1. The use of mobile phone technology as a tool to improve patient flow in KATH ED By Dr Paa Kobina Forson 26 th February, 2014 WACS Conference, Kumasi

2. Outline Background Objectives Methods Results Challenges Conclusions and future projections References

3. Background ED overcrowding affects quality of care of the patient Overcrowding causes Increases in morbidity and mortality Increased stress to health workers Dissatisfaction to patients and workers (Campbell, 2007; ACEP, 2004)

4. Background KATH ED receives an average of 84 patients per day and 28,000 patients in a year Overcrowding and long boarding hours has been a challenge in the ED A number of initiatives have been taken to deal with long boarding hours in the ED and to increase patient flow. Staff in KATH perceive overcrowding to influence poor attitudes to work, turning patient away (Forson PK, 2013)

5. Initiatives Contacting doctors on phones to review patients – Gotta phones Bed managers have been introduced Some Improvements in patient flow seen Bed states reports are more frequent Reports come in every morning Alas! These initiatives were fraught with challenges so did not make much impact.

6. Challenges Phones were few and did not have a wide coverage Bed state reports from admitting wards are brought in the morning only. However bed state report reflects the state of the ward per unit time NOT for 24 hours. Ward state dynamics are not reflected for the rest of the day Bed managers have to trek through the ward to update records on available bed spaces Bed managers not on cover at night, so night transfers of patients are virtually non-existent

7. What do we need in the ED Real-time monitoring of patient flow could help improve quality care and address the challenges of above Round-the-clock transfers of patients to wards This system has been used in Scotland. It involves the integration of information technology to aid the monitoring of bed states and patient transfers (Theummler et al, 2005) Mobile phone penetrance in Ghana is more than 90%

8. Objectives To institute a system where round-the-clock monitoring of bed states and patient transfers are improved

9. Methods A interventional study started in November 2013 It involved the use of mobile phones by nurses on the admitting wards to send two-hourly bed state reports via text messaging through a specially developed code The hospital brokered a deal with a Airtel Telecom to supply phones with specialized numbers All nurses in the admitting ward were trained in November to be able to send text messages

10. Methods These text messages are received by bed managers in the ED The report from the text messages are interpreted and serves as basis for transferring patients to the ward Ward nurses are to send bed states by text messaging every 2 hours. Prior to this, bed state reports are sent once in the morning and this served as the basis for ward transfers throughout the day

11. Codes for text messages W – Ward e.g. B3 T – Total beds in the ward e.g. 15 O – Number of Occupied beds in the ward e.g. 13 D – Number of beds occupied by Discharged patients e.g. 5 E – Number of Empty beds available in the ward e.g. 2

12. Codes for text messages R – Number of reserved beds i.e. a bed reserved for a patient in theatre, is in ICU Has been temporarily discharged Is a pre-op patient who has not yet arrived in the ward X – Number of oXygen ports available e.g. 3 C - Number of Cots available (B3 only)

13. Example 2 At 12:00 midday, Ward Z1 has a total of 20 beds. 18 of these beds are occupied. 3 patients have been discharged but are waiting to pay their hospital bills before they go home. 2 beds are empty and available to receive patients. 2 of the 2 empty beds have been reserved for 1 pre-op patient who will arrive tomorrow, and 1 patient on the ICU who may be sent back to the ward later today. The ward in Charge is Smillie Zugar

14. Cont. The text message will read as: WZ1/T20/O18/D3/E2/R2/SZ This tells us that though there are 2 more beds empty since 11:00am, both are not available for patient transfers at 12:00 noon

15. Methods - Codes

16. Methods After two months of implementation reports of bed states were analyzed and compared to data collated from three months before the introduction of the text messaging system.

17. Results Most wards are able to send bed states report of their wards 2 hourly from 8am to 10pm Bed states reports show more opportunities of bed spaces on the wards through the day unlike formerly when the morning bed state report served as the only report of bed space for the whole day Long boarding hours and over spilling in the ED wards has been observed to have decreased since December, 2013.

18. Bed state Dynamics – Cumulative frequencies

19. 2 hourly Ward states showing dynamics in bed spaces – trans-ins and discharges in Jan.- Feb Wards8am10am12noon2pm4pm6pm8pmTOTALWARD TRAN SFERS INCRE ASES IN BED SPACE S B2 3682141343012452201761675518167 C1A 4222381893362982712081962361147 C4 166723312192836963618588 D4 2018074144115936176821070 D5 14237609067452346417253

20. Ward transfers from the ED(before and after)

21. Patient flow and decreased boarding in the ED using trans-out patterns

22. Interpretation The slow descent of the line curve from July to November in the two graphs above show increased boarding hours of patients between July to October. The introduction of the 2 hourly bed state reports from the admitting wards increased the number of opportunities for ward transfers and has reduced long boarding in the ED

23. Limitations Short period since the introduction of the mobile phone text messaging We have not achieved full compliance of the use of the mobile phone in the hospital Telco delay in crediting the phones with units. When units run- out, text messaging is hampered

24. Research Team Project Lead – Dr George Oduro Team members: Dr Rockefeller Oteng Mrs. Patience Ampong Dr Joseph Bonney Dr Kwame Ekremet Mr. Francis Atuahene Akuoko Mrs. Freda Osei – Wusu Mrs. Herty Kwawununu Staff of EM Research Office

25. References