Evaluation of Emergency Medicine Ward (EMW) Service in a pilot Hospital. Dr. C.H. Lit

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1 Evaluation of Emergency Medicine Ward (EMW) Service in a pilot Hospital Dr. C.H. Lit 1

2 PMH EM Ward Opening Opening ceremony (2 Nov 2007) Commencement of operation (5 Nov 2007) 2

3 Timing for Evaluation (PMH EMW) Just opened in Nov 2007 Exceptional situation in Feb-March 08 Prolonged cold spell Flu upsurge 3

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6 Total A&E Attendance in HK Compared with % increase in 2007 & 5.3% increase in , No. of A&E first attendances 180, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,000 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 6

7 Total A&E M&G Admissions in HK (Including all A&E with or without EM Ward Admissions) Compared with % increase in 2007 & 13.8% increase in , N o. of A&E adm issions 26,000 24,000 22,000 20,000 24,091 23,070 21,719 25,824 21,428 19,832 24,599 23,413 22,458 22,329 22,371 21,614 20,879 23,205 22,401 21,977 22,411 22,385 20,799 21,633 20,718 21,599 21,005 20,846 20,558 22,742 22,411 18,000 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec * Including all AEDs with or without EM Ward admission 7

8 PMH A&E / EMW 8

9 A&E 1 st Attendance 13, N o. o f A & E firs t a tte n d a n ce s 12,000 11,000 10,000 9,000 11,233 10,854 10,563 10,801 10,611 10,619 10,323 10,010 10,324 10,314 10,274 10,080 10,046 9,647 9,307 11,256 11,082 10,591 10,306 10,363 10,160 10,968 10,398 10,470 10,165 10,592 10,553 8,000 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 9

10 A&E Admission (EMW Only) 1,000 No. of A&E admissions (EM only) No. of A&E admissions Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 10

11 A&E Admission (All Specialties) (Exclude EMW, include lateral transfer from EMW) 4, No. of A&E admissions 4,000 3,500 3,000 3,477 3,375 3,174 3,532 3,601 3,453 3,512 3,423 3,262 3,282 3,451 3,417 3,606 3,175 3,068 3,352 3,214 3,244 3,165 3,222 3,179 3,169 3,532 2,939 2,952 3,533 3,049 2,500 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 11

12 Hosp Adm (excluding EMW Adm, including Lat Adm from EMW) (PMH) Jan Feb March April May June July Aug Sept Oct Nov Dec 12

13 A&E Admission (M&G) (Exclude EMW, include lateral transfer from EMW) 2, No. of A&E admissions 2,100 2,000 1,900 1,800 1,700 1,600 1,500 1,916 1,919 1,696 1,961 1,941 1,811 1,857 1,706 1,674 1,834 1,814 1,971 1,766 1,904 1,810 1,926 1,822 1,809 1,784 1,873 1,719 1,712 1,695 1,844 1,596 1,928 1,623 1,400 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 13

14 M&G Adm (including lateral transfer from EMW) (PMH) Jan Feb March April May June July Aug Sept Oct Nov Dec 14

15 Admission (PMH) 07/08 vs. 06/07 Nov 07 March 08 Nov 07 January 08 All Admission M&G Admission

16 Admission (PMH) 07/08 vs. 06/07 Nov 07 March 08 Nov 07 January 08 All Admission M&G Admission

17 Each hospital is different Confounding Factors to Note 17

18 Confounding Factors Complexity of service within Cluster Scale of A&E service before implementation of EMW Hosp / Cluster service rationalization Oncology Major trauma diversion (expanded scope & enhancement) Others Local population profile (age / dependency on HA) Staff movement Others 18

19 Scale of A&E service before implementation of EMW A&E A&E + (OW) A&E + OW A&E + EMWequivalent A&E + EMW A&E Observation Ward EMW equivalent 19

20 Impact of Oncology Service (PMH) Def 1 Def vs 2005 (% increase) 2007 vs 2005 (% increase) Q Q Q4 Def 1: >/= 1 Oncology FU in 12m Def 2: >/= 2 Oncology FU in 6m PMH Oncology service started in Q

