CHILDREN AND YOUNG PEOPLE’S HEALTH SUPPORT GROUP

Unscheduled Care

Helen MaitlandNational Lead

4 Hour Emergency Access Standard

No patient should spend longer than 4 hours between arriving at the A&E unit and admission, discharge or transfer, unless there are stated clinical reasons for keeping the patient in the unit.

This time limit also applies to other emergency care in minor injury or illness units or areas of assessment units where chairs and/or trolleys are used e.g. if a patient is referred by a GP to an acute medical/surgical unit (see definition of AMU) and is placed on a chair/trolley they should be included in the standard.

Interim Milestone

95% of patients will wait less than 4 hours from arrival to admission,

discharge or transfer for accident and emergency treatment by year

ending September 2014

103254712371871496791

1933181119 413991

20112332241011 341022464935212212 24425993

187

487579121

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194126

5196

655040166298

138

323

425

8992161

25250

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500

5,000

80%

82%

84%

86%

88%

90%

92%

94%

96%

98%

100%

Jul 2

007

Sep

200

7

No

v 20

07

Jan

200

8

Mar

20

08

May

200

8

Jul 2

008

Sep

200

8

No

v 20

08

Jan

200

9

Mar

20

09

May

200

9

Jul 2

009

Sep

200

9

No

v 20

09

Jan

201

0

Mar

20

10

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201

0

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201

0

No

v 20

10

Jan

201

1

Mar

20

11

May

201

1

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011

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201

1

No

v 20

11

Jan

201

2

Mar

20

12

May

201

2

Jul 2

012

Sep

201

2

No

v 20

12

Jan

201

3

Mar

20

13

May

201

3

Jul 2

013

Avg daily ED* attendance (Jul 2013): 4,547 12 hr ED* LoS breaches (Jul 2013): 4 4 hr ED* LoS compliance (Jul 2013): 95.9%Avg 4 hr ED* LoS compliance: 96.2% Upper/lower/natural process limits** National standard : 98.0%

4 h

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Sources: local management information reports covering unscheduled activity for ED sites Jul 2007 to Jul 2013

Scotland ED* attendance, 4 hr emergency care standard compliance, 12 hr ED* LoS breachesMonthly compliance with 4 hr emergency access standard, %; average daily core ED* attendance, n; ED* LoS > 12 hr, n

Notes: (i) ED* refers to EDs, MIUs and trolleyed assessment areas; (ii) **unadjusted, XmR-based process control limits recalculated against Wheeler rules 1,4 and 24-pt baseline;(iii) data have been imputed where required due to local PMS issues; (iv) results are intended for management information only and are subject to change

*July 2013 -Local Management Information only

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3,000

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4,000

4,500

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88%

90%

92%

94%

96%

98%

100%

Jul 2

007

Sep

200

7

No

v 20

07

Jan

200

8

Mar

20

08

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200

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008

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v 20

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v 20

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20

12

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v 20

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Jan

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3

Mar

20

13

May

201

3

Jul 2

013

Avg daily ED* attendance (Jul 2013): 4,547 12 hr ED* LoS breaches (Jul 2013): 4 4 hr ED* LoS compliance (Jul 2013): 95.9%Avg 4 hr ED* LoS compliance: 96.2% Upper/lower/natural process limits** National standard : 98.0%

4 h

r em

erg

ency

car

e st

and

ard

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mp

lian

ce, %

Avg

dai

ly E

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atte

nd

ance

, n

Sources: local management information reports covering unscheduled activity for ED sites Jul 2007 to Jul 2013

Scotland ED* attendance, 4 hr emergency care standard compliance, 12 hr ED* LoS breachesMonthly compliance with 4 hr emergency access standard, %; average daily core ED* attendance, n; ED* LoS > 12 hr, n

Notes: (i) ED* refers to EDs, MIUs and trolleyed assessment areas; (ii) **unadjusted, XmR-based process control limits recalculated against Wheeler rules 1,4 and 24-pt baseline;(iii) data have been imputed where required due to local PMS issues; (iv) results are intended for management information only and are subject to change

Winter 2009

Winter 2011

Winter 2012

Winter 2010

Winter 2013

Winter 2008

Winter Planning

Flow Management

Whole System Acute Patient Flow

Whole System Patient Flow

Scheduled Care

Unscheduled Care

Flow 1 – Minor

illness injury

Flow 2- Acute

Assessment

Flow 3 – Medical

Admissions

Flow 4 – Surgical

Admission

Health & Social Care

Acute Care

Acute Care

Unscheduled Care Governance Group

Unscheduled Care Expert Group

(Chair: Richard Carey)

