1. 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

2. The Emergency Care Intensive Support Team

3. 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

4. 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
: 39 weeks were worse than the previous year
12 hour breaches Average 2-3 week previous 2 years, but sudden increase starting Q to 12 a week (one spike of 38 w/e )

5. 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

6. 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

7. 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

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

9. 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

10. 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

11. 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;

12. % 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):

13. % 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):

14. 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.

15. 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

16. 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

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

18. 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

19. 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

20. 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

21. 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

22. 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

23. The result - performance slides off a cliff
4-hour performance (type 1 emergency departments) % %
Last weekly SITREP – 90.4%*
Only 27 of 144 Trusts achieving >95%*
Only 4 achieving >98%*
*WE

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. Can these principles be applied outside of hospital?

33. Early senior review :
application in primary care

35. Peak DTAs between and 21.00

37. Can potential admissions
be turned around?

38. 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

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

40. 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

41. Thanks for listening r.emeny@nhs.net