Roles of Emergency Medicine Ward (EMW)
57
Dr. Gordon Wong Chief-of-Service Accident & Emergency Department QEH
Transcript of Roles of Emergency Medicine Ward (EMW)
Dr. Gordon Wong Chief-of-Service Accident & Emergency Department QEH
Highlights
EMW
Development
Achievement
Quality & Quantity
Efficiency
Cost-effectiveness & LOS
Roles of EMW
Present
Future
Observation Room / Short Stay Unit (SSU) / Clinical Decision Unit since 2000’s
Short period of
Observation
Monitoring
Lab tests
Treatment
Objectives
Appropriate admission
Safe discharge
Patient satisfaction
Emergency Short Stay Unit (ESSU) Observation Room
QEH
TMH
QMH
NDH
UCH
…
TMH ESSU - case-mix Year 2003 2004 2005 2006
Daily new cases 20 22 23 25
Chest pain 0 2 3 4
DO 2 3 3 5
Disturbed / Psych
4 5 5 5
COAD 2 2 2 1
DM 1 2 2 2
Cellulitis 0 0 1 1
Pyelonephritis 0 0 1 1
Back Pain 2 2 1 1
Others 9 7 5 5
“Chest Pain” TMH ESSU ALOS:
Medical ~48 hrs EM ~20 hrs
↓50% in adm to Medical sp
“Drug Overdose” TMH ESSU
ALOS: Medical ~2.1 days EM ~17 hrs
↓75% in adm to Medical sp
Emergency Medicine Ward Task Force (2006)
Wait
&
See
Treat
&
Review
ALL A&Es 2002-2012 (SJH excluded)
0
5
10
15
20
25
30
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Total Att (exc SJH) (100000) 22.4 18.1 19.7 19.5 19.4 19.8 20.3 21.1 21.4 21.2 22.2
Adm rate (HA ave) (exc SJH) 22.1 23.8 24.1 24.7 25.3 25.3 26.3 26.2 27.3 28.0 28.7
Amb-in Rate % (HA ave) 16.3 19.1 20.2 21.8 21.4 22 22.6 22.3 22.7 23.3 23.7
↓A&E attendance after A&E charging
Ambulance-in AED attendance Hospital G
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
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Brought by Ambulance (%) Hosp G - Amb-in 40+% (HA average - 25%)
Ambulance-in patient Triage categories Hospital G (2011 – 2013)
70+% amb-in patients = Triage Cat 1-3
70% line
Increasing demand (HA overall)
Yearly A&E 1st attendance by Triage Categories
Emergency Medicine Ward Visions & Goals
Certain target disease groups benefit from the model of care within a short time frame, preferably within 48 hrs
Efficient operation Manned by Emergency Physicians Frequent rounds Integrated clinical care-plan Expedited access to sophisticated Ix
Hub for multi-disciplinary collaboration Different clinical specialties, esp Psy, Geriatricians Community & psychiatric nursing Allied health
Cost-effective Reduce admission to acute wards Shortened LOS Rationalize in-hospital service during night time - “Doctor Work
Reform” (DWR)
Development milestones of EMW
QEH Jan 2007 40 beds (7%) TMH Jan 2007 30 beds (5%) PYNEH May 2007 20 beds (5%) POH Sep 2007 30 beds (12%) PWH Oct 2007 26 beds (7%) CMC Nov 2007 34 beds (9%) PMH Nov 2007 32 beds (9%) QMH Dec 2008 16 beds (5%) YCH Dec 2008 32 beds (9%) AHNH Dec 2008 20 beds (6%) NDH Aug 2013 20 beds (6%)
No. of beds in EMW ( ) = % of A&E daily attendance in prior yr
Results & Achievements
Impact of EMW on reducing avoidable acute admissions (Jan 08 - Jun 09 Vs Jan 06 – Jun 07)
EMW established in 2007
34 Beds=9% 32 Beds=9% 20 Beds=5%
A&E Adm & Adm Rate % as A&E 1st Att (HA overall)
Total Adm
Adm excl EMW adm
Total Adm
Adm excl EMW adm
A&E Adm & Adm Rate % as A&E 1st Att in 10 HA hospitals with EMW
Adm Rate to EM & Medical (Hosp E)
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
2005 2006 2007 2008 2009 2010 2011 2012
