Winter pressures report 2008/2009

Winter pressures report 2008/2009Dr Daniel BeckettIntroductionShort term (3 month) report commissioned by the Emergency Access Delivery Team (EADT) at the Scottish Government in March 2009 into pressures experienced by NHS Scotland over winter 2008/2009

Main driver for this was the drop in performance against the four hour target for access of emergency care

IntroductionThe Project was commissioned to Give a clear description of the demands on the system, levels of activity and pressure points over the winter periodAssess the extent to which the system coped or showed signs of strain Describe the aspects of winter planning and system response which worked and which didntDerive lessons for the future, and explore how recommendations may be implementedIdentify the extent to which additional capacity in primary care can improve the effectiveness of the whole system of unscheduled care.MethodsQualitative study70 one-on-one semi-structured interviewsAll 14 territorial boards visitedHospital managementChief ExecutivesDirectors of operationsGeneral managersBed managementSecondary care clinicians (Clinical leads for emergency and acute medicine)GP out of hours representatives (managers/clinicians)

MethodsQualitative studySpecial boardsNHS24Scottish Ambulance ServiceNHS Education for Scotland (NES)Health Protection Scotland (HPS)Social work representatives from several boardsMethodsQuantitative studyData collected by Information Services Scotland (ISD) and Analytical Services Scotland (ASD)A&E datamartSMR01 codingData also submitted byNHS24Scottish Ambulance ServiceADASTRA Software LtdSome data obtained through local enquiryWe asked...The local health system coped well with winter pressures this year1 2 3 4 5 6 7Disagree Neutral Agree

If there were times when the system struggled to cope was this due to predictable or unpredictable factors?1 2 3 4 5 6 7Predictable CombinationUnpredictable = GP out of hours = ED cliniciansWe asked...In your opinion and experience, what were the major pressures noted in your healthcare system over winter 2008/2009?People said...It seemed busier this winterPatients being admitted seemed to be older, frailer, and sickerMore patients were admitted with respiratory illnessPatients admitted over this winter seemed to have a greater length of stayThe data said...The data said...The data said...The data said...The data said8% increase in emergency admissions December 2008, 2% increase in emergency admissions January 2009 (compared with 5 year mean)11% per week more admissions with respiratory illness compared with winter 2006/2007Age profile of emergency admissions similar to winter 2006/2007There was no evidence of a disproportionate increase in length of stay of patients admitted over winter 2008/2009People said...There are were very few discharges from the hospital over the festive periodThere were no consultants in the downstream wardsSocial work werent availablePeople were in holiday modeDischarge infrastructure falls apartThere is a perception of no pressure on the system as there are so many empty beds over Christmas

The data said...The data said...The data said...Compared to the weekly average for December and January Discharges week ending 28th December 8% down (and this includes the Christmas Eve surge...)Discharges week ending 4th January 21% downPeople said...Weve had problems filling our medical rotas...particularly in the Emergency DepartmentIf the Emergency Department is understaffed then they cant assess people in time and then just rush to admit themThe busier the Emergency Department gets, the more patients they admitThe data said...The data said...The data said...Evidence in poorly performing boards that the majority of discharges from the Emergency Department occur after 3hours 45 minutesThere was no evidence that as activity in Emergency Departments increased the proportion of patients admitted increasedThe converse may be true in well staffed departments

The data said...Well recognised shortage middle grade medical staff in many acute specialitiesEmergency medicine/Acute medicineAcute surgeryObstetrics and GynaecologyPaediatricsFTSTA posts impossible to fill/no locumsNot all due to MMC...Some NHS Boards already trading in funding for unfilled FTSTA posts for new consultant postsPeople said...System Watch isnt helpfulIts too complicatedIt counts conditions not relevant to medicineSystem Watch just isnt accurate enough for a small boardWhats System Watch?

The data said...

