CFHI Interview with Marilyn El Bestawi

January 2016

Improvement-Conversations-Marilyn-El-Bestawi


In an occasional feature, we interview leads of current and recent CFHI-supported projects. This month we profile Marilyn El Bestawi, a senior healthcare executive who has worked in both community and teaching hospitals throughout her career. Her positions have spanned the range from staff nurse to senior management including a one year interim Chief Nursing Executive role


During her 2011 EXTRA fellowship, Marilyn developed a novel tool to prevent avoidable emergency department visits by long-term care residents. In November 2015, she was invited to present her innovation at the Spread and Scale Innovators’ Den at the OLTCA This Is Long Term Care Conference where her innovation was awarded first place in the Spread and Scale category

What key challenge will your innovation solve?

I developed PREVIEW-ED a research informed tool to help long-term care staff identify the early stages of health decline in LTC residents. Many times a decline in health status is easily missed because the early warning signs are so subtle.

According to the literature, within a six month period in 2005, one quarter of LTC residents in Ontario visited an emergency department at least once. Nearly 25% of these initial visits were classified as potentially avoidable. It’s really important to identify health decline early, so that action can be taken before a resident needs to be transferred to an ED.

Once a resident is transferred to an ED, there are associated risks for hospital acquired complications such as delirium, pressure ulcers, falls or infections that could have potentially serious or fatal complications. The cost in terms of quality of life, as well as the economic impact of avoidable hospitalizations is significant.

Could you describe how your tool works?

The assessment tool is named PREVIEW-ED and it guides personal support workers through a simple assessment based on their daily observations of the resident to measure changes in the resident and instruct regarding action steps.

PSWs typically provide approximately 75% of the direct care in LTC facilities. The tool is easy to use and takes only 8-15 seconds per resident to complete on a daily basis. The tool is written in clear language and action steps built into the tool are based on a straightforward, research informed scoring metric.

The pilot results were promising, as a 57% decrease in transfers to hospital was achieved for four conditions that account for 49% of the potentially avoidable hospitalizations: pneumonia, urinary tract infection, dehydration and congestive heart failure.

How does your innovation improve care for patients, families and caregivers?

By avoiding unnecessary ED visits, residents are able to receive treatment in familiar surroundings, with staff that know them. This results in less physical and mental deterioration for the resident as well as less stress for family members.

In the 90 day testing phase, families were supportive of this new tool and the potential impact on improved quality of life for their loved one living in LTC.

What are the potential cost savings for the healthcare system?

A model was developed to calculate the potential cost savings if the tool was implemented on a Toronto Central LHIN (Local Health Integration Network)-wide basis. The annual LHIN-wide estimated savings are in the order of $500,000.

In Ontario, more than 75,000 people aged 65 and older currently live in LTC facilities. If this tool were applied across the province, the system could realize potential savings of $6.2 million annually.

How did CFHI’s EXTRA program help you develop, implement and evaluate this innovation?

PREVIEW-ED was developed as part of the requirements of the EXTRA program. When I began the EXTRA program I knew what organizational issue I wanted to address, however I didn’t have a preconceived notion of how it could be accomplished. Through the various learning modules, the guidance and suggestions of expert faculty and two amazing mentors that I had access to throughout the program, the solution began to evolve and take shape. The development of PREVIEW-ED verged on a research approach as it seemed appropriate to not only devise the tool but also to test it. This was new territory for both myself and the EXTRA Program.

The leadership team and support staff at CFHI have been extremely supportive of myself and PREVIEW-ED, inviting me to present to various CFHI funded events including presenting to the CFHI Board of Directors.

How will you motivate care team members to use/implement your innovation?

PSWs have expressed high levels of satisfaction with the tool. They could easily appreciate the difference that early identification in the decline of health status of a resident could make in preventing a transfer to hospital. They felt that PREVIEW-ED gave them a mechanism to better express the subtle changes they were noting in the residents’ health status. Registered staff who spoke English as a second language also identified that the tool helped to give them words to better express changes in a resident’s condition, making it easier to articulate the concerns when phoning the physician. Physicians appreciated the increased information and quantification in the decline of the health status to determine the best treatment options.

How could this tool be spread and what are potential challenges to its spread?

Currently the project has two external partners – the Ontario Brain Institute and the Canadian Foundation for Healthcare Improvement. As the developer of this tool, I would be heavily involved with potential spread initiatives. If the tool continues to show positive results, then its use could potentially be recommended by the Ontario Ministry of Health and Long Term Care for all LTC facilities across the province.

The tool can be easily replicated in any LTC facility or community. The potential challenges to rolling out this innovation relate primarily to organizational readiness and involvement by facility leaders and physicians. Successful spread requires champions’ in the LTC facility that is implementing it, who can support, communicate and monitor the implementation.

Currently I have four LTC facilities in British Columbia who in concert with Fraser Health are discussing a potential pilot of PREVIEW-ED. If results similar to the initial improvement project are achieved, I would expect that there will be increased interest in implementation.