17.6%
17.5%
17.2%
15.4%
14.9%
15.0%
14.8% 15.5%
1.0%
5.5%
4.9% 4.8% 4.8% 4.4%
EM Adm Rate
M&G Adm Rate
Triage categories of EMW patients (2012)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Hospital A Hosp B Hosp C Hosp D Hosp E Hosp F Hosp G Hosp H Hosp J Hosp K
Cat 5
Cat 4
Cat 3
Cat 2
Cat 1
T/O to other specialties (%) from EMW in different Hospitals (2011)
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
A B C D E F G H J K
EMW Transfer out rate – NO relationship with NUMBER of EMW adm
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
0
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4000
6000
8000
10000
12000
14000
16000
18000
T/O rate from EMW (2011)
EMW Transfer out rate – ? relationship with Triaged Cat of EMW adm
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
0
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4000
6000
8000
10000
12000
14000
16000
18000
T/O rate from EMW (2011)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Cat 5
Cat 4
Cat 3
Cat 2
Cat 1
EMW patients discharge destination (2011)
Number of IP/DP discharges and deaths with ever treated under Emergency Medicine (EM) specialtyReporting period: discharged year in 2011
(Source: CDR as at 4 Sept 2012)
By admission and discharge specialty
Dischg spec
= EM
Dischg spec
= Non-EMSub-total
Dischg spec
= EM
Dischg spec
= Non-EMSub-total
AHN 2 850 1 433 4 283 251 251 4 534
CMC 5 124 565 5 689 5 689
PMH 5 871 940 6 811 6 811
POH 5 403 902 6 305 5 5 6 310
PWH 5 637 1 569 7 206 7 206
PYN 9 395 1 523 10 918 3 9 12 10 930
QEH 13 238 2 688 15 926 24 24 15 950
QMH 5 504 873 6 377 6 377
TMH 9 070 864 9 934 12 12 9 946
YCH 4 461 544 5 005 5 005
Overall 66 553 11 901 78 454 295 9 304 78 758
By discharge type (for those episodes with admission specialty = EM and dischg spec = EM only) i.e. n = 66 553
DeathHome with
follow up
Home no
follow upAcute bed
Non-acute
bedDAMA Missing Others Walk Away
AHN 0 519 1 804 9 504 14 0 0 0 2 850
CMC 2 1 836 2 587 21 515 159 0 0 4 5 124
PMH 1 94 5 319 99 201 154 2 1 0 5 871
POH 0 312 4 551 377 6 144 1 11 1 5 403
PWH 3 621 4 928 1 21 61 1 0 1 5 637
PYN 2 1 131 8 203 2 2 52 0 1 2 9 395
QEH 21 1 192 10 507 537 711 267 2 0 1 13 238
QMH 2 409 4 869 57 135 27 0 1 4 5 504
TMH 3 2 790 5 280 785 3 205 2 2 0 9 070
YCH 0 384 3 770 147 3 156 0 1 0 4 461
Overall 34 9 288 51 818 2 035 2 101 1 239 8 17 13 66 553
By care type at discharge (for those episodes with admission specialty = EM and dischg spec = non-EM) i.e. n = 11 901
Acute bed Non-acute
AHN 1 433 0 1 433
CMC 487 78 565
PMH 842 98 940
POH 769 133 902
PWH 1 569 0 1 569
PYN 1 363 160 1 523
QEH 2 688 0 2 688
QMH 821 52 873
TMH 687 177 864
YCH 501 43 544
Total 11 160 741 11 901
Estimated Distribution of Discharge Destination (based on those episodes with admission specialty = EM only) i.e. n = 78 454
AHN 2 323 (54.2%) 1 442 (33.7%) 504 (11.8%) 0 (0.0%) 14 (0.3%) 4 283 (100%)
CMC 4 423 (77.7%) 508 (8.9%) 593 (10.4%) 2 (0.0%) 163 (2.9%) 5 689 (100%)
PMH 5 413 (79.5%) 941 (13.8%) 299 (4.4%) 1 (0.0%) 157 (2.3%) 6 811 (100%)
POH 4 863 (77.1%) 1 146 (18.2%) 139 (2.2%) 0 (0.0%) 157 (2.5%) 6 305 (100%)
PWH 5 549 (77.0%) 1 570 (21.8%) 21 (0.3%) 3 (0.0%) 63 (0.9%) 7 206 (100%)
PYN 9 334 (85.5%) 1 365 (12.5%) 162 (1.5%) 2 (0.0%) 55 (0.5%) 10 918 (100%)
