How to streamline inter-hospital transfers Dr Richard Levy Wythenshawe Hospital, Manchester CHD Collaborative National Clinical Lead

“Real life” technical considerations ?

What is the evidence?

The majority of patients waiting for transfer were waiting with acute coronary syndrome (73%)

Number of patients reported awaiting transfer at each hospital Manchester Dec 2003 Hospitals Number of patients

Inter-hospital transfer for revascularisation At a CHD Collaborative Angina Workshop in September 2003 this was identified as national problem # 1 Organise a national survey and audit of current practice in patients with ACS

ACS Transfer Study from Manchester Royal Infirmary from May to October 2003 recorded 212 patients in 16 DGHs occupying 1755 bed days waiting for transfer (N Curzen, Lancet letter 2004)

Inter-hospital transfers for revascularisation “ view from the DGH”

Inter-hospital transfers; view from the DGH We do all the right things We triage the patients, identify the high risk patients (Troponin testing etc) We select the correct patients for angiography+/- revascularisation and refer to the Centre And then we wait and wait

Inter-hospital transfers for revascularisation “ view from the Ambulance Service”

Inter-hospital transfers; view from the Ambulance service We have to match the type of vehicle, equipment and crew to needs This can have an adverse impact on category A calls The patient is never ready when we arrive And then we wait and wait

Inter-hospital transfers for revascularisation “view from the Centre”

Inter-hospital transfers; view from the Centre We must first meet our targets for elective revascularisation [PCI & CABG] This will dictate our “star rating” and application for Foundation status We have a “white board” for listing patients for transfer for non-elective revascularisation This is always full

Inter-hospital transfers; view from the Centre We do our best to deliver non-elective revascularisation --- and in time we do deliver After revascularisation we may need to transfer patients back to the DGH The DGH is always full And then we wait ---- and wait

Inter-hospital transfers for revascularisation This is a major challenge for Cardiology Unrecorded waiting list Surge in referrals due to advances in clinical practice No indicator for non-elective revascularisation

CHD-C Survey and Audit National survey to scope the problem of interhospital transfer for the treatment of ACS Review of Central Returns (RoCR) insisted on voluntary contribution Collect baseline data about referring DGHs, transfer process and interventional/surgical centres across England Identify process redesign work already introduced and share best practice

CHD-C Survey and Audit Collect data about waiting times for transfer from DGH to referral centre for angiography and revascularisation in England over 4 weeks in March 2004 These data provide a snapshot of our capacity to provide non-elective revascularisation Expose any limitations in the system

Sometimes Wythenshawe seems very far away……

ACS transfer Data suggest that at-risk patients with ACS benefit from early invasive assessment within 72hrs and this is recommended in local, national and international guidelines

A National Study of Transfer of Cardiac Patients March 2004

Submitted Forms We tried to reach all the trusts in England 141/148 Trusts submitted forms

Team organisation

Admitted To DGH Angiogram Referred TransferredProcedure Inter-hospital Transfers Audit Topline Average Waits 5.9 Days 1.6 Days 7.5 Days1.5 Days 16.5 Days 15 Days

Admitted To DGH Angiogram Referred Transferred Procedure Difference between PCI and Cardiac Surgery 5.2 Days2.4 Days11.1 Days3.5 Days PCI CARDIAC SURGERY 5.9 Days1.3 Days7.6 Days1.2 Days 14.8 Days 18.7 Days 16 Days 22.2 Days

Admitted To DGH Angiogram Referred TransferredProcedure Intervention on site or transfer 6.3 Days1.7 Days 8.0 Days1.1 Days INTERVENTION ON SITE TRANSFERRED FOR INTERVENTION 3 Days1.5 Days3.8 Days2.2 Days 8.3 Days 16 Days

DGH with a Catheter Lab5.5 Days DGH without a lab8.2 Days 40.1% of the DGHs submitting data had a Cath Lab of some sort Average waiting time between admission and angio :

Wait after transfer to procedure

The North Average wait from admission to PCI : 12.8 Average wait from admission to cardiac surgery: 16.3 Average wait from admission to procedure (all) : 12.9 The South and West Average wait from admission to PCI: 23.5 Average wait from admission to cardiac surgery:25.4 Average wait from admission to procedure (all): 20.9 The Midlands and Anglia Average wait from admission to PCI : 12.6 Average wait from admission to cardiac surgery : 23.0 Average wait from admission to procedure (all): 14.5 The South East & London Average wait from admission to PCI : 15.5 Average wait from admission to cardiac surgery:19.9 Average wait from admission to procedure (all): 17.0 Geographical Differences In Average Waits (Days)

The North Number of Interventional Cardiology Sites submitting data : 17 The South and West Number of Interventional Cardiology Sites submitting data : 6 The Midlands and Anglia Number of Interventional Cardiology Sites submitting data : 10 The South East & London Number of Interventional Cardiology Sites submitting data : 10 Number of centres submitting data

AVON BEDS BIRM CHES CUMB DORS DURH ESS HAMP KENT LEIC LINC MANC NCL NEL NORF NWL SEL SHROP SURR SWL SWPEN SYORK THAME TRENT TYNE WMIDS WYORK

