In 2002 Hornsby Ku-ring-gai Health Service experienced 60% access block with 98% occupancy of the acute wards. There was no flexibility in the system.

The Emergency Department (ED) had an Average Length of Stay (ALOS) of 14 hours. However, an ED audit found that patients over 65 years had an ALOS of 27 hours. Despite having 70% of bed days occupied by people over the age of 70 years acute aged care wasn't seen as core business.

The elderly patients journey through the hospital was process mapped and leverage points identified. The leverage points guided a staged implementation of aged care initiatives designed to facilitate and improve the elderly patients' journey.

The initiatives resulted in a reduction in ALOS, readmissions in 28 days, improved discharge planning and contributed to a reduction in the access block down to 17% in May 2006 with increased patient and staff satisfaction.

To provide integrated Rehabilitation and Aged Care Service (RACS) across the Hornsby Ku-ring-gai continuum thereby facilitating and improving the patient journey through staged implementation of aged care initiatives.

In 2002 Hornsby experienced 55-60% access block with 98% occupancy of the acute wards. There was no flexibility in the system. Emergency Department (ED) had an Average Length of Stay of 14 hours but an ED audit found that patients over 65 years had an average length of stay of 27 hours. There were high numbers of patients waiting for nursing home beds (often > 20) combined with longer Length of Stay (LOS) in medical patients than the peer group. There were high numbers of older people with complex problems presenting to ED and requiring admission.

The Director and Nurse Manager of the RACS reviewed data and literature on models of care that improved the journey of acutely ill elderly patients. The process improvement commenced with the Acute Care of the Elderly (ACE) model of care.

A multidisciplinary Steering Committee were established for all projects with two consumer representatives for ACE and Geriatric Rapid Acute Care Evaluation (GRACE) and one for Sub Acute Fast Track Evaluation (SAFTE).

The elderly acute care processes were mapped and leverage points identified. The stakeholders who included nurses, doctors, allied health, pharmacists, consumers and other health providers assisted with the process mapping. Issues identified were discussed at the Steering Committees. Leverage points within the project scope were prioritised and strategies developed to implement change. Change champions were identified and communication strategies implemented.

Diagnostic tools used included process mapping (high and low level), Ishikawa and Pareto charts followed by Plan-do-study-act methodology for ACE and subsequent projects. Interviews, surveys, process and outcome measures were used to evaluate interventions, and to measure safety, sound clinical practice, effectiveness and stakeholder acceptance.

Consultation, identifying change champions and feedback have been central to the process.

1. Commencement of ACE (Acute Care of the Elderly) unit 2002: to address inappropriate care of acutely ill older people in hospital using a shared care model of care (physician and geriatrician) with a focus on maintaining function
2. Introduction of ASET (Aged Services in Emergency Team) 2003: to provide comprehensive multidisciplinary assessment of older people in ED, collaborating with GP, family, service providers, and aged care facilities
3. Opening of EMU (Emergency Medical Unit) 2003: to provide short stay admissions for assessment and stabilisation of patients prior to discharge, or transfer to rehabilitation wards
4. Introduction of Aged Care Liaison Nurse 2003: to facilitate discharge plans for high level care patients
5. Introduction of orthogeriatric service 2004: to provide geriatric medical care to older orthopaedic surgical patients both pre- and post-surgery
6. Introduction of GRACE (Geriatric Rapid Acute Care Evaluation) 2005: to provide rapid assessment and stabilisation/management in ED / EMU for residential care facilities patients, and to facilitate transfer back to nursing home/hostel with assistance of services as necessary. ("Quick Turnaround Team")
7. Introduction of SAFTE Care (Sub Acute Fast Track Elderly Care) 2006: early intervention in the sub-acute phase of illness in older community based patients(>75 yrs) using comprehensive geriatric assessment and community services as necessary

The patient journey is improved through targeted coordination, communication and staged implementation of initiatives facilitating the flow of aged care patients with flexible integrated services, such as in the example below for a patient suffering from dementia.

Aged Care Assessment Team (ACAT) contacted re patients short term memory loss > referral to the Memory Clinic > Memory assessment by a clinical nurse consultant with geriatrician review > opportunity to be involved in international dementia clinical drug trial > access to Dementia Day Care and occasional respite care > patient deteriorating in the community > referral to SAFTE > health and community assessment with medical assessment as required and provision of up to 6 weeks of community assistance > patient maintained in the community with ongoing services > Pt ?CVA and SAFTE Team notifies ASET of patients transfer and relating issues > information accessed on CHIME (Electronic medical record) > ASET facilitates admission > admitted to ACE ward > short stay in rehab ward > returns home with support from Rehabilitation Discharge Team (home based rehabilitation) > extension of CVA > acute admission with ASET > Aged Care Liaison Nurse facilitates nursing home journey > Nursing Home admission > acutely unwell > GRACE intervention and patient safely maintained.

Aged Care Liaison NurseIn 2002 a monthly average of 20 patients waiting for placement with an Average Length of Stay (ALOS) of 20 days. In 2006 reduced to 5 patients with an ALOS of 4.2 days per month.

ACE: Reduction in:

• ALOS by 0.25 days.
• 28 day readmissions in the cardiac and respiratory DRG target groups from 12.4% in "controls" to 3% in ACE unit patients.

Rehabilitation Wards:

• ALOS 19 days - below benchmark.
• ACE patients rehabilitation ALOS decreased from average 19 to 11 days.

GRACE:

• ALOS for GRACE patients in ED is 7.25 hours compared to 23 hours for patients over 65 years in 2003.
• ALOS for admitted nursing homes patients has reduced from 7 days in November 2005 to 4.2 days in April 2006.
• Monthly nursing home bed days decreased from 536 in November 2005 to 300 bed days in April 2006.
• 55% of GRACE EMU patients admitted for less than 48 hours.
• assisted to reduce access block, 30% in August 2005 to 17% in May 2006.
• Average of 12 avoided admissions per month.

HKHS Acute Funding Stream Performance despite increased admissions - Refer below

These initiatives are sustainable as they improve the patient journey, contribute to a reduction in ALOS and occupancy across the hospital, increase bed flexibility and reduce access block.

Future work will include the role of Advanced Care Planning/Directives and Transitional Beds in improving the patients journey.

Curran Chair in Health Care of Older People Faculty of Medicine, University of Sydney
Clinical Director and Senior Staff Specialist Division of Rehabilitation and Aged Care, Hornsby Ku-ring-gai Hospital
Phone: 02 9477 9514
Fax: 02 9477 5684