Managing Acute Patient Flows
1. EXECUTIVE SUMMARY
1.1 Introduction
Victoria’s public hospitals are major providers of acute and
sub-acute health care. Acute care involves diagnosis and intensive
treatment over a short time frame to reduce the symptoms or
severity of illness or to provide a cure.
Hospitals most often provide acute care:
- in
emergency departments
- through
the provision of elective and emergency surgery
- through
the provision of medical inpatient care
- for
planned treatment of existing illness, such as chemotherapy or
renal dialysis.
Traditionally, hospitals have treated these patients in an acute
inpatient setting, such as a hospital ward. The ability to move
patients into and out of an acute inpatient setting without undue
delay, while maintaining appropriate standards of care is a key aim
of the public hospital system.
Demand for acute care has increased steadily over the past
decade and Victoria has the second highest public hospital
admission rate in Australia. The ability of hospitals to manage
this demand relies on there being sufficient capacity across the
health system. Traditionally, hospital capacity has been measured
by the number of available beds. However, this is no longer a
particularly useful measure of capacity in light of new models of
care such as day surgery and bed substitutes such as Hospital in
the Home (HITH), which reduce the need for acute patients to stay
overnight, or longer.
The changing models of care and a shift to same-day services
have resulted in shorter hospital stays and reduced the need for
more beds across the hospital system. How a hospital applies the
models of care and manages the flow of patients through the
hospital from admission to discharge, has a greater bearing on its
capacity to treat acute patients than the number of available
beds.
Victoria compares favourably with other states in its use of
acute inpatient beds, having both the highest level of bed
utilisation and the shortest average length-of-stay, indicative of
a comparatively efficient public hospital system.
Nevertheless, delays in access to emergency departments and
elective surgery indicate that there is room for improvement in the
way that Victorian public hospitals manage their patient flows.
Good patient flow has patients moving through a hospital without
delay, eliminating waits and delays and saving time, effort and
costs. Realistically, perfect patient flow through a hospital is
not achievable, however, the extent to which hospitals manage the
identifiable bottlenecks that interrupt flow and slow a patient’s
journey has a direct influence on patient flow.
A significant cause of bottlenecks and delays in hospitals is
‘variation’. Managing variation in patient flow is a natural part
of every health and hospital system and requires differences in
patient illness and injury, demand through emergency departments
and patient demographics to be addressed. Variation can lead to
significant differences in the average length-of-stay for the same
patient condition across hospitals.
Audit objective and method
The audit objective was to determine
whether patient flow and bed management in Victoria’s public
hospitals was effective and efficient. To achieve this objective,
the audit examined how the Department of Human Services (DHS) and
health services:
- planned for inpatient services
- managed demand for inpatient services
(focusing on program interventions)
- managed planned and unplanned admissions
- managed the use of inpatient beds
- discharged patients from an inpatient setting
(either to within their homes with community support or residential
aged care facilities).
Findings
Planning for acute inpatient services
Both DHS and hospitals plan for
inpatient services to provide sufficient capacity, in terms of
resources and care models, to meet demand.
DHS has developed planning frameworks
for both metropolitan and regional and rural hospitals that
consider service, capital and workforce needs: the Metropolitan
Health Strategy (MHS) for metropolitan hospitals and Rural
Directions for a Better State of Health (RDBSH) for rural and
regional hospitals. DHS is developing a health asset strategy to
guide its expenditure and service planning over the next ten
years.
Each of the five hospitals we audited
conducted service planning that took account of acute inpatient
services and informed future capital requirements. Planning
occurred in collaboration with DHS, which also coordinated the
process. This gave DHS an understanding of the system-wide
implications of individual service plans and whether they were
consistent with the strategic directions for each program area.
The availability and use of reliable
data is essential for effective planning. It is used to identify
trends and patterns in the demand for, and use of, health services
and enables planners to target funding and resources accurately.
Much of the data used to inform planning for DHS and hospitals came
from datasets that DHS maintained. However, the mechanisms to
manage data reliability did not always ensure that the data were
reliable.
Each of the hospitals used a range of
clinical and administrative data to plan, monitor performance and
improve practices. Hospitals not having benchmarking data limited
their ability to identify areas for improvement. DHS’s recent
variation project aims to rectify this by providing detailed
benchmarking data for acute care.
DHS purchases acute inpatient services
through the casemix funding system and links into hospital planning
through the negotiations around the annual Statement of Priorities.
Casemix funding represents about 84 per cent of all admitted acute
inpatient funding—the remainder consisting of various grants and
performance bonuses. The casemix approach aims to closely match
funding with the actual costs of treating patients and encourages
efficiency by providing incentives for hospitals to treat and
discharge patients as quickly as possible. As this is most likely
to occur in hospitals with good processes and systems, casemix
encourages better patient flow through the hospital.
