Emergency Care Intensive Support Team Review 31 January – 13 March 2013 Overview and next steps 20 March 2013

Overview BSUH invited the Emergency Care Intensive Support Team (ECIST) to review our emergency care pathways at both the Royal Sussex County and Princess Royal Hospitals. There were two visits, 31 January – 1 February and 27 February. Written feedback reports followed on 1 March and 13 March and comments on points of accuracy were requested. These have now been taken and this slide set: - Summarises the ECIST conclusions and recommendations (Slides 3 – 8) - Sets out our planned response and next steps (Slides 9-12). This is not a ‘quick fix’. It will require significant change in systems, excellent engagement and flawless execution. In the meantime we will need to focus daily on maximising the number of discharges each day and supporting our clinical teams as they work with what we have and take on new ways of working. Slide 2 of 16

The Emergency Care Intensive Support Team told us that: Our medical staffing levels and quality is very good, our nursing therapy and wider workforces are dedicated and of good quality but patient flow is poor, largely due to an outdated and ineffective medical take model. Our hospital ‘crisis’ could not be put down to excessive demand, a general increase in acuity or problems with delayed transfers of care alone. Referrers to AMU should be offered one of five choices: Advice / Access to OP / Ambulatory Emergency Care / Admission direct to AMU (not via ED) / And admission to a speciality where the specialty is defined. Our systems do not offer that clear level of definition. ECIST conclusions (1 of 3) Slide 3 of 16

The ECIST LOS review on 27 February 2013 indicated that: Expected dates for discharge are not taken seriously Significant numbers of patients wait for a doctor or therapist to make a decision in relation to their discharge and daily senior ward rounds are not in evidence There is no clear process in place for escalation around delays A small but significant numbers of tertiary patients await repatriation The process for engaging external agencies in relation to arrangements on discharge needs to be simpler and more transparent Keeping older patients who are ‘medically fit for discharge’ in a hospital bed without 7/7 rehabilitation means they lose more function than if they had been discharged. The review noted that ‘It is decision making that gives systems capacity not beds’ ECIST conclusions (2 of 3) Slide 4 of 16

Too few patients use intermediate care and reablement pathways. The whole system needs to develop a vision that supports people to remain in their own homes wherever possible through home to home pathways and strengthening the intermediate tier. We know from our own data that we do not run a 7 day a week hospital with discharges dropping at weekends (Appendix One refers). We also know that we discharge our patients too late in the day to be ready for our expected admissions that day (Appendix Two). Even so: The ‘crisis’ is within the grip of BSUH to resolve through internal changes & multi agency working. ECIST conclusions (3 of 3) Slide 5 of 16

Emergency Department Move from triage to ‘see and treat’ model and re-designate the areas into majors (using both Zones 2 and 3) and minors (Urgent Care Centre). Introduce ‘Rapid Assessment and Treatment’ so there is senior clinical decision making when a 999 patient arrives Introduce internal professional handover standards for all parts of the emergency pathway. Ensure GP expected pts go directly to AMU. Acute Medical Unit Move to 7/7 cover 12 hours a day In the meantime introduce a three consultant model for AMU: Consultant A to manage telephone referrals and review admissions Consultant B to review short stay patients and support Ambulatory Emergency Care Consultant C to manage frail elderly patients Two consultants share a ward round at the weekend (one for new admissions and one for short stay). AND ECIST recommendations (1 of 3) Slide 6 of 16

Clear and separate pathways for patients with different needs: Assessment Unit - <12 hrs – CDU/short stay Ambulatory Emergency Care For up to 20% of our emergency referrals Short stay - ‘2 midnights or less short stay’ – AMU Managed by acute medical team, x2 daily senior review ‘Sick specialty stream’ – expected LOS of 2 midnights or more (72 hrs) Managed by the specialty with pts ‘pulled’ into the relevant specialty bed Frailty stream – ‘from home to home’ with system partners ECIST suggests a separate area for assertive management of frail older people to include rehabilitation. This will need a base. All supported by community led intervention from a single point, focussed on admission avoidance and ‘home to home’ for frail patients ECIST recommendations (2 of 3) Slide 7 of 16

DISCHARGE PLANNING - GENERAL WARDS Implement: one stop ward rounds & a checklist approach to ensure their effectiveness & consistency Internal professional standards: - front loading of therapy - criteria led discharge - all wards teams to focus on discharges before 12 noon AND ensure Specialties work with their nursing, therapy and support teams to identify criteria based discharge processes that would apply to the majority of patient discharges. A clear escalation process for families who decline a care package which in turn increases length of stay for that patient. All underpinned by a set of simple rules that govern our approach to care and treatment ECIST recommendations (3 of 3) Slide 8 of 16

