RealTime - Reduce Length of Stay, with Discharge-Driven Bed Management

Why RealTime?

The Problem

Financial improvement within hospitals depends on a number of factors, including improvements in the day to day management of hospitalised patients and the development of a clinical culture that is supportive of efficient care delivery representing key leverage points.

Hospitals do not know in real time where their patients are ‘at a glance’, either in terms of their physical location or their position on a care pathway, en route to discharge. Hospitals equally do not know reliably in real time which resources are available by category for new admissions and transfers. This leads to daily confusion that reduces throughput and creates significant inefficiencies in management of the patient journey through the hospital.

The largest clinical opportunities are typically in the area of care of the elderly. Establishing a strategy for the elderly would involve targeting patients over 65 years with certain diagnoses—pneumonia, COPD, CHF, MI, stroke and occasionally some surgical diagnoses. For example, the average length of stay for the top 10 best-performing Trusts for stroke is 2.3 times the average for the hospitals in the US (13.2 days vs 5.7 days) . A similar comparison for hip fracture shows more than twice the US average (10.9 days vs 4.6 days). In general, 10-20 diagnoses make up 50% of the hospital admissions of elderly patients. Therefore, a very focused effort on this patient demographic can lead to significant improvements in hospital performance.

The Solution

RealTime helps hospitals solve three key problems:

Reducing average length of stay (ALOS);
Knowing where the patients are;
Reducing and monitoring Healthcare Associated Infections.

Reducing average length of stay

The methodology behind RealTime has been deployed in the US for many years by Eagle Medical Management LLC (Dr. Jess Boyer, Principal Consultant for Eagle and Chief Medical Officer for RealTime). This methodology is based on a unique approach that involves establishment of an improvement programme through close collaboration with physicians and staff. The approach relies on two simultaneous activities:

Improving the performance of the hospital discharge planning teams through clinical education and focused daily actions, and
Developing working relationships with physicians and coaching them to support and drive ongoing improvement efforts.

Sustained accomplishment of both of these activities is highly data driven; both are dependent on the use of clinical evidence and information feedback. By providing the evidence and feedback daily, RealTime drives the changes needed.
This approach is unique because it is based on targeting financial improvements, analyzing potential clinical improvements and coaching clinicians and staff to achieve and sustain these improvements. The improvements in efficiency and quality of care drive the achievement of the financial goals. The initial analysis for potential improvements involves manual medical record reviews of key diagnoses or groups of diagnoses, in which hospital performance is compared to known best practices. This is very labour and time intensive. During the next phase (implementation and coaching), information is also key and is derived significantly from manual record reviews. We then share this information with physicians and coach them on how to improve care. Sustainability of results is dependent on the information feedback to physicians and staff.

EAGLE has consistently been able to improve hospital average length of stay by 10-30% and engage physicians in ongoing improvements. This has yielded sustained financial improvements of $5-20M annually for clients.

Quality of care is also improved as measured by decreased readmissions of patients and improvements in meeting chronic disease specific national standard of care targets. Hospital readmissions are improved by means of daily monitoring of defined quality parameters for patients with key diagnoses. Prior to discharge, these parameters must all meet thresholds for a safe discharge. Achievement of national targets is improved through ensuring that key treatments are provided prior to or shortly after discharge. Real time knowledge of the medical record drives all of these improvements. This process would be much more efficient and accurate if the data gathering were done electronically with concurrent clinical management follow-up.

Reducing ALOS will result in reduction of healthcare associated infections. In the UK, each day that is saved will result in approximately a 4% reduction in the MRSA infection rate. This has significant financial implications for the acute trust and the overall NHS.
Even though the healthcare system is different in the UK, the issues are very similar to the issues that are being addressed in the US. The goals of improving revenue, reducing costs, and improving service and care are the key challenges in both systems. As payment by results and patient choice increase in the UK, the competitive pressures on hospitals will increase. Through reducing hospital length of stay, costs will be reduced and throughput will be increased. This will drive increased productivity and decreased wait times for procedures.
Similarly, by measuring performance in real time versus accepted clinical standards, both inpatient care and chronic disease care improvements will be driven. These goals can be much more efficiently and effectively accomplished through linking EHR, clinical evidence and management capabilities. Sources of data can not only be more quickly identified and accessed, but they can be more rapidly and more thoroughly analyzed.

In the UK, as in the US, there are hospital staff that perform the clinical and social discharge planning functions. In these two countries, the position titles are different, but the functions are the same. The wide variability in process across and within countries provides additional opportunities to improve performance. (Back to top...)

Knowing where the patients are

The RealTime software application provides real time views of bed occupancy across whole trusts, categorised by ward, condition, diagnosis, breach reason, etc. These fully configurable, graphical views are accessible around-the-clock across the entire hospital or healthcare establishment with drill down into ward/department based views to show the location, status of care and expected time of discharge for each individual patient.

Fully web-based, interaction with the system is designed to save time, to be convenient and easy to use — combining mouse with touch screen technology for viewing and updating information. Through two-way HL7 messaging interfaces, RealTime can drive Admission, Discharge and Transfer (ADT) processes when existing systems are unable to reflect the real time situation. The same interfaces enable users to benefit from information in those existing systems that are known to be accurate.

RealTime stores, analyses and reports on a continual basis all events and actions implemented or recorded in RealTime concerning admissions, discharges, transfers and care pathway monitoring, including all variance and breach reasons.

The ‘RealTime’ name refers not only to the visibility in real time of all bed states and patients’ positions on their pathways, but also to the analysis engine that continually measures all activity against agreed KPIs. This analysis engine has been designed to automate much of the manual data analysis carried out by Eagle Medical Management during their engagement. You can configure graphical ‘widgets’ to display performance of any key metrics as needed. All event data is stored in the long term, which enables new queries to be developed retrospectively as greater understanding evolves. (Back to top...)

Reducing and monitoring Healthcare Associated Infections;

The RealTime system provides automated alerting, automated ‘patient journey’ reports, trust-wide overviews of infected patients, audit trail support and ‘playback’ functionality to support an understanding of patient movements over time. The RealTime system provides instant, automated, always available reports:

Where has the patient been in the hospital?
Who has been / is in a neighbouring bed?
All relevant dates and times;
Neighbours still present, or already discharged?
Total overview of all infected patients by infection and location;
The total overview can be set up to display as much or as little information as the system contains, e.g.:

Time infection reported;
Time patient moved to side ward;
Hospital number, and other demographics;
Attending nurse / consultant;
Whether there is a history of previous infection;

Procedures performed and by whom (if recorded in RealTime)…

RealTime ‘remembers’ all events at fine level of detail. Using the Infection Control time manager, users can move backwards and forwards in time to see exactly how wards were occupied at any given point. All authorised users can do this, from anywhere in the hospital. This enables staff to see at a glance areas that are likely to be high or low risk, and to act accordingly. (Back to top...)