Imagine your loved one arriving at your community’s hospital from Saskatoon and when he arrives, the hospital’s staff and physicians there have all the information and supplies your loved one needs. Now, imagine you know the transfer is going to happen days in advance.

It’s a scenario that Team 2: Transitions of Care is hoping becomes the norm, and not the exception.

Saskatoon Health Region staff moving a patient.

Saskatoon Health Region staff moving a patient.

Since the 14 Day Challenge in February, two floors at Royal University Hospital (RUH) have been piloting this new process and have improved it even further to make that scenario a reality. The new process was initially developed in January during an improvement event.

Repatriation focuses on transitioning patients from main hospitals in Saskatoon back to their home hospitals to continue their care. The key to ensuring this smooth transition is to determine a patient’s predicted transition date when they first arrive at hospital in Saskatoon.

Now, the next goal is to have the training and implementation of this new process rolled out to all three Saskatoon hospitals.

“It’s ambitious. This really is a bit of a culture change in the way we think and the way we work,” says Deb Ginther with Client Patient Access Services who is leading this improvement work for Team 2. “Our success is hinged on our staff and physicians thinking about discharge at the moment of admission.”

Over the past six weeks, since the 14 Day Challenge ended, Ginther has continued to refine the work standards and has been working on rolling out the new process to the rest of RUH as well as St. Paul’s Hospital and Saskatoon City Hospital.

But to do that, having everyone use a predicted transition date is critical.

“If we don’t give an estimated or a planned transition date, it makes it tougher for the patient to plan and for the receiving hospital to plan for the patient,” says Dorothy Sagan, Director, Patient Flow and Navigation.

Sagan explains that staff and physicians need to get comfortable with the idea of a transition date and that having one doesn’t mean the date is set in stone.

“If the care needs change then the transition date can change too,” she says. “You just have to make sure it gets changed and documented in the Patient Flow System as well.”

Having an idea of a predicted transition date gives others service providers a chance and opportunity to know what resources and supports they need to have ready.

“For example, if an individual is being transferred to Wadena, which is within our Region, they don’t have a 24 hour pharmacy at that site,” says Sagan. “So if the patient requires medications but arrives in Wadena outside of pharmacy hours, they either have to come with the medications or a plan has to be made in advance so the pharmacy can have them prepared for the patient ahead of time.” Prepping three days out rather than 10 minutes before the patient is out the door, allows for a smoother transition of care, avoiding harm, delay and hopefully, frustration.

The Region has assigned a repatriation coordinator under Acute Care Access Services (ACAS) to assist with the work.

“We’re providing a consistent approach to transferring people out of our Region to the other regions or from one of our hospitals in the city to a rural hospital within our Region,” says Ginther. “It should be easier and flow more smoothly to have that single point of contact rather than five or six contacts.”

Staff on the piloting floors at RUH have been instrumental in refining and streamlining the standard work to make the process better and ready for Region roll out. A team is working on a provincial agreement so that all the health regions are operating in the same manner.

Prince Albert Parkland Health Region and Prairie North Health Region are also involved in the repatriation work because they have comparatively higher numbers of patients transferred.

“At the end of 90 days, we want communication to be happening further in advance and to be working with more health regions to make transfers smoother for our patients,” says Ginther. “We also want to have more people cross trained and responsible for repatriation. Right now, repatriation is really just Monday to Friday and we need to develop it, so it’s really a seven-day-a-week operation. We know our care doesn’t stop on the weekends.”

See the website for more information about 90 Days of Innovation: Ready Every Day.