An Implementation Board chaired by the Chief of Medicine and supported by a Project Director from the Executive Team to meet fortnightly for 6/12, supported by 5 workstreams each with its own clinical lead and project manager: CIU will provide analytical support, an expert patient group will help us develop and critique solutions and ECIST will peer review our progress. The Implementation Board will report directly to the Chief Operating Officer who will brief the Executive Team and Board of Directors. The two slides overleaf set out the interdependencies, the who, what and how for the work streams and next steps. BSUH response (1 of 3) Implementation Board Chair Chief of Medicine (linking with other Chiefs as required) Project Director Director of Service Transformation AND Clinical leads from 5 work streams CIU Analytical Support ECIST Peer Review 1 Frontload clinical decision making and handover In ED 2 Streamline processes and pathways incl for frail & vulnerable patients on Level 5 3 Re-organise medical cover to underpin these pathways on Level 5 4 Early daily review and decision making of all inpatients. Consistency of approach and escalation if required 5 Increase options for rehab at home rely less on beds for discharge. Care model of ‘home to home Expert Patient Group Slide 9 of 16

BSUH response (2 of 3) The action plan produced in the early stages of the ECIST review has been refreshed, RAG rated and actions assigned across the five work streams. This work crosses over with our Cost Improvement Programme. Our Delivery Unit will provide project support. The Implementation Board will be responsible for ensuring that all work streams progress at pace. Otherwise we risk lack of progress on one work stream removing the benefit of the next. The high level summary of the intended outcomes and measures of success are summarised overleaf. Slide 10 of 16 Overall outcome Patients seen and treated promptly in ED referred through a pathway that is right for their needs and maximises their ability to return home soonest. Unnecessary time in hospital is minimised. 1 ED Frontload clinical decision making and handover 2 Level 5 Streamline processes and pathways incl. for frail & vulnerable patients 3 Level 5 Re-organise medical cover to underpin these pathways 4 Inpatient pathways Early daily review and decision making. Consistency and escalation if required 5 Home to home Increase options for rehab at home & rely less on beds for discharge

BSUH response (3 of 3) 1 ED Frontload clinical decision making and handover Streamline processes and pathways incl. for frail & vulnerable patients Re-organise medical cover to underpin these pathways 4 Inpatient pathways Early daily review and decision making. Consistency and escalation if required 5 Home to home Increase options for rehab at home & rely less on beds for discharge Martin Duff Consultant in Emerg. Medicine Jo Wailing Matron Workstreams Who Steve Barden (add title) Rob Galloway Consultant in Emergency Medicine Tom Hutchinson (add title) Chris Ashcroft (Matron – TBC) Jeremy Tibble Deputy Chief of Medicine Mark Bayliss Consultant COE ?Snr Nurse Rep Emma Sheriff Head of Nursing Discharge & P’ships Outcome -90 discharges daily. 10 by 10am /30 by 12noon/50 by 3pm - <?5% of EDDs slip - <3% DTOCs -Pts surveyed rate as good or very good Dates for discharge set on admission taken seriously, agreed with pts and delivered consistently. - Decrease in referrals - Decrease in admits - Increase in discharges to place of residence Slide 11 of 16 Measure Alternatives to admission available 7/7 Consistent medical cover in place that supports the delivery of these pathways 24/7 - Compliance with stds on timeliness and discharge from each of the 5 designated pathways - Surveys indicate pts engaged & informed - TBC% Reduction in conversion rates - TBC% reduction in LOS Clear and separate pathways available for patients with different needs. Pts are clear & content - No delays in ambulance h’overs - Compliance with internal stds - Delivery of 4 hr std - Decrease in admits Successful Introduction of ‘see and treat’ & internal handover stds that ensure delivery of 4 hr target Implementation Board 2 and 3 - Level 5, RSCH

Conclusion and next steps The ‘crisis’ is within the grip of BSUH to resolve through internal changes & multi agency working. We have set in place the necessary governance arrangements and the second meeting of the Implementation Board will be held on 26 March 2013 when we will: –Finalise and RAG rate the high level implementation plan for each of the 5 work streams –Task each of the Project Managers with establishing the detailed actions and additional metrics that are key to ensuring delivery We will also request peer review support from ECIST, set in place our expert patient group and gather together our dashboard of data to ensure that we can track our progress going forward. Slide 12 of 16

Discharges by Day of Week at RSCH 01/03/ /02/2013 Appendix One 1 of 3 Slide 13 of 16

Appendix One – 2 of 3 Discharges by Day of Week at PRH 01/03/ /02/2013 Slide 14 of 16

Discharges by Day of Week at RSCH & PRH 01/12/ /02/2013 Appendix One 3 of 3 Slide 15 of 16

Appendix Two Discharges by hour of the day 11 Feb – 17 March 2013 Slide 16 of 16