1.  Dr Evil's guide to crowding Part 2 Strategies for the ED Dr Ian Higginson MSc FACEM FCEM Emergency Physician ianhigginson@nhs.net

3. Crowding is EVIL!

4. It’s important

6. Pragmatic approach to crowding Cunning plan

7. Summary of what we know Summary  The most important problem facing EDs in the developed world  Definition and measurement not agreed  Makes it hard to nail down causes, effects … and solutions  UK-specific research is thin on the ground

8. Solutions (possibly)  Multipronged recommended  Using operations research  System wide reforms  Strategic planning  Occupancy rates  Improving ED processing capacity  Process redesign  Improved access to diagnostics  Reducing process delays (eg consults, direct admissions)  Getting staffing and skillmix right  Observation / assessment units

9. Not solutions (probably)  What doesn’t work  Ambulance diversion  Demand management (except ? chronic disease)  GPs in the ED  Although colocation may be useful  Building bigger EDs ….. ?

10. Solutions

11. Strategy  Optimise what you do control  Influence what you don’t

13. Culture  Internal  Relentlessly positive (avoid being the victim)  Realistic and honest  Be intolerant of poor quality of care  Don’t chase targets at the expense of patient care  External  Frame the problem  Crowding isn’t OK: crowding is EVIL  It’s a system problem

14. It’s all about quality

15. It’s also about branding

16.  Emergency Medicine in the UK is subject to an outdated value proposition  This underpins the current crisis in Emergency Departments The ED brand

17. So what?  People perceive things  Perception drives expectations  Expectations drive perception of quality  Perceived quality drives perceived value

18. Emergency Departments

19. We know crowding when we see it

20. Me to CEO: It’s really bad and it‘s getting worse CEO: It’s always bad. How bad is it? Me: Dunno. More really bad than the last time I told you it was really bad CEO: La la la la la la I can’t hear you The power of narrative ….

21. The power of data

22. Occupancy and 4 hour performance

24. Use the levers Targets + Francis = pressure 2

25. The power of narrative  “Higgi  Another horrible night in the ED ……”

26. Manage Mordor

27. It’s still about branding

28. Keep your side of the street clean  Clear leadership, coherent team, consistent approach and message  Fat and thin controller, flow coordinators  Match capacity to demand, sustainably  Coherent workforce plan  Get “minors” sorted  Implement best practice  Clinical  Process

30. The power of data (2)

32. Internal strategies to deal with a crowded department  Proactive “escalation” and comms re risk levels  Treat it differently but also work out how to do “normal” things  Some standard safety systems protect patients when ED is crowded (eg) Fat Controller, ECG / gas sign-off  Actively (collaboratively) manage the ambulance Q  Safety rounds, patient comfort, patient comms  Extra staff  Protect your resus, ambulatory areas, CDU

33. Inform and educate  Incident forms  Risk register  Performance meetings  Commissioning environment  Comms to colleagues  Opportunities for advocacy

35. Expectations of others  Acceptance as a system problem not an “ED problem”  Internal standards  Timely response / diagnostics  Consume their own smoke  Effective escalation  Full capacity protocol  Extended hours / seven day working / support  Advocate improved flow (with all that entails)

36. Strategy  Get your own house in order, and your department on the front foot  Create a strong local brand and service concept  (re) Frame the problem, don’t allow crowding to be OK  Influence the system change needed

37. Summary  The science behind crowding is evolving  The solutions are elusive and difficult to implement  But you can make an impact