AVON BEDS BIRM CHES CUMB DORS DURH ESS HAMP KENT LEIC LINC MANC NCL NEL NORF NWL SEL SHROP SURR SWL SWPEN SYORK THAME TRENT TYNE WMIDS WYORK

AVON BIRM ESS HAMP KENT LINC MANC NORF NWL SEL SURR SWL THAME TRENT TYNE WMIDS WYORK

Tertiary Centres – Names and codes

Admitted To DGH Referred TransferredProcedure Inter-hospital Transfers Audit Average Admission to Procedure Waits by Trust – 1 March to 28 March 2004 Angiography +/- PCI (with and without angiography)

Admitted To DGH Referred TransferredProcedure Inter-hospital Transfers Audit Average Admission to Referral Waits by Trust – 1 March to 28 March 2004 Angiography +/- PCI (with and without angiography)

Admitted To DGH Referred TransferredProcedure Inter-hospital Transfers Audit Average Referral to Transfer Waits by Trust – 1 March to 28 March 2004 Angiography +/- PCI (with and without angiography)

Admitted To DGH Referred TransferredProcedure Inter-hospital Transfers Audit Average Transfer to Procedure Waits by Trust – 1 March to 28 March 2004 Angiography +/- PCI (with and without angiography)

Admitted To DGH Referred TransferredProcedure Inter-hospital Transfers Audit Average Admission to Procedure Waits by Trust – 1 March to 28 March 2004 CABG

Admitted To DGH Referred TransferredProcedure Inter-hospital Transfers Audit Average Admission to Referral Waits by Trust – 1 March to 28 March 2004 CABG

Admitted To DGH Referred TransferredProcedure Inter-hospital Transfers Audit Average Referral to Transfer Waits by Trust – 1 March to 28 March 2004 CABG

Admitted To DGH Referred TransferredProcedure Inter-hospital Transfers Audit Average Transfer to Procedure Waits by Trust – 1 March to 28 March 2004 CABG

Admitted To DGH Referred TransferredProcedure Inter-hospital Transfers Audit Average Admission to Procedure Waits by Trust – 1 March to 28 March 2004 Definite PCI

Admitted To DGH Referred TransferredProcedure Inter-hospital Transfers Audit Average Admission to Referral Waits by Trust – 1 March to 28 March 2004 Definite PCI

Admitted To DGH Referred TransferredProcedure Inter-hospital Transfers Audit Average Referral to Transfer Waits by Trust – 1 March to 28 March 2004 Definite PCI

Admitted To DGH Referred TransferredProcedure Inter-hospital Transfers Audit Average Transfer to Procedure Waits by Trust – 1 March to 28 March 2004 Definite PCI

Names of tertiary centres and codes

TransferredProcedure Interventional Centres Overall – All procedures

TransferredProcedure Interventional Centres Angiography +/- proceed

TransferredProcedure Interventional Centres CABG

TransferredProcedure Interventional Centres Definite PCI

Average days wait in DGH15.3 Days Patients admitted to a DGH during 4 week audit period2196 Occupied Bed Days for ACS pts13295 over 4 weeks based on 3 days for Possible proceed and 7 days for CABG Summary

Clear unambiguous guidelines……

Interhospital Transfers Redesign work

What are we doing to address this? Competencies for transfer Treat and return Transfer service Working together across the network Shared care of patients Electronic communication Jointly developed pathways / processes Coordinator role Optimise the patient - fit for procedure Dedicated beds

Coordinator role Middlesborough James Cook Hospital appointed Cardiology Pathways Coordinator Reduced DGH average wait from 12 – 6 days Co-ordinates transfers with 11 referring DGHs – single point of contact Arranges booking and scheduling of lists Ensures consistent data management Leads weekly meetings to review list based on clinical priorities

Streamlining the Process Walsall Hospitals NHS Trust Reduced average times from decision to proceed through to discharge following PCI from 19 to 5 days Faxed referral proforma Tracking document across organisations from referral to rehabilitation Educational sessions for all staff on process Patient information leaflet at DGH – patient better informed before transfer.

Working across boundaries 11 referring hospitals in North East London and Essex with Barts and the London NHS Trust Complete review of transfer process Pre-schedule slots for DGHs according to demand Prebook ambulance slots with private ambulance provider Plans to use NHS paramedic service to eliminate the need for nurse escort

A redesigned service West Yorkshire – 13 DGHs and Leeds general Infirmary Previously median wait of 8.2 days to approx 2.5 days for PCI since 2001 Cardiac Cath lab scheduler post Ring fenced beds – DGHs and Centre Common waiting list Demand and capacity work which led to case specific sessions, equalising the working day for all staff Nurse led intervention beds

“ I believe that public servants are working flat out but in a system that shrieks out for fundamental change…If we don’t get the systems and structures right we will never get to the roots of the problem, only prune its visible branches. The key to reform is redesigning the system round the user.” Tony Blair Prime Minister October 2002

2005 Agree a national standard for inter-hospital transfers eg 72hrs Repeat study planned for September 2005

The power of free speech!! British intellectual sophistication!!