Prognosis for Emergency Care Delivery in Nord- og Midtjylland: Bright Future vs. Impending Crisis

Transcription

1 Prognosis for Emergency Care Delivery in Nord- og Midtjylland: Bright Future vs. Impending Crisis

2 Project Partners Region Midtjylland: Hans Peder Graversen Erika Frischknecht Christensen Helle Hygum Olsen Lars Dahl Pedersen Morten Helleberg Christiansen Jan Greve Region Nordjylland: Flemming Knudsen Charlotte Albeck Peter Larsen Jens Ole Skov Heidi Trapp Thomas Mulvad Frank Brøgger Jørn Munkhof Møller 2

3 Goals External assessment of current emergency care system and plans for modifying system Propose strategy for developing training programs for personnel to staff future FAM Recommendations for optimizing future FAM and related aspects of the emergency care system 3

4 Methods Review of data and reports Primarily organizational and infrastructural information Limited process and outcome data Site visit (June, October 2007) FAM Hospitals Prehospital system Vagtlaege system Meetings 4

5 The Present

6 Current Emergency Care System 112 Alarm central Vagt central EMS Other akut modtagelse (AMA, MVA, KVA, etc.) Skadestuen Hospital Inpatient Departments Laegevagt Konsultation EL / VL mobile Egen Laege or Laegevagt telefon visitation 6

7 Macro vs. Micro perspectives Micro - level Individual sector, hospital, department Focus on patient care within sector Majority of process and outcome data at this level Macro - level Regional healthcare system How do the individual sectors come together as a system? Coordination of activities between sectors Continuity of patient care Patient care quality Minimal process and outcome data at this level 7

8 Strengths Primary care sector Physician staffed prehospital care Hospital based specialty care Micro-level data gathering and analysis Prehospital electronic medical record system (Nordjylland) Selected hospitals (Midtjylland) Micro-level quality standards IKAS Danish Quality Model (hospitals) 8

9 Limitations Alarm / dispatch accuracy Potential for variability in emergency patient care pathways Ambiguity in access to emergency care Different provider groups, expertise, guidelines Macro-level coordination of patient care between sectors cross sectoral quality standards data gathering and analysis Multiple entry points to hospital based care Unsupervised junior physicians Personnel shortages Speciallaeger Restrictive work rules 9

10 Opportunities Coordinate prehospital emergency care activities across sectors Alarmcentral / AMK / vagtlaege visitation 112 ambulance system and mobile vagtlaege Ambulance system and hospital system Consolidate entry points for acute patients at hospital FAM concept Coordinate FAM / VLK Common triage Personnel, services, support Emergency physician and nurse roles for FAM Use other specialists effectively Quality standards & evidence based guidelines System wide quality Measure process and outcomes better and more accurately 10

11 Threats Denial, resistance to change What is the problem? Resistance to akutlaege role from other specialties My patients are unique. Dominance of hospital based emergency care by other specialties Lack of interest among mid-career specialist physicians in switching to akutmedicin Career advancement Professional, academic recognition Too broad scope of practice for the FAM Resource needs Conflicting work mentalities Assumptions about future FAM patient volume, case mix Low volume/high acuity High volume mixed acuity Aging population increasing emergency care workload Shrinking general practitioner workforce decreasing emergency care capacity 11

12 Winners & Losers Among Emergency Patients Under current system, some categories of emergency patients appear to receive good care, while others do not: 3 categories of emergency patients: Clearly ill; clear diagnosis Clearly NOT significantly ill Moderately ill; unclear diagnosis Conclusion based on: Significant opportunities for variability in care losers Anecdotal reports suggest that this group gets suboptimal care winners 12

13 The moderately ill patient with unclear or multiple diagnoses Referred to hospital akutmodtagelse Initial care by inexperienced physician trainees without supervision Opportunity for large variability in care; delays in diagnosis and treatment; errors in management In U.S. this category is large part of emergency patient population 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Initial triage acuity on ED arrival BIDMC 13

14 Per Capita Hospital Admission Rates: DK vs. US (2005) Comparable elective admission rates Acute admission rates more than 3 times higher in DK Patients with unclear diagnoses??? 2,500 2,000 1,500 1, Per 10,000 pop DK elective admissions US acute admissions Styrket Akutberedskab planlægningsgrundlag for det regionale sundhedsvæsen. 2007, Sundhedsstyrelsen. DeFrances CJ, Cullen KA, Kozak LJ. National Hospital Discharge Survey: 2005 annual summary with detailed diagnosis and procedure data. National Center for Health Statistics. Vital Health Stat 13(165)

15 The Future

16 National / Regional Goals for Emergency Care Delivery High quality emergency care delivery for all citizens Uniform quality regardless of time or place same patient should get same care regardless of time of place 16

