Winnipeg Health Region Wave, September / October 2013
Albert Taylor can't remember how he ended up in a bed at the Grace Hospital.
All the 94-year-old Winnipeg man knows is that one minute he was in his apartment, and the next he was in the Emergency Department undergoing treatment for a stroke.
"I'm lucky," says Taylor. "I didn't have paralysis and I can talk."
Taylor was taken to the Grace on July 27 by his daughter after he experienced trouble speaking, weakness and fatigue. Following the initial diagnosis and treatment for stroke, he was admitted to hospital for more care and rehabilitation.
Fortunately, Taylor was able to make a relatively quick recovery. While in hospital, he worked with nursing staff and a physiotherapist to regain his mobility and an occupational therapist who helped him work on small tasks, such as getting dressed and pouring a drink of water for himself. Twentythree days later, Taylor was ready to be discharged from hospital and return home, with support from Home Care.
In the past, patients like Taylor spent an average of 25 days longer than neccesary in hospital before being discharged.
Not any more. Today, patients are less likely to linger in hospital longer than medically necessary, thanks to a project known as the Overstay Reduction initiative.
Introduced at the Grace last July, the initiative has been rolled out to selected internal medicine units at St. Boniface Hospital, Victoria Hospital and Health Sciences Centre over the last year.
The result has been a significant improvement in patient flow. Statistics show the initiative has helped reduce the length of stay for all patients by an average of two days, or 14 per cent at the Grace and St. Boniface hospitals. That's good for the patient because it enables them to get home sooner.
But it's also good for those awaiting care. By enhancing the flow of patients through the medical wards, the initiative frees more beds to treat more patients sooner, including those from the Emergency Department.
In fact, admissions to the Grace and St. Boniface hospitals have jumped between five and six per cent during the first eight months of the last reporting period. That represents about 100 more patient admissions over that time. Projections suggest that the reduction in unnecessary hospital stays at the Grace and St. Boniface hospitals could accommodate as many as 600 more admissions annually.
The Overstay Reduction initiative is the brainchild of Dr. Dan Roberts and a team that included healthcare providers, a data analyst and an industrial engineer.
An internal medicine specialist by training, Roberts has long had a keen interest in quality improvement research. In 1988, while serving as Director of the Medical Intensive Care Unit at Health Sciences Centre, he created the first comprehensive Critical Care Database in Canada. He then developed a city-wide integrated adult intensive care service, which included an administrative and research database, city-wide transport service and a central bed registry. The databases keep track of whether patients released from one hospital are subsequently re-admitted to another. This allows for staff to better monitor patients' outcomes, thereby enhancing quality of care.
In 2011, Roberts was re-appointed for his third term as head of the Region's Internal Medicine program, making him responsible for managing the use of internal medicine beds at the Health Sciences Centre, Grace, Victoria and St. Boniface hospitals. Soon after assuming his duties, Roberts, who is also Head of the Department of Internal Medicine at the University of Manitoba's Faculty of Medicine, decided to look into whether it would be possible to improve the flow of patients through hospital wards.
Working with a data analyst, he reviewed about 30,000 admission records on an electronic database. The review showed that the vast majority of people admitted to hospital were treated and discharged in a timely manner. But it also found that some were not. In fact, some patients were still in hospital awaiting discharge as long as five weeks after they were medically ready to go home.
"We found that 75 per cent of people go home immediately after they're medically ready," says Roberts. "Out of the other 25 per cent, all stayed longer than they should have. But of that 25 per cent, seven per cent stayed an average of 25 days longer than neccessary," he says.
In fact, Roberts found that the seven per cent who stayed an extra 10 days or more than neccessary, accounted for 80 per cent of total overstay days. "Some people were still in hospital eight or nine months later . . . Compare that to the average hospital admission of 14 or 15 days, and you can see the problem."
To help solve it, Roberts brought in industrial engineer Linda Hathout, whom he had hired eight years earlier to find process improvements in the delivery of medical services in the intensive care and medical units.
