1

Does an efficient Em SSU reduce or redistribute admission ? And

the By-products ? From Panda’s Eyes

to Aussie Kangaroo’s HopCW Kam TMH AED COS

5 May 2008

http://hk.wrs.yahoo.com/_ylt=AuhzwAaSw.oAS_riZhi2v0K.ygt.;_ylu=X3oDMTA4NDgyNWN0BHNlYwNwcm9m/SIG=12557bvgt/**http%3a//www.free-desktop-wallpaper.de/wallpaper-animals/panda.jpg

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Emergency Medicine1) Broad-based Specialty

A Specialty of Multi-specialties / sub-specialties

2) Excel in some in-depth subspecialtiesResuscitology / TraumatologyToxicology / Em USG / PHECEm Short-stay Care

3) Not = Jack of all trades & King of noneMuch more >> the Gate-keeperDx & Rx

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Issues in 2002 – Attd Vs AdmDaily Avg 2002 TMH AED

Cat Attd Adm %1 3.7 2.6 712 14 13.4 963 177 107 614 405 54 145 93 1.7 2U 12 1.5 13

Total 705 181 25.8

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Hypothesis : AED can help reduce in-pat ward congestion ….

if provided with - additionalWard(s)Man-power : doctors / nurses / HCAResources

in a more cost-effective fashion

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Em Ward – 30 Bedsfrom 27 Jan 2003 in TMH AED

Opening Ceremony

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EOP Ward (2003)Vs EMW (2007)

Em Observation & Pre-admObservational Med - PassiveWait & see until patient ‘dies’

EMWTreat & actively reviewTo QA good outcome

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Daily Clinical Activities – Em SSU

1) 3 Specialist Ward Rounds – t d s2 Regular & timely input by Psy, Physicians

(CGAT), MSW, PhysioRx3) Minimize non-value-added consultation

4) Rapid access to Lab Tests / Imaging (CT & USG) – short Turn-around-time (TaT)

5) Delete “Wait & See” Concept >> Change to “Treat & Actively Review”

6) Optimization - training time - Ward Rounds

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Reduction - Em Adm No.& Excess Bed (133 69 / day)

Feb & Mar – 2002 Vs 2003Adm No. & Xs Beds

184

198

177

145 144

133

103

69

0

50

100

150

200

250

2002 Feb Mar02 Feb Mar03

Period

No. Daily Adm No

Excess Bed

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Reduction - Em Adm No.& Excess Bed (133 69 / day)

Feb & Mar – 2002 Vs 2003

Feb - Mar EMW Extra Excess

Avg Daily Attd Adm Cases Discharge Bed

2002 706 188 0 0 133

2003 700 140 23 17 70

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Critical Changes in Admission -2004 Vs 2002

Daily Avg 2002 TMH AED 2004 TMH AED

Cat Attd Adm % Attd Adm %

1 3.7 2.6 71 3.3 1.9 59

2 14 13.4 96 13.8 10 74

3 177 107 61 158 82 52

4 405 54 14 350 39 11

5 93 1.7 2 54 0.8 1.5

U 12 1.5 13 25 4 16

Total 705 181 25.8 604 137 22.7

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Obvious Drop : In-patient Chest Pain - Monthly Adm.

133

68

32

70 72

0

20

40

60

80

100

120

140

2002 2003 2004

In-pt.

M&GEOP

~65 vs 02 63 vs 02

cTnT a/v 1.3.2003ALOS

MED -2 days

Em W - 20 hr

Adm. Rate of EOP : 10%

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Obvious Drop : In-patient Drug OD - Monthly Adm.

36

9

41

8

46

0

10

20

30

40

50

2002 2003 2004

In-pt.

M&GEOP

ALOS

MED - 2.1 days

Em W -17 hrs

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Ketamine Sniffer – Subs Abuser

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Obvious Drop : In-patient Suicidal / DSH - Monthly Adm.

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15

22

1312

0

5

10

15

20

25

30

2002 2003 2004

In-pt.

