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Hospitals on the edge Crisis in acute medical services

Hospitals on the edge Crisis in acute medical services. Dr Mark Temple Consultant Physician & Nephrologist Acute care fellow Royal College of Physicians. Overview: crisis in acute medical services . Symptoms . The treatment. The case for consultant delivered care

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Hospitals on the edge Crisis in acute medical services

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  1. Hospitals on the edgeCrisis in acute medical services Dr Mark Temple Consultant Physician & Nephrologist Acute care fellow Royal College of Physicians

  2. Overview: crisis in acute medical services Symptoms The treatment The case for consultant delivered care Acute care toolkits – organisation of care & consultant working What type of consultant? generalists vs specialist 7 day working Hospitals on the edge – priority areas (summary) • Hospitals on the edge • Changing pts changing needs • Out of hours care breakdown • Weekend mortality • Imbalance of care community / 2o care

  3. Crisis : Hospitals on the edge September 2012 Clinical demand • 37% admissions (10yr) 33% acute beds (25yr) Casemix/organisation • Age, co-morbidity & expectation complex care available to all • Changes to out of hours care. Over-reliance on secondary care OOH Workforce crisis • pressure consultants 70% (3yr) • 27% SpRs unmanageable workload • Recruitment EM, elderly care, GIM training • Pressure : Nurse, AHP staffing

  4. Increased Emergency Admissions HEFT 07-09 13.6% increase Emergency Admissions (>0 days) Sept 07 – Dec 07 Sept 08 – Dec 08 Sept 09 – Dec 09

  5. RCP Health Bill survey All members & fellows - March 2012 Top 5 Concerns – wider health agenda • Lack continuity of care • Efficiency savings/funding • Clinical staff shortages • Health reforms • Education training & research

  6. RCP: Members & Fellows survey • Recommend their hospital to family member? • 1:10 NO, 1:4 not sure • Hospital’s ability to deliver high quality care 24/7? • 34% average, 10% poor • Continuity or care the norm? 43% average, 25% poor • Stable teams care & teaching? 40% average, 21% poor • Discharge with realistic allocation responsibility for further actions: 38% average, 21% poor • Success of handover : 16% felt 80% handovers successful <10% felt 90% successful

  7. Hospitals on the edge RCP September 2012 Fractured care • Lack of continuity of care major concern March 12 • Multiple ward moves, handover, LOS Outcomes: • mortality w/e (10%) • NCEPOD – high quality care = consultant care (time to intervene DNAR) • Francis report (ii) - Mid Staffs – systematic failure of good care Inadequate staffing / patient centred care • NHS financial climate

  8. Medical workforce Emergency Medicine • 1:10 posts vacant • 1:5 SpR posts vacant • 1:8 trainees change to another specialty in first 3yrs Elderly care • 50% posts last 12/12 unfilled and of these 2/3 no applicants GIM - unpopular undervalued 54% SpR dual accredit • Of these only 42% wish practice GIM as cons SpR “unmanagable workload” o/c Rota gaps SpR 10-15% NE England

  9. Elephants in the room • Social care funding & occupancy of acute medical beds. 7/7 admission 5/7 discharge • NHS 7 day working = secondary care Failure to develop alternatives to hospital admission

  10. Changing profile of patients changing needs • 65% admissions > 65 • Pts > 65 occupy 70% of bed days • > 85 - 25% bed days • Last decade : 65% increase admissions age >75 [31% age 18-59] • Mean LOS Age > 85 LOS 11 days Age < 65 LOS 3 days 25% of all in-patients have dementia

  11. Out of hours care breakdown Secondary care is the health service OOH • Factors influencing decision to admit: • Lack of alternatives to admission - accessible 7/7 • Less experienced staff (OOH) admit “senior review mane” • “Momentum to admit” NH resident OOH carer expectation • Baseline clinical status uncertain “less responsive”, “not eating”, “off legs” • Minor illness/major social support issues -admit “safe” option & perceived as only way to assess adequately

