Refining and Redefining Emergency Flows

Dr Veronica DevlinProgramme Lead

Service Improvement and Clinical Governance

Emergency Care

Defining flows

• Resus <5%• Majors 40-45%• Minors 55-60%

• Admitted, by specialty

• Assessment majors• Minors• Planned returns• Ward work

A&E52,398

Minors 32,388 61.8%

Medical 8,620 16.5%

Acute ass. 7,713 14.7%

GP follow up

# 7,912

15.1%

Avg. 113 min

Patient Numbers Accident & Emergency March-May 2009 (3months)

NHSL Overall

No Follow Up

# 28,302

54.0%

Avg. 107 min

# 5,190

9.9%

Avg. 137 min

AdmissionDeaths 82 0.2%

Other*

Emergency Receiving

Unit

# 7,973

15.2%

Avg. 144 min

# 3,021

5.8%

Avg. 81 min

*e.g. Other Hospitals, Primary Care Emergency Centre

Surgical 3,595 6.9%

Theory…..

Practice….

• History of specialty• 3 ED’s• Fewer middle

grades• Recruitment issues• Retention issues• Casemix challenge• Access block• Audit Scotland• Quality standards• Delivery

Theory….

Practice…

Lean in emergency flow

Lean principles

• Specify value• Map the value stream (patient flow)• Implement flow• Establish pull where you can’t flow• Work to perfection

• Voice of the customer

Lean tools

• Standard work • Standard operating procedures• Managing variation• Metrics• Dashboards

In God we trust

all others must bring data

Deming

• You can’t manage on visible figures alone

• Figures on the most important areas of management may be unknown or unknowable, and successful managers must nevertheless manage those areas.

Vital Signs - measurement

• ED • TTFA• DNW’S• Unplanned returns• Planned returns• Delays to care

Vital Signs - measurement• Admission/

discharge balance• Discharges before

noon• Diversions• 8 and 12 hour

delays to care• Boarders• Additional beds• Delayed discharges

• Length of stay on Medical Receiving Unit

• Total hospital length of stay

• Diversions• Cancelled electives

due to lack of capacity

• Surge capacity• Use of off site beds

Monklands

• Minors flow• Majors pitstop• ACE• GP assessment bay

minors

Minors flow Monklands

• Maintaining operation• Timing of stream operation• Staffing• Operational set up• Monitoring• Follow up arrangements

Patients had to go outside after registration

reception

store

xray

Patients’ journey contained within the department – and no compromise in Waiting Room space

receptionstore

xray

Majors Pitstop

• Proof of concept• Dedicated approach for assessment

of majors• Negotiated diagnostics• Senior decision-making• Average tat 102 minutes during

trystorm

Majors pitstop

GP assessment bay

• Complete team based assessment• Meds rec• Admission avoidance• Decide to admit vs admit to decide

Implement ASSESSMENT BAY and ACE

Hairmyres STATUS CHANGE

• Medical Assessment bay• Minors flow• CPAU pathway• Stroke pathway

AMRU Dashboard Key Performance Indicators

LENGTH OF STAY

am/pm Ward Round

Start Times

Ward Pull

Parent Specialty Mix

Porter Response Times

MAB Performance

Surge Beds

Patient moves

Before noon

Admissions vs.

Discharges &

Transfers

Medical Assessment Bay (MAB)

Consistent staffing, bed availabilityAmbulance Service/ERC Criteria for access.

JULY MAB ADMISSIONS VS D/C

0

10

20

30

40

50

60

70

80

90

ADMIT DISCHARGE

Change Detail Sustainability

Key Performance Indicators

4 Trolley bay in AMRU for the review of GP referred medical patients between 9am and 7pm weekdays)

25% of patients

Discharged from MAB

MAB Activity

0

2

4

6

8

10

12

Medical Assessment Bay (MAB)

Consistent staffing, bed availability? Senior Decision Maker availability in MAB

Change Detail Sustainability

Key Performance Indicators

4 Trolley bay in AMRU for the review of GP referred medical patients between 9am and 7pm (weekdays)

Average Total Journey Time July 2010

0 50 100 150 200 250

A&E (Medical Flow)

MAB

mins

Ave TTFA - July 2010

0 10 20 30 40 50 60 70 80

A&E (Medical Flow)

MAB

mins

% Patients Admitted to Bed in <2hrs

Pre-Kaizen

Improvement

Remainder

% Patients Admitted after 210 mins

Pre-Kaizen

Remainder

% Patients Admitted after 210 mins

Post-Kaizen

Remainder

MAB journey time

37 mins

less than A&E

MAB TTFA

30 mins

less than A&E

Was 9%

Now 18% admitted

in <2hrs

From 48% to 33%

Admitted between

210 & 240 mins

Daily Dashboard

Change Detail Sustainability

• Visual management• Target driven• Updated and

reviewed daily• Also for surgical

and medical flow• Monitors individual

ward performance

Positives

Excellent clinical engagementData drivenPerceive the service from customer

viewpoint

But….

Reshaping Emergency Medicine

• Clinical Director• Consultant appointments• Review of skillmix• Standard operating procedures• Quality Standards• Safety Brief• Roles and Responsibilities redefined

Consolidate core service

Non core ED work