QEH 11 699 (73.5%) 3 225 (20.2%) 711 (4.5%) 21 (0.1%) 270 (1.7%) 15 926 (100%)
QMH 5 278 (82.8%) 878 (13.8%) 187 (2.9%) 2 (0.0%) 32 (0.5%) 6 377 (100%)
TMH 8 070 (81.2%) 1 472 (14.8%) 180 (1.8%) 3 (0.0%) 209 (2.1%) 9 934 (100%)
YCH 4 154 (83.0%) 648 (12.9%) 46 (0.9%) 0 (0.0%) 157 (3.1%) 5 005 (100%)
Total 61 106 (77.9%) 13 195 (16.8%) 2 842 (3.6%) 34 (0.0%) 1 277 (1.6%) 78 454 (100%)
Hospital
Discharge Type
Total
Admission Spec = EM Admission Spec = Non-EM
OverallHospital
HospitalCare Type at Dischrage
Total
HospitalHome Acute bed Non-acute Death Others
TotalDischarge Destination
Availability of non-acute beds (subacute, rehab, convalescent, infirmary)
Hosp A Hosp B Hosp C Hosp D Hosp E Hosp F Hosp G Hosp H Hosp J Hosp K
Re-att & Re-adm rate after EMW discharge (2012)
Hospital A Hosp B Hosp C Hosp D Hosp E Hosp F Hosp G Hosp H Hosp J Hosp K
re-ATT AED rate 5.3% 3.8% 2.6% 4.4% 3.4% 2.3% 3.0% 2.8% 3.4% 2.4%
re-ADM Hosp rate 1.5% 0.5% 0.2% 0.5% 0.4% 0.2% 0.4% 0.2% 0.4% 0.2%
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
6.0%
ALOS in EMW (2011)
Number of IP/DP discharges and deaths with ever treated under Emergency Medicine (EM) specialtyReporting period: discharged year in 2011(Source: CDR as at 4 Sept 2012)
Table 3: By discharge type
DeathHome with
follow up
Home no
follow upAcute bed
Non-acute
bedDAMA Missing Others Walk Away
AHN 6 1 802 1 961 48 678 38 1 4 534
CMC 31 2 299 2 622 28 533 171 5 5 689
PMH 24 662 5 628 107 221 165 2 1 1 6 811
POH 28 1 124 4 558 417 9 160 2 11 1 6 310
PWH 38 1 662 4 955 5 471 70 1 1 3 7 206
PYN 13 2 273 8 429 5 106 99 3 2 10 930
QEH 123 2 574 11 116 570 1 239 324 2 2 15 950
QMH 8 1 037 4 911 59 308 45 1 4 4 6 377
TMH 26 3 549 5 318 809 15 224 3 2 9 946
YCH 15 737 3 925 152 3 171 1 1 5 005
Overall 312 17 719 53 423 2 200 3 583 1 467 11 23 20 78 758
Overall (excl. AHN) 306 15 917 51 462 2 152 2 905 1 429 11 23 19 74 224
Table 4: By length of stay (LOS) of EM specialty
LOS of EM specialty
0 to less than 24 hours 24 to less than 36 hours 36 to less than 48 hours 48 hours or above
N % N % N % N %
AHN 3 847 85% 260 6% 307 7% 120 3% 4 534
CMC 2 456 43% 973 17% 1 049 18% 1 211 21% 5 689
PMH 2 588 38% 1 414 21% 1 256 18% 1 553 23% 6 811
POH 3 283 52% 859 14% 887 14% 1 281 20% 6 310
PWH 2 914 40% 894 12% 1 324 18% 2 074 29% 7 206
PYN 7 203 66% 1 850 17% 1 024 9% 853 8% 10 930
QEH 10 734 67% 2 134 13% 1 787 11% 1 295 8% 15 950
QMH 5 287 83% 638 10% 277 4% 175 3% 6 377
TMH 6 753 68% 1 343 14% 917 9% 933 9% 9 946
YCH 1 762 35% 937 19% 984 20% 1 322 26% 5 005
Overall HA 46 827 59% 11 302 14% 9 812 12% 10 817 14% 78 758
Overall (excl. AHN) 42 980 58% 11 042 15% 9 505 13% 10 697 14% 74 224
Hospital Total
Hospital
Discharge Type
Total
Hosp A Hosp B Hosp C Hosp D Hosp E Hosp F Hosp G Hosp H Hosp J Hosp K
ALOS for specific Dx
Limitation – not for direct comparison across EMWs
Difference in mode of practice
Intensity of specialty collaboration
SOPD appt, fast-track EMW assessment, CPG, AH
• Compliance and validity in Dx coding entry
• Other factors
socio-economical background
community support
ALOS (back pain) in EMW vs O&T specialties (2012)
0
1
2
3
4
5
6
7
8
9
HospitalA
Hosp B Hosp C Hosp D Hosp E Hosp F Hosp G Hosp H Hosp J Hosp K
5.16 4.93
5.7 5.57
6.42
4.49
8.8
5.44
6.05
3.82
1
1.92 1.69
2.21 2.47
1.34 1.51
1.14
1.51
2.43
Back Pain ALOS(O&T)
