Key Success Factors in delivering
great emergency care
Russell Emeny,
Director
Emergency Care Intensive Support Team,
NHS IMAS (a part of NHS IQ)
A gathering storm
• Rising demand for emergency services,
reducing resources and a loss of public
confidence
• Past winter and spring showed our system is
fragile
Why is the system so fragile?
Rising tides and many
small waves
Cause 1– demographics and finance
• Rising life expectancy
• Growing population (but new immigrants use the
NHS least!)
• Life style – obesity, inactivity, alcohol
• Growing inequality – lower skilled less likely to
adopt healthy life styles
• Funding not keeping up with demand growth
Cause 2 – changing acute care
• 37% increase in emergency admissions over past 10
years
• Only 40% of this is due to changing demography
• Rate of intervention growing much faster than rate of
ageing
• Much of growth is in short stay admissions
• Various hypotheses:
• Improved medical technology and knowledge
allowing more conditions to be managed
• Risk adversity by (usually junior) doctors
• Less experienced junior doctors managing
admissions
Cause 3 – aggregate impact of small
(negative) affects #1
NHS 111
• Small impact on ED attendance
• Possible larger impact on admissions
National and media messages
• 4-hours
• Out of hours
Francis report (Mid Staffordshire Foundation Trust)
• Targets, risk
Aggregate impact of small affects (more)
System management during ‘transition’
• Relationships
• Grip
Funding
• Social care
• Primary care
• Commissioning (continuing health care)
Other issues
• Deregistration of nursing homes
(Winterbourne)
• Mental Capacity Act
Probably not
• GP Out of Hours contract
• Over-utilisation by new immigrants
• Tariff changes
So why did some systems do better
than others?
Cause 4 – unwarranted variation and
failure to adopt good practice
• Four-fold variation in admission rate of people
over 65 years old
• Length of hospital stay varies between
consultants for same conditions
• Weekend mortality is 10% higher than weekday
• Medicine is slow systematically to adopt good
practice, even where proven
• Variable application of good practice
Triggers
• Admissions – 4% up between 2011/12 and
2012/13
• Discharge delays – social care and health
• Cold March following milder weather
• But not type 1 A&E attendances in most areas –
1.2% annual increase
11
And so……..
• The combined effect of:
• long term trends;
• a failure systematically to implement good
practice;
• and many small stimuli……..
• Has created a fragile system vulnerable to
small impacts
12
Symptoms
• Crowding in ED due to patients waiting for
beds
• Over-full hospitals
• Long trolley waits for admission
• ‘Outliers’ – hospital patients not on the
correct specialty wards
• Ambulance queuing
13
Associated with
•
•
•
•
Poor patient experience
Failure to achieve key access standards
Increased costs
Increased harm events and mortality
Symptoms
• Crowding in ED – why it’s a very bad thing
• Long trolley waits
• ‘Outliers’ – hospital patients in the wrong
beds
• Ambulance queuing
15
The dangerously crowded A&E
department
What’s the evidence?
A study by Richardson found a 43% increase in
mortality at 10 days after admission through a
crowded A&E
Richardson DB. Increase in patient mortality at 10 days associated with emergency department overcrowding. Med J
Aust2006;184:213-6
Liew found that length of stay in the emergency
department independently predicted inpatient
length of stay
ED stay 4-8 hours increases inpatient length of stay
by 1.3 days
ED stay >12 hours increases inpatient length of stay
by 2.35 days
Liew D, Liew D, Kennedy M. Emergency Department Length of Stay Independently Predicts Inpatient Length of Stay. MJA 2003; 179; 524526
Pines found that in crowded
emergency departments,
administration of 70% of prescribed
IV antibiotics for patients with
community acquired pneumonia
were delayed over 4 hours
Pines JM et al. The impact of emergency department crowding measures on time to antibiotics for patients with community
acquired pneumonia. Annals of Emergency Medicine, 2005, 50(5):510-516
CURB-65
Mortality
pneumonia
severity score
0
0.7%
1
3.2%
2
13%
3
17%
4
41.5%
5
57%
Lim W.S., M.M. van der Eerden et al. Defining community acquired pneumonia severity on presentation to hospital: an international
derivation and validation study. Thorax 2003;58:377 – 382.
For patients who are seen and discharged from
an A&E, the longer they have waited to be seen,
the higher the chance that they will die during
the following 7 days
•
Guttmann A, Schull MJ, Vermeulen MJ, Stukel TA. Association between waiting times and short term
mortality and hospital admission after departure from emergency department: population based cohort
study from Ontario, Canada. BMJ2011;342:d2983
Towards some solutions
There are many steps that if implemented in a
systematic fashion, using improvement
methodologies, could save lives and reduce inhospital mortality.
Key tactical solutions
• Tackle avoidable hospitalisation
• Focus on home-based rather than
bed-based solutions for discharge
• Tackle silo working and ‘gate keeping’
along pathway
• Improve patient flow along the
pathway and particularly through and
out of hospitals
The eight principles of great patient
flow
• Early senior review
• Daily senior review
• A focus on discharge
• Continuity of care
• Appropriate standardisation and
matching capacity to demand
24
The eight principles of great patient
flow
• Internal professional standards
• Ambulatory emergency care as the
‘default’ position
• Use of flow streams to cohort
admissions, with minimal handovers
25
Let’s look at just three
• Daily senior review
• A focus on discharge
• Continuity of care
Does daily senior review work?
Twice weekly consultant ward rounds compared with
twice daily ward rounds
Impact:
• Over study period, no change in length of stay on
‘control’ wards
• Average length of stay on study wards fell from 10.4 – 5.3
• The impact of twice-daily consultant ward rounds on the
length of stay in two general medical wards
• No deterioration in other indicators (readmissions,
mortality, bed occupancy)
The impact of twice-daily consultant ward rounds on the length of
stay in two general medical wards
Aftab Ahmad, Tejpal S Purewal, Dushyant Sharma and Philip J WestonClinical Medicine 2011, Vol 11, No 6: 524–8
Continuity of care and regular reviews
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.
An evaluation of consultant input into acute medical admissions management in England,
RCP, January 2012
Potential for improvement
• Only 50% of AMUs have twice daily ward
rounds, and 9% have consultants on-take in
blocks of >1day (RCP 2012)
• Considerable scope to reduce mortality by
adopting RCP guidance
Focus on discharge
• 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.
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
Can these
principles be
applied outside of
hospital?
Can potential admissions
be turned around?
Think early senior review
Most studies suggest that admissions can be
avoided in 20-30% of >75 year old frail persons
“Avoiding admissions in this group of older people depended on
high quality decision making around the time of admission,
either by GPs or hospital doctors. Crucially it also depended on
sufficient appropriate capacity in alternative community
services (notably intermediate care) so that a person’s needs
can be met outside hospital, so avoiding ‘defaulting’ into acute
beds as the only solution to problems in the community”.
Mytton et al. British Journal of Healthcare Management 2012 Vol. 18 No 11
To sum up
• Current performance problems arise from
multiple factors
• We are not helpless!
• We need to apply known good practice
systematically and reduce variation
• We also need to understand complex trends
and the impact of small affects on complex
systems in order to achieve sustainable
improvement
Thanks for listening
[email protected]