10/18/2018

1

Acute Medicine: The Scottish perspective

Essential actions, flow and a touch of realism

@djbeckett

10/18/2018

2

“The Scottish Patient Safety Programmemarks Scotland as leader,

second to no nation on earth, in its commitment to reducing

harm to patientsdramatically and continually”

Donald M Berwick, MPPFormer President and CEOInstitute for Healthcare Improvement

10/18/2018

3

Fill rates

0%

20%

40%

60%

80%

100%

Scotland England

Fill rates, A(I)M, 2015

0%

20%

40%

60%

80%

100%

2013 2014 2015

Acute (Internal) Medicine fill rates, Scotland

Unfilled

Filled

SAM Scotland

• Hosted by RCPE

• Route of entry through SAM UK, initially with no additional cost (regional representation)

• Annual conference (next is December 14th 2018 at FVRH…)

@weeSAMScotland

10/18/2018

4

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2013 2014 2015 2016 2017 2018

Acute (Internal) Medicine fill rates, Scotland

Unfilled

Filled

Scottish Government

• ‘Acute Physicians play a key role in the Unscheduled Care process and we are keen to see a vibrant and representative SAM Scotland work with us and the other key partners to improve patient and staff experience which are inextricably linked’

Alan Hunter, Director of Performance,

10/18/2018

5

Emergency Access Standard

• The Emergency Department cannot deliver this target alone

• It requires a whole system response to ensure capacity meets demand - by hour of the day and day of the week

• Whole system barometer

Crowding

There is an association between ED crowding and:

• Mortality

• Increased length of stay both in ED and I/P

• Reduced quality of care

• Poor patient experience

• Staff burnout

• Difficulty recruiting and retaining staff

10/18/2018

6

5.1%

3.6%

5.4%

1.3%

4.6%

2.0%

3.0%

6.1%

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

11%

12%

13%

14%

15%0

8/1

1/2

009

22/1

1/2

009

06/1

2/2

009

20/1

2/2

009

03/0

1/2

010

17/0

1/2

010

31/0

1/2

010

14/0

2/2

010

28/0

2/2

010

14/0

3/2

010

07/1

1/2

010

21/1

1/2

010

05/1

2/2

010

19/1

2/2

010

02/0

1/2

011

16/0

1/2

011

30/0

1/2

011

13/0

2/2

011

27/0

2/2

011

13/0

3/2

011

06/1

1/2

011

20/1

1/2

011

04/1

2/2

011

18/1

2/2

011

01/0

1/2

012

15/0

1/2

012

29/0

1/2

012

12/0

2/2

012

26/0

2/2

012

11/0

3/2

012

11/1

1/2

012

25/1

1/2

012

09/1

2/2

012

23/1

2/2

012

06/0

1/2

013

20/0

1/2

013

03/0

2/2

013

17/0

2/2

013

03/0

3/2

013

17/0

3/2

013

31/0

3/2

013

14/0

4/2

013

28/0

4/2

013

12/0

5/2

013

26/0

5/2

013

09/0

6/2

013

23/0

6/2

013

07/0

7/2

013

21/0

7/2

013

04/0

8/2

013

18/0

8/2

013

01/0

9/2

013

15/0

9/2

013

29/0

9/2

013

13/1

0/2

013

27/1

0/2

013

10/1

1/2

013

24/1

1/2

013

08/1

2/2

013

22/1

2/2

013

05/0

1/2

014

19/0

1/2

014

02/0

2/2

014

16/0

2/2

014

02/0

3/2

014

16/0

3/2

014

30/0

3/2

014

13/0

4/2

014

27/0

4/2

014

11/0

5/2

014

25/0

5/2

014

08/0

6/2

014

22/0

6/2

014

06/0

7/2

014

20/0

7/2

014

03/0

8/2

014

17/0

8/2

014

31/0

8/2

014

14/0

9/2

014

28/0

9/2

014

12/1

0/2

014

26/1

0/2

014

Scotland: weekly, self-reported acute inpatient boarding rates, Nov 2009 to Oct 2014Proportion of estimated staffed acute inpatient beds reported occupied by boarded patients, %Sources: (i) SG weekly monitoring submissions; (ii) hospital-level ISD(S)1-derived ISD IR2012-00483 and hospital bed statistics publications