21 Major Trauma Calls (PMH Trauma Team Activation) (PMH) Trauma Call (PMH) 21

22 Aging Local Population Attendance (Mean Age) Jan-Dec Jan-Dec Age (Mean) 2006 Age ( Mean) 2007 Age (Mean)

23 Aging Local Population Admitted cases (All Spec) (Mean Age) Jan-Dec Age (Mean) 2006 Age (Mean) 2007 Age (Mean) 2008 Jan-Dec 23

24 Aging Local Population (More than nature in PMH!) Admission (All Specialties) (Mean Age) Admitted (All Spec) Age (Mean) 2006 Age (Mean) 2007 Age (Mean) Jan-Dec Jan-Dec Age (Mean) 2006 Age (Mean) 2007 Age (Mean) 2008 Increased

25 Looking at it from other angles 25

26 Case Mix 26

27 Top 20 Principal Diagnosis Group (EMW vs. M&G) (Dec 07-Jan 08) EMW M&G Number Principal Diagnosis Code (3-digit) Admission Specialty (EIS) EM No. of Diagnosis Principal Diagnosis Description (3-digit) GENERAL SYMPTOMS RESP SYS/OTH CHEST SYMP CHR AIRWAY OBSTRUCT NEC ESSENTIAL HYPERTENSION PNEUMONIA, ORGANISM NOS OTH ABDOMEN/PELVIS SYMP DIABETES MELLITUS BACK DISORDER NEC & NOS ILL-DEFINED INTEST INF OTHER BRAIN INJURY SYMPTOMS INVOL HEAD/NECK CARDIOVASCULAR SYS SYMP OTH URINARY TRACT DISOR OTHER CELLULITIS/ABSCESS HEART FAILURE AC URI MULT SITES/NOS FLUID/ELECTROLYTE DIS VERTIGINOUS SYNDROMES GOUT INTESTINAL INFECTION NEC ASTHMA 14 Number Principal Diagnosis Code (3-digit) Admission Specialty (EIS) 27 MED No. of Diagnosis Principal Diagnosis Description (3-digit) PNEUMONIA, ORGANISM NOS CHR AIRWAY OBSTRUCT NEC GENERAL SYMPTOMS HEART FAILURE CEREBRAL ARTERY OCCLUS RESP SYS/OTH CHEST SYMP OTH URINARY TRACT DISOR CARDIAC DYSRHYTHMIAS SEPTICEMIA FLUID/ELECTROLYTE DIS ACUTE MYOCARDIAL INFARCT CHRONIC RENAL FAILURE DIABETES MELLITUS ILL-DEFINED INTEST INF OTH AC ISCHEMIC HRT DIS AC URI MULT SITES/NOS ICH, Non-traumatic OTH BACTERIAL PNEUMONIA EPILEPSY OTH CHR ISCHEMIC HRT DIS 34

28 Top 20 Principal Diagnosis Group (EMW vs. M&G) (Dec 07-Jan 08) EMW M&G Number Principal Diagnosis Code (3-digit) Admission Specialty (EIS) EM No. of Diagnosis Principal Diagnosis Description (3-digit) GENERAL SYMPTOMS RESP SYS/OTH CHEST SYMP CHR AIRWAY OBSTRUCT NEC ESSENTIAL HYPERTENSION PNEUMONIA, ORGANISM NOS OTH ABDOMEN/PELVIS SYMP DIABETES MELLITUS BACK DISORDER NEC & NOS ILL-DEFINED INTEST INF OTHER BRAIN INJURY SYMPTOMS INVOL HEAD/NECK CARDIOVASCULAR SYS SYMP OTH URINARY TRACT DISOR OTHER CELLULITIS/ABSCESS HEART FAILURE AC URI MULT SITES/NOS FLUID/ELECTROLYTE DIS VERTIGINOUS SYNDROMES GOUT INTESTINAL INFECTION NEC ASTHMA 14 Number Principal Diagnosis Code (3-digit) Admission Specialty (EIS) 28 MED No. of Diagnosis Principal Diagnosis Description (3-digit) PNEUMONIA, ORGANISM NOS CHR AIRWAY OBSTRUCT NEC GENERAL SYMPTOMS HEART FAILURE CEREBRAL ARTERY OCCLUS RESP SYS/OTH CHEST SYMP OTH URINARY TRACT DISOR CARDIAC DYSRHYTHMIAS SEPTICEMIA FLUID/ELECTROLYTE DIS ACUTE MYOCARDIAL INFARCT CHRONIC RENAL FAILURE DIABETES MELLITUS ILL-DEFINED INTEST INF OTH AC ISCHEMIC HRT DIS AC URI MULT SITES/NOS ICH, Non-traumatic OTH BACTERIAL PNEUMONIA EPILEPSY OTH CHR ISCHEMIC HRT DIS 34

