Key Success Factors in delivering great emergency care

Russell Emeny, DirectorEmergency 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• 11.8% increase in emergency admissions over 5 years

(2004/5 -2008/9)• Only 40% of this is due to the aging population• 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

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• 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

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

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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

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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

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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; 524-526

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 pneumonia severity score

Mortality

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 in-hospital 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

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The eight principles of great patient flow (continued)

• Internal professional standards• Ambulatory emergency care as the

‘default’ position• Use of flow streams to cohort

admissions, with minimal handovers

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Let’s look at just three

• Daily senior review

• A focus on discharge

• Continuity of care

Twice weekly consultant ward rounds compared with twice daily ward roundsImpact: • 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 ofstay in two general medical wardsAftab Ahmad, Tejpal S Purewal, Dushyant Sharma and Philip J WestonClinical Medicine 2011, Vol 11, No 6: 524–8

Does daily senior review work?

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

Continuity of care and regular reviews

• 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

Potential for improvement

• 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.

Focus on discharge

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

r.emeny@nhs.net