1. Lessons from the NHS Intensive Support Team Key principles for managing emergency flow Russell Emeny Director – ECIST r.emeny@nhs.net Mobile 07930 252049

2. Crowded A&E departments are dangerous Poor understanding of the causes of hospital and ED crowding leads to ineffective solutions Hospitals can do a lot by applying a number of key principles to improve patient flow Applying these principles along the entire patient pathways will relieve pressure on the whole system My main arguments:

3. The toxically crowded A&E department Test your knowledge……

4. Increased mortality at 10 days after admission through a crowded A&E? a)10% b)25% c)40% d)60% c. 43%. Richardson DB. Increase in patient mortality at 10 days associated with emergency department overcrowding. Med J Aust2006;184:213-6

5. Increased hospital length of stay after a long stay 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; 524- 526

6. % 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 20% 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):510-516

7. 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.

8. True or false? Patients who leave emergency departments without being seen are at greater risk than those who wait and are seen. Evidence poor 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

9. For patients who are seen and discharged from A&E, the longer they have waited in ED, the higher the chance that they will die during the following 7 days Evidence good 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 True of false?

10. What are the causes of, and solutions to, A&E crowding?

11. Patients using A&E rather than going to their GP? Educate patients GPs in ED to redirect Primary care ‘front ends’ Hospitals admitting patients to ‘cash in’ on the emergency tariff? GP triage Coding reviews Not enough acute beds to admit every patient that needs one?

12. A pause to reflect? Do we increase hospital capacity when we open more beds? No! Beds are NOT capacity.

13. Hospitals full of patients waiting for social care placement? Tackle ‘choice’ issue by improving hospital processes Lack of intermediate and rehabilitation care beds? More beds NHS Direct/111/Primary Care Out of Hours sending callers to ED? Re-specify service through market testing Provide service locally Get very grumpy

14. What are the causes of, and solutions to, A&E crowding?

15. The cause of A&E crowding is patients waiting for beds Key causes of waits for beds: Failure to tackle avoidable hospitalisation Inappropriate focus on bed-based rather than home-based solutions Silo working and ‘gate keeping’ along pathway Poor patient flow through hospital

16. When visiting a hospital, we look for 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

17. Twice weekly consultant ward rounds compared with twice daily ward rounds Impact: Over study period, no change in length of stay on ‘control’ wards ALOS 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 Weston Clinical Medicine 2011, Vol 11, No 6: 524–8 Does daily senior review work?

18. 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 Continuity of care and regular reviews

19. How much lower? RCP suggests the NNT (number needed to treat) is 443 (for every 443 admissions, one death is avoided) 50% of AMUs have twice daily ward rounds, and 9% have consultants on-take in blocks of >1day. July 2011 – June 2012, 5,272,587 emergency admissions (5,272,587 / 433) /2 = 6,088 deaths could be avoided? ………..only a correlation? …….even more if the progress of every patient, on every ward, was reviewed twice a day by a consultant.

20. 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

21. Can these principles be applied outside of hospital?

22. Early senior review : application in primary care

24. Peak DTAs between 16.00 and 21.00

26. Can potential admissions be turned around?

27. 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

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

29. Crowded A&E departments are dangerous Poor understanding of the causes of hospital and ED crowding leads to ineffective solutions Hospitals can do a lot by applying 8 key principles to improve patient flow Applying these principles along the entire patient pathways will relieve pressure on the whole system To sum up

30. Eight principles that drive 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

31. Results from Trusts applying these principles

32. HSMR

33. Crude mortality

34. Improvement programme starts

35. Inpatients with > 14 day LOS

36. Average length of stay

37. Thanks