4. Create seamless transitions in care for patients across our regional health-care system

The care patients receive while in hospital is typically excellent. However, patients who require different levels of care over an extended period of time in multiple settings often have trouble receiving care across different parts of the health system and at transition points. Communication can be difficult, wait times can be long, and patients and families can feel like they are 'falling through cracks' in the system. This year, we will continue to work with our regional partners to implement and measure the effectiveness of clear pathways across the entire continuum of care for patients with chronic obstructive pulmonary disease, hip fractures and life-limiting illnesses who require palliative care.

By 2019:

KHSC is fully engaged with our community partners to support patients with complex-acute and chronic conditions


Continue to implement and measure the effectiveness of care pathways for chronic obstructive pulmonary disease, hip fractures and palliative care

How are we doing?

Chronic obstructive pulmonary disease:

In Q1 we worked to develop COPD order sets by involving different sectors, including the Canadian Foundation for Healthcare Improvement and the Inspired Team from Ottawa, who presented their Inspired Plan.

In Q2 we will launch the acute admission order set for COPD and work on drafting the critical care ventilated COPD patient order set for team review

We are on track with our deliverables to meet the target that was set for this fiscal year. A digital order set for COPD admissions has been approved for KHSC in the last month.


Hip fractures:

At KHSC an order set for patients presenting with a hip fracture is used consistently, however, there are process differences across the SE LHIN for this patient group. We are collaborating with our regional partners to develop one standardized order set for use across the SE LHIN.

In Q1 we reviewed and assessed clinical frailty scales to determine the best scale to adopt regionally, standardize the assessment forms and develop education materials. In Q2 the team will finalize the transfer of care model, including criteria for transporting patients across sites and working with Criticall Ontario to update a hip fracture agreement.

We are on track to meet the target for this fiscal year. In Q3 a pilot project will be done that will see the  implementation of the order set based on the provincial QBP digital order set and the KHSC pre- and post-surgery order sets.


Palliative care:

Phase 1 of this initiative includes developing a search strategy to review daily admissions to KHSC to assess each against triggers embedded in the Palliative Care Pathways. Phase 1 is designed to validate triggers as well as determine an order of magnitude for the clinical demand for access to Palliative Care that will be created once an active patient assessment is launched in Phase 2 (Q3). In Q1 the search strategy for Phase 1 was finalized for the downloading of daily admissions.

Case Finding commenced May 15th. A Research Associate was trained on pathways (triggers) and the process for screening the daily admissions. The search strategy was further refined to exclude admissions related to pediatrics, obstetrics and newborns, and continues to be refined as we progress.

The Palliative Care Pathways project is on track. Specifically, 2,383 KGH admissions were screened May 15th ‑ June 30: 269 (11.29%) patients met one or more of the pathway triggers and would benefit from palliative care; 48 (2%) patients were identified with “other advanced life limiting illness” but were out of scope for the designed pathways (unintended outcome and of benefit to KHSC future pathway work).

On a daily basis, an average of five new cases are identified as patients who will benefit from a palliative care approach concurrent to disease management or a referral to Palliative Medicine. The significance of this finding will allow appropriate clinical resource planning to meet the needs of patients who are identified as needing palliative care at KHSC.