Back Pain ALOS(EM)
ALOS (chest pain) in EMW vs Medical specialties (2012)
0
0.5
1
1.5
2
2.5
3
3.5
4
Hospital A Hosp B Hosp C Hosp D Hosp E Hosp F Hosp G Hosp H Hosp J Hosp K
3.19
3
2.64
3.05 2.93
2.22
3.68
1.62
2.83
2.39
1.07 1.19
1.19 1.11
1.49
1.04 1.06 1.01 1.03
1.41
ALOS(Med)
ALOS(EM)
0
0.5
1
1.5
2
2.5
3
3.5
4
Hospital A Hosp B Hosp C Hosp D Hosp E Hosp F Hosp G Hosp H Hosp J Hosp K
3.59
2.83
3 2.96
3.59
2.29
3.95
1.74
2.55 2.65
1.13
1.51
1.4
1.66
1.59
1.19 1.22
1.05
1.24
1.82
ALOS (Med)
ALOS (EM)
ALOS (dizziness) in EMW vs Medical specialties (2012)
ALOS (Hypoglycaemia) in EMW vs Medical sp (2012)
0
1
2
3
4
5
6
7
8
Hospital A Hosp B Hosp C Hosp D Hosp E Hosp F Hosp G Hosp H Hosp J Hosp K
5.01
6.91 7.07
6.64
5.92
3.84
6.38
2.38
6.31
4.69
1.15
2.17 1.95
2.48 2.31
2
1.6 1.44 1.34
2.93
ALOS(Med) ALOS(EM)
Average in-patient cost per patient day (2012/13)
$2400 (EMW) $3400 (Med)
$4000-5000 (O&T)
Average in-patient cost per patient day (2012/13)
$1800-2800 (EMW) $3400-4400 (Med) $3700-5000 (O&T)
?? Redistribution of patients ?? ?? Relabeling of Medical wards ??
RIGHT care delivered
by the RIGHT expertise
to the RIGHT patient
at the RIGHT place
With RIGHT utilization of resources
Can we go ahead
without
EMW
0
500
1000
1500
2000
2500
2006
-01
2006
-05
2006
-09
2007
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2007
-05
2007
-09
2008
-01
2008
-05
2008
-09
2009
-01
2009
-05
2009
-09
2010
-01
2010
-05
2010
-09
2011
-01
2011
-05
2011
-09
2012
-01
2012
-05
2012
-09
MG+EM
M&G
EM
Opening of 34 beds EMW 2 Nov 2007
Downsizing EMW to 16 beds
24 EM beds
34 beds -> 16 beds -> 24 beds
A&E attendances in Hospital B (Jan 2006 to Sept 2012)
0
2000
4000
6000
8000
10000
12000
14000
16000
2006
-01
2006
-05
2006
-09
2007
-01
2007
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2008
-01
2008
-05
2008
-09
2009
-01
2009
-05
2009
-09
2010
-01
2010
-05
2010
-09
2011
-01
2011
-05
2011
-09
2012
-01
2012
-05
2012
-09
Opening of 34 beds EMW 2-Nov-2007
16 Beds EMW
3-Oct-2011
24 Beds EMW
1-Aug-2012
Triage and Waiting Hall
Observation room
Urgent cases waiting area
Temp. Holding area
QEH A&E 6th Jan 2014
41
Admission block in QEH (2013)
2013 Dec
8 hours 12 hours 24 hours
Adm block to Medical Sp QEH 2013
Discharge stat of “extended EMW” (Jan – Apr 2014)
44
Total no. Adm
Medical
Adm other
specialties
Adm EMW -
> Home
Adm EMW -->
t/o to acute
ward
Adm
Subacute
hospitals
Adm subacute
then transfer
back ≤ 48hr
Home Home -> Re-
admit ≤ 48hr
Home ->
Re-admit
> 48hr &
≤ 1 week
DAMA
Subtotal 1178 815 31 79 23 105 1 115 2 3 4
% 100.0% 69.2% 2.6% 6.7% 2.0% 8.9% 0.1% 9.8% 0.2% 0.3% 0.3%
Total 1178 846 102 106 120 4
% 100.0% 71.8% 8.7% 9.0% 10.2% 0.3%
~30% did not require acute hospital admission
74% - need adm to acute wards
Buffering capacity Busy hospital admission
Erratic rise in service demand
Night time
Weekend & PH
Admission block
Winter surge, Spring surge, Summer surge, Autumn surge
Disaster
Cohort Management
Toxicology Service
Drugged
Poisoned
Overdosed
Academic & Subspecialty
training & development
Cohort Management
Selected patients with
Emotional
Psychiatric
Suicidal
Violent
Disturbed
Drunk
Advantages
Central management
↓disturbance to other wards
Safety – Workplace Violence
Index patients
Other patients
staff
Targeted training
Economy of scale
