Why is emergency care performance in England deteriorating? Russell Emeny, Director Emergency Care Intensive Support Team, NHS IMAS (a part of NHS IQ) Organisation / date

The Emergency Care Intensive Support Team

My thesis The combined effect of long term trends and many smaller stimuli, has created a fragile system vulnerable to small impacts The system has lost equilibrium and is struggling – recovery is slow The NHS needs to implement a number of proven tactics to restabilise the system in the immediate term

Current performance 4-hour arrival to departure performance in ED is lowest in ten years 12 hour ‘trolley-wait’ breaches Time to assessment holding up, but…. Time from initial assessment to start of treatment growing Time from start of treatment to decision to admit growing Hospital occupancy increasing Length of stay increasing 2012-13: 39 weeks were worse than the previous year 12 hour breaches Average 2-3 week previous 2 years, but sudden increase starting Q4 2012-13 to 12 a week (one spike of 38 w/e 17.3.18)

Current performance – our observations Longer waits for admission Cost improvement programmes closing beds Beds being reopened in escalation Ambulance hand-over delays Hospitals attributing issues to externally generated problems: NHS 111 Social care and continuing health care delays Difficulty discharging into community beds

What problems is this causing? Crowding in ED Long trolley waits for admission ‘Outliers’ – hospital patients not on the correct specialty wards Ambulance queuing Evidence suggests these lead to worse patient outcomes

What problems is this causing? Crowding in ED – why it’s a very bad thing Long trolley waits ‘Outliers’ – hospital patients in the wrong beds Ambulance queuing

The dangerously crowded A&E department Test your knowledge……

Increased mortality at 10 days after admission through a crowded A&E? 10% 25% 40% 60% Richardson DB. Increase in patient mortality at 10 days associated with emergency department overcrowding. Med J Aust2006;184:213-6

Increased mortality at 10 days after admission through a crowded A&E? 10% 25% 43% 60% Richardson DB. Increase in patient mortality at 10 days associated with emergency department overcrowding. Med J Aust2006;184:213-6

Increased hospital length of stay after a long period in A&E? ED stay 4-8 hours increases inpatient length of stay by………minutes/days/months? Average increase of 1.3 days ED stay >12 hours increases inpatient length of stay by………minutes/days/months? Average increase 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

% of cases where there is a delay of >4 hours in the administration of prescribed IV antibiotics to patients with community acquired pneumonia: Days when NOT crowded 5% 15% 20% 30% Days when crowded 50% 70% 90% 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

% of cases where there is a delay of >4 hours in the administration of prescribed IV antibiotics to patients with community acquired pneumonia: Days when NOT crowded 5% 15% 20% 30% Days when crowded 50% 70% 90% 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 0.7% 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.

True or false? Patients who leave emergency departments without being seen are at greater risk than those who wait and are seen. Evidence weak 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

True of false? 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 Evidence strong 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

Rising tides and many small waves What‘s causing this? Rising tides and many small waves

Cause 1– demographics and finance Rising life expectancy Growing population 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 – unwarranted variation Four-fold variation in admission rate of people over 65 years old Rurality is greatest determinant of this variation ED attendances influenced by proximity to ED Length of hospital stay varies between consultants for same conditions Patients managed through acute medical units have shorter length of stay and lower mortality Weekend mortality is 10% higher than weekday Medicine is slow systematically to adopt good practice, even where proven

Cause 3 – changing acute care 37% increase in emergency admissions over past 10 years Only 40% of this is due to changing demography 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 Reduced threshold for admission Risk adversity by (usually junior) doctors Less experienced junior doctors managing admissions

Cause 4 – 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 #2 System management Relationships Grip Funding Social care Primary care Commissioning (continuing health care) Probably not…. 4-hour standard; GP out of hours; internal market

The result - performance slides off a cliff 4-hour performance (type 1 emergency departments) 2011-12 - 94.9% 2012-13 - 93.8% Last weekly SITREP – 90.4%* Only 27 of 144 Trusts achieving >95%* Only 4 achieving >98%* *WE 21.4.13

Trigger of current issues 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 – 1.2% annual increase

My thesis Combined effect of long term trends, financial pressures, medical practice and many small stimuli has created a fragile system vulnerable to small impacts The system has lost equilibrium and is struggling – recovery is slow The NHS must turn to tactical solutions to reduce variation and optimise performance as a short term measure to restabilise the system

Key tactical solutions Tackle avoidable hospitalisation Focus on home-based rather than bed-based solutions Tackle silo working and ‘gate keeping’ along pathway Improve patient flow along the pathway and particularly through hospitals

The 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 Internal professional standards Ambulatory emergency care as the ‘default’ position Use of flow streams to cohort admissions, with minimal handovers

Does daily senior review work? Twice weekly consultant ward rounds compared with twice daily ward rounds Impact: 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 of stay in two general medical wards Aftab Ahmad, Tejpal S Purewal, Dushyant Sharma and Philip J WestonClinical Medicine 2011, Vol 11, No 6: 524–8

Continuity of care and regular reviews Where the admitting consultant was present for more than four hours, seven days per week, there was a lower 28-day readmission rate 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

Potential for improvement 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

Focus on discharge 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. 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?

Early senior review : application in primary care

Peak DTAs between 16.00 and 21.00

Can potential admissions be turned around?

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

Groups worth targeting Frail elderly at home Terminally ill Nursing and residential homes Some specific groups (e.g. heart failure)

To sum up Current performance problems arise from multiple factors and constitute a ‘wicked problem’ We are not helpless! We need to apply known good practice systematically 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