As project manager for the Overstay Reduction initiative, Hathout was charged with designing a process map to help patients get home sooner.
A working group, including Hathout, Dr. Nick Hajidiacos, nursing staff, and members of the allied health workers team - physiotherapists, occupational therapists, social workers and home care workers - was formed to look at the data for patients staying longer than 10 days.
"We audited 170 charts of patients who stayed more than 10 days beyond their discharge-ready date to see what trends existed in their discharge planning process," says Hathout.
Digging deeper into the data, the working group discovered the main reason patients weren't being discharged in a timely manner was rooted in the decision-making process on the ward.
Each ward or unit is typically made up of doctors and nurses, as well as members of the allied health team. In theory, the discharge planning process starts when a patient is admitted to a hospital unit or ward. But the working group found that sometimes health-care staff would hesitate to discharge a patient unless they had been seen by one or more members of the allied health team, even if such consultations were not warranted. In addition, patients sometimes remained in hospital because family members weren't sure whether they should be discharged to go home or be admitted to a personal care home.
"By assuming the patient needs to be seen and assessed by every team member, the process of getting a patient home slowed considerably," explains Mary Anne Lynch, Program Director of Medicine Programs for the Region and the Grace Hospital, and a member of the working group. "We wanted to streamline this approach so that (the allied health team members) were directed to the patients who needed them. We knew we could improve the process if we could plan ahead for those particular patients and do it faster than we were."
To expedite the process, the working group developed a two-part screening process, including a patient questionnaire.
Once the screening questionnaire was finalized, it was introduced to the staff of 5-North ward at the Grace through inservices by Rianna Bettencourt, clinical nurse educator for the medicine program. Helen Cherwinski, Manager for 5-North, played a key role in the implementation and continued support of the program during its initial phase. After a two month trial, this program was expanded to the other internal medicine units under the guidance of clinical nurse educator Leslie Frye.
Under the new system, a patient admitted to one of the medical units is interviewed by a nurse who, as part of the assessment, asks six specific questions designed to highlight potential discharge concerns. Within 48 hours, this information is analyzed by a data collector who uses a mathematical algorithm to determine whether to categorize a patient as green, yellow or red.
Typically, a patient marked as green will pose little risk for discharge delays. When their medical issues are addressed, they will likely be able to go home that day. Patients in the yellow category are considered to be at moderate risk for discharge delays. This means they may need a few extra days in hospital as their strength improves or home care services are put in place, for example. A patient marked as red is considered to be at high risk for discharge delay. This means that even after their medical issue is stabilized, they may end up staying in hospital for more than 10 days to allow for certain requirements to be met so they can return home.
As part of the new process, each red patient is assigned a transition co-ordinator from the allied health-care team. The transition co-ordinator is responsible for ensuring appropriate consultations have been made and that discharge issues are being addressed in a timely manner.
In the beginning, some health-care providers were concerned about the Overstay Reduction initiative because they thought all patients would end up being red-flagged.
"The entire team was initially worried about an additional workload," says Lynch. "But we've discovered the new process is working quite well, and allied health consultations have decreased at some of our sites." In addition, there has been no change in re-admission rates, and no concerns or complaints from patients have been reported.
Brenda Brelinski, a physiotherapist and one of the transition co-ordinators at the Grace, says the new system is working well. "The change went really smoothly on 5-North," she says. "I now have one or two red-flagged patients at a time, and it's my job to help them navigate to the right care, as early as possible in their hospital stay."
Brelinski says part of her job is to talk to families about the benefits of being discharged from hospital as soon as a patient is medically cleared for release. "As a transition co-ordinator, it's my job to open up the conversation, and find a way to remove the barriers to getting people back to their homes."
Anthony Barto, a social worker on 3-South at the Grace, says he has three to five red-flagged patients at any one time on his list. "Many of my patients need supports put in place before they can go home. It's the nature of the neighbourhood around the hospital; we see a lot of older patients, whose families aren't sure their parents should be going home."
