On the case

With more than 5,500 staff and 750 beds, the Royal Liverpool and Broadgreen University Hospitals NHS Trust is among the busiest in the North of England, delivering services across two sites and three hospitals. Each year, it treats over half a million outpatients and around 150,000 emergency patients and day case admissions.

After auditing patient flow, the trust’s management had become concerned about excessive lengths of stay resulting in a shortage of available inpatient beds and congestion in A&E. It meant patients were often waiting longer to be admitted and treated which, in turn, was impacting the patient experience and possible outcome.

Adding to their concern was the government’s Payment by Results funding model, which is based on shorter stays and does not reimburse hospitals for the cost of extra patient days.

Moreover, the trust needed to meet the NHS Emergency Access Target whereby 98% of patients must be discharged or admitted within four hours of arrival in A&E; a decision to admit clearly requires an available bed, otherwise patients can find themselves in limbo.

“Although we were managing to meet this target, it was always a big challenge to juggle capacity, demand and availability,” says Trish Armstrong-Child, director of operations.

“To compound the situation, our trust’s new, £450m state-of-the-art facility – due to open in 2017 – will have considerably fewer beds in line with the government’s drive toward more ambulatory and community-based care delivery.”

Armstrong-Child says the trust’s management realised it needed to pinpoint delays in transferring patients from hospital to community-based care and work towards speeding up this process. She says they were equally keen to identify hospital-based delays and how these might be managed systematically.

“After auditing patient flow, we did initially achieve a measure of success in reducing length of stay,” she says. “But there was still room for improvement and a need to ensure any changes we made were sustainable.

“We therefore needed to help multi-disciplinary ward teams clear obstacles to efficient and timely patient flow. Moreover, in order to manage with far fewer beds in the future, we knew we needed to explore new models of care and ensure they were effective before moving into the new hospital.”

Case management solution

Armstrong-Child and her team came up with what is thought to be the first case management system of its kind in the UK, whereby each acute care patient is assigned a case manager upon admission to hospital.

The case manager’s role is to work proactively with ward staff, consultants and associated health professionals – plus community and social service partners – to coordinate each patient’s care stream and move them toward clinical stability and discharge.

Having decided on this new way of working, Armstrong-Child’s team then reviewed possible supporting technologies before choosing the Medworxx clinical utilisation management system as the most suitable for use in conjunction with a case management approach to patient flow.

Initially implemented in A&E, the medical assessment, intensive care and coronary care units, plus medical, surgical and rehabilitation wards, the Medworxx system pulls a direct feed of patient information from the trust’s iPM patient administration system.

A specific case manager is then responsible for assessing the management of each patient based on the information provided, which includes identifying any factors that delay their treatment or discharge, such as hold-ups in test results.

Positive results

“There were so many facets to what we needed to achieve, and in healthcare there’s never just one silver bullet,” says Armstrong-Child.

“The Medworxx system gave credibility to what we’d already set out to do and it is helping to sustain what we need to achieve going forward. We knew what the issues were, but the system backed up a lot of our thinking and helped take us from an anecdotal to a factual understanding of our case management challenge.”

Initial use of the case management approach and Medworxx software was closely monitored by consulting partner Model Advice DC Consulting, who compared the number of patients who were ‘ready for discharge’ pre- and post-implementation.

They also measured the effect on revenue lost though exceeding PbR-allowed length of stay and reported a 30% reduction in ready for discharge days after only three months. Furthermore, the average number of patients on the ready for discharge list dropped from 45 to 18 after 12 months, while average cumulative ready for discharge days dropped from 500 to 100 over the same period.

According to Medworxx, its system also helped the Royal Liverpool achieve a 15% increase in respiratory patient throughput volume and a reduction in length of stay from 10.5 to 9.7 days; plus a 30% increase in the number of referrals into community beds, indicating better utilisation of existing intermediate care capacity.

Moreover, the successful introduction of the case manager role – supported by the Medworxx patient flow management software – produced such significant results that it has now been extended from an initial six sites and rolled out across all beds within the trust.

Broader potential

Indeed, Armstrong-Child says that, overall, the introduction of Medworxx utilisation management system has helped Royal Liverpool and Broadgreen reach many milestones of positive change.

“It has enabled us to send very detailed reports that help address bed-requests," she says. “This in turn has helped us improve the patient journey, whilst bridging clinical and operational assessments of appropriate care intensity from admission to discharge.

“We’re extremely proud to have won the EHI Award 20112 for ‘outstanding work in IT-enabled change in healthcare’,” she adds. “We only set up this project a year earlier and never expected to achieve so much, so quickly. IT has been an enabler for changing our culture and enabled us to sustain that change.”

Armstrong-Child believes the use of patient flow software and a case managed approach can potentially help all trusts and commissioners meet ‘Nicholson Challenge’ targets to improve efficiency and productivity, while improving patient care.

“As well as enabling NHS organisations to reallocate limited resources, it can contribute toward systemic improvement in transitioning patients between levels of care and help address the barriers that need to be removed,” she concludes.

If you have been involved in a great IT or information-enabled project, you have only a few days left to enter it into the EHI Awards 2013 in association with CGI. The closing date for entries this year is Friday, 10 May, at 4pm.

 

This year’s black tie awards dinner will be held at the prestigious Roundhouse in north London on 10 October. For information about sponsorship opportunities contact head of events Neil Hadland. Tickets will be on sale soon.