Notes: (i) interpretation of inpatient boarding definition may vary between Health Boards, hence caution should be taken when interpreting trends; (ii) reported measure changed from Mon census in 2009/10

to bed day usage from 2010/11; (iii) data imputed where required, except for Highland Health Board, for which no consistent data are available; (iv) results are intended for management information only

Health Board

variation

2010/11 onwards:

total boarded

bed days

2009/10:

boarder census

at Mon 23.59

Nov 2012 onwards:

continuous collection of

weekly monitoring submissions

Standardised resultsSummary

Multilevel model standardisation

Expected values: Crude rates:

Non-

boarded,

no

sitespec

boarding

Non-

boarded,

site-

specialty

boarding

present

Boarded,

site-

specialty

boarding

present

Non-

boarded,

no

sitespec

boarding

Non-

boarded,

site-

specialty

boarding

present

Boarded,

site-

specialty

boarding

present

Total

Spells 31.6% 59.2% 9.2% 981,798 1,836,546 285,688 3,104,032

days, n 3.2 4.3 5.3 1.7 4.5 9.4 4.1

99% CIlower 3.1 4.2 5.0

99% CIupper 3.4 4.4 5.6

7 days, % 3.7% 4.5% 5.2% 3.3% 4.8% 4.9% 4.3%

99% CIlower 3.6% 4.5% 5.0%

99% CIupper 3.8% 4.5% 5.3%

30 days, % 7.9% 9.5% 10.7% 6.4% 10.3% 11.5% 9.2%

99% CIlower 7.8% 9.4% 10.5%

99% CIupper 8.0% 9.5% 10.8%

7 days, % 2.1% 2.4% 2.6% 1.0% 2.8% 3.7% 2.3%

99% CIlower 2.0% 2.4% 2.5%

99% CIupper 2.1% 2.4% 2.7%

30 days, % 3.0% 3.4% 3.8% 1.5% 4.1% 5.6% 3.4%

99% CIlower 3.0% 3.4% 3.7%

99% CIupper 3.1% 3.5% 3.8%

Spell LoS:

Emergency

readmission

within, of

discharge:

Death within,

of discharge:

10/18/2018

7

Standardised resultsSummary

Multilevel model standardisation

Expected values: Crude rates:

Non-

boarded,

no

sitespec

boarding

Non-

boarded,

site-

specialty

boarding

present

Boarded,

site-

specialty

boarding

present

Non-

boarded,

no

sitespec

boarding

Non-

boarded,

site-

specialty

boarding

present

Boarded,

site-

specialty

boarding

present

Total

Spells 31.6% 59.2% 9.2% 981,798 1,836,546 285,688 3,104,032

days, n 3.2 4.3 5.3 1.7 4.5 9.4 4.1

99% CIlower 3.1 4.2 5.0

99% CIupper 3.4 4.4 5.6

7 days, % 3.7% 4.5% 5.2% 3.3% 4.8% 4.9% 4.3%

99% CIlower 3.6% 4.5% 5.0%

99% CIupper 3.8% 4.5% 5.3%

30 days, % 7.9% 9.5% 10.7% 6.4% 10.3% 11.5% 9.2%

99% CIlower 7.8% 9.4% 10.5%

99% CIupper 8.0% 9.5% 10.8%

7 days, % 2.1% 2.4% 2.6% 1.0% 2.8% 3.7% 2.3%

99% CIlower 2.0% 2.4% 2.5%

99% CIupper 2.1% 2.4% 2.7%

30 days, % 3.0% 3.4% 3.8% 1.5% 4.1% 5.6% 3.4%

99% CIlower 3.0% 3.4% 3.7%

99% CIupper 3.1% 3.5% 3.8%

Spell LoS:

Emergency

readmission

within, of

discharge:

Death within,

of discharge:

10/18/2018

8

Six Essential Actions Improvement Approach

Launched in May 2015

Developed in partnership with the Academy of RoyalColleges, NHSScotland and Scottish Government

Aims to improve the patient and staff experience ofUnscheduled Care

Delivery of 95% target for all patients to be admitted,discharged or transferred from the EmergencyDepartment within 4 hours.