M&GEOP

ALOS

M&G -2.5 days

EOP –17 hrs

46 to CPH; 11 admitted

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Obvious Drop : In-patient Drunk Cases - Monthly Adm.

16

2

7

2

9

0

2

4

6

8

10

12

14

16

2002 2003 2004

In-pt. M&GEOP

ALOS

MED -1.5 days

Em W -16 hrs

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LOS (hrs) – Comparison : 2003 & 04

In-pat Ward EMW

DSH 60 17

DO 50 17

Chest Pain 48 20

Drunk 36 16

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Em SSU – Australia & Singapore

A) Perth : Em Adm - 10 most common DRGA decreased ALOSfrom 3.97 to 2.59 daysPat no. = 19 % increaseBed-days = 23 % decreaseWilliams AG. Med J Aust 2000

B) SGH - 6.4% saving for in-pt admissionn = 9126; Abdo PainALOS – Median 5.6 hrs Lateef & Anantharaman. Am J Emerg Med 2000

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Healthcare SustainabilityKam CW – Sharing Forum of HAHO 2006

1) Rapid Turn-over EmSSUEfficiency to tackle CongestionMore EMWs started in 2007

2) 還 [ 症 ] 於民Participatory Community healthcare

3) 醫院無彊界Hospitals without boundariesJAPA : Joint Ambulatory Parental Antibiotic Prog. (Cellulitis / Acute Pyelonephritis)

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An Overview of Emergency Department

Short Stay Wardin Hong Kong

Dr KL Tsui, Dr HT Fung, Dr KK Lam, Dr CW Kam

Accident & Emergency Department,Tuen Mun Hospital, NTWC, HA

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HKJEM – July 2007 & HA Convention 2007

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Efficacy Cutoff PointsNo local / HK benchmarkLOS less than 24 hrHospital admission rate of less than 30%1,2

1 Zalenski RJ. Ann Emerg Med. 1997;29:99-108.2 Gomez MA. J Am Coll Cardiol. 1996;28:25-33.

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Results – TMH AED SSU10,111 patients - in SSW in 20064.6% of total AED attendances680 patients (7%) were excluded -missing data

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12.7

7.6 7.46.5

5.3 4.84

3.2 3 2.7 2.6 2 1.6 1.3 1.3 1.2 1.1 1 0.8 0.5 0.4

2.50.9

15.9

0

2

4

6

8

10

12

14

16

18

Psych

iatric

Chest

pain

Muscu

loske

latal

pain

Dizzi

ness

Poiso

ning

Trau

ma

Gastr

oenter

itisDi

abete

sCO

PD

Card

iac rh

ythm

Hype

rtensi

on

Skin

infect

ion

Abdo

mina

l pain

Fever

unkn

own o

rigin

Conv

ulsion

Acute

airw

ayPn

eumo

niaAR

OULo

wer U

TIAl

lergy

Pyelo

neph

ritis

URTI

Blood

resul

tsHe

adach

e

AROU: acute retention of urine, COPD: chronic obstructive pulmonary disease, Lower UTI: lower urinary tract infection. URTI: upper respiratory tract infection`

Case-mix of patients treated in SSW

%

24

0

10

20

30

40

50

60

Poiso

ning

Psych

iatric

Hype

rtensi

onCh

est pa

in

Gastr

oenter

itisCo

nvuls

ionHe

adach

eAc

ute ai

rway

Pyelo

neph

ritis

Dizzi

ness

Skin

infect

ionDi

abete

sTr

auma UR

TILo

wer U

TIAl

lergy

Card

iac rh

ythm

Pneu

monia

Muscu

loske

letal

pain

Blood

resul

tsCO

PD

Abdo

mina

l pain AU

R

Fever

unkn

own o

rigin

Admission rate LO S

Cutoff (30%)

Cutoff (24 hr)

Comparison of LOS and Admission Rate among different DRGs

COPD

MS Pain

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Overall EffectivenessAverage LOS = 23.4hrOverall hospital admission = 26.8%Both below the efficacy cutoff points = Good Performance

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AED Adm Performance + SSUAverage

