their home with enhanced services. The ED Notification System implemented in 2009/10 has identified clients known to the CCAC Case Managers in addition to identifying clients who could be cared for in an alternate health care setting such as am outpatient clinic. Finally, the Year 2 ED Pay For Results hospitals implemented a data quality improvement initiative to collect and monitor accurate data to support ongoing performance improvement. Furthermore, weekly ER/ALC data will be available to frontline staff and physicians. Supplementary Measures Baseline Fiscal 08/09 Target Current Performance Quarterly Performance (Data Source: EDRS) Key Considerations Past: Performance has declined at both sites from Q2 2008/09 to Q2 2009/10. Part of this is due to the rapid increase in growth in ED visits particularly at BCH by 15.25% from Q1 2008/09 to Q4 2008/09 and into Q1 2009/10 (8.1%). Proportion of admitted patients treated within the LOS target of ≤ 8 hours 28% 10 point improvement in percentage 28% Current: At EGH the performance has improved by 3% (Q1 09/10 to Q2 09/10), despite a lack of physical space in the ED. More than 50% of the ED stretchers are occupied by admitted patients at any given time. To address the volume of admitted patients in the ED, 8 inpatient flex beds have been implemented. These 8 beds will provide further capacity for patients in the ED by facilitating throughput of admitted patients. At BCH performance has remained unchanged from Q1 (08/09) to Q2 (09/10) at 27%. A two day Lean workshop has recently been held with staff and physicians to review processes for triage, Ambulatory Treatment Centre and for CTAS II patients presenting to the ED. At both sites, Physician consultant response times results are monitored by the Chief of Staff and Department Chiefs on a monthly basis. Consultants can no longer “HOLD” patients in the ED, rather a disposition decision is made. Other strategies include daily bed meetings twice daily. ED Physician hours have been realigned to meet the demand for high acuity patients in the ED. Future: WOHS continues to work through its process redesign utilization and bed management initiatives. Future Lean workshops are anticipated to further address Ambulance Offload. Furthermore, to address Diagnostic Imaging response time, the hours of operation will be extended by the end of February 2010. Past: The decline in performance between Q2 2008/09 to Q2 2009/10 at BCH can be attributed to the increase in ED volume. Proportion of nonadmitted high acuity patients treated within their respective targets of ≤ 8 hours for CTAS I-II and ≤ 6 hours for CTAS III 74% 10 point improvement in percentage 72% Current: There has been a 5% improvement from Q1 (09/10) to Q2 (09/10) for this indicator at BCH. This can be attributed to the implementation of the Rapid Assessment Zone in June 2009. At EGH there has been a 2% improvement in performance. This can be attributed to the implementation of the Ambulatory Treatment Centre. This area provides care for CTAS III patients as well as CTAS IV and V patients during the hours the Urgent Care Clinic is not in operation. Further best practices within the ED at BCH include the implementation of ‘torpedo triage’ which is a process to streamline low acuity patients inside the department into the Fast Track area or Rapid Assessment Zone. Future: Recent changes to triage process and redesign through LEAN methodology is anticipated to demonstrate a decreased ED LOS in all CTAS Levels. Early data from the hospital reportedly demonstrates early improvement in ED LOS. A Rapid Assessment Zone for CTAS II patients presenting with chest pain is underway. Furthermore, WOHS has developed an agreement with Trillium Health Centre for those patients presenting to the ED with ST elevation Myocardial infarction (STEMI) These patients are transferred to Trillium Health Centre for Percutaneous Coronary Intervention (PCI) Furthermore, to address the high Pediatric volume presenting to WOHS, (25%) a Pediatric Rapid Assessment Zone is to be implemented that is anticipated to further impact ED LOS. Past: The proportion of CTAS IV and V patients treated within 4h at BCH has improved from Q2 2008/09 to Q2 2009/10 by 20%. The successful implementation of the After Hours Clinic at BCH continues to provide care to the low acuity patents. At EGH there has been a 1% improvement in performance for this metric. This can be attributed to the implementation of the Ambulatory Treatment Centre at the end of June 2009. Proportion of nonadmitted low acuity patients treated within the LOS target of ≤ 4 hours 79% 10 point improvement in percentage 83% Current: At BCH there has been a 5% improvement in performance from Q1 2009/10 to Q2 2009/10 despite an increase in growth of CTAS IV patients by 1034 visits (15.7 %). This significant improvement can be attributed to After Hours Clinic at BCH and the extension of hours for the Rapid Assessment Zone. At EGH performance has improved by 2% despite the increase in growth of CTAS IV patients by 288 patients or 7.7% Q1 2009/10 