Acute Admissions Management at the Royal Derby Hospital Dr David Staples MBiochem(Oxon) BMBCh(Oxon) MRCP MMedSci(ClinEd) FRSA Consultant Physician in Acute Medicine. Lead Consultant for Service Development. TPD, Acute Medicine (East Midlands North). Director, Aesclepius Ltd.

The Royal Derby Hospital

Hit the 4 hour target Improve patient experience Train the trainees Get the right patient to the right ward Discharge patients earlier Save money

The old process Patient referred for acute medical assessment. Patient waits to be clerked by a junior doctor. Patient waits for review by registrar or consultant. Patient waits for bed on medical specialty ward. Patient moved to (any) bed on a base ward. Patient waits for specialty physician review. All patients put in a bed. Observations may not be done by a qualified nurse.

First assessment by least experienced staff.

Triage GP A+E Ambulatory Care Home Short Stay / “..ology” Clinic

AMU Triage Consultant’s chair F1’s chair

Acute Medical Unit Triage Band 6 nurse led. Collate referral story. Observations, EWS, allergies, pain score. Bloods, ECG, microbiology. Prioritisation for clerking. Transfer to ambulatory care. Alert specialty teams.

Analysis of intervention Pre and post March cases. June, October & February before 03/10 June, October & February after 03/ patients from each month. Wide range of quantitative and qualitative measures.

Process time results

Reduction in re-attendance

Summary of Outcomes Reduction in waiting time to see the first practitioner. Reduction in time to see a senior doctor. Reduction in time to receive an agreed management plan and pathway allocation. Reduction in admissions to base wards. Reduction in re-attendance rates. Increase in proportion of patients completing care on AMU.

Triage GP A+E Ambulatory Care Home Short Stay / “..ology” Clinic

Principles of Hospital Ambulatory Care “Ambulatory care means they sit on a chair”

Triage GP A+E Ambulatory Care Home Short Stay / “..ology” Clinic

Comfortable environment

Ambulatory Care Centre consultation rooms

Ambulatory Care

Who Do We Want in ACC? High number of ‘easy wins’ – Well – Mobile – Self Caring – Sane (?) ‘Rule Outs’ for unlikely but serious conditions (PE / ACS)

Process

Abnormal LFT’s Adult First Seizure Anaemia Anaphylaxis Asthma Cardiac Chest Pain Cellulitis COPD DVT Headache Pleural Effusion Pneumothorax Pulmonary Embolism Seizure in a Known Epileptic Syncope SVT Upper GI Bleed + Generic ambulants

The Selection Process Patient arrives in “Pitstop” in ED Seen by Consultant (Middle Grade if no Consultant available) Deemed appropriate for designated pathway All appropriate initial investigations performed Transferred to ACC for further treatment, investigation and follow-up

Outcome

Triage GP A+E Ambulatory Care Home Short Stay / “..ology” Clinic

Triage GP A+E Ambulatory Care Home Short Stay / “..ology” Clinic

Discussion with senior generalist for all incoming medical patients – Reduce unnecessary admissions – Provide an accessible specialist advice service – Stream patients to the right place, first time – Improve patient flow from A+E to MAU GP Phone Triage

Options: – Ambulatory Care (see but not stay…) – O/P clinic – Service Navigation Team (Community beds / Rehab / Social) – Medical Assessment Unit – A+E – Remain where they are with appropriate advice – Other Services Planned investigation unit Rapid access chest pain service Stroke / TIA Service GP Phone Triage

Time of GP Calls

Results: (n=619)

What have we achieved? 39% reduction in overnight admissions from the community (n=1600)

ACCAvoided Age Ranges

Re-admission within 7 days: n=10 – 2 straight to rehab from GP – 3 seen in AMU LOS 0 days – 1 vaginal pain – 1 admitted despite LCP agreed – 3 medical LRTI (LOS 2) GE (LOS 5) UTI (LOS 1) Validation “Avoided”

n=50 (from 184) – 7 admitted 3 x CAP (LOS 1,3,6) 1 x COPD (LOS 3) 1 x PE (LOS 5) 1 x CVA (LOS 3) 1 x AML (LOS 50) Validation “ACC”

Intervention Components – Trialled using a LLP to provide consultant clinical expertise, migrating to job plan PAs when proved successful. – Change referral phone call management protocols. – Capital investment in upgrading Ambulatory Care Centre. 80% increase in workload with up to ½ of the medical take now passing through it.