Aiming towards a standard of 98%

Ministerial objective

10/18/2018

9

Clinically Focussed Empowered Leadership Responsive Operational Management

Whole System EscalationTriumvirate Leadership Team

- Site Director, - Chief Nurse, - Chief Doctor

Capacity and Patient Flow Realignment

Determining and utilising appropriate information and trend data for performance improvement

to ensure correct resources are applied to meet demand and

system need

Patient Rather Than Bed Management

Daily Dynamic Discharge Shifting the discharge curve left

Developing a coordinated, multidisciplinary approach to

discharge planning encompassing acute and community resources

Medical and Surgical Processes Aligned for Optimal Care

Designed to pull patients from ED

through assessment and diagnostics process to be

seen at right time, by right person in right place

7 Day Services

To reduce variation in access to all services across

weekend and out of hours. Includes clinical assessment, diagnostics, and access to

Senior Decision Makers. Also support services such as

porters, cleaning and transport

Ensuring Patients Care for at Home

Pathways to reduce attendance, avoid admission and if admission necessary ensure home when ready

Basic Building Blocks

Improve rate of early in day and weekends

Signposting and redirection to appropriate community services

18

Admissions

Discharges

Emergency

admissions

with

ED* LoS

> 4 hr, %

Scheduled

and direct

admissions

Hospital

discharges

with XRI AU

LoS > 24 hr

10/18/2018

10

Daily Dynamic Discharge

Make sure we align the clinical and therapeutic pathways

Creating the Plan

Dynamic MDT Planning from admission - EDD

Effective Ward Rounds –management planning

Daily Communication of Changes

Dependant tasks considered

Executing the Plan

Rapid Daily Whiteboard Meetings (sick, discharge, new) x 2 per day

Ordered ward rounds (sick, discharge, new)

Non-slip task management

Check, chase, challenge reinforcement

In the moment escalation

Discharging when ready

Following criteria for discharge

Escalation/expediting of delay causing tasks

Discharge lounge?

SHIFT

THE

CURVE

How we DDD on Ward 7CIN THE MORNING:• At 9amWe choose:• A facilitator, task sheet scribe and

ward view updaterWe discuss:• Sick patients/safety issues• Patients for discharge today and

tomorrow• Any relevant others (new patients/

urgent tasks)We agree:• Things that need done TODAY, by

whom, by when (write on task sheet)We summarise:• Bed numbers to be seen firstWe finish:• By copying the task sheet for each

team

IN THE AFTERNOON:• At 3pmWe choose:• A facilitator, task sheet scribe, ward

view updaterWe discuss:• Task sheet from this morning• Plans for all patients – EDD, tasks etcWe agree:• Any new tasks to be added to today’s

sheet (from ward rounds)• Any changes to earlier tasks• Escalations (preventing/possibly

preventing discharge)We summarise:• What ELSE needs done TODAYWe finish:• Agree to mark task sheet off before

leaving/handover to next shift

SIGNED (SCN): SIGNED (CONSULTANT:

MANAGE TODAY

PLAN FOR TOMORROW

10/18/2018

11

Noon

PRE-NOON

Noon

14% - February 2017

26% - February 2018

12% improvement in one year

PRE-NOON

10/18/2018

12

2pm

29% - Feb 2017

46% - Feb 2018

17% improvement in one year

PRE-2PM

3pm

60% - Feb 2018

42% - Feb 2017

18% improvement in one year

PRE-3PM

10/18/2018

13

10/18/2018

14

Variability Methodology

Analyse data to assess

variability in patient flow

Select flow priority based on

opportunities to reduce variation

identified in analysis

Develop standardised clinical processes to identify natural and artificial variation

