Peter Ward Senior Physiotherapist Acute Medicine Driving Healthcare Change Through HSCP Research February 28 th, 2014 Carole Murphy Senior Occupational Therapist Emergency Department

Background Historically OT and Social Work providing services within this setting No physiotherapy, SLT or Dietetics services available Care pathways established in response to Government policy and organisational change

Impetus for Change Clinical Care Programs, 2010 Lis Nixon Report, 2011 Establishment of Special Delivery Unit (SDU), 2011

Service Objectives Provide rapid access to MDT assessment for patients in ED, AMAU and SSU who are deemed medically fit for D\C that day Reduce unnecessary non- medical admissions to hospital If appropriate, support early discharge from hospital, improve throughput and prevent re-admission

Design Phase Establishment of a steering group with representatives from the key HSCP groups Responsibility with the clinicians to oversee the design phase This included development of: 1. Care pathway 2. Single assessment tool 3. Role of teamlead

Referral to the BRAT service should be considered for patients who are medically fit to be discharged that day and present with the following:  Frail Elderly  +/- Living Alone  Falls Prevention  Upper/Lower Limb Fractures  Confusion  Exacerbation of Chronic Condition Does patient present with new difficulties with transfers/ mobility? Does the patient present as confused? Does the patient appear unkempt? YES Is there a concern regarding patient’s ability to cope at home? Referral to BRAT not indicated. Patient at previous functional status with adequate supports in place. YES Contact BRAT Team Lead. Dect: 8457 Referral to BRAT not indicated. Patient at previous functional status with adequate supports in place. No NO

Team Lead Rotational team lead between Occupational therapy, Physiotherapy and MSW Responsibilities include - Morning handover - Carries BRAT phone - Screens appropriate patients - Completes common assessment form as appropriate - Contacts relevant profession

Aims of Study To establish a profile of the patients referred to the BRAT service To analyse the patient profile of those readmitted to the hospital within thirty days of BRAT review To determine the efficacy of the BRAT service in relation to cost saving, bed day saving and admission avoidance

Beaumont Rapid Assessment Team 2012/13 From February 1 st 2012-January 31 st patients reviewed in 253 working days (1.1 patients\day) - Average age: 76 years and 9 months; Range females, 94 males (2:1 ratio) % lived alone - 48% were 80 years old or over

Age Categories

ED Attendances AgeTotalReviewed% , % , % , % % Total 51, %

Discharge V Admission

Gender Distribution of Admissions

Reason for Referral (Total & Discharge)

Onward Destination

Re-presentations 44 (23.6%) people of the 186 init1ally discharged re-presented within 30 days Of these 44: - 75% were deemed medical re-presentation - 25% were related to ongoing physical/functional issues Average time to represent was 11.5 days (Range 1- 30)

Age of re-presenters

Team Performance Average response time: 19 minutes 44.7% seen within 10 minutes

Cost Savings Average Medical LOS was days 770 bed days saved Average cost of medical bed is €950 per night Saving calculated at €731,500

Challenges to Service Provision Medical complications Limited access to: Home Care Packages Access to step down facilities: - rehabilitation - interim care - respite No Out of Hours Service

Limitations of Study Short time frame for research Cost estimate is quite conservative Difficult to establishing an exact cost saving due to: - complexity of the group of patients reviewed - costs are based on hospital averages and therefore do not address the individual variables which can arise in the ‘frail elderly’ - Doesn’t take into account those under ED service or subsequent cost of re-presentations

Positive Service Outcomes Coordinated MDT assessment at point of entry to Beaumont hospital Team lead and the common assessment form enhances communication Equipment provision Onward referral to both in-house & community services Prioritisation for rehabilitation and discharge planning

Conclusion Provide rapid access to MDT assessment for patients in ED, AMAU and SSU who are deemed medically fit for D\C that day Reduce unnecessary non- medical admissions to hospital If appropriate, support early discharge from hospital, improve throughput and prevent re-admission

Acknowledgements Members of BRAT HSCP Managers Senior Nursing Staff Emergency Department Consultants Rebecca Mahon – 3 rd year Physiotherapy Student RCSI Dr. Frances Horgan – Senior Physiotherapy lecturer RCSI Hospital Management HSCP Education & Development Advisory Group

QUESTIONS???

References Nixon L, Wolford S. Reports into the Emergency Care Pathways in Beaumont Hospital (2010) Beaumont Hospital HIPE Hospital Inpatient Enquiry) Data, ( ) Beaumont Hospital Annual Report 2011 Report of the unannounced monitoring assessment at Beaumont Hospital, Dublin. HIQA (2013)