In addition to indecision on the part of medical staff, the working group discovered that discharges were sometimes delayed because patients were waiting to be "panelled," the process by which applicants are reviewed for placement in a personal care home.
"Panelling shouldn't be done in hospital if it's not necessary," says Lynch.
"The Overstay Reduction initiative has made the team aware of this, and as a result, there has been a decrease in the number of patients panelled in hospital by 49 per cent," she says. "So instead of waiting months in hospital for placement in a personal care home, people are going home with appropriate supports in place. The Winnipeg Health Region Home Care program has been a great partner, working with us to ensure the people are going home safely with the right supports."
Hathout says the two-day average reduction in length of stay for all patients at the Grace is the result of a lot of things. "I attribute this to all the components. We're flagging the right patients. The allied health team assigns them a transition coordinator. The nursing staff is aware and engaged in discharge planning. The medical team is embracing the concept that home is best. There has been a shift in thinking. And there's home care support for patients who can then be panelled from home."
"Home really is the best place," says Lynch. "Hospital is where we stabilize the patients and treat their medical conditions. But once they're medically able, home is where they want to be, and we're doing our best to help make that happen for them faster."
One of the most important things about the initiative is that it was implemented without any additional operating funds. "There was no other money required," says Roberts. "We didn't hire any additional staff, we just changed the way people worked."
After spending just over three weeks on 5-North at the Grace, Albert Taylor is up and walking the halls under the watchful eye of a physiotherapist. "Albert was originally red-flagged upon admission because of the way he answered the questionnaire," says his nurse, Val Irving. "We knew that he would need help recovering and help when he goes home. He already has some services where he's living, like daily meals and laundry, so he'll need home care to come in and give him extra assistance with medication and mobility."
Taylor, who once was a Lieutenant Colonel in the Canadian Militia, met and married his wife, Sheila, in London during World War II. They had four children, and were married for 65 years, before Sheila passed four years ago. Now Taylor lives alone.
Irving laughs as Taylor tells her that while he's feeling cold, he's been sleeping really well while in hospital. "Are you sorry you can't stay with us?" Irving asks.
Taylor smiles back, letting her know he is ready to go home.
Susie Strachan is a communications advisor for the Winnipeg Health Region.
Eliminating the barriers
A hospital discharge delay (overstay) occurs when a patient who is medically stable is not discharged due to non-medical reasons. The Winnipeg Health Region's Internal Medicine program has been working to reduce hospital discharge delays through the Overstay Reduction initiative. The initiative was implemented at the Grace Hospital in July 2012 and at St. Boniface Hospital in November 2012. It was also rolled out at the Victoria Hospital in February of this year and at the Health Sciences Centre in May.
The initiative includes:
Identification of patients likely to be at risk for discharge delays
Assignment of a transition co-ordinator to this high-risk group to oversee discharge planning activities
Increasing awareness of and engagement of nursing staff in discharge planning requirements
Tighter screening of the panelling process (used to assess patients for possible placement in a personal care home) to identify candidates appropriate for panelling from home
An increase in home care support for patients panelled from home
Early appropriate allied health and home care consultations for patients likely to experience discharge issues
How the Overstay Reduction initiative works
Within 24 hours of admission to hospital, patients are assessed, interviewed by a nurse, and asked six questions that give a picture of their mental and physical health, their home conditions, their family support and how they would deal with an emergency situation. In subsequent days, clinical information is also compiled from their medical chart.
Once the data on each patient is collected and analyzed, green, yellow or red stickers are attached to the patient's chart, indicating whether they will need discharge planning help.
Green patients are cleared to leave hospital when medically able. Yellow patients require some caution on the part of the staff, who will work on their discharge planning.
Red patients are assigned to a transition co-ordinator, who, as part of the allied health team, works with all the team members ensuring the required consultations are completed from the allied health-care team: physiotherapy, occupational therapy, social work or home care. The transition co-ordinator makes a recommendation to the doctors once they feel the patient is ready to be discharged.