  12. Weekend mortality for emergency admissions Aylin P et al (2010) QualSaf Health Care; 19: 213-217 • 2005/6 emergency admissions England (4.3M) • In hospital deaths (medical, surgical, cancer) • 215,054 deaths crude mortality 5% • Odds death admit at w/e compared with during the week -adjusted age sex comorbidity socio-economic status & diagnosis

  13. Weekend mortality increased - all admissions + 8/32 diagnostic groups with highest deaths Aylin P et al (2010) Qual Saf Health Care; 19: 213-217

  14. 10% higher odds death admitted w/e • 3369 “excess” deaths – • 3201 all road deaths 2006 • “excess mortality may reflect differences in standards of care” • Pts should expect same standard of care irrespective of day of week admitted • Recommendation - Hospitals revise: • patterns of care • Level of service provision at w/e

  15. Mortality: patients admitted on a weekday vs weekend – preliminary data 2012 Dr Foster

  16. Rate of diagnostic procedure on the day of admission Dr Foster 2012. Expressed: % admissions including the diagnostic procedure Dr Foster

  17. Benefits of consultant delivered care. Academy Royal Medical Colleges 2012 • Rapid, appropriate decision making (endorse DNACPR where CPR futile) • Improved outcomes • More efficient use of resources • GP access to fully trained Dr • Pt expectation of access to appropriately skilled clinician & info • Benefits to training junior doctors

  18. Benefits of consultant delivered careAcademy Royal Medical Colleges • Increased mortality & morbidity associated with delay in consultant involvement – range of fields (acute medicine) • Increased mortality at w/es attributed to reduced consultant input in care • Studies designed to improve pt care incorporating earlier consultant involvement – improved outcomes

  19. Consultant presenceRCP Position statement 11/2010 • Hospitals undertaking the admission of acutely ill medical patients should have a consultant physician on site for at least 12 hours per day, seven days a week, at times relating to peak admission periods. The consultant should have no other duties scheduled during this period. • Currently - average hospital consultant cover gap: • Weekday 4.4 hrs - requires 35% increase cons hrs • Weekend 7.3 hrs - 60% increase consultant hours

  20. RCP initiatives : consultant delivered care/ organisation of care Consultant care: AMU Consultant care : wards Deteriorating patient detection / escalation Clinical decision making include CPR decisions Acute Care toolkit 2 - 2011 Evaluation consultant working 2011 Acute Care toolkit 4 – Oct 2012 Toolkit 2 – High Quality Acute Care NEWS – July 2012 Toolkit 6:The medical patient at risk Effective Ward Round – Oct 2011 Early cons. Review 7/7 – Toolkits 2,4 Future Hospital Commission

  21. ACT 2: High quality care for acutely ill patients 1: AMU • Consultant on site 12 hours day without conflicting duties • At least 2 consultant WRs during 12 hrs • In period AMU staffed by consultant all newly admitted patients should be seen within 6-8 hrs. • Patients admitted overnight seen within 12-14 hrs • The staffing, resources and specialist support services involved in the care of medical emergencies should be organised on the basis of 7 day working

  22. AMU: Support for patterns consultant working: RCP survey Feb-April 2010: Association pattern of cons cover acute medical admissions & patient outcomes : • Admitting cons > 4hrs/day, 7 days a week lower 28/7 re-admissions rate • Consultant on call no other fixed commitments lower adjusted case fatality rate • Consultants conducting >2 WRs / day on AMU lower adjusted mortality pts LOS > 7days • Consultant on call works blocks of >1 day, < 7days lower overall week-end mortality Clin Med 2011 (11) 1: 17-19

  23. ACT 2: High quality care for acutely ill patients Improving care - Medical and surgical wards Particular risk: Transfer out of AMU within 48 hrs – evolving acute illness Move to a different landscape! From AMU : enhanced staffing (cons) organisation of care To wards: • Unfamiliar with pt/acute care • Uncertainties about diagnosis & management • Quality monitoring /response pt deterioration? Patient transfer Friday pm (next cons round 72 hours +?)