17 Strategy Outline for Achieving Quality Goals: Reduce number of hospital with akutmodtagelse function Consolidate existing akutmodtagelse functions within designated hospitals within single faelles akutmodtagelse (FAM) Hospital within hospital with observation up to hours Staff FAM with senior physicians additional education and training fagområde vs. specialty Expand advanced prehospital care delivery options Develop additional urgent care capacity Primary sector Non-FAME hospitals 17

18 Assumptions Shift 30% - 40% of existing skadestuen patient volume from hospital sector to primary sector FAM patient volume / case mix : lower volume of patients than today But with higher acuity Extended management up to hours of selected patient types in FAM Significant involvement by other hospital specialists for providing clinical care in FAM Resuscitations, procedural skills, medical decision making 18

19 Impact on future akutlæge role Would need to manage relatively fewer patients than current system higher acuity for longer periods of time (up to hours) = many handoffs Dependent on other specialists for core EM skills and decision making (airway management, resuscitation, critical care, etc.) Shared medical decision making with other specialties with patients in FAM Very different from Emergency Physician in US Clinical role Educational requirements 19

20 Will this strategy succeed? Depends on whether assumptions are valid Multiple specialists in FAM operations Specialist shortages throughout system Specialist responsibilities elsewhere in hospital Shifting significant patient volume to primary sector Can primary sector absorb this? What about in 5 10 years? 20

21 2%-3% annual growth in GP contacts Thousands 3,800 3,700 3,600 3,500 3,400 3,300 3,200 3,100 Region Nordjylland Thousands 8,400 8,200 8,000 7,800 7,600 7,400 7,200 Region Midtjylland 3, , Styrket Akutberedskab planlægningsgrundlag for det regionale sundhedsvæsen. 2007, Sundhedsstyrelsen. 21

22 Population age 60 years or older Population is aging More chronic diseases More acute exacerbations of these Continued or increased growth in demand for primary care services 30.0% 28.0% 26.0% 24.0% 22.0% 20.0% 18.0% Region Nord Region Midt Source: Danmarks Statistik 22

23 Age distribution of GP workforce (2007) 30% Region Nordjylland 24% Region Midtjylland 60+ år 60+ år år år Delplan - fastholdelse og rekruttering af alment praktiserende læger. Region Nordjylland. 1. april Delpraksisplan for rekruttering og fastholdelse i almen praksis. Region Midtjylland. 20. februar 2008

24 Too few new GPs to replace retirees 20%-30% of GPs will retire within 10 years Average retirement age = 60 years; how many extra years? Not enough trainees to replace retirees What percent of GP trainees remain in region after training? Region Nord (55% - 85%) Region Midt (?) What percent of new GPs choose part-time practice? 0 50 New GPs vs. Retiring GPs ( ) Region Nord Region Midt New GPs Retiring GPs Delplan - fastholdelse og rekruttering af alment praktiserende læger. Region Nordjylland. 1. april 2007 Delpraksisplan for rekruttering og fastholdelse i almen praksis. Region Midtjylland. 20. februar

25 Delplan - fastholdelse og rekruttering af alment praktiserende læger. Region Nordjylland. 1. april

26 Sidst men ikke mindst er det en nødvendig forudsætning for succes, at såvel regionen som de alment praktiserende læger erkender problemets omfang og åbent fremlægger handleplaner til imødegåelse af almen praksis kollaps. Delplan - fastholdelse og rekruttering af alment praktiserende læger. Region Nordjylland. 1. april 2007

27 Worst Case Scenario GP workforce shortage becomes so severe that unable to provide primary care needs of all patients Patients need to go to hospital system for primary care needs Increasing cost to Regions as primary sector patient care shifts to hospital sector Increasing workload on remaining GP workforce Early retirement for older GP s Less attractive for younger physicians 27

28 How many Ghost Patients in 2011 Region Midtjylland If GP s delay retirement until age 62 GP deficit = ,200 people without GP 18.1% 1:6 Region Nordjylland If GPs delay retirement until age 64 GP deficit = ,000 people without GP Delplan - fastholdelse og rekruttering af alment praktiserende læger. Region Nordjylland. 1. april 2007 Delpraksisplan for rekruttering og fastholdelse i almen praksis. Region Midtjylland. 20. februar % 1:3 Total pop: 1,252,263 Danmarks Statistik Total pop: 576,280 28

29 Where will these patients go for care? Remaining GPs Vagtlaege system 30%? 20%? 10%? Normal per capita utilization of GP services = 6 contacts / person / yr If assume patients with no GP would increase utilization of vagtlaege konsultation = 10% of GP contacts Vagtlaege volume increases by 85% in Nordjylland 56% in Midtjylland This is a conservative estimate. How would you manage this? 29

30 FAM needs to be a Plan B FAM would need to care for some of these patients; how many? 75%? 350, , % 50%? 250,000 25%? If FAM absorbed 25% of extra vagtlaege patient volume (2.5% of uncovered GP patient visits) 200, , ,000 50, % Nord: 31,903 (55.7% increase) Midt: 36,977 (44.3% increase) 0 Region Nord Anticipated volume Region Midt Potential volume 30

