Complex Care Planning in the Emergency Department: Demonstrating Rehabilitation Contributions CAOT Conference 2016 Inspired for Higher Summits Banff, AB
No conflict of interest Project Team all from Sunnybrook Health Sciences Centre Isabella Cheng Professional and Educational Leader, Occupational Therapy Nicole Cooper Professional Leader, Physiotherapy *Stephanie Horner Occupational Therapist *Evelyn Chong Physiotherapist Emily Stairs Occupational Therapist Ray Howald Clinical Educator, Emergency Department Zuhair Alsharafi Physician, Emergency Department Tracey DasGupta Director of Interprofessional Practice *presenting today 2
Sunnybrook Health Sciences Centre Largest single-site hospital in Canada 1.2+ million patient visits annually 10,400 staff and 2,000 volunteers Fully affiliated with the University of Toronto 4,000 students 4 strategic areas: 1) Trauma, Emergency & Critical Care 2) Heart & Stroke 3) Cancer 4) Women & Babies 3
Learning Objectives 1. Describe the implementation approach and steps of the demonstration project to include rehabilitation professionals into the emergency department at Sunnybrook Health Sciences Centre. 2. Identify the Decision Support findings and the key factors that lead to success in implementing rehabilitation professionals into a new area in an acute care setting. 4
Project Background Rehab professionals needed in the Emergency Department (ED) to provide functional assessments Demonstration project with OT and/or PT into the ED as functional consultants Alignment of TAHSNp Fellowship, allowing a quality improvement approach Aimed for resource securement for functional consultant position, either OT or PT, or combination Approval and funding by Senior Leadership for a demonstration project, Nov. 2014 Can this patient go home? Does this person need admission? 5
AIM Statement To reduce hospital occupancy rates by: - Diverting inappropriate admissions from acute care - Enabling faster physician decisions from initial assessment to disposition - Reducing the length of stay for patients who are admitted acute care units By the provision of Occupational Therapy and/or Physiotherapy assessment to elderly patients with complex issues presenting to the Sunnybrook Health Sciences Centre Emergency Department 6
Project Development Review of 2014 data, with Decision Support expertise and guidance Evidence gathered on: Clinical opportunities Target population Feasibility 7
Number of patients assessed Patient Volumes vs. Bed Requests Peak ED arrival times: - 11:00 12:00-20:00 21:00 MD assessment = 2 hours 4-6 hrs (or more): Decision for disposition Time Opportunity 8
Evening and Overnight Admission Rates Opportunity For patients with < 2-day length-ofstay, physicians are more likely to admit a patient if deciding during overnight hours as compared to the day * Source: DAD, EDIS 9 If our 00:00 to 07:00 ED Admission Rate was similar to our daily average, we would have a potential of nearly 4 bed savings.
Opportunity Early OT/PT assessment to inform decision making 10
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Functional Assessment Consult Team (FACTeam) Composition 0.5 FTE Occupational Therapist 0.5 FTE Physiotherapist Timeline February 2nd to April 30 th, 2015 Hours of service 1200 1900 Monday to Friday Service Comprehensive functional assessment and intervention for geriatric patients presenting with complex issues to the ED 12
FACTeam Target Population 65+ years Required functional assessment Potential to be discharged directly from the ED Collaborate with the ED team to develop comprehensive recommendations and discharge plans to optimize disposition decisions identify appropriate acute care admissions Decrease occupancy by reducing inpatient bed occupancy improve overall patient flow reduce wait times in the Emergency Department 13
Referral Process 1. Emergency Department Information System (EDIS) triage terms RN inputs triage terms into EDIS Automatic email sent to FACTeam if EDIS terms match Review of patient information to determine appropriateness for FACTeam intervention 2. Verbal referrals from ED team members Triage terms to initiate FACTeam involvement Dementia Delirium Confusion Fall Skin ulcer 14 Failure to thrive / failure to cope Weakness Social placement issues Decreased ambulation Altered mobility
FACTeam Assessment Functional task based assessment include: Baseline information from patient, family, living facility, old chart Physical, cognitive and psychosocial components of task performance Interplay of deficits on function Identification of current functional status and care needs Assessments completed at patient s bedside Collaboration with other ED team members RN, GEM RN, SW, CCAC, PA, MD 15
