Whittington HealthEnhanced Recovery Health System
Dr Martin KuperMedical Director and Intensive Care ConsultantWhittington Health, London Previously…National Clinical Advisor to NHS ImprovementClinical Lead for Enhanced Recovery in London
Clinical strategy
Integrated care
Ambulatory care
Enhanced recovery
• Coordinate health and social care • Patients targeted:
– Complex – 65+ / LTCs– Frequent ED attenders– High users of social services
• Now 4 locaity MDT teams• Discussed more than 500 patients
• Integrated Care MDT Teleconferences• GPs – the lead clinician• Community Health Teams (DNs, CMs)• Hospital Pharmacist• Social Services• Consultant physician (NMH or Whittington) • Consultant psychiatrist (BEH MHT)
Integrated Care
Preliminary results – but risk regression to mean • 17% reduction in A&E attendances• 86% of the patients had fewer admissions
afterwards
All care should be ambulatory or enhanced recovery
Ambulatory Care• Senior decision making, advanced diagnostics • Consultants - Acute Medicine/ ED• Ambulatory Care Coordinator• Community Matrons • Patient and staff designed area and pathways• Leverage community services • Avoid unnecessary admissions• Support discharges - reduce length of stay• Pharmacist
0
1
2
3
4
5
6
7
8
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Total
median total
DVT ADMISSIONS
Ambulatory CareDirectory of Ambulatory Care - medical
Reduction in LOS coincides with increase in Ambulatory Care in Summer 2012 (subset of overall Medical LOS (see previous chart).
Directory of Ambulatory Care used as a proxy for conditions suitable for Ambulatory Care
NHS Institute of Innovation & Improvement, Directory of Ambulatory Care, 2012
General Medical conditions only
MonthlyTo August 2013
Average LOS for Directory of Ambulatory Care (Medical Conditions)
2
3
4
5
6
7
8
4/30
/201
0
6/30
/201
0
8/31
/201
0
10/3
1/20
10
12/3
1/20
10
2/28
/201
1
4/30
/201
1
6/30
/201
1
8/31
/201
1
10/3
1/20
11
12/3
1/20
11
2/29
/201
2
4/30
/201
2
6/30
/201
2
8/31
/201
2
10/3
1/20
12
12/3
1/20
12
2/28
/201
3
4/30
/201
3
6/30
/201
3
8/31
/201
3
Month
Ambulatory CareThroughput
Interim Model from March 2012, Initial implementation complete by summer 2012 with gradual increase to max capacity Current activity is below plan Increased activity in November 2013 to February 2014 -extended opening hours (620 pm)Increased activity in March 2014 - scheduled opening of the new unit – increases in14/15 to 1650 pm.
Count of ED attendances where location = “AEC”
Monthly dataTo October 0213
0
100
200
300
400
500
600
700
800
900
Oct
-11
Dec
-11
Feb
-12
Apr
-12
Jun-
12
Aug
-12
Oct
-12
Dec
-12
Feb
-13
Apr
-13
Jun-
13
Aug
-13
Oct
-13
Dec
-13
Feb
-14
Vo
lum
e o
f A
mb
ula
tory
Car
e at
ten
dan
ces
Activity Plan
9
Ambulatory Care
…getting better sooner
Enhanced Recovery
…getting better sooner
ENHANCED RECOVERY HOSPITAL
Home
Social care
D+T - OPA
IC
Specialist units
MAU – multiple handovers within and between day.
ChurnHandover
Handover
Handover
GP referrals
A+E Referrals
Handover
Churn
MAU
IST summary
Elderly Care
Adult Admission Unit
Speciality pathwaysa) Medicineb) Surgery
ACU
Ambulatory care
Emergency Department
Speciality Wards
Intensive Care
Ambulatory care A
cute E
R / G
oing h
ome bu
ndle
Improvement and information
• Improvement is not an accident and needs to be resourced
• Information is key
Enhanced recovery from acute illness
time
function
Common elements
• Involvement• Clothes• Nutrition• Hydration• Mobilisation• Sleep• Pain• Discharge planning
‘Variation is the enemy of Quality’
W Edwards Deming
Standardised condition specific managementeg sepsis checklist
ER training programme
• 09:10 What is Enhanced Recovery?
