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Refining and Redefining Emergency Flows

Refining and Redefining Emergency Flows. Dr Veronica Devlin Programme Lead Service Improvement and Clinical Governance Emergency Care. Resus <5% Majors 40-45% Minors 55-60%. Admitted, by specialty Assessment majors Minors Planned returns Ward work. Defining flows.

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Refining and Redefining Emergency Flows

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  1. Refining and Redefining Emergency Flows Dr Veronica Devlin Programme Lead Service Improvement and Clinical Governance Emergency Care

  2. Resus <5% Majors 40-45% Minors 55-60% Admitted, by specialty Assessment majors Minors Planned returns Ward work Defining flows

  3. Patient Numbers Accident & Emergency March-May 2009 (3months)NHSL Overall No Follow Up # 28,302 54.0% Avg. 107 min GP follow up A&E # 7,912 15.1% Avg. 113 min Minors 32,388 61.8% Medical 8,620 16.5% 52,398 Acute ass. 7,713 14.7% Surgical 3,595 6.9% # 7,973 15.2% Avg. 144 min Emergency Receiving Unit Deaths 82 0.2% Admission # 5,190 9.9% Avg. 137 min # 3,021 5.8% Avg. 81 min Other* *e.g. Other Hospitals, Primary Care Emergency Centre

  4. Theory…..

  5. Practice….

  6. History of specialty • 3 ED’s • Fewer middle grades • Recruitment issues • Retention issues • Casemix challenge • Access block • Audit Scotland • Quality standards • Delivery

  7. Theory….

  8. Practice…

  9. Lean in emergency flow

  10. Lean principles • Specify value • Map the value stream (patient flow) • Implement flow • Establish pull where you can’t flow • Work to perfection • Voice of the customer

  11. Lean tools • Standard work • Standard operating procedures • Managing variation • Metrics • Dashboards

  12. In God we trust all others must bring data

  13. Deming • You can’t manage on visible figures alone • Figures on the most important areas of management may be unknown or unknowable, and successful managers must nevertheless manage those areas.

  14. Vital Signs - measurement • ED • TTFA • DNW’S • Unplanned returns • Planned returns • Delays to care

  15. Admission/discharge balance Discharges before noon Diversions 8 and 12 hour delays to care Boarders Additional beds Delayed discharges Length of stay on Medical Receiving Unit Total hospital length of stay Diversions Cancelled electives due to lack of capacity Surge capacity Use of off site beds Vital Signs - measurement

  16. Monklands • Minors flow • Majors pitstop • ACE • GP assessment bay

  17. minors

  18. Minors flow Monklands • Maintaining operation • Timing of stream operation • Staffing • Operational set up • Monitoring • Follow up arrangements

  19. reception store xray Patients had to go outside after registration

  20. store reception Patients’ journey contained within the department – and no compromise in Waiting Room space xray

  21. Majors Pitstop • Proof of concept • Dedicated approach for assessment of majors • Negotiated diagnostics • Senior decision-making • Average tat 102 minutes during trystorm

  22. Majors pitstop

  23. GP assessment bay • Complete team based assessment • Meds rec • Admission avoidance • Decide to admit vs admit to decide

  24. Implement ASSESSMENT BAY and ACE

  25. Hairmyres STATUS CHANGE • Medical Assessment bay • Minors flow • CPAU pathway • Stroke pathway

  26. LENGTH OF STAY AMRU Dashboard Patient moves Before noon am/pm Ward Round Start Times Key Performance Indicators Ward Pull Parent Specialty Mix Porter Response Times Admissions vs. Discharges & Transfers MAB Performance Surge Beds

  27. Sustainability Change Detail 4 Trolley bay in AMRU for the review of GP referred medical patients between 9am and 7pm weekdays) Medical Assessment Bay (MAB) Consistent staffing, bed availability Ambulance Service/ERC Criteria for access. Key Performance Indicators 25% of patients Discharged from MAB

  28. Change Detail Sustainability 4 Trolley bay in AMRU for the review of GP referred medical patients between 9am and 7pm (weekdays) Medical Assessment Bay (MAB) Consistent staffing, bed availability ? Senior Decision Maker availability in MAB Was 9% Now 18% admitted in <2hrs Key Performance Indicators MAB journey time 37 mins less than A&E MAB TTFA 30 mins less than A&E From 48% to 33% Admitted between 210 & 240 mins

  29. ChangeDetail Sustainability • Visual management • Target driven • Updated and reviewed daily • Also for surgical and medical flow • Monitors individual ward performance Daily Dashboard

  30. Positives Excellent clinical engagement Data driven Perceive the service from customer viewpoint But….

  31. Reshaping Emergency Medicine • Clinical Director • Consultant appointments • Review of skillmix • Standard operating procedures • Quality Standards • Safety Brief • Roles and Responsibilities redefined

  32. Consolidate core service

  33. Non core ED work

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