  24. ACT 2: Pts transferred out of AMU – receive a consultant review within 24 hrs – 7/7 Patients transferred out AMU: Enhanced review - Consultant of team responsible for continuing care • “Golden Hour” priority duty in first working hour • Template cons physician working 7/7 all wards • “Buddy” arrangements : link medical teams to Surgical wards • Weekday: reschedule conflicting duties 8.30-10 • Weekend: consultand rota for shared bed patch • Review all New + acutely ill Facilitates:Reliable cons review critical time acute illness • Confirm: Diagnosis, Rx, discharge, ceilings of care, • Support ward nurses & covering med staff • Review newly transferred & acutely ill

  25. Heartlands Hospital – Consultant duties 7 / 7 • AMU: 8am: 2 Consultants review pts • All Medical and Surgical Wards: 8.45am (weekday) - 6 Consultant Physicians reviewing patients (new and/or sick) – all will provide ongoing care 9.15am (weekend) – 4 Consultant Physicians reviewing patients [Previously 2 physicians “safari”of pts - no ongoing care responsibility ]

  26. How to change consultant working The Physicians story - Paul Woodmansey (2011) • AMU consultant cover 12hrs w/d, 6-8hrs w/e • W/E Troubleshooting Consultant visits all med wards : sick & quick d/c • Increase early discharge • Coincided reduction mortality (all and w/e) • Major change working life : introduced with relative ease • Consultant proposed tried & accepted • Good for pt care • “Greatest challenge is cons delivered (not led) service required” • “Pace .. in hospital .. pts need daily senior input” Clin Med 2011 (11) 1: 17-19

  27. Acute care toolkit 4: Consultant 12 hour 7 day presence – October 2012

  28. More consultants needed: - support acute take 7/7What type of consultant? Changing patients & needs The generalist – Back to the future? DeLorean 1981 GIM physician – once dynamic! Now unpopular – flight to specialty away from acute take < 25 % dual trainees (GIM /specialty) wish to practice GIM Pts now rarely present with a isolated single organ illness Renaissance for GIM?

  29. Supporting the consultant led 7 day ward round (1) : the 7 day Hospital • Diagnostics • Assessment & treatment: • Therapists, SW, specialist nurses • Nursing culture monitoring progress – proactive use consultant decision making • ceilings of care (DNACPR) • Escalation enhanced care beds (level 1 – 1.5) • Discharge support • pathways out (intermediate care, interim beds) • Ambulatory care – default alternative to admission?

  30. Supporting the consultant led 7 day ward round (2) : the community RCP – Hospitals on the edge - admissions Move focus from episodic care [crisis] – Kings Fund to: • Prevention – post d/c what to do in an emergency • Proactive management declining health: advanced care decisions • Integrated care (COPD) - manage chronic disease • Consistent standards primary care - 7 day • Develop alternatives to admission that work 7/7 • Discharge pathways working consistently 7/7

  31. Summary Hospitals on the edge – a time for action 10 priority areas (1-5) • Dignity and patient centred care • Patient placement acuity of illness, staffing • Redesign services / organisation of care • Design : maximise continuity, min. ward moves • Medical education & training/ right skill mix • Right balance generalist / specialist skills • More extensive training elderly care skills • Re-invigorate GIM

  32. Hospitals on the edge – a time for action Priority areas 6-10 • Improve availability of primary care • Integrated care • 7/7 services 2o care in community • Revolutionise: use of information, EPR • Embed quality improvement • Relevant, timely performance data • Renegotiate the new deal • Provide national leadership: implement national standards & systems where this is in the interest of patient care

  33. RCP - Future Hospital Commission www.rcplondon.ac.uk/futurehospitalreports 3/13 Workstreams: • Place and process • Patients &compassion • People • Planning & infrastructure • Data for improvement Focus: • Patient centred care • Continuity of care • Staffing, skills & organisation of care to match pts needs across community & 2o care [enhanced care beds 1-1.5] • 7 day working

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