1. Harrogate and District NHS Foundation Trust
Emergency Care Winter Challenge
Dr Matt Shepherd & Mike Forster

2. BRACE YOURSELF!

3. 4 Hour target – A measure of system performance
The target is a measure of the % of patients who are either treated and discharged or admitted from the ED within four hours.
Delivery requires the whole system to work effectively to support rapid assessment and treatment of patients in ED and availability of bed capacity for those that require admission.
Clinical evidence shows that extended waits in ED results in:
Poorer outcomes
longer stays in hospital
worse morbidity and mortality
Delivery of the target results in additional (PSF) income for Trusts.
Nationally 4 hours is used to assess how well a system is coping. This is especially true in Winter due to media and political interest.

4. What’s different about winter to any other time of the year?
Sustained cold spell:
Higher incidences of heart attacks, strokes, influenza like illnesses and respiratory conditions
Vulnerable people, particularly those with long term, chronic conditions are particularly susceptible.
Higher conversion of ED attendances to admission and more complex discharge arrangements due to acuity of patients.
Norovirus is most prevalent over the months of October to March resulting in bed closures
Impact of Christmas and New Year bank holiday periods results in lower discharge rates due to lack of available alternatives
Increased demand for primary care services
Pressures during winter greater for those patients requiring admission due to above so focus is on supporting flow through the hospital and into the community.

5. HDFT Trend
Harrogate ED and the hospital continues to receive more acutely ill or injured patients each year.
Higher acuity leads to more admissions
Can result in increase waits for admission in ED

6. Winter Pressures

7. TARGETS ED performance target for 90% Jan /Feb and 95% for March.
Delayed Transfers of Care (DTOC) – 3.5%
Long stay patients – 53 (26% reduction)
Waiting lists at March 2017
Zero 52 week waits

8. HDFT Approach

9. 4 hour target - Not just for Christmas!
Stop avoidable attendance to ED
Streaming to collocated GPOOH service
111 Clinical Advisors and direct access slots / GP Extended Access
Improving awareness of alternatives
Have alternatives for those that do attend
Joint Assessment Unit adjacent to ED
Minimise avoidable delays
See and Treat / Protecting Minor Streams in ED
SAFER - reduction in “non productive” days in hospital
Enhanced Supportive Discharge Service
Multi Agency Discharge Hub
Improved capacity in out of hospital rehab / reablement beds
Patients awaiting decisions on long term care transferred for assessment outside hospital
Good infection control processes to minimise spread of infection and loss of beds
Some of these are part of our Winter Plan but will start in December and support our resilience all year round

10. Other actions over winter
System Winter Plan
Operational Pressures and Escalation Levels – OPEL
Weekly teleconference with WY&H and NHSE
Bed Escalation Plan
Flu - Target 100% of front line clinical staff
Communication Plan / Choose well
Every Hour Matters

11. NHSE and PHE Winter Communications Plan
National Communication Plan
NHSE and PHE Winter Communications Plan

12. Every Hour Matters - Approach to managing bank holidays
Mon
Tues
Weds
Thurs
Fri
Sat
Sun
1.1.19
2.1.19
3.1.19
4.1.19
5.1.19
6.1.19
7.1.19
8.1.19
9.1.19
Maximising Discharge - Lowering Bed Occupancy to 75%
Weekend service
Acute Focus
Weekend cover
Bank Holiday BH
Every Hour Matters - Acute Focus and Recovery
Over weekends and bank holidays discharges reduce due to lack of 7 day services (external and some internal) Requires a distinct plan to recover:
Every Hour Matters
Free up dairies and job plans to focus on acute work / minimise elective work to outpatients and day cases
Clear diagnostic / assessment backlogs
Senior decision makers on the wards / clear plans well communicated
Plan to be at highest level of escalation / Multi System Command and Control

13. Every Hour Matters - Approach to managing bank holidays
Recovered target by 5th Jan 18
Reduced bed occupancy back to below 100% by 8th Jan 18
Outliers reduced by 34 in 5 days

14. Any questions?