UCEG: In Hospital (Chair: Gerry

Marr)

UCEG: Out of Hospital

(Chair: Pauline Howie)

Local Unscheduled Care Action Plan (LUCAP)

Identify changes and improvements across a whole system approach focussing on:

– Getting emergency patients to the care they need

– Promoting senior decision makers– Assuring effective and safe care 24/7– Making the community the right place– The primary care response

LUCAP Process

June

2013

• Guidance issued on development of Local Unscheduled Care Action Plans

• Board Exec Unscheduled Care leads identified

July 2013

• Health Boards submitted LUCAP including winter planning arrangements

• National meeting of Board Exec leads• Self Assessment Guidance issued

August 201

3

• Submitted LUCAPs reviewed and feedback given• Funding awarded and allocated

Interlinking trio

• Demand Management– Changing or re-channelling demand– ‘how and why people demand health care’

• Capacity Management– Response to demand– Organisation has capability to respond to demand– Decisions re allocation of key resources

• Organisational Performance– Depends on ability to match capacity with demand

Jack and Powers, IJOMR, 2009

Demand Management

Current service pressures • OOH service at risk of delivery

– Recruitment and retention incentives• Integration/ close working with ED’s• Links with NHS 24• SAS see and treat• Anticipatory Care Planning

Capacity Management

• Surge Capacity, including Contingency Plans

• Beds in the right place• Acute beds for acutely ill patients• Development of Community Services

including Rehabilitation Pathways, Palliative Care etc.

• Improved Assessment pathways

Organisational Performance

• Sustainable performance depends on ability to match capacity with demand

• First contact in care is a measure of effectiveness of healthcare (in reducing morbidity and mortality)

• Non acute care should shift services from hospital -based to community based

• Provision of highly specialised and acute emergency care is efficient and effective

Matching Capacity and DemandA

ll P

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3,500

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Attendance Rate Admission Rate

Rat

e P

er 1

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op

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n

NHS SCOTLAND Attendance & Admission Rates per 100,000 Population for Jun-2013

Reducing A&E Attendances HEAT (T10) - by 5 % by year end 2014

Milestone 7: Develop specific actions to reduce dependence by parents on A&E for routine advice, care or treatment for children.

• Analyse pre and post 5 years old attendances with minor illness / injuries.• Analyse correlation between access to general practice in-hours and

attendance at T10 sites and if so, engage with general practice teams to improve urgent access

• Engage with partners in review of protocols / algorithms to reduce the number of referrals to A&E for minor conditions

• Work with public health, CHPs, PFPI representatives and others to develop information for parents and carers on how to access appropriate services.

• Give practices and health visitors information on child frequent attenders to enable them to determine the cause for attendances and establish what action, if any, is required of them.

Ayrshire

& Arra

n

Borders

Dumfries

& Galloway Fif

e

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Valley

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d

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shire

Lothian

Shetl

and

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de

West

ern Isl

es0

100

200

300

400

500

600

700

800

Paediatric ED Attendance Rates by NHS Board and Age Band - 2012/13

0 to 12 to 45 to 1213 to 15

Source: A&E Data Mart, ISD ScotlandPopulation: 2012 Mid Year Population Estimate, NRS

Rate

per

1,0

00 P

opul

ation

Reducing Emergency Admissions

National Indicator: Reduce proportion of people aged 65 and over admitted as emergency inpatients 2 or more times in a single year

Whole System Approach Every patient is seen by the right person, at the right time, in the right place.. every time

17

Emergency admissions rate per 100,000 population by age group for Scotland

Potential Causes of Short Term Admissions -on arrival at ED

• Decrease in exposure to (and training for) triage of children with potentially serious illness during general practice training

• Decrease in hospital clinician’s ability to triage effectively or to accept risk

• Lack of availability of a Senior Decision Maker to offer second opinion

• Increase in decision to admit rather than further observe in order to reach 4Hr LoS waiting time standard

19

Next Steps

• National event 27th September @ Beardmore • Explore reasons for attendances and most

appropriate pathway for care• Ensure efficient and effective assessment with

appropriate senior decision maker• Discharge is provided when patient fit and

ready• Whole system approach is a reality

20