Impact – 39% reduction in community admissions staying overnight: NOT creating unmet need. 7 day and 30 day re-admissions low. ? Increased LoS… ? Worse standardised mortality… – Improved patient experience through: Improved environment Clinical pathway standardisation, streamlining and redesign Active management of patient expectation – Improved communications between primary and secondary care. – Smoothing the 1600h bump…

ED MAUT/ Amb. Assess MAU Base Wards Rehab Urgent Care Pathway – Adult, Medicine ~90K Adult Attendances to ED Self Referrals & Ambulance, 77K Discharged or external transfer, 59K Non-med internal transfer, 10K GP & other, 13K Direct ad to Med ward, 6K GP /BB, 11K Discharged, 7K 15K 19K Discharged, 5K Non-med internal transfer, 1K Discharged, 17K 2K 13K Discharged, 2K

ED MAUT/ACC MAU Urgent Care Pathway – Adult, Medicine Subject to 30% tariff Locally agreed price ED + top up Admissions attract national tariff for an inpatient stay GP /BB Locally agreed price more than ED due to less work up.

Financial Impact Locally Agreed Tariff for MAU attendees We do not attract ambulatory Best Practice Tariff (not counted as an admission) Commissioners. Pushing more activity through MAU triage = increased cost, BUT saving made through avoidable admissions is greater. Attractive to Commissioners Hospital. Increased activity paid at locally agreed tariff but major benefit because of increased patient throughput from ED and 4 hour target effects. Attractive to Hospital Management

Barriers Consultant resistance to new Role – Work from home – Linking shifts to locum payments – Only using those that wanted to do it individualised job plans Resistance from some GPs – Ensuring adequate call handling (better experience) – Positive message events and early consultation with GP leaders – GPs manning the unit Management ‘Buy In’ – Coordinators seeing the bigger picture

Factors for Success Senior Decision Makers with good working knowledge of local services (not ‘cheap’ medical decision makers) Generalist Decision Makers with working clinical knowledge of a wide range of specialties (Elderly Care & Acute Physicians) Single point of access for community referrals Supportive management able to see potential benefits Well developed community services and pathways Flexible dynamic department

Questions… Copies of presentation and slides:

Consultant in triage 08:00 to 13:00 Consultant in triage 13:00 to 17:00 Consultant in triage 17:00 to 20:00

Consultant in triage 08:00 to 13:00 Consultant in triage 13:00 to 17:00 Consultant in triage 17:00 to 20:00

Consultant in triage 08:00 to 13:00 Consultant in triage 13:00 to 17:00 Consultant in triage 17:00 to 20:00 PTWR 20:00 to 22:00 PTWR 17:00 to 19:00 PTWR 14:00 to 16:00

Consultant in triage 08:00 to 13:00 Consultant in triage 13:00 to 17:00 Consultant in triage 17:00 to 20:00 PTWR 20:00 to 22:00 PTWR 17:00 to 19:00 PTWR 14:00 to 16:00 Night take PTWR 08:00 to 12:00

Consultant in triage 08:00 to 13:00 Consultant in triage 13:00 to 17:00 Consultant in triage 17:00 to 20:00 PTWR 20:00 to 22:00 PTWR 17:00 to 19:00 PTWR 14:00 to 16:00 Night take PTWR 08:00 to 12:00 With night take team With early take team With late take team

Primary care providers have a single telephone number for all urgent referrals. The acute Trust will deliver clinically competent advice and direction for the most appropriate secondary care services. Single point of access.

Immediate triage on arrival. All patients are triaged by a qualified nurse or midwife within 15 minutes of arrival. This process will indicate the start of specific observations or physiological monitoring (EWS) where necessary.

Timely, senior-led assessment with all records. All patients have a formal clinical assessment within 2 hours of arrival. The outcome of assessment will be a diagnosis or explanation satisfactory to the patient of their circumstances.

Senior review within 4 hours. Senior review of patients is indicated by the formal clinical assessment and subspecialty agreed protocols. It will occur within 4 hours of arrival. Care pathways may be completed without the involvement of senior staff.

Ongoing care pathway - agreed, recorded and communicated. What happens next will be agreed with the patient, detailed in the records and communicated to the next provider. This includes handover to inpatient and outpatient teams.

Immediate electronic discharge summaries. The timely provision of an accurate and appropriately detailed discharge summary is fundamental to successful continuity of care. Similarly admitting providers need to supply accurate and relevant patient information.

Set criteria for specific care pathways. Specific care pathways written for named conditions or patient groups should be evidenced, efficient, diagnostic, allow senior judgment and integrate and communicate with Primary Care.

Reassess when providers or condition changes. Patients will recommence the assessment process if they are moved during urgent care or if their needs change. Transfers will be appropriate, safe, and in the patient’s best interest.

Diagnostics and interventions have agreed timed targets. Subspecialty protocols will agree the timing of urgent access to diagnostic services. All intravenous antibiotics will be given within 30 minutes of the decision to treat severe sepsis.