Managing acute inpatient admissions
Admission is the process where the
hospital assumes responsibility for a patient’s care or treatment
and accommodates them on either a same-day or overnight basis.
Hospitals face a daily challenge managing inpatient admissions,
with demand for acute inpatient care and increasing patient illness
acuity placing increasing pressure in hospital resources. The need
to manage this demand, while also working to balance competing
demands for elective surgery and emergency admissions, adds to this
challenge.
Each of the audited hospitals had
implemented demand management strategies that both substituted for,
and diverted patients from, inpatient care. The lack of local
evaluation, however, meant that it was not possible for hospitals
to assess just how effective these strategies had been. This
represents a missed opportunity to finetune their strategies and
improve patient flow.
While all hospitals planned their acute
inpatient admissions, the effectiveness of the planning was reduced
as monitoring of the balance between elective surgery and emergency
department admissions was not done on a regular and ongoing basis.
Each hospital had postponed elective surgery because it prioritised
emergency department patients. While presentations to emergency
departments are unplanned, they are also highly predictable and by
identifying trends, such as the increase in demand for emergency
admissions during the winter period, hospitals should be able to
predict with a high degree of certainty the number of inpatient
beds emergency department patients will require. There is an
opportunity for hospitals to improve elective surgery planning by
understanding variation in emergency admission demand and planning
elective admissions in response.
All hospitals had a range of processes
to manage inpatient admissions that improved patient flow. These
related primarily to elective surgery. However, the processes for
emergency admissions were less effective, placing a heavy reliance
on emergency department staff to actively manage admissions by
‘pushing’ patients onto wards. Ward staff were less inclined to
‘pull’ patients from the emergency department. This resulted in
delayed admissions and longer emergency department waits.
To improve the ‘pulling’ culture within
wards—where ward staff actively seek patients for their
beds—hospitals should set expectations for staff participation in
facilitating emergency admissions, improve communication regarding
waiting patients and identify and address cultural issues, which
act as barriers to smooth transition from the emergency
department.
Managing the acute inpatient stay
How well hospital staff manage their
beds can have a significant impact on how well patients flow
through the hospital. If the hospital does not have enough beds
available for the day’s admissions, patients may wait in the
emergency department longer than is clinically desirable, which has
a flow-on effect for those in the emergency department waiting
rooms. The hospital may also have to postpone elective
surgery—adding to waiting lists and delaying access to care for
these patients.
All hospitals had bed managers, enabling
a coordinated and collaborative approach to managing beds
hospital-wide. However, hospitals relied on custom and practice
rather than detailed, relevant bed management policies and
procedures, which led to inconsistent and inefficient bed
management practices.
Hospitals relied on paper-based bed
management tools to collect information on the hospital’s
bed-state. These tools were often complex, used inconsistently and
difficult to complete. The collated information was difficult to
interpret and reduced the accuracy of the hospital’s bed-state
data. Because these tools were manual the hospitals did not have
real time data on the hospital’s bed-state to support planning for
admissions.
The absence of real time information was
symptomatic of poor IT systems to support bed management. None of
the audited hospitals had robust and effective bed management IT
systems to provide real time data to aid admission planning—a major
impediment to improved patient flow. DHS has recognised the
limitations of IT systems in Victoria’s public hospitals and is
piloting a dedicated bed management IT system.
Managing acute inpatient discharges
Hospitals did not have detailed
procedures and clearly stated roles and responsibilities to guide
patient discharge, limiting the effectiveness of the discharge
process. Hospital managers need to ensure that all staff are aware
of their roles and responsibilities in the discharge process to
prevent discharge delays due to non-participation or poor
coordination.
Early discharge planning at each of the
hospitals was a positive development, enabling staff to begin
preparing patients for timely transition to a more appropriate
setting when their treatment was complete—decreasing the likelihood
that the hospital would experience discharge delays. Ward rounds
and discharge meetings provided hospital staff with regular
opportunities to identify patients who were ready for discharge.
They were most effective when conducted early in the morning,
reducing the likelihood that patients spend additional and
unnecessary time in an acute inpatient bed.
Junior doctors can be reluctant to
discharge patients without first consulting with senior medical
staff. This is common in most hospitals. It was a concern at the
two hospitals we audited that were reliant on visiting medical
officers (VMOs). The limited availability of VMOs may be
unavoidable, but should not be allowed to create bottlenecks that
delay discharge. Hospitals need to establish processes to overcome
these bottlenecks, such as criteria-led discharges, where senior
medical staff identify key conditions that patients must meet
before the hospital can discharge them. Criteria-led discharges are
being used increasingly across the sector, and could be a useful
way to improve the timeliness of discharges.
