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Improving patient transport

Improving patient transport

What is patient transport?

Waitemata DHB use an average of 896 St John ambulances each month to move more than 1000 patients between hospitals regionally, nationally and back into the community.  We represent 50% of the regional demand for the St John patient transfer service ambulances with more than 80% of our patient movement going between the Waitakere, North Shore and Auckland Hospitals.

Value: ConnectedThere are two reasons why patients are transported between hospitals:

  1. Patient needs specialist care that is not provided at their current location.  Example:  An unwell child at North Shore is transferred to Starship Hospital, or a Waitakere Hospital patient is transferred to North Shore Hospital for surgery.
  2. Patient needs to be transferred back to their local hospital following an emergency presentation.  Example:  An elderly patient from Birkenhead has an unexpected fall while visiting a friend in Papakura needs to be transferred back to North Shore Hospital from Middlemore Hospital.

What are we trying to achieve?

There were a lot of complaints about patient transport from staff and we were asked to find out whether there was a problem.


What did we find?

There are 64 areas within Waitakere and North Shore Hospitals that patients are transferred from, and more than 214 areas around the country that they are transferred to.  The clinical reasons for patient transfers are just as complex, however the high level process is the same for all:


Process Steps

Explanation

Ambulance Transport Process

Step 2:  An assessment is completed on the patient's medication condition and stability.  This assessment defines whether they need to have someone accompany them in the ambulance.  This could be a healthcare assistant, a nurse or a doctor.  There are very limited transport resources and they are in high demand.  Not all transports require the patient to be accompanied.

Step 5:   There are many factors to assembling a team for transport.  The patient needs to be ready, including all notes and belongings.  The ambulance needs to have arrived at the required time.  Equipment needs to be assembled and the transport team needs to be available to leave without delay.

Step 9:  Once the patient has reached their destination we need to get the staff and the equipment back to where they came from.  There can be significant cost and time implications in this step.


What have we done?

With an accurate understanding of the demand and how the process works across our organisation, the project team selected three areas for further investigation:

Work Stream

Explanation

1. Critically Ill Patient Transport

Critically Ill Patient TransportThese patients are very unwell and require urgent transportation accompanied by a very specialised team to provide life support in transit. While the number of patients is relatively small, the level of risk associated with the process is very high and the availability of appropriate staff to accompany patients is perceived to be limited.

2. Waitakere Emergency Department to North Shore Patient Transport

Waitakere ED to NSH TransportPatients leaving from Waitakere Hospital Emergency Department (ED) account for 24% of all patient transports, 68% of which are going to North Shore Hospital for specialist services not available at Waitakere.  This area was selected for investigation due to the pressure that the high demand puts on the St John service.

3. St John Ambulance Ordering Process

St John Ambulance OrderingWe have an exclusive contract with St John Ambulance Service that requires standards to be met from both a St John and a Waitemata DHB perspective.  It is perceived that neither party are currently meeting those contractual requirements.


Critically Ill Patient Transport1. Critically Ill Patient Transport


Problem Statement

There is variation in the availability of appropriate personnel and equipment to attend and transport patients and results in patient movement delays.  Administrative and non-clinical delays in moving patients result in compromised clinical care.

There is a lack of clarity and publication of the process across the organisation as well as a lack of agreement around who is to accompany each classification of patient.

Project Goals

Critically ill patients are transported from North Shore or Waitakere Hospitals to North Shore, Waitakere or Auckland Hospitals within the following time frames:

  1. 70% within 60 minutes
  2. 90% within 90 minutes

We have now implemented a data collection process to help us to understand our current performance and have analysed 27 transports.


Critically Ill Patient Transfer FormCritially Ill Patient Transfer Form

A Critically Ill Patient Transfer Form is completed for every transfer.   It includes the following timeline information:

  • Decision made
  • Transport team arrived
  • Departure time
  • Arrival time

Details of the transfer team that accompanied the patient is also captured on the reverse so we can start to build an accurate picture of the most frequently used resources.


Results of initial analysis

It takes between 36 minutes and 3 hours to move a critically ill patient, from when decision is made to the patient arriving at destination, with the average time being 93 minutes.


Next Steps:

High level process mapping has been completed to understand how the process currently work.  These process maps will then be used to identify specific area for improvement that will be worked on over the coming months.

Patient Transport Process

 

Waitakere ED to NSH Transport2. Waitakere Emergency Department to North Shore Patient Transport

a. Transferred patients admittance rate - can we reduce the number of transferred patients?

Waitakere Emergency Department (ED) transfers an average of 313 patients a month out of their department, of which 68% move to North Shore ED or to the Admission and Diagnostic Unit (ADU) to see the following specialties:

  • Surgical: 39%
  • Medical: 22%
  • Orthopaedic: 18%
  • Gynaecology: 15%

The aim of this work stream was to analyse the number of patients transferred to North Shore Hospital that were sent home without being admitted.  If the numbers were high, then we could potentially have these patients seen at Waitakere Hospital and reduce the number of patients transferred.


Results

Only 23% of patients transferred to North Shore Hospital were not admitted.  Gynaecology was the exception with 63%, however the number of patients was very low at less than 4 a week.

Transferred Patients Admitted Chart


Decision

There is not enough evidence to support the view that changing the way we see and assess our patients at the moment would yield any significant reduction in the number of transports from Waitakere Hospital to North Shore Hospital.


b. Transferred patients length of stay - what impact are they having on the flow of the department?

