Cardiology Admissions Single Point Emergency Referral (CASPER) Principal Investigator Ms. Heather La Bash, University of Queensland   Co-Investigators Dr. Andrew Staib  Dr. Clair Sullivan Dr. Robert Eley Dr. Bronwyn Griffin Dr. Ian Scott Dr. Paul Garrahy Princess Alexandra Hospital & University of Queensland School of Medicine Acknowldege staff, division of medicine and emergency department for their collaboration. At the moment, CASPER has been introduced for in hours and we will be show out of hours as a comparison. Phili Kaye *ED, Paul Garrhey *C I would like to thank the director and the staff of the emergency for hosting me and to UQ for providing funds.

Why the need for process change? Increased LOS  increased adverse patient outcomes NEAT targets Cardiology patients Time sensitive High volume group  opportunity to reduce overcrowding Non-compliant to NEAT 1 in 6 patients, enough patients that it is worth doing Can actually say that am just going to summerzie background, since they are a knowledgable audience locally, that cohort of pnt admissions was complicatead, consequence was longer stay in ED (and longer inpatient stay) waiting ot be sorted,m this was not good as longer lentght of stay in ED can lead to increased adverse effects and overcrwoding. This is also not good because of the process measure of NEAT was being blown out by these patients. Others are also blowing out the NEAT, but cardiology is a significant cohort. are especially affected by ED LOS – inconsistency and complicated, which affected their LOS overall. 15% of admitted patients are cardiology. NEAT 4 hours, many cardiolgoy patients were not being processed in a manner that

Previous Admission Process Patient transferred Cardiology decides on team, Admission processed in ED, Bed called Multiple ED residents, registrars, consultant call Cardiology Multiple cardiology registrars, consultants To compare CASPER with what happened before, here’s the flow.

CASPER One ED registrar or consultant One senior cardiology registrar Patient transferred & admission completed One senior cardiology registrar One ED registrar or consultant Senior cardiology – selected based on being advanced trainees and because of their communication skills (in the first run – 2 of the 5) “Patients are then transferred to one of the cardiology inpatient units.” M-F, 8am- 5pm Procedure for contacting the cardiology team single senior cardiology registrar with a dedicated telephone number Physical location of the admission procedure cardiology ward Seniority of the ED staff contacting the cardiology team registrar Direct admission notification of admission

Research Questions CASPER – Direct to ward admissions to the cardiology service via ED …decrease ED LOS? …change in patient outcomes? ward changes RRT CA …change ward LOS? Use the pointer. These are the three research questions.

Methodology Study type: Period: Participants: Pre and post intervention descriptive study. Comparative analysis. Period: Pre-intervention (Sept 29th – Oct 26th) Post-intervention (Oct 27th – Nov 24th) Participants: All patients 18 and over, who were admitted to cardiology via the ED Mention that CASPER started on the 27th of October. Implemented, Implemententation

Methodology Study population: 243 pre- and 242 post-intervention Exclusions: those with non-cardiology destinations & out of hours consultations Final study cohort CASPER = 80 Matched pre-intervention = 92 Data from EDIS and HIMS ED LOS WARD LOS Ward transfers RRT / CA Statistical analysis: SPSS, Anova, Chi square Could talk about renal patient. Original data set was all patients who had any symptom that was indicative of Only , Anova, Chi square HIMS – health informaiton management system – covers all the patient records, procedures, for the entire hospital ) I set of datasets EDIS- specific to ED Dedicated EM dept inof system, EDIS, and HIMS, which has all the other data from the hospital. Make sure to stress that EDIS is dedicated, HIMS is data on all admitted patients. RRT – O2 less than 92%, BP less than 80 systloic (there are paramenters), staff concern, Ryan’s rule – based on a boy Ryan who died – parents are able to escalate above standard care. RRT doesn’t apply to wards with critical care (ICU, ED). Just in general ward.

ED LOS for Emergency Cardiology Admissions to Inpatient Wards with CASPER Out of hours, there was no CASPER and no significant effect. As there has been no change in resourse and process for out of hours. Describe clearly to what each color refers to. Blue – pre intervention, Red post. Left hand shows in hours (between 8 and 5),. Out of hours. In hours shows significant changed in length of stay. There are two effects here. One is an “out of hours” effect. But the main one, which I want to focus your intention on is the difference between the CASPER and non-CASPER. There are no dedicated cardiology registrars out of hours. Spend a bit of time. Explain Can change this to add an astrix and which test was done…. P value by the x- test. Parametric vs. non-metric …. T-tests?

Improvement in NEAT Compliance for Emergency Cardiology Admissions to Inpatient Wards with CASPER 21% increase in NEAT compliance. Out of hours, there was no CASPER and no significant effect. NEAT went up. While the NEAT for the out of hours patients remained the same. There was no change in Describe clearly to what each color refers to. Blue – pre intervention, Red post. Left hand shows in hours (between 8 and 5),. Out of hours. In hours shows significant changed in length of stay. There are two effects here. One is an “out of hours” effect. But the main one, which I want to focus your intention on is the difference between the CASPER and non-CASPER. There are no dedicated cardiology registrars out of hours. Spend a bit of time. Explain Can change this to add an astrix and which test was done…. P value by the x- test. Parametric vs. non-metric …. T-tests?

Summary Faster: CASPER effect Safe: No changes in adverse outcomes 66 mins difference in ED LOS, p= <.001 Safe: No changes in adverse outcomes RRT CA No increase in ward transfers Effective: No change in ward LOS Not shifting work from ED onto cardiology

Conclusion Protocol has been in use for 7 months now. Continue to see no increase in adverse effects. Very well received within ED and cardiology. Multi-disciplinary Collaboration Staib A, Sullivan, C., Eley, R., LaBash, H., Griffin, B., Barnes, H., McCormack, L., Moore, P., Garrahy, P., Scott, I. Cardiology Single Point Emergency Referral (CASPER): Reducing ED overcrowding with a direct to ward emergency admission model for cardiac patients. EMA. 2015;Under Review REPRESENTS A SUCCESSFUL MULTI-DISCIPLENARY STRATEGY TO IMPROVE PATIENT CARE and increase compliance with national time targets. Summerize In conclusin, Multi- disclip- Internal medicine, patient flow unit, ED, Cariodlgoy, nurses (and multi-disciplinary – nurses, doctors, allied health. Targets drive a lot of process (4 hour rule) – not possible to meet some of them without cross department collaboration. Database EDIS (screenshot) – manually went through each of the records over the 8 week study period, had to look through the text as a consequence of doing it this way, ED developed a simpler way to capture CAPSER data, for easier review and analysis

Thank you Questions?