130: An Alternate Care Environment to Decrease Inpatient Length-of-Stay

In an increasingly challenging fiscal climate, there is pressure to reduce inpatient length-of-stay. Current research suggests that unnecessarily-prolonged paediatric admissions are common, and that for many diseases, day-hospital management provides efficient care that is well-liked by patients and families. Many current paediatric inpatients may not require overnight nursing, and remain as inpatients to facilitate rapid services. To develop and evaluate an Alternate Care Environment (“ACE Space”) that transitions inpatients to a day-hospital setting where they receive rapidly-arranged follow-up, investigations, interventions, and specialty consultations, while reducing inpatient length-of-stay. At our single tertiary-care facility in Spring 2014, all paediatric medicine inpatients were audited for potential to be managed in a day-hospital setting. Families identified by ward staff were interviewed to determine their interest in day-hospital care. Physicians and nurses were interviewed to determine patient inclusion criteria. A Rapid Improvement Event finalized the ACE's design. An ongoing pilot was launched in August 2014. In the ACE, patients receive inpatient-level access to hospital services. Outcome measures (ACE visit number, satisfaction, estimated savings of inpatient days, average inpatient length-of-stay), process measures (referral source, diagnosis, hours per visit, investigations, interventions, and specialty consultations), and balancing measures (ACE patients requiring inpatient admission, nursing resource utilization) are being tracked. Pre-pilot audits identified on average four patients per day (7.8% of total patients) as potentially manageable in a day-hospital setting. Sixteen of 26 “ACE-eligible” families (61.5%) said they would prefer going home at night. In its first 3.5 months, the ACE had 146 patient visits (39.6/ month), saving an estimated 139 inpatient bed days (38.2/month). There was a heterogeneous mix of diagnoses. Fifty-three of 55 families (96.4%) rated their overall experience as “very good” or “excellent”. Thirty-two patients received laboratory investigations, and 35 received diagnostic imaging (e.g. MRI). There were 18 IV or subcutaneous medication administrations, six central line procedures, 16 other procedures (e.g. urinary catheterization), 63 subspecialty consultations, and 21 allied health consultations. Four (2.7%) patients required inpatient admission from the ACE. These data demonstrate that some paediatric inpatients do not require overnight nursing, and can be safely managed in a day-hospital setting. The ACE provides a safe inpatient alternative for a heterogeneous mix of diagnoses and patient needs, and services that are not available or expedient in a clinic setting. Future work will analyze the ACE's effect on inpatient length-of-stay and cost.

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