FACTeam Interventions Recommendations provided regarding need for admission For patients discharged home from ED: Community resources Education for patients and families/ caregivers Equipment recommendations Caregiver/ facility update on changes in function 16
Staff Engagement Implementation team FACTeam T-shirts Posters in the ED Email Screen saver Ongoing introductions and face to face engagement Staff meeting Frequent informal check-ins with the implementation team ED physicians, Clinical Educator 17
Does your patient need an OT or PT assessment? Do you think your patient will have difficulty managing at home? Has your patient had: Falls Confusion Weakness Dementia Difficulty with ADLs Stephanie, Occupational Therapist Evelyn, Physiotherapist Functional Assessment Consult Team (FACTeam) Stephanie, Occupational Therapist, pager 7626 Evelyn, Physiotherapist, pager 6531 Please see the assignment board in the Green zone for on-service FACTeam member (OT or PT) and pager number During off-hours, email referrals to FACTeamED@sunnybrook.ca A therapist will be in the ED from Monday Friday 1200 to 1900 18
Results FACTeam assessed and treated 208 patients Referrals 121 (58%) EDIS triage terms only 44 (21.15%) EDIS triage terms and verbal referral 43 (20.67%) Verbal referral Recommendations 114 (54.81%) Cleared for discharge from a functional perspective 37 (17.79 %) Recommended admission to acute care 19
Qualitative Evaluation Patient experience questionnaires n=35 Acute care OT&PT and GIM Physician experience questionnaires ED staff and ED Physician experience questionnaires I am very impressed with the FACTeam I truly believe there is a need for this in every emerg dept especially in relation to elderly individuals who do not end up in emerg because of serious health issues, but where they are having ongoing for example falls and need assessment (both physical and mental) to aid both the individual and family (or friend) to make serous changes in where/how they live. Very impressed! ~Patient With the help of the FACT I was able to discharge a patient referred to me with "failure to cope". Also I was able to get urgent chest physio on a patient in ED. Great start and thanks to the team!!! ~GIM Physician 20
Quantitative Evaluation In collaboration with Decision Support Comparing FACTeam data to same patient population from the same fiscal quarter in 2014, for 3 key indicators: 1) Impact on appropriately diverted admissions from acute care 2) Impact on Physician decision time 3) Impact on length of stay for patients admitted to acute care 21
Percentage 1) Diverted Admissions 55.00 50.00 Percentage of FACTeam Patients Admitted FACTeam Patients 45.00 40.00 35.00 2015 Cohort Average Admissions 2014 Cohort Average Admissions 30.00 Feb March April 22
2) Physician Decision Time Aim to enable faster decisions from Physician Initial Assessment (PIA) to discharge disposition PIA to Disposition 50 th Percentile 2015 2014 Change All patients 4:08 4:45-13% Admitted patients 6:04 5:50 4% Discharge patients 2:57 3:56-25% 23
3) Length of Stay Cohort 2014 Length of stay 7.6 days Cohort 2015 Length of stay 7.5 days Clinically saw few admissions for functional assessments so the brief 1-2 day LOS were no longer contributing to the LOS average 24
Value Add of Rehab in the ED Demonstration project highlighted need and use of FACTeam beyond target population Capacity to assess and treat patients bed-spaced in the ED Potential to discharge from ED Decrease LOS Improve communication and transfer of accountability for patients transferred from the ED to the ward 25
Continued Conversations This fiscal year, decision to fund another initiative to meet breadth of demands within the ED Continued support from Senior Leadership and ongoing discussions for implementation next year Poster of Distinction Award for the category Health Links: Improving care for patients with complex care conditions at the Health Quality Ontario conference, Health Quality Transformation (Oct 14, 2015). 26
Reflections Breadth of stakeholders for demonstration project 3 months is not long enough! Formal check-ins more often Including LOS data lengthens project in terms of gathering and interpreting results Decision Support guidance is valuable ED is big! 27
Questions? 28
FACTeam Patient Experience Questionnaire 29
Contact us Isabella.Cheng@Sunnybrook.ca Professional & Education Leader, Occupational Therapy Corporate Lead, Person-Centred Care Sunnybrook Health Sciences Centre H385-2075 Bayview Avenue, Toronto, ON M4N 3M5 416-480-6100 ext. 3047 Stephanie.Horner@Sunnybrook.ca Occupational Therapist, General Internal Medicine and Nephrology 30