Implement and monitor standardised

clinical processes. Collect data for

modelling and benefitsConstruct model of improved flow

Use simulation and analysis to identify

appropriate capacity to meet scheduled & unscheduled demand

Select redesign recommendation and implement changes

e.g. cohort homogenous groups

Benefits Realisation

10/18/2018

15

10/18/2018

16

Variability: Daily Number of Surgical Cases

Elective

UrgentEmergencyNatural

Variation

ArtificialVariation

10/18/2018

17

10/18/2018

18

10/18/2018

19

UCL

LCL

1500

1600

1700

1800

1900

2000

2100

2200

2300

2400

2500

Aug-1

1S

ep-1

1O

ct-

11

Nov-1

1D

ec-1

1Jan-1

2F

eb-1

2M

ar-

12

Apr-

12

May-1

2Jun-1

2Jul-12

Aug-1

2S

ep-1

2O

ct-

12

Nov-1

2D

ec-1

2Jan-1

3F

eb-1

3M

ar-

13

Apr-

13

May-1

3Jun-1

3Jul-13

Aug-1

3S

ep-1

3O

ct-

13

Nov-1

3D

ec-1

3Jan-1

4F

eb-1

4M

ar-

14

Apr-

14

May-1

4Jun-1

4Jul-14

Aug-1

4S

ep-1

4O

ct-

14

Nov-1

4D

ec-1

4Jan-1

5F

eb-1

5M

ar-

15

Apr-

15

May-1

5Jun-1

5Jul-15

Aug-1

5S

ep-1

5O

ct-

15

Nov-1

5D

ec-1

5Jan-1

6F

eb-1

6

Admissions to FVRH AMUPatients

UCL

LCL

75%

80%

85%

90%

95%

100%

Jul-11

Aug-1

1S

ep-1

1O

ct-

11

Nov-1

1D

ec-1

1Jan-1

2F

eb-1

2M

ar-

12

Apr-

12

May-1

2Jun-1

2Jul-12

Aug-1

2S

ep-1

2O

ct-

12

Nov-1

2D

ec-1

2Jan-1

3F

eb-1

3M

ar-

13

Apr-

13

May-1

3Jun-1

3Jul-13

Aug-1

3S

ep-1

3O

ct-

13

Nov-1

3D

ec-1

3Jan-1

4F

eb-1

4M

ar-

14

Apr-

14

May-1

4Jun-1

4Jul-14

Aug-1

4S

ep-1

4O

ct-

14

Nov-1

4D

ec-1

4Jan-1

5F

eb-1

5M

ar-

15

Apr-

15

May-1

5Jun-1

5Jul-15

Aug-1

5S

ep-1

5O

ct-

15

Nov-1

5D

ec-1

5Jan-1

6F

eb-1

6

FVRH compliance with the emergency access standardPercent

80.9%

97.4%

10/18/2018

20

39

KEEP

CALMAND

MANAGE

VARIABILITY

10/18/2018

21

0 10 20 30 40 50 60 70 80

WB21 (235)

WA32 (407)

WA31 (501)

WB22 (192)

WA11 (519)

WA12 (574)

WA21 (18)

WB32 (551)

WB12 (776)

Card (421)

WB11 (868)

WA22 (373)

WB23 (111)

WB31 (356)

Average AU LOS (Hours)

Un

it (

Nu

mb

er

of

AU

Ad

mis

sio

ns

to U

nit

)

14. Average AMU LOS by Post-AMU Admitting Unit in Hours with 10th/90th Percentile Error Bars

NHS Forth Valley, [01-Jan-2014 to 30-Jun-2014], All DaysNumbers in parentheses = Total AU admissions to unit

