Vincent Connolly

Clinical Lead ECIST

Emergency Care is a ‘wicked problem’

A social or cultural problem that is difficult or impossible to solve because:

of incomplete or contradictory knowledge;

of the number of people/opinions involved;

of the large economic burden; and

of the interconnected nature of this and other problems

Russell L. Ackoff wrote about complex problems as: "Every problem interacts with other problems and is

therefore part of a set of interrelated problems, a system of problems…. I choose to call such a system a mess."

Care Coordination

The health system delivered the required care, but was it in a time frame that suited the patient, carer or staff ?

time

Demand Capacity

Queue

Can’t pass unused capacity forward to next week

Reducing waiting times in the NHS: is lack of capacity the problem?Bevan et al Clinician in Management (2004) 12:

Arrange beds around patient streams: Clinical Decision Unit (CDU) / Ambulatory Emergency Care (AEC), Acute Assessment Unit (AAU), short stay, specialty, complex dischargeMinimise handoversCombat outliers

Organise beds to improve patient flow

New medical model for urgent care patientsAll non elective activity at the 85th percentile

Route and processExpected LOS Minors

Acute Assessment

Short Stay Admission

Discharge

Specialist referral/ Admissions

CAU and short stay Bed

requirementActivity 248 183Discharge 230 97Admissions Minors 18Admissions Majors 78 96

Patient review/referral/discharge from CAU (55% of CAU)

1 midnight

19 19 26

Patient review/referral/discharge from CAU (45% of CAU)

2 midnights

19 6

3 midnights can not be managed by CAU 3 LOS+

zero LOS

64

6

Ambulatory and observation patients

(28% total)

27 5

Estimated Requirement

Assessment 16-20 spaces

Short Stay 60 beds

Specialty total @ 10 nights = 200

@ eight nights = 160

@ seven nights = 140

@ six nights = 120

What type of system?

Acute Bed Pool

two nights

Decision to admit

Respiratory Unit

Metabolic Unit

Acute Rehabilitation

Unit

Gastro- Intestinal

Unit

Stroke Unit

Critical care

Cardiac Unit

Acute Bed Pool

two nights

Decision to admit

Respiratory Unit

Metabolic Unit

Acute Rehabilitation

Unit

Gastro- Intestinal

Unit

Stroke Unit

Critical care

Cardiac Unit

Specialist “in-reach”

Acute Bed Pool

two nights

Decision to admit

Respiratory Unit

Metabolic Unit

Acute Rehabilitation

Unit

Gastro- Intestinal

Unit

Stroke Unit

Critical care

Cardiac Unit

A&EA&E

PCTPCT

The right people are more important than the right system as long as it isWell describedAddresses patient care requirementsEverybody understands their roleAppropriate support from other servicesLocation is fit for purposeAdequately scopedSupported by staff

Managing the StreamsIdentify the stream

Short stay Sick specialty Sick general Complex Allocate early to teams skilled in that stream

0

50

100

150

200

250

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59

Length of stay (days)

Nu

mb

er o

f p

atie

nts

Clarity of specialty criteriaSpecialty case management plan at

Handover – no delaysGreen bed days vs. red bed days

Short stay – manage to the hourMaximise ambulatory care

Complex needs – how much is decompensation?Detect early and design

simple rules for discharge

Minimise handoverDecompensation risk

Early assertive managementGreen bed days vs. red bed days

Pareto Analysis

Glenday Sieve

30%

20

8050% of demand = 7% of types:Green stream: ‘Runners’ \

15%

5% of demand: Red stream: Rare Strangers

Sick Specialty

0

100%

Cumulative Demand

LOS

Sick General

Short Stay

Complex

LOS Cumulative ProfileExcl Paeds, Obstetrics and Midwifery, Zero LOS

ANHST Top 25

50% = 3 midnights 2 midnights

80% = 10 midnights 7 midnights

95% = 29 midnights 23 midnights

Cumulative OBD by LOS Excl Paeds, Obstetrics and Midwifery , Zero LOS

ANHST %OBD

<50% = 3 midnights 10.8%

<80% = 10 midnights 35.3%

<95% = 29 midnights 69.4%

>95% = >29 midnights 30.6%

Consistently prioritising discharge activities can significantly reduce length of stay in elective or emergency clinical care pathways.

Prioritising discharge activities only when beds are full may have little impact on patient throughput or average length of stay.

Increasing beds may increase length of stay with no benefit to patient throughput.