Patient Disposition to Discharge Chart

Patient Disposition to Transfer Chart

Patient Disposition to Admission Chart

Decision

Length of Stay

Discharged

2 hr 1 min

Transferred

3 hrs 41 mins

Admitted

3 hrs 57 mins

There was a strong perception that delays in patients transferred out of the Waitakere Hospital ED contributed significantly to bed block and congestion within the department.  The first step for this work stream was to analyse whether or not patients transferring out to another hospital in fact spent significantly longer in the department than those admitted or discharged directly from the ED.


Results

The analysis showed that patients transferring out to another hospital spend longer in the Waitakere Hospital ED than those discharged but not longer than those admitted to stay in Waitakere Hospital.

Analysis was also completed to understand the time spent waiting for an ambulance and what part it plays in the overall length of stay being 3 hours and 41 minutes.  Given the average wait time for an ambulance to arrive is 85 minutes, transferred patients spend on average only 15 minutes longer waiting for a decision to be made than patients that are discharged home.


Decision

The team agreed that the perception is incorrect - there is not enough evidence to support that transferred patients alone cause significant bed block or congestion.


c. Ambulance availability - could we provide a faster service?

There was a strong perception that delays in ambulance availability causes significant delays for patients transferred to North Shore Hospital.  The aim of this work stream was to look at whether a dedicated transport service running at regular intervals would reduce delays in transporting patients during peak times to North Shore Hospital.


Analysis

St John have provided data to indicate an average of 21 minutes to load and unload patients at both pick up and drop off locations, as well as an average travel time if 58 minutes to North Shore Hospital from Waitakere.

Ambulance Waitakere to North Shore CycleAmbulance Waitakere to North Shore Cycle

The complete cycle time from Waitakere Hospital to North Shore Hospital and back would be 2 hours 38 minutes.

Ambulances by Day of Week ChartWe transfer an average of 9 patient a day to North Shore, using an average of 5 ambulances.  We know that St John require 90 minutes notice when booking an ambulance and that their average wait time is 85 minutes.  We looked at the length of time between patients being ready to go to identify what interval we would need to have alternative transport scheduled for.

Time to Next Patient Box PlotThe boxplot graph shows the length of time between patient transports being ordered based on the hour of the day.

The red line indicates the current service level that St John provide for us, so the proposed service would only be of benefit during those times of the day where the average is below the red line - between 10pm and 2pm.

Ambulance Wait vs Demand ChartThe line graph shows the relationship between the number of ambulances required and the average wait time based on the hour of day.  The red line indicates the current service level that St John provide for us.

We have the largest demand for patient transport between the hours of 10pm and 2am.  It also show this is when St John have the lowest wait time of an average of 62 minutes.


Conclusion

A dedicated ambulance service running at regular intervals during peak times has the potential to reduce the waiting time for ambulances.  Given the number of transports required and their frequency, the interval between transports would need to be a maximum of 45 minutes to be of benefit.

Given the cycle time of 2 hours and 38 minutes, we would need to have multiple ambulances doing trips back and forth, and we would not have enough patients to fill them.


Decision

The cost far outweighs the potential benefits - do not proceed.


St John Ambulance Ordering3. St John Ambulance Ordering Process

There is a strong perception that St John ambulance availability and reliability impacts significantly on our ability to efficiently move patients between hospitals.  The aim of this work stream is to understand both St John and Waitemata DHB performance against targets set in the contract. 

There are two types of orders for ambulances:

  1. Appointment Transports:  This type of ambulance is ordered when patients have an appointment for an intervention or procedure at another location and often includes a return trip.  Example: A Cardiology patient at Waitakere Hospital having an appointment at North Shore Hospital in the Cardiovascular Intervention Unit for an angiogram.
  2. Adhoc Transports:  This type of ambulance is ordered to transport a patient one way to receive specialist care that is not offered at their current location.  The majority of these requests are made by our emergency departments, however there are some requests that come from the wards.

Appointment Patient Transfer Target: 90% of patients are on time to their appointments

St John data shows May 2013 performance of 83% and year to date performance of 81%.

Of the 17% that do not meet the target, 81% are within 5 minutes.  This indicates that only 3% of patients are significantly impacted by delays resulting in missed appointments.


Standard Patient Transfer Target: Ambulance arrives within 90 minutes

Initial analysis shows that the average wait time for an ambulance in our Emergency Departments is:

  • 69 minutes for North Shore Hospital ED
  • 75 minutes for Waitakere Hospital ED

Data from Waitakere Hospital ED indicates an average performance of 85%.

Patient Transfer Target: Waitemata DHB provides St John 90 minutes notice when booking an ambulance

This performance measure applies to both appointment and adhoc transport requests. Data provided by St John shows that in May 2013 performance, 62% of the time we gave St John sufficient notice, with a year to date performance of 56%.

In November 2011, a project was initiated to identify ways to improve performance. The solution that was implemented was to create a centralised ambulance booking service (CABS) that sees all non-urgent ambulances being managed by one team rather than being individually managed by wards.

St John KPI ChartThis service has been rolled out using a phased approach, starting with North Shore Hospital's Tower Block in July 2012.  This graph shows the impact on Waitemata DHB performance at the various stages of the CABS roll outs.  It shows an increase of 24% (from 38% to 62%) in 18 months.  CABS now manage 37% of all non-urgent ambulance bookings across the two hospital sites.


Stage

% Impact

Performance

Stage 1: Project kick off and communication about 90 minute notice requirement

11% increase

49%

Stage 2: North Shore Hospital Tower Block

5% increase

54%

Stage 3: Waitakere Hospital Medical Wards

4% increase

62%

By the end of 2013, all wards across both hospitals will be using this service, which will see Waitemata DHB consistently reaching its target.