People said...This board has no problems with delayed discharges either under 6 weeks or over 6 weeksOur biggest problem is delayed dischargesUp to 50% of our delayed discharges arent reported to ISD because of coding washoutWe use code 9 complex case imaginativelyThe data said...People said...We couldnt get people out to Community HospitalsUnavailability of Patient Transport Services (particularly at short notice for example from the Emergency Department)Complex (and sometimes archaic) referral processesPatient choice

The data said...We also asked...What worked particularly well in your health system over this winter?People said...Staff worked bloody hard

The festive periods were well planned forGP out of hours planned well, and it worked well

Lots of other things read your Examples of good practice document!

The data said...The data said...In one board, GP out of hours activity increased almost 30% from summer 2008 to winter 2008/2009Despite this there was no discernible difference in the performance against the primary KPI over this timeCompare this with only an 8% increase in Emergency Admissions to Hospital from summer 2008 to winter 2008/2009Anything else?Some boards voiced concern that the 18 week Referral to Treatment Target was being prioritised above the four hour emergency access targetSurgical wards remaining closed despite 8 hour trolley waits in the Emergency DepartmentWaiting list initiatives on 5th January with high levels of unplanned medical activity predictedLoss of corporate memory since the disbanding of the UCCAnything else?Lack of clarity in some boards regarding escalation plansSome reports of misuse, and others of deliberate refusal to escalateVariable input from Community Health PartnershipsClinicians disengaged from bed management issues

Anything else?Boarding patients (aka outliers, decants and sleepers)Used as a solution to capacity issues over winter 2008/2009 in all 11 mainland Health BoardsSome boards have made big improvements (reduced 70%) by actively managing LOS In other boards 20% of medical patients were boarded at any one time, occupying >10% of the total hospital bed capacityIncreasing move to board from AMU (and the ED)Conclusions...Staff worked hard!Winter pressure is something of a misnomer there are few winter specific problems but overall activity is increased and weak areas in the system are exposed, particularly during surges in demand

There is no single reason why NHS Scotland failed to deliver the 98% target over winter 2008/2009, but commonalities exist between boards to allow recommendations to be made

RecommendationsHealth Boards should ensure that their winter planning starts early and that the process includes Community Health Partnerships and Social Work Departments. There should be a clear relationship between the winter plan and pandemic flu plan.Integral to the winter plan should be the escalation plan. This should involve all stakeholders including Community Health Partnerships. This includes the utilisation of beds in Community Hospitals, and protocols for referral should be agreed now, dealing with any challenges regarding perceived bed ownership

RecommendationsBoards should undertake more accurate modelling over the festive period to plan elective capacity and optimise the use of bed capacity. This may then enable hospitals to reduce the number of elective admissions on the first Monday in January. Further consideration should be given to front loading the first week in January with minor procedures, and back loading with majors. Also medical elective activity (such as clinics and endoscopy lists) could be back loaded during this week.

RecommendationsSystem Watch should be used systematically for long to medium term predictions of unscheduled activity, and those predictions should be acted upon to create the required capacity, both in terms of beds and to support initiatives to avoid admission. Consideration should also be given to the use of System Watch for planning of elective activity over the winter months.

RecommendationsThe level of discharges over the holiday period should be improved. This might include:increased consultant presence with dedicated discharge ward rounds in downstream wardsutilisation of a rapid response team (or equivalent) of AHPs with access to homecare packages without recourse to social work assessmentre-energising and establishing ownership of the Estimated Date of Discharge policy, plus introducing Nurse Led Discharges (NLDs)

RecommendationsIf all the above measures have been undertaken, including consultant review and discharge of downstream patients, and all capacity beds filled (including community beds) then the 98% standard for emergency access of care should be achievableIf ongoing difficulties then priority should be given to emergency admissions over routine elective proceduresThe Scottish Government has, for the last 10 years, made it clear that clinical decision making always trumps routine elective targets.

RecommendationsBoards should work towards eliminating the boarding of patients as a solution to bed capacity problems. Specifically, the boarding of patients from the Admissions Unit and/or Emergency Department should never occur.

What have I learnt?...Scotland is a very big placeNo two Health Boards think they are the same...Never trust Professor Bell if he rings up asking if you want to help with a little bit of research...

That its impossible to fit 3 months of work into 30 minutes so email me any time for more informationdbeckett@doctors.org.ukFull report (82 pages) out next week...Thank you!