Daily 2002 2003 2004 2005 2006

Attd 706 551 605 627 607

Total Adm 184 131 140 141 145

Adm % 26.1 23.8 23.1 22.5 23.9

Med Adm 92 64 67 69 72

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Admission Cut 23 % Much Greater > Attd Reduction 11 %(Yr 02 Vs 05) - TMH

-40

-30

-20

-10

0

10

20

Attd Total Adm Total Adm % Med Attd Med Adm No Med Adm % Cat 1 Cat 2 Cat 3 Cat 4 Cat 5

%

11%

23 %

+ 13 %

25 %

Total Med

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Emergency Adm Cut (05 Vs 01) - TMH : Top

Q

EH

R

H

K

WH

QM

H PW

H

N

DH

YC

H

U

CH

C

MC

PM

H

TK

OH

TM

H

PY

NEH

A

HN

H

Ove

rall

/A

vera

ge

-30%

-25%

-20%

-15%

-10%

-5%

0%

5%

10%

15%

20%

25%

% Change -23.3% -20.4% -16.4% -16.3% -13.5% -10.8% -9.5% -9.0% -5.1% -2.9% -1.8% -1.7% -1.7% 5.6% 19.8%

TMH QEH RH KWH PYNEH QMH Overall /Average

AHNH PWH NDH YCH UCH CMC PMH TKOH

QEH & TMH – more structured Em SSU Vs Em Obs Wards in others

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Standardized Adm Formula - Controversial Wisdom

Standardized admission rateObserved no. of admission

=Sum of expected no. of admission for each age, sex, triage and ambulance-in path groupx HA-wide admission rate

Expected no. of admissionsfor each age, sex, triage and ambulance-in path group= No. of A&E 1st attendances in each group

x HA-wide group-specific admission rate

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Admission Trend – TMH Vs HAAdm % Comparison - TMH Vs HA

0.05.0

10.015.020.025.030.0

2002

2004

2006

%

Adm % -TMH

StdAdm % -HA

StdAdm % -TMH

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TMH EMW Performance 2007 -Sustained

LOS – Avg / Median 23.5 / 19 hrs

In-pat Transfer 23 %

Med Adm Reduction 30 %

AED Adm Rate 26.6 %

AED Adm Rate - EMW 23.3 %

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Patient Satisfaction – Em SSU / Em Obs Unit

More cost effective (LOS) Vs traditional admission in UKImprove patient satisfaction- Safe, earlier Senior Involvement- Decrease LOS, more proactive Mx.- Reduce Unnecessary Admissions in DRG (Drunk, Asthma, DO, GE, Chest Pain, Dizziness)Cooke MW, Higgins J, Kidd P. Emerg Med J 2003

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Cooke%20MW%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Higgins%20J%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlushttp://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Kidd%20P%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus

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Patient Satisfaction : Fruit Baskets - Helping Patients & Saving Lives : AED Motto

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New Future Roles - EMW

an evolving roleHospital at Nightto rationalizenocturnal man-power need

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Transforming from Panda toPeri-orbital dark circles – tired lookClinicians : Exhausted appearance

System factor >> over-work

[ Patients : # of skull base ]

http://hk.wrs.yahoo.com/_ylt=AuhzwAaSw.oAS_riZhi2v0K.ygt.;_ylu=X3oDMTA4NDgyNWN0BHNlYwNwcm9m/SIG=12557bvgt/**http%3a//www.free-desktop-wallpaper.de/wallpaper-animals/panda.jpg

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Panda’s Eye Pretty Visionary Hosp Authority

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Healthcare Sustainability

Health maintenance – agingAmbulatory HealthcareShort LOSMinimize cost – man-power / inventory / consumablesTap new resources

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Optimization of AED Services

To achiever efficiency & efficacy

FactorsVolume – workloadCase-mixWork-flowKeep LEANWaste Reduction

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Healthcare Policy -the basic mimimum

No one ought to be deprived of the necessary medical services thro’ lack of means

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Flu Crisis (Mar 08) >> AEDRobust + Innovative

