ED Attendance/Admission Avoidance

1. ED Attendance/Admission Avoidance Miss Ruchi Joshi, Clinical Director – Emergency and Acute Care Group 24 September 2014

2. Issues • In the last few years, there has been exponential rise in the acuity of patients attending ED • There is increased attendance of elderly patients attending ED with complex medical and social problems • There is evidence of confusion amongst patients as to which service suits them best • Increased patient expectations – ‘1 stop shop’ • 2013 – a record 24 million people attended ED with up to ¼ saying that they were there because they could not get a GP appointment (Imperial College London)

3. Issues • Unplanned attendance/admission is seen as a sign of community failure by DOH • It is seen as a sign that the health of community in general is not good • The present tariff system is not fit for purpose – although out of hours service is provided at premium rates, the tariff does not reflect that. Hence ED is set up to fail as a business

4. Recent Study • University of Bristol – 24 July 2014 – attendances at EDs can be reduced by enabling patients to see the same GP everytime they visit their doctor’s surgery (result in published in open access journal –BMJ open, and was carried out in collaboration with Universities of Manchester, Oxford and UCL

5. Further Factors Affecting ED Attendance • How easy is it for patients to access the GP surgery and primary care provider • The distance the patient lives away from the ED • The number of confusing options patients have for accessing emergency care

6. Suggestions from Kings Fund Report • Admission amongst people with long term conditions that could have been managed in primary care costs the NHS £1.4 billion per year. This could be reduced up to 18% through investment in primary and community based services • Providing continuity of care and making it easier for patients to get access to their GPs can help achieve this reduction in unplanned admission/attendance • Targeted increase in continuity of care by GPs, with special reference to nursing/residential homes

7. Overcrowding in ED • Increased alcohol and mental health attendances • Increased re-attendance rate • Increased failed discharges • Path of least resistance – ED is seen as a path of least resistance by patients

8. Knock on Effect • Overcrowding in ED results in poor quality and standard of care provided to the patient. It leads to safety issues within the department • It also has a knock on effect on the rest of the organisation, i.e. regular theatre lists get cancelled leading to failure of the targets • Patients are admitted in the wrong place on the wrong wards resulting in safety concerns

9. Example 1 • Patient (DH) • 24 ED attendances since January 2014 • Out of 24 attendances, there were 4 admissions • Presenting condition – abdominal pain • Patient has had a diagnosis of pancreatitis. ? How should she be managed

10. Example 2 • Patient (DH) • 5 ED attendances since March 2014 • On all 5 attendances he was admitted • Presenting condition – chest pain • ? Patient education and expectation is not being dealt with adequately and appropriately

11. Example 3 • Patient (TW) • 31 ED attendances since April 2014 • Out of the 31 attendances she was admitted on 3 occasions • Presenting conditions – chest pain/abdominal pain • She is an IVDU and she presents with vague and non-specific symptoms • ? Who should be managing her

12. Example 4 • Patient (JR) • 14 ED attendances since January 2014 • Out of the 14 attendances, on 5 occasions he was admitted • Presenting conditions - ?overdose/intoxication/withdrawal/vomiting • The patient does not engage with any of the services offered to him

13. Example 5 • Patient (JD) • 8 attendances to ED since January 2014 • Out of the 8 attendances, 5/8 admissions • Presenting conditions – overdose/self harm/abdominal pain • The patient suffers with mental health problems and frequents ED

14. Inappropriate Referrals to ED from the Walk in Centre • CWS – had cauterisation of nose at BCH for recurrent epistaxis • Second post-operative day, Mum took patient to Walk in Centre due to crusting around the nasal cavity • Walk in Centre referred to the ED for ? Infection • Ideally the patient goes back to BCH for post-operative complication or the patient is referred to ENT • Sending to the ED should not be the option

15. Walk in Centre Inappropriate referrals example:- • A well patient with a history of 4 day diarrhoea was referred to ED at the weekend for renal function tests. No history of vomiting. The patient was eating, drinking and well hydrated. • Inappropriate referral to ED • Also the walk in centre doctor told the patient that ED will do blood tests, hence the expectation by the patient that he will have his bloods checked. • This further embeds false expectations amongst patients.

16. Walk in Centre • A patient visited the Walk in Centre during lunchtime because she had taken a few tablets of Lorazepam the night before due to stress • The patient was referred to ED for ? Management of Lorazepam overdose and ? referral to mental health services • This patient could have been managed in the community by the mental health team

17. Alcohol Re-attendances What have we done so far:- • The top 10 alcohol re-attendances and re-admissions – a letter has been sent to their GP, the Commissioner for Alcohol, and Addaction • I would like to arrange a multi-disciplinary meeting which should involve the patient and his/her family, GP, Addaction Services, Mental Health Services • A management plan should be written up

18. Chronic Disease management- integration of community services. • Re-attenders with chronic conditions are identified by the community services – Donna Chaloner is working on this • Multi-disciplinary team approach (Community Nurse, GP and Secondary Care Consultant) should be involved in active management of such patients to prevent acute exacerbations their chronic conditions • Her plan is to continue with the analysis of data and also to develop a database specifically for patients with long term conditions. This will ensure that all community teams have an active caseload of patients that are known to have frequent re-admissions

19. How can we support GPs? • AMU telephone line • Access to Ambulatory care: the Ambulatory team would like to offer their services to the GPs between the hours of 10am to 4pm via the bleep number 2039 held by the dedicated Ambulatory nurse • Access to hot clinics, i.e. gastro, respiratory, diabetic • Access to On-call Specialist Consultant • Timely sharing of good quality information.

20. Future Plans • As per the Bruce Keogh report, plans to be made for elderly patients. This will reduce multiple admissions into the hospital. • Amalgamation of all urgent care services, i.e. ED/Urgent Care Centre/Walk in Centres

21. Help From DOH • Department of Health to change the way that commissioning is done • Department of Health and Government to address patient expectations • Patient education – both in primary and secondary care