31 What would this mean for the FAM? FAM patient volume HIGHER patient volume than currently anticipated FAM patient case mix More lower acuity patients from primary sector = more DIVERSE FAM case mix Mostly medical patients, fewer general surgical and orthopedic, little major trauma 31

32 Impact on future akutlæge role Will need to be able to manage: relatively higher patient volume than today greater mix of acuity (high and low acuity) Will need to move quickly needs to have knowledge and skill set to function independently from other specialists Manage resuscitation, stabilization Initiate diagnostic workups and therapeutic interventions Extensive shared decision making with many physicians will slow down patient flow Very similar to Emergency Physician in U.S. Clinical role Educational requirements 32

33 Fagområde vs. Specialty Need to prepare for high volume, mixed acuity scenario Competencies for managing this clinical scenario have been well described in many countries = Emergency Medicine For the system to deliver uniform & high quality emergency care, all akutlaeger need to have uniform body of knowledge and skills For the akutlaege to succeed in this role, they need this body of knowledge and skills Doesn t matter if you call it a fagområde or a specialty 33

34 Recommendations

35 Current Emergency Care System Future Consolidated Emergency Care System 35

36 Future Consolidated Emergency Care System Tighter integration between alarmcentral, vagtcentral and vagtlaege telefonvisitation; with medical authority over whole operation Selected patient groups bypass FAM: STEMI, OB/GYN, Pediatric Fewer entry points to hospital for emergency patients Selected patient groups Vagt central EMS 112 Alarm central Egen Laege or Laegevagt telefon visitation TRIAGE Faelles Akut Modtagelses Enhed Laegevagt Konsultation Hospital Inpatient Departments Selected patient groups Increase vagtlaege system coverage to 24 hours; may need to eliminate mobile vagtlaege to cover additional shifts Faelles triage on hospital arrival Tighter integration between FAM and vagtlaege konsultation (extra costs offset by savings from reductions in other areas) 36

37 Training Programs for Emergency Physicians Competency based education First need to agree on the clinical model and competencies Low volume/high acuity vs. high volume/mixed acuity Training curriculum Don t need to start from scratch; many examples internationally Modify to match Danish FAM patient population Fagområde i akutmedicin now; Develop akutlaege workforce of mid-career physicians with prior specialization Dilemma of non-uniform knowledge and skills among participants New specialty in akutmedicin in 5 years Need to start working on this now Sustain akutlaege workforce with young physicians Fagområde model (double specialty training) is costly, unnecessary and unappealing to young physicians 37

38 Program participants Training Programs for Emergency Physicians Complicated; at least 4 different specialty backgrounds (physicians) Gap analysis based on Akutmedicin body of knowledge/skills Training program one size fits all program won t work Need at least 4 different programs based on needs of participants from different specialties Goal: uniform knowledge/skill set among program graduates Certification Process Verify knowledge acquisition written, oral examination Establish credibility within medical community and public 38

39 Training Program Elements Theoretical & practical training Clinical practice under supervision by clinical experts Focused clinical rotations in relevant departments Defined goals and objectives Graduated responsibility Didactic elements Lectures, seminars, case conferences Short courses, skills workshops Medical simulation exercises Spectrum of didactic elements of emergency physician training 39

40 Other Recommendations

41 Healthcare quality depends on analysis of data from entire patient forløb Example: 72 hour returns with admission on 2 nd visit Patient with chest pain calls 112; EKG in ambulance shows STEMI Patient transported to interventional cardiology hospital; successful PCI within target timeframe Good example of high-quality emergency care But, if same patient had contacted vagtlaege 12 hours prior to calling 112; Patient complained of vague symptoms, prescribed symptomatic treatment, told to follow up with GP Example of potentially significant delay in diagnosis and treatment action consequence series of multiple patient encounters 41

42 Additional recommendations Data/Quality Interlocking set of quality standards and evidence-based guidelines for emergency care across all sectors Regional office for healthcare data and informatics to develop and maintain integrated emergency patient data registry All three emergency care sectors Standardized emergency patient encounter data sets for all emergency care sectors 42

43 Additional recommendations Data/Quality Standardized emergency patient care documentations forms at all FAM Informatics tools to support accurate and efficient patient data entry and patient care throughout system Electronic patient medical record Electronic patient data tracking systems 43

44 Prognosis Impending crisis can be avoided Recognize scope of current problems; plan for worst case scenario, not best case Increased focus on coordination / consolidation between sectors FAM as effective, lower cost alternative to inpatient admission Reduce unnecessary admissions Extra costs offset by reductions in other areas Support and closely coordinate with vagtlaege konsulation Able to manage high volume, mixed acuity patient population Be ready to save the primary sector!! Competency based training for emergency physicians and nurses Agree on clinical role, scope of practice Fagområde now; specialty soon 44