29 Some of the Targeted Condition Groups 29

30 Some Targeted Conditions Chest pain & IHD (Except AMI & AMI complications) Including: Ischemic heart disease (IHD) / Angina Chest pain of other causes / non-specific Excluding: acute myocardial infarction 410 postmyocardial infarction syndrome Aneursym of heart Poisoning & DO Including: Poisoning Toxic effect (nonmedicinal) Accidental poisoning (drugs) E850 - E858 Accidental poisoning (other substances) E860 - E869 Psychiatry & Self-harm Including: Mental disorders Psychiatric Suicide / self-inflicted injury E950 - E959 DM Complications (except DKA & Hyperglycemic coma) Including DM without mention of complication DM with other specified manifestations DM with unspecified complication Hypoglycemia 251.0, 251.1,

31 Pre-EMW M&G (Dec 06-Jan 07) Condition Adm No. Av LOS (Hrs) Med LOS (Hrs) Bed-Day Chest pain & IHD (Except AMI & AMI complication) Poisoning & DO Psychiatry & Self-harm DM Complications (except DKA & Hyperglycemic coma)

32 Post-EMW EMW M&G EMW (Dec 07-Jan 08) M&G (Dec 07-Jan 08) Condition Adm No. Av LOS (Hrs) Med LOS (Hrs) Bed-Day Condition Adm No. Av LOS (Hrs) Med LOS (Hrs) Bed-Day Chest pain & IHD (Except AMI & AMI complication) Chest pain & IHD (Except AMI & AMI complication) Poisoning & DO Poisoning & DO Psychiatry & Self-harm Psychiatry & Self-harm DM Complications (except DKA & Hyperglycemic coma) DM Complications (except DKA & Hyperglycemic coma)

33 Post-EMW vs. Pre-EMW Diff % (M&G) Diff % (M&G) Diff % (EMW + M&G) Diff % (EMW + M&G) Condition Adm Bed-Day Adm Bed-Day Chest pain & IHD (Except AMI & AMI complication) Poisoning & DO Psychiatry & Self-harm DM Complications (except DKA & Hyperglycemic coma)

34 Reattend HA A&E within 48hr (Post-EMW) EMW (Dec 07 - Jan 08) Condition Reattn % Chest pain & IHD (Except AMI & AMI complication) Poisoning & DO Psychiatry & Self-harm DM Complications (except DKA & Hyperglycemic coma)

35 A&E Reattendance (Hong Kong Wide) Hospitals Jan 08 Feb 08 Mar 08 Overall PMH Overall

36 Targets A&E admission to other specialties special case admission Drug overdose / toxicology Psychiatric (Medical) admission Safe discharge & no significant increase in re-attendance Sustainability 23 36

37 Pre-requisite Manpower adequate Doctors / Nurses / Supporting Staff Training of A&E medical and nursing staff New / old Equipment adequate (e.g. bedside USG) Assess to diagnostic examinations (e.g. CT) Availability of fast-track quota Comprehensive clinical guidelines Collaboration with other specialities Mandate for mode of service Appropriate experienced staff to assess patients Early FU / Referral channel 37

38 There is often more than one way to do a particular task.. 38

39 Impact of EM Ward Reduced avoidable admission to other clinical specialties especially M&G Enhanced treat & review function of A&E Enhanced quality of care Safer A&E practice Concentrate patients with disturbing behaviour / drug overdose in EMW Others 39

40 Emergency Medicine Ward (EM Ward) Given time, we will grow & mature 40

41 Thank you 41