Rapid Review of Hospital
Element of Unscheduled Care
Services in North Wales
Dr Rob Atenstaedt
Consultant in Public Health Medicine
Public Health Director for Conwy & Denbighshire
Siobhan Jones
Specialty Registrar
Background
Need for review driven by:
• NW reviews including Llandudno Hospital Review &
• difficulties in sustaining surgical on call rota across 3
hospital sites.
Part of NW Clinical Strategy. Included 2 other 90 day
reviews:
• Primary/ Community Care
• Mental Health
Key Question to emerge
How should the hospital element of
Unscheduled Care be delivered
across NW?
Process (1)
• 90 day research methodology
• 3 x 30 day ‘cycles’
• Expert/stakeholder events held after each
30 day cycle - 2 weeks in-between cycles
for feedback
• 1st 30 days for gathering/considering
evidence – huge amount PH work done in
this cycle!
Process (2)
Weekly meetings core project team;
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Chief Exec – DLHB Project Lead
Planning
Clinical Directors/ Leads
PH
Welsh Ambulance Service
Separate teleconferences to direct PH work
Public Health input
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Dr Rob Atenstaedt, Consultant (Lead)
Siobhan Jones, StR (Deputy Lead)
Claire Jones, HIAT (data)
Dinah Roberts, LKMS (Lit Search)
Mary Webb, HSCQ (Lit Review)
Margaret Webber, HIAT (Drivetime)
Andrew Jones, RPHD (QA)
Objectives of PH Input
Due short timescale, pragmatic review by allWales team:
• Examine burden of accidents & emergencies in
NW
• Determine what elements high quality hospital
USC service should provide
• Examine need for hospital element of USC
services in NW, in particular no. A&Es
• Review current hospital element of USC service
provided in NW including hospital activity data
Progress with PH Input
Series of NPHS reports produced including:
• Population Profile of NW
• Overview of epidemiology of conditions needing
A&E management in NW
• Drivetime analysis
• Lit review on best practice in USC Services
• Profile of current USC services in NW
• Data report on hospital USC activity across NW
(Joint PH/NW NHS Trust Report)
Location Current NW UC
Services
Key Messages from the
literature
Profile of A&E attenders from
research
1 in 1000 with major trauma
1 in 100 with life threatening illness or injury, of
which 75% major illness, 15% trauma, 3% drug
over-dose
1 in 4 whose condition does not need facilities
of major A&E dept
9 in 10 who attend without first consulting a GP
1 in 6/7 admitted as inpatient
1 in 4/5 is child
1 in 700 dies in A&E dept
Elements of high quality hospital USC
service – review of evidence
High quality USC service:
• 24 hr access - radiology, CT, Utrasound,
MRI, anaesthetics, general surgery, A&E
medicine, neurosurgery and orthopaedic
surgery, ICU
• Senior Dr presence in ED 24/7 to assess
those requiring surgery
• Observation wards/CDU’s ↓ length of stay
and safety net for inappropriate discharge
Elements of high quality hospital USC
service – review of evidence
• 25% attending ED children –level 3 critical
care vital
• Trauma teams
• EM consultant for 18 hrs/ day
• Nurse practitioners ↓ waiting times. Pt
satisfaction/ level care = middle grade
doctors
• Paucity of lit on cost effectiveness
Need for Hospital Element of
USC Service in North Wales
• Trend has been for demand for USC to increase
• Little predictive evidence on future demand
• Min catchment pop 450,000 for acute hospital/
hospital network (RCS)
• Pop 300,000 more realistic for geographically
isolated areas (RCS)
• EDs in small hospitals with < 40,000
attendances per yr, if < 10km apart, should be
merged (CEM)
• For distances of 10-20km emergency services
should be sustained (CEM)
Need for Hospital Element of
USC Service
Evidence indicated that:
• Merging EDs did not always produce expected
cost savings
• Further work required on economics and cost
effectiveness
• For life threatening conditions e.g. stroke, head
injury and acute coronary syndromes delays in
tx lead to adverse outcomes.
• The ‘golden hour’ effect for major conditions only
available for:
CONDITION
RECOMMENDED JOURNEY TIME TO A & E
DEPARTMENT/TREATMENT
Acute myocardial
infarction
Maximum of 60 minutes of the patient arriving at the
hospital where the PCI will be performed. The
Call to Needle Time should be 60 minutes (NSF
and Welsh Cardiac Network)
Stroke
10 minutes to emergency medicine physician
evaluation, neurologist assessment within 10
minutes, and 25 minutes to CT scan, allowing
tPA administration within an hour (NICE CG 68)
Head injury
A journey time to the neurosciences unit of < 20
minutes direct transport might improve
outcomes but beyond this time, direct transport
might worsen outcomes (NICE CG56)
Violence
A doctor should be available within 30 minutes of
rapid tranquillisation, physical interventions
and/or seclusion of a violent patient (NICE
CG25)
Drivetime analysis
Drivetime analysis found:
• Having 3 A&Es in NW, or 2 A&Es at
Bangor/Wrexham or Bangor/Glan Clwyd
produces similar proportions residents who
travel to nearest A&E < 1 hr (98%)
• Having 3 A&Es in NW produces least travel time
– 81% of residents < 30 mins
• Having only 1 A&E at Glan Clwyd produces
lowest proportion residents reaching nearest
A&E within 30 mins (51.5%)
• Public transport travel times calculated by WAG
Unscheduled Care Activity Data
• First time data from all 3 hospital trust
extracted and compared over 5 years
• Looked at A&E attendance, transfers,
emergency admissions
• Patterns of A&E attendance & emergency
admissions notably similar across hospital
sites
Next Steps
RR informed wider project which has:
• come up with set of aims/ vision for service
• drawn up non-financial option appraisal
criteria
• Defined set of core services
• scored no. models of care
• identified further work including:
- undertaking financial & economic appraisal
- undertaking Equality Impact Assessment
- exploring concept of comms hub
- agreeing process for next stage, including
approach to engagement needed
Reflections
• Very tight timescales of 90-day
research methodology when PH input
needed mainly in first 30 days
• Delays in receiving data from
partners
• National PH model worked well and
promptly