0 10 20 30 40 50 60 70 80

WB21 (235)

WA32 (407)

WA31 (501)

WB22 (192)

WA11 (519)

WA12 (574)

WA21 (18)

WB32 (551)

WB12 (776)

Card (421)

WB11 (868)

WA22 (373)

WB23 (111)

WB31 (356)

Average AU LOS (Hours)

Un

it (

Nu

mb

er o

f A

U A

dm

issi

on

s to

Un

it)

14. Average AMU LOS by Post-AMU Admitting Unit in Hours with 10th/90th Percentile Error Bars

NHS Forth Valley, [01-Jan-2014 to 30-Jun-2014], All DaysNumbers in parentheses = Total AU admissions to unit

10/18/2018

22

6.0

9.5

8.28.0 7.9

7.5

5.7

7.9

2.9

5.8

4.8

5.6

4.9

4.2

3.0

4.8

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

9.00

10.00

Sun (1.70) Mon (4.34) Tue (4.54) Wed (4.37) Thu (4.16) Fri (5.18) Sat (2.00) Overall (26.33)

Ave

rage

/ M

edia

n L

OS

(in

day

s)

DOW of Discharge/Transfer-out

LOS by DOW Of Discharge/ Transfer-out (Based on Actual Move Date)NHS FV, Ward B32, Jan'13 - May'15, All Days

Average LOS Median LOS

Note: LOS calculated based on Date & Time

43

43

ADT Criteria

10/18/2018

23

Downstream Ward Median Discharge Times

2014 2015 2016

Median

Discharge

Time

Median

Discharge

Time

November

A12 16:00 15:07 14:17

A31 16:03 15:00 14:47

B12 16:14 15:38 15:33

B32 16:00 14:34 14:30

Ward

3039 annualised bed days saved

10/18/2018

24

84

86

88

90

92

94

96

98

100

102

104

106

0

10

20

30

40

50

60

70

80

11/2/15 12/2/15 1/2/16 2/2/16 3/2/16 4/2/16 5/2/16 6/2/16 7/2/16 8/2/16 9/2/16

'Co

re' b

ed

occ

up

ancy

Nu

mb

er

of

bo

ard

ers

FVRH 'core bed' occupancy and number of boarders

Core' bed occupancy Boarders

0

50

100

150

200

250

300

350

400

450

500

FVRH 'wait for AMU bed' breaches, Oct 2014-Sep 2016

10/18/2018

25

Sustained improvement New Temporary Median of

1.16

Provisional reduction of 54%

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

5.0

Jan

13

Mar

13

May

13

Jul 1

3

Sep

13

No

v 13

Jan

14

Mar

14

May

14

Jul 1

4

Sep

14

No

v 14

Jan

15

Mar

15

May

15

Jul 1

5

Sep

15

No

v 15

Jan

16

Mar

16

May

16

Jul 1

6

Sep

16

No

v 16

Jan

17

Rat

e p

er

100

0 d

isch

arge

s

Cardiac Arrest RateNHS Forth Valley

FVRH

10/18/2018

26

10/18/2018

27

Most people in Scotland with any long term condition have multiple

conditions

23

13

7

5

48

31

23

22

18

14

13

9

7

6

3

22

21

17

13

20

23

21

24

19

20

21

16

13

14

9

18

21

20

18

12

16

17

19

17

19

21

19

16

18

14

36

46

56

64

21

29

39

35

47

47

46

56

65

62

74

0% 20% 40% 60% 80% 100%

Depression

Schizophrenia/bipolar

Anxiety

Dementia

Asthma

Epilepsy

Cancer

Hypertension

COPD

Diabetes

Painful condition

Coronary heart disease

Atrial fibrillation

Stroke/TIA

Heart failure

Percentage of patients with each condition who have other conditions

This condition only This condition + 1 other + 2 others + 3 or more others

10/18/2018

28

Public Finances – Fall in Government Expenditure

10/18/2018

29

Realism in Healthcare

• Doctors generally choose less treatment for themselves than for patients

• Striving to provide relief from disability, illness and death, modern medicine may have overreached itself – is it now causing hidden harm?

