Mark Poulden Lead Consultant in Emergency Medicine Andrew Carruthers Directorate Manager Medicine ABM University NHS

1. “Making the front door work!” Mark Poulden Lead Consultant in Emergency Medicine Andrew Carruthers Directorate Manager Medicine ABM University NHS Trust

2. COMPETING DEMANDS & TARGETS Reduce emergency admissions Emergency Department 95% 4 hour Waiting time IP/OP/DC ED Saphte scores within acceptible limits Reduce LOS Achieve EWTD targets Reduce DTOCs Evidence based clinical effectiveness Financial Stability Reduce cancellations due to lack of bed

3. Remember the patient We work hard and don’t succeed We don’t work together It feels like a mammoth task…..so do nothing New approach to team-work What do you do – can it be done differently Where do we start?

5. How Did it start? • Accept that 95% was hospital (system) not ED target. • Realisation that it should drive/derive from better patient care. • Streaming patients in the hospital as well as at the front door – learning and sharing things previously thought of as separate! • Form following function – processes changed before the geographical change – do not wait until the new build • A leap of faith that this could work WITHIN current recurrent resources – it would otherwise never have been done • Along came WECAC…………..

6. Bro Morgannwg Emergency Services Transformation (BEST) programme:Ingredients for success • Strong, enthusiastic clinical leadership • Supported and driven by committed management team • Executive champion • Mapping processes/pathways: identifying constraints, delays, duplication • Focus – determine what will make a difference, not what may be interesting……. • Use information/tools/techniques/evaluation • Learn from others/share good practice • Small step changes (PDSA cycles), Theory of constraints, LEAN methodology etc.

7. Key Diagnostic Work • Process Mapping • Key elements of process mapped during August / Sept • 7 day ED analysis • August 2004 – yielded limited information • Breach analysis • From September 2004 – over 5000 individual breaches analysed • In patient flow analysis • February 2005 – helped understand admission / discharge gap • In patient ‘snapshot’ audit • May 2005 – helped understand issues associated with clinician review, diagnostic delays and discharge planning

8. Model for improvement Specific aims Measurement – where are the problems? What will lead to improvement? Ask why? - all the time Plan-Do-Study-Act cycle Simple things Incremental change Improvement Collaborative approach

9. Success factors • Streaming • Frontload Decision Makers • Clinical Pathways • Some easy wins • Access to diagnostics • Clinically driven IM&T • Minimise Duplication • Joined up working • Continual Processing • Bed management • Discharge planning

10. Bringing Together Individual PDSA’s

15. Early Success – Minors Streaming Weekdays Weekends Before After

16. BRATZ • Triage removed • Team • All patients for assessment • Assessment • Initiate treatment • Initiate Investigations (Recipe Book) • Who can see • Where can go

18. BRATZ Issues…….. • Big investment • Safer • Increase use of XR • Difficult • How much time • 24/7 • Peak times • Consultant & middle grade shortages

19. Traditional Patient Pathway Arrive & Book in Triage Emergency Dept SHO Have a think Do some tests Consultant Discharge Do take homes Have a think Results available Take homes ready Refer to Specialty Specialty Tests Can go home Serum rhubarb Transfer to “ology” ward Care package cancelled Plan “senior review” Seen by consultant “ologist” Seen by Specialty SpR Refer to “ologist” Decision to Admit Seen by on call consultant Transfer to MAU

20. Process Segregated Silo Working Uniform Efficient Collaborative Team

21. Clinical Pathways - Duplication • High Impact (numbers/problems/evidence) • Multi-specialty • Diagnostic support • Beware “best fit” • Documentation from front door • Pooled juniors – 1st one completes • Added value at each step

22. New Patient Pathway Arrive & Book in & streamed to appropriate area/service Senior decision maker plans care Discharge as planned Active bed management Care Pathway with EDD Discharge planned inc TTH & care “Prescribed” investigations Seen by appropriate team Team “dooer” Transfer to appropriate bed

24. Process developments…… • Generic doctors or doctors with generic skills? • Clerking quality • Teamwork vs work avoidance • Clinical responsibility (senior & junior) • Communication with primary care