An Exploratory Study on Patient Satisfaction in Emergency Medicine Ward AHNH Mr. Choi TY Kenny, Ms Tong YT Mavis, Ms Lo SM
December 2010
183 of 423 EMW patients participated
Findings % respondents
Nurses were skilful in carrying out nursing procedure 96.2%
Nurses have professional knowledge in answering their questions 94%
Appropriate medical management were received 90.7%
Comfortable environment 92.3%
Food quality acceptable 96.7%
Mean satisfaction score – 8.37 out of 10 (SD 1.72, 95% CI 8.11-8.62)
0
100
200
300
400
500
600
Jul-10
Aug-10
Sep-10
Oct-10
Nov-10
Dec-10
Jan-11
Feb-11
Mar-11
Apr-11
May-11
Jun-11
Jul-11
admit EMW (2100-0900) 399 480 493 416 326 392 500 414 413 517 439 397 380
admit Med (2100-0900) 170 223 207 199 185 252 262 232 244 232 218 207 239
Hospital A – “OWL ward” Night admission EMW vs MEDICAL
(July 2010 – July 2011)
“We Care” collaboration in Hospital A Geriatricians screening at 0900
(July 2010 – July 2011)
0
20
40
60
80
100
120
140
Jul-10 Aug-10Sep-10Oct-10Nov-10Dec-10 Jan-11 Feb-11Mar-11Apr-11May-11Jun-11 Jul-11
Jul-10Aug-
10Sep-10Oct-10
Nov-10
Dec-10Jan-11 Feb-11Mar-
11Apr-11
May-11
Jun-11 Jul-11
Screened 92 100 99 93 79 98 125 97 109 112 101 75 76
Home 35 38 22 22 24 31 42 36 51 50 38 33 39
To TPH 46 48 61 56 47 62 62 43 46 53 46 37 31
To Medical 11 13 16 15 7 5 16 15 12 6 15 5 5
Convalesccent hosp
Jan Feb Mar Apr May June Jul Aug Sep Oct Nov Dec
2008 1156 1197 1247 1148 1142 1015 1236 1110 1198 1185 1178 959
2009 876 776 800 699 791 802 823 816 781 779 889 893
2010 836 797 911 830 734 734 778 862 785 756 762 863
2011 902 828 890 777 724 739
0
200
400
600
800
1000
1200
1400
# EMW started in Mid Dec 2008
1. ↓ (safe) avoidable hospital admission
↑ quality of short-stay patient care
↑ efficiency & cost-effectiveness with shortened ALOS
↑ safety of patients discharged from AED
Enhanced patient satisfaction 2. Buffer hospital adm thereby reducing workload of other
specialties during night & weekend, service surge, disaster
3. Cohorting patients with emotional, psychiatric, violent & drunk problems
4. Toxicologically expert management of drugged, poisoned, overdosed patients – service & subspecialty development
5. Core competency training of new generation of Emergency Physicians beyond the first few hours
Roles of EMW
Operation of EMW - “treat & review” Essential success factors
Bed capacity = 8-10% of daily A&E attendance Support & maximize EMW functions Dependent on case-mix, expertise, cross-specialty support
Targeted clinical conditions Low acuity & undifferentiated presentation Disturbed ± toxicology patients
Senior rounds/oversight, frequent rounds (3+/day) Protocol & guidelines-driven Fast track Dx work-up – CT (brain, thorax & abd), USG, OGD Expedited SOPD appt Hub
cross-specialty & multi-disciplinary collaboration Geriatricians, Psy, AH… Community care support
Direct transfer out to specialty wards Availability of sub-acute, rehab & convalescent beds / hospitals
Way Forward Other specialty presentation
Paediatric short-stay
Surgical symptomatology
Align practice & cross-specialty collaboration
Integrated care plans development
Deliverables monitoring: Adm rate to EMW
transfer-out rate to other clinical specialties
ALOS
Re-attendance to A&E & re-adm rate
Morbidity & Mortality in EMW
Patient satisfaction
Thank You