Discharge performance was generally
consistent across the five hospitals and with the statewide
average. However, in line with better practice and the hospitals’
own discharge policies, hospitals need to direct more effort to
increasing the percentage of patients being discharged early in the
morning. Hospitals also need to improve the rate of weekend
discharge. The low rate of weekend discharges has been an issue for
the past decade. It was raised in 2000 by Victoria’s Patient
Management Taskforce. Since then only limited improvements have
been made.
Hospitals should focus their weekend
effort on ‘simple’ discharges—that is, discharge of those patients
who do not require complex social service support. As increasing
weekend discharges may require additional staff, and subsequently
additional costs, hospitals should assess the costs of increased
weekend staffing against the benefits of better patient access and
flow.
GENERAL RESPONSE provided by the
Secretary, Department of Human Services
The findings that both DHS and
hospitals are adequately planning for in-patient services to
provide sufficient capacity to meet demand is pleasing.
Current patient flow processes have
allowed Victoria to achieve amongst the best time to treatment and
bed efficiency performance levels in Australia, but more can and
needs to be done to further improve the efficiency and
effectiveness of these processes.
DHS acknowledges the importance of
ensuring high quality data is available to accurately monitor
performance and inform planning processes. DHS is in the process of
engaging consultants to undertake an audit of the Victorian
Emergency Minimum Dataset to address issues with data reliability
and improve hospital data and its quality.
The audit report’s recommendations and
identified areas for improvement are consistent with the range of
work being undertaken by DHS to improve patient flow across
Victoria’s public hospitals.
Recommendations
Planning for acute inpatient admissions
Public hospitals need to:
- reduce pressure on existing resources by
maximising the use of care models that substitute for inpatient
beds. This will require collaboration with DHS to ensure timely and
effective implementation (Recommendation 4.1)
- reduce bottlenecks that delay admission for
emergency department patients, including by promoting greater use
of interim orders and focus on the pulling of patients from the
emergency department into ward beds (Recommendation
4.2)
- undertake more regular and
comprehensive analysis and monitoring of data to inform their
scheduling, and more actively manage changes in demand and capacity
(Recommendation 4.3).
- The Department of Human Services should work
with hospitals to monitor emergency admissions and to balance
emergency and elective demand more effectively
(Recommendation 4.4).
RESPONSE provided by the
Secretary, Department of Human Services
Accepted in principle. DHS will
consider this recommendation in the context of the Redesigning
Hospital Care Program and the development of tools that support
hospital access management. DHS has funded a four-year Redesigning
Hospital Care Program to build health service capability to create
and spread sustainable improvements in emergency and elective
inpatient care.
Managing the acute inpatient stay
The Department of Human Services
should:
- develop, in conjunction with hospitals,
comprehensive bed management guidance for achieving better
practice, just as it has developed guidance on elective admissions
(Recommendation 5.1)
- introduce the preferred system to each Victorian
hospital as a key tool for improving patient access and flow,
giving consideration for the life-cycle costs of implementation,
following the pilot and evaluation of the electronic bed management
systems (Recommendation 5.2).
RESPONSE provided by the
Secretary, Department of Human Services
Recommendation 5.1
Accepted in principle. The Elective Surgery access policy developed
by DHS provides guidance for managing patients receiving elective
surgery in Victorian hospitals. DHS will consider this
recommendation in the future development of inpatient program
guidelines that relate to admission and discharge practices, such
as short stay observation unit guidelines.
Recommendation 5.2
Accepted in principle. DHS has funded an electronic bed management
system that will provide hospitals with the capability for ‘real
time’ organisation wide monitoring and management of bed capacity.
DHS will consider this recommendation following the evaluation of
the electronic bed management systems currently being piloted in
selected Victorian hospitals.
Managing acute inpatient discharges
Public hospitals should:
- develop comprehensive discharge policies and
procedures that clearly identify staff roles and responsibilities,
particularly those responsible for the coordination of discharges
(Recommendation 6.1)
- promote the use of criteria-led
discharges to reduce discharge bottlenecks caused by senior medical
staff being unavailable, and reduce duplicated effort across
hospitals. (Recommendation 6.2)
- increase the rate of weekend
discharge for those patients able to return to their homes without
the need for community support (Recommendation
6.3).
The Department of Human Services should
facilitate the development of discharge criteria to enable a
consistent approach and to reduce duplicated effort
(Recommendation 6.4).
RESPONSE provided by the Secretary, Department of
Human Services
Accepted in principle. DHS has funded
Victorian hospitals to expand and mainstream care coordination
services to support discharge from emergency departments and early
discharge planning for inpatients. DHS will consider this
recommendation in the context of the inpatient program guidelines
that include admission and discharge.