to Q2 2009/10. The Ambulatory Treatment Centre has also complimented this improvement in performance at EGH. Future: The hours of operation of the Urgent Care Clinic will be further evaluated in an effort to meet the needs of the community. The current hours of operation are from 430 pm to 1030 pm. Similarly further exploration of the hours of operation for ATC at BCH will be explored by WOHS in an effort to further impact ED LOS 5 CENTRAL WEST LHIN Goal: Improved Bed Utilization Intervention: Aging at Home (AAH) and Urgent Priorities Fund (UPF)– The Central West LHIN targeted Urgent Priority Funding for 2008/09 specifically towards the goal of improved bed utilization. The LHIN directed funds to the Central West CCAC with the expectation that this allocation will be deployed towards efforts focused on promoting optimal utilization of acute care services. The allocation was directly applied to enhancing the level of community support services available to patients on discharge from hospital. Bed utilization efforts were further supported by the assignment of a dedicated CCAC Case Manager in the Emergency Department at William Osler Health Centre (WOHC). The Case Manager focuses on case finding of “hard to reach” seniors who present to the Emergency Department. The Case Manager identifies the services required that may assist in avoiding admission. The focus on admission avoidance stops the seniors from potentially becoming ALC. The Home at Last Program enables earlier discharge by providing personal support services, transportation and home assessments to patents discharged from hospital. The Nurse Practitioner Rapid Response Teams are deployed to Long Term Care Homes, where they provide care and services to residents that historically have been provided in hospital. Supplementary Measures Baseline Target Current Performance Quarterly Performance Key Considerations Past: The Central West LHIN demonstrated steady improvement in the ‘Percentage of ALC Days’ from Q2 (09/10). Past improvement may be partially attributed to several initiatives implemented by the Central West CCAC. For example, one such initiative was the placement of CCAC Case Managers in the ED. This initiative resulted in 437 clients being discharged home from the ED with enhanced services in a quarter, and as a result, the CCAC estimated that 2,840 hospital bed days were saved to the system based on the assumption that 1 hospital day is equivalent to 6 days of home care. Percentage ALC Days 10% 9.00% Current: The Central West LHIN remains of of the best performers in the ‘Percentage of ALC Days’. In Q2 (09/10) the percentage of ALC days remains below the LHIN target of 9%. A slight increase in Q2 (09/10) may be attributed to the implementation of the new ALC definition. 8.91% Future: The Central West LHIN plans to continue to support current initiatives implemented by the CCAC that have supported performance in this area to date. In addition, Aging at Home initiatives for year 3 are anticipated to provide further support to the hospital in managing ALC. Q4 FY06/07, Q1-Q3 FY07/08 Data Source: CIHI-DAD Number of days from ALC designation to discharge by discharge destination 43 Days TBD Past: The Central West LHIN has performed well below baseline in the previous quarter demonstrating a relatively short wait in hospital for patients who are designated ALC. In the past the longest wait has been for ALC patients waiting for LTC placement. Current: At 21 days, the current performance in ‘Number of Days from ALC Designation to Discharge Destination’ remains similar to the previous quarter and well below the baseline of 43 days. As with the previous quarter, the longest wait from ALC designation to discharge destination is for patients waiting for LTC placement (WOHS 38 days). The wait time to LTC placement remains one of the lowest among the 14 LHINS. The slight increase in the number of days from ALC designation in Q2 (09/10) may be attributed to the change in the definition of ALC. Slight increases in the number of days from ALC designation to discharge destination were observed for patients waiting for Rehabilitation and Complex Continuing Care, which the LHIN anticipated to result from the inclusion of these categories in the new ALC definition. Future: The largest hospital in the LHIN (William Osler Health System) is implementing strategies that are anticipated to improve patient flow through the hospital and into the community. These strategies are intended to develop a consistent care management model, which will include defined roles and responsibilities of discharge planners and other key players in the management of patients through the continuum of care. A key element of this strategy is the development and implementation of an estimated date of discharge tool. The Central West CCAC will continue to support WOHS in improving bed utilization through the continuation of initiatives they have implemented to support early discharges to the community and further impact % of ALC days. 21 Days FY 07/08 Data Source: CIHI-DAD 6