• Focus on unwarranted variation in clinical practice and outcomes

• Multiple conditions – management leading to over-complex medical regimes?

• Clinicians have duty to acknowledge powerlessness at times

JJ Gallo et al. Life-sustaining treatments: what do physicians want and do they express their wishes to others?J Am Geriatr Soc. 2003 Jul;51(7):961-9.

10/18/2018

30

Value Based Healthcare

10/18/2018

31

Reducing harm and waste

• Harm in healthcare not just missed diagnoses or under-intervention but ‘hidden harm’ exists in over treatment, excessive interventions and medicalising normality. – This is far harder to measure.

• Focus on better value care – including ‘the gentle art of doing nothing’– This isn’t always in the nature of Acute

Physicians…

Gawande, A. (2014). Being mortal: Medicine and what matters in the end (First edition.). New York: Metropolitan Books.

10/18/2018

32

Over-investigation and over-diagnosis…

10/18/2018

33

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34

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35

Doctors and risk

• Managing risk is an inherent part of our role

• There is risk associated with every clinical decision, whether it is to do something or to do nothing

• The importance of positive risk taking –avoidance raises anxiety rather than reduces it

• It is psychologically healthy to stimulate and empower ourselves by taking risks

10/18/2018

36

So…‘Realistic AcuteMedicine’?

How are we doing?...

10/18/2018

37

Variation between AMUs

• We all know it exists

• It’s very hard to measure

• Poor coding

• Activity data variably recorded

– Admission vs Attendance vs Ambulatory Care

– In-patient vs Out-patient

10/18/2018

38

LEM Reid et al (2016).The effectiveness and variation of Acute Medical Units; a systematic review. IJQHC 28; 433-446

10/18/2018

39

Imison C and Vaughan L (2018) Acute medical care in England: Findings from a survey of smaller acute hospitals. Slide-set resource. www.nuffieldtrust.org.uk/research/acute-medical-care-in-england-findings-from-a-survey-of-smaller-acute-hospitals

10/18/2018

40

Variation within an AMU

40.0%

45.0%

50.0%

55.0%

60.0%

65.0%

70.0%

A B C D E F G H I J K L M N O P Q R S T U V

Direct discharge rate from FVRH AMU, per consultant physician 2014-2016

Practising Realistic Acute Medicine is hard…

10/18/2018

41

10/18/2018

42

10/18/2018

43

Where do we start?

• Hunt out the dogma and the pseudoaxioms

• Look for ‘Must’, ‘All’ and ‘Should’…

All admissions to an Acute Medical Unit need a set of baseline bloods

All admissions to an Acute Medical Unit need a baseline ECG

All patients with pneumonic consolidation must have follow up CXR

All patients admitted to an AMU with an overdose must be reviewed by psychiatry before discharge

All patients with ‘CT-negative’ thunderclap headache need a lumbar puncture…

All patients with ‘fast AF’ need to be admitted to hospital…AND on a cardiac monitor…

10/18/2018

44

10/18/2018

45

drlynndickson

drlynndickson

10/18/2018

46

‘Right person, right place, right time’

#RightCareEveryTime

Acknowledgements

• Six essential actions (@6EAScot)– Helen.Maitland@scot.gov– Andrea.Jamieson@scot.gov– Jacques.Kerr@scot.gov

• Patient flow program (@patientflowsg)– Martin.Hopkins@scot.gov– Institute for Healthcare Optimization

• Realistic Medicine (@RealisticMed)– @drgregorsmith, Deputy CMO– @CathCalderwood1, CMO– @damson29, National Clinical Lead for Realistic Medicine– @ChristineGregs5, ST7 in GIM and ID

10/18/2018

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@djbeckett@weeSAMScotland

#RightCareEveryTime