Focus on discharge

Simulation of patient flows in A&E and elective surgery Discharge Priority: reducing length of stay and bed occupancy Michael Allen, Mathew Cooke & Steve Thornton, Clinical Systems Improvement 2010

Every patient should be reviewed every day by a senior decision maker

Use expected date of discharge (EDD) to support case management for all inpatients

Ensure all patients have criteria for discharge

Implement morning check-outs so that patients are ‘home for coffee’

Focus on early supported discharge

Focus on discharge

Which type of doctor?Acute Physician General Physician

Specific trainingFocus on acute medAssessment & 1st 48 hoursWill develop acute medOut of hours

Generic trainingHolistic approachLong ward roundsOffice hours

The doctor needs to have:Team workerHumilityDisciplineMeasures performanceService improvementChallenges the orthodoxyAccepts and embraces peer challengeConcerned about quality not volumeCan describe the systemBuilds service around the needs of patients

RedesignFocus on decisions, tasks and workflows to optimise

careSort out the high variationReconfigure the supporting infrastructure to match

the redesigned clinical processesDesign structures and processes to help learning

from daily work

Fixing Healthcare from Inside and Out, Harvard Business Review

Twice weekly consultant ward rounds compared with twice daily ward rounds

Impact: Over study period, no change in length of stay on ‘control’ wardsAverage length of stay (ALOS) on study wards fell from 10.4 – 5.3The impact of twice-daily consultant ward rounds on the length of stay in two general medical wardsNo deterioration in other indicators (readmissions, mortality, bed occupancy)

The impact of twice-daily consultant ward rounds on the length ofstay in two general medical wardsAftab Ahmad, Tejpal S Purewal, Dushyant Sharma and Philip J WestonClinical Medicine 2011, Vol 11, No 6: 524–8

Does daily senior review work?

Hospitals with two or more AMU ward rounds per day on weekdays AND admitting consultants working blocks of more than one day had a lower adjusted case fatality rate.

Where the admitting consultant was present for more than four hours, seven days per week they had a lower 28 day readmission rate

RCP Taskforce 2007

Continuity of care and regular reviews

Internal Professional Standards for AAUTime to first review 15 minsCompletion of clerk in Two hoursMiddle grade review in Four hoursConsultant Two-three hours day

time, 12 hours out of hours

Diagnostics within Four hoursReferral response half a day

Quality measuresMortalityMortality & morbidity (M&M) meetings24 hour discharge rateDelivery of Internal Professional Standards (IPS)Readmissions seven daysAdverse eventsA&E flowPatient experience

Admission avoidance & early discharge Strong evidence Weak evidence

Admission prevention from nursing homes

Ambulatory emergency care (e.g. 60-90% reduction in overnight stays for pulmonary embolism (PE))

Improve urgent access to primary care Intermediate care in-reach to

emergency department (ED) and assessment units

Assertive case management of frail patients with dementia

Continuity of care with a GP Hospital at home as an alternative to

admission Assertive case management in mental

health Early senior review in A&E Multidisciplinary interventions and tele-

monitoring in heart failure Integration of primary and secondary

care

GPs in ED Walk in centres (WICs) and urgent

care centres (UCCs) (unless co-located with EDs with integrated governance)

Public education Pharmacist home-based medication

review (Unfocussed) intermediate care Community-based case management

(generic conditions) Early discharge to hospital at home

on readmissions Nurse-led interventions pre- and post-

discharge for patients with chronic obstructive pulmonary disease (COPD)

Telemedicine (except for heart failure)

Crude Mortality

0

10

20

30

40

50

60

70

80

90

100

Ap

ril

May

Jun

e

July

Aug

ust

Sep

tem

ber

Oct

obe

r

No

vem

ber

Dec

embe

r

Jan

uary

Feb

ruar

y

Mar

ch

2011/12 Target - A 20% reduction in the number of actual cardiac arrests, based on 2010/11 data

Cumulative Ward Cardiac Arrests 2011/2012 Target

Ward cardiac arrests

45.00

1 4 811 12 13 14

17

0.005.00

10.0015.0020.0025.0030.0035.0040.0045.0050.00

Ap

ril

Ma

y

Jun

e

July

Au

gu

st

Se

pte

mb

er

Oct

ob

er

No

vem

be

r

De

cem

be

r

Jan

ua

ry

Fe

bru

ary

Ma

rch

CQUIN Target/Cumulative Serious Harm Falls 2011/12

CQUIN Target YTD Cumulative Serious Harm Falls

Hospital Falls

A&E - Time to be seen

A&E – Wait to treatment time

No of patients with LoS > 14 days

An example of success

The Ten Commandments1. Ensure timely access and continuity in primary care2. There should be early senior review of all patients along all parts of the pathway,

to maintain the momentum of care – there should be a senior review of every inpatient’s care plan every day

3. Get patients on the right pathways – Concentrate on patient flow4. Work together across the whole system to systematically and predictably –

implement internal professional standards – to minimise variation5. Plan and manage capacity to meet demand 6. Avoid unnecessary overnight stays – implement ambulatory emergency care7. There should be a relentless focus on discharge8. Develop clear models of care for assertive management of the frail elderly9. Measure the effect and impact of interventions using SPC and follow up with

further improvements10. Remember this will all be delivered by people so talk, engage, lead, follow &

LISTEN