• 09:55 Skills for supporting patient engagement
• 10:15 The role of volunteers• 10:45 Specific areas
– Mobility and Strength (OT/Physio)
– Yellow Plan and links to discharge checklist
– Pain – Nutrition & positioning for
feeding – Sleep – Hydration
• 12:00 Going home bundle• Rationale for focusing on patient flow• Criteria for Discharge & EDDs • 12:35 Board rounds & whiteboards • 12:55 Morning Discharges • 13:10 The discharge checklist • 14:15 Delays escalation • 14:30 Community Referrals (District
Nursing) • 15:05 Working with social services • 15:35 Continuing Health Care • 15:55 Equipment
PROGRESS
Enhanced recovery after hip fracture
Emergency Medical LOS
Interim model started mainly with Medical patients. See activity chart for Ambulatory Care – there is a drop in Medical LOS at the same time as increased Ambulatory Care increased
Excludes admissions to ISIS Ward under the ED consultants.
Emergency Medicine Average LOS
5
6
7
8
9
10
Apr-1
0
Jun-
10
Aug-
10
Oct
-10
Dec-
10
Feb-
11
Apr-1
1
Jun-
11
Aug-
11
Oct
-11
Dec-
11
Feb-
12
Apr-1
2
Jun-
12
Aug-
12
Oct
-12
Dec-
12
Feb-
13
Apr-1
3
Jun-
13
Aug-
13
Month
ER in Medicine/Going Home BundleAverage LOS for patients over 70 years
Increased in LOS in April & May 2013 breaks the run of data points. Nevertheless Los for older people has come down
Average LOS for discharged patients aged 70 or over.
Excludes day cases
Medical Specialties only
The date period is between April 2010 and August 2013.
Average LOS Medical patients over 70 years
8
9
10
11
12
13
14
4/30
/201
0
6/30
/201
0
8/31
/201
0
10/3
1/20
10
12/3
1/20
10
2/28
/201
1
4/30
/201
1
6/30
/201
1
8/31
/201
1
10/3
1/20
11
12/3
1/20
11
2/29
/201
2
4/30
/201
2
6/30
/201
2
8/31
/201
2
10/3
1/20
12
12/3
1/20
12
2/28
/201
3
4/30
/201
3
6/30
/201
3
8/31
/201
3
Month
ER in Medicine/Going Home Bundle 95th Percentile Length of Stay
Reduced variation from July 2013 – Enhanced Recovery Programme commences on wards: ward conversations, discharge escalation process, consultation on design of discharge checklist and Going Home Bundle itself.
95th Percentile LOS for Acute discharges
Excludes day casesExcludes Maternity, Children & Babies.Excludes ED/ISIS
The date period is between August 2011 and August 2013.
SHMI
SHMI is Summary Hospital-level Mortality Indicator and measures whether
hospital deaths are higher or lower than expected.
Methodology varies from HSMR.
Outcome Metrics
0
20
40
60
80
100
120
Jul 11 - Jun12 Oct 11 - Sep 12 Jan 12 - Dec 12 Apr 12 - Mar 13
SHMI Threshold
Apr 12 - Mar 13Acute Myocardial Infarction 96.35Cardiac Arrest and Ventricular Fibrillation 112.91Congestive Heart Failure, non hypertensive 70.22Pneumonia 71.05COPD and bronchiectasis -Acute and unspecified renal failure 34.11
Surgery, Cancer and Diagnostics
Fractured Neck of Femur 79.81
Integrated Care and
Acute Medicine
Threshold Jul 11 - Jun12 Oct 11 - Sep 12 Jan 12 - Dec 12 Apr 12 - Mar 13SHMI 100 71.08 71.28 70.31 65
Summary
• Enhanced recovery principles apply to acute illness• Systematic implementation can drive change across
a hospital• Ambulatory care is a key component of enhanced
recovery• Maximal implementation depends on close
integration with local primary care and community services
• These aspects have implications for the ‘future hospital’ agenda
RCP commission
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