Key Success Factors in delivering great emergency care Russell Emeny, Director Emergency 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 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 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 11 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 12

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 13

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 15

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;

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):

CURB-65 pneumonia severity score Mortality 00.7% 13.2% 213% 317% 441.5% 557% 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 24

The eight principles of great patient flow Internal professional standards Ambulatory emergency care as the ‘default’ position Use of flow streams to cohort admissions, with minimal handovers 25

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 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 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