25. Rapid Diagnostics • Access to diagnostics where decisions can be made on admission and discharge • Access to urgent out patient tests • Dedicated slots each day for previous days admissions • Access to tests 7 days a week

26. IM&T PDM (Patient Duration Monitor)

27. What PDM has delivered • Introduced data entry as part of clinical process • Real time view of department status • Visual aid to pre-empt potential breaches • Patient whereabouts • Clinical usefulness • And demonstrated potential…

29. PIMS+: Using technology as a tool to improve clinical processes • Traffic light concept • Live view of Inpatients by: • ward • expected date of discharge (EDD) • Driven by simple, easy to use ADT functions • Helping to manage the discharge process • Managing beds in a live environment • The potential to use live information to streamline other processes

30. IM&T next steps…….. • Dependance • Accuracy & timeliness • Confidentiality • ETOC – time/rapid enough • Stepwise EPR or wait??? • Clinically useful vs beancounting

31. Bed Management • Bed finding • Critical level of occupancy • Forecasting tools (ADT matching) • Real time bed monitoring • Not just walking the wards

32. Discharges • Ward rounds/discharge decisions 7days a week • Discharge planning from day 1 (pull rather than push) • Pharmacy • Discharge lounges • Early social care involvement • Discharge facilitators

33. In hospital process……. • Nurse facilitated • Weekend/OOH plan • Specialist nurse (DN, Resp, Card) • Patient to ward vs doctor to patient • Specialist vs generalist • Tertiary transfers • Elderly Care PDSA / NH Ward rounds?

34. Processes had to be in place BEFORE building work started – to compensate for the loss of space/facilities

35. Clinical Decision Units • No size fits all (28 beds/trolleys?) • Personalities • Agreed clinical pathways • Rapid turnover - Continual “processing” • Multispecialty including ED • Joined up working • 24hrs / 7 days a week / 365 days a year • Location & Design “By defining the top 10 presenting symptoms and developing pathways most hospitals could improve the care of 80-90% of their emergency admissions”

36. Ambulatory 48 Hr 24 Hr 4 Hr Minors

37. CDU next steps… • CDU size • Suffers from effectiveness • Ineffective when inappropriate • Ambulatory evolution • Role of ACP vs OCP • Knock on effect on ward (LOS & dependency)

38. Primary DECS focus ?

39. Capacity Issues – bed occupancy

40. Efficiency Clinical Effectiveness Capacity

41. 95% target… 92% Nov 2008

42. What’s worked for us • No single factor responsible for improvements • Combined impact of multiple changes to processes including: • Changes to ED working • PDM – live information / breach prevention • Sieve and Sort / See and Treat • Majors assessment • Changes to Acute Assessment processes • Acute Care Physician • ED interface improvements • Improvements in diagnostics and discharge • Changes to inpatient flow management • PIMS+ • Estimated dates of discharge • Transfer teams / discharge pull

43. Resource Issues

44. Effective resources? • Clinical engagement and lead from the start – involving several Directorates; • High profile Executive input and robust senior management leads; • Process issues addressed – detail (e.g. when Trop T taken/analysed) and staffing (identifying when required); • Empowering staff and encouraging PDSA cycles – have a go! • Reorganisation of job plans, leading to introduction of 2nd Acute Care Physician; • Reorganisation of Directorate structures to improve communication and remove any perceived barriers • Streaming – senior presence at extended triage, ambulatory streams, 24 and 48 hour areas, and also ward based working • Availability of “live” data – after breach takes place is too late! • Changes to geographical layout – bringing three separate areas together • Analyse impact – daily, weekly and monthly information – keep on top of things!

45. Cannot be seen in isolation…….. • Hawthorne Effect • Sustainability • (March madness) • Knock on effects • Generalisation

46. Challenges for DECS • Consistent initial assessment & streaming pathway. • Realistic configuration of all UCS – safe, sustainable & clinically effective vs politically driven. • Balanced capacity. • Suitable & timely services for an ageing population.

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