Working together we can create a beautiful World

同心協力

創建美好

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Efficient Em SSU : Summary

Adm Reduction = Out-pat WardRedistribution = In-pat Ward

By-products Shorter LOC : Pat Bed-HrReduced Ward Congestion

Saved $ Millions

Improved Satisfaction

Healthcare - sustainability

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Please try our EMW if U cannot find a Hotel Room – Short-stay Rx

Tuen Mun Hospital

Hong Kong

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Aussie Kangaroo’s HopEnergetic - Hopping but not in a hurryAbdominal pouch -caring not just for the young but all patientsMobile organism >> Ambulatory care & SSUVs conventional mode

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KangarooThanks for not having fallen at sleep !!

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Let’s Go to our EOPW

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Moved to F3B Ward on 31-7-2003

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To C2 on 6-11-2003

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@ 5-Point Policy PlanTMH AED (2007-10)

1) Service Efficiency2) Ambulatory Care3) Staff Empowerment 4) Training & Research5) Life Career Partnership

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EMW – Reduce Vs RedistributeAdm >> Efficiency

Main impact - Em SSUNot - absolute admission reductionBut Reduction – LOS (Pat Bed-Hr)Specific patient domainEnhance the cost-efficiencyIn-patient bed utilization (less congestion – both Wards & AED)Patients - hospital-based Rx

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Multi-Win Situation -Reduction

In-pat Ward : CongestionAED : Over-crowdedness / AdmAdmin : Less Expense

Notional cut= 25 pat x 1 day (LOS cut)/ each day x $5,000= $ 3M per month & $ 30M per yr

Patients : LOS (Satisfaction)

Does an efficient Em SSU reduce or redistribute admission ? And the By-products ? �From Panda’s Eyes �to Aussie Kangaroo’s HoEmergency MedicineIssues in 2002 – Attd Vs AdmHypothesis : AED can help reduce in-pat ward congestion ….Em Ward – 30 Beds �from 27 Jan 2003 in TMH AEDEOP Ward (2003)�Vs EMW (2007)Daily Clinical Activities – Em SSUReduction - Em Adm No. �& Excess Bed (133 69 / day)�Feb & Mar – 2002 Vs 2003 Reduction - Em Adm No. �& Excess Bed (133 69 / day)�Feb & Mar – 2002 Vs 2003 Critical Changes in Admission - 2004 Vs 2002Obvious Drop : In-patient Chest Pain - Monthly Adm. Obvious Drop : In-patient �Drug OD - Monthly Adm.Ketamine Sniffer – Subs AbuserObvious Drop : In-patient Suicidal / DSH - Monthly Adm.Obvious Drop : In-patient Drunk Cases - Monthly Adm.LOS (hrs) – Comparison : �2003 & 04Em SSU �– Australia & Singapore Healthcare Sustainability�Kam CW – Sharing Forum of HAHO 2006An Overview of �Emergency Department �Short Stay Ward �in Hong KongHKJEM – July 2007 �& HA Convention 2007Efficacy Cutoff PointsResults – TMH AED SSUOverall EffectivenessAED Adm Performance + SSUAdmission Cut 23 % Much Greater > Attd Reduction 11 % �(Yr 02 Vs 05) - TMHStandardized Adm Formula �- Controversial WisdomAdmission Trend – TMH Vs HATMH EMW Performance 2007 - SustainedPatient Satisfaction �– Em SSU / Em Obs UnitPatient Satisfaction : Fruit Baskets - Helping Patients & Saving Lives : AED MottoNew Future Roles - EMWTransforming from Panda toPanda’s Eye Pretty Visionary Hosp Authority Healthcare SustainabilityOptimization of AED ServicesHealthcare Policy - �the basic mimimumFlu Crisis (Mar 08) >> AED�Robust + InnovativeEfficient Em SSU : SummaryPlease try our EMW if U cannot find a Hotel Room – Short-stay RxAussie Kangaroo’s HopKangarooLet’s Go to our � EOPW@ 5-Point Policy Plan�TMH AED (2007-10)EMW – Reduce Vs Redistribute Adm >> EfficiencyMulti-Win Situation - Reduction