a&e improvement programme north region · good practice in the north region case study one –...

A&E Improvement Programme

North Region

Examples of Good Practice in A&E across the North region

December 2016

Background and Context

The challenges facing acute providers in delivering Accident and Emergency (A&E) services effectively,

efficiently, safely and to the required levels of quality are well known. The continued deterioration in

A&E performance has, in the past, generally been met with increased levels of performance

management from system leaders and regulators. This has, unfortunately, proved to be largely

ineffective in arresting the deterioration in performance, as ever-increasing pressures have continued

to result in ongoing poorer performance against the 95% 4 hour target nationally.

NHS Improvement has therefore been working with providers across the north region over the past 90

days to consider and develop an alternative approach and, instead of yet more performance

management, apply an improvement methodology and mind-set. The first phase of the programme has

therefore focussed on delivering a 90 day improvement and innovation cycle across the region to:

• map the patient flow metrics currently in use and work alongside trusts to improve the data

collection and analysis of patient flow metrics in real time;

• identify the ‘best in class’ examples of performance at each stage of the patient pathway for urgent

and emergency care across the region; and

• connect teams to each other to rapidly share best practice.

Phase one of the programme has brought together all acute providers across the region to share

examples of innovation, improvements and good practice. It is evident that there is fantastic and

innovative work being done to manage A&E performance and to do the best for patients in very

challenging circumstances.

Completion of Phase One

The A&E Improvement Summit on 2 December 2016 represents the conclusion of the initial phase

one of the Improvement Programme. This has consisted of:

• 1. Step 1 (days 1-30): review of system data to identify the greatest system constraints and a

self-assessment diagnostic against the secondary drivers. A suite of streamlined patient flow

metrics was developed and a number of key “microsystems” within the overall A&E system

identified.

• 2. Step 2 (days 31-60): learning sessions have been held and specific improvement support

offered to particularly challenged providers. Networks have been strengthened across the region

and mechanisms put in place to better share knowledge of good practice.

• 3. Step 3 (days 61-90): providers asked to test and scale up of the small tests of change,

implementation of further changes and identification of next steps. A number of “masterclasses”

have been held focusing on key themes presenting good practice in place across the region.

Phase one has primarily allowed networks and relationships to be strengthened across the region and

for knowledge and experience to be shared amongst providers. The next phase will be critical in

ensuring examples of good practice are implemented across all providers over all elements of patient

flow.

A&E Improvement Programme Phase Two

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We are aware that the significant challenges affecting A&E performance will require greater, more

sustained and longer-term attention to truly address.

The first phase of the programme has achieved its objectives of sharing learning and connecting

teams - significant further work is required to ensure further practical improvements are made and

embedded and A&E performance improves to meet constitutional standards, supporting improved

patient safety.

Phase two of the programme will focus on building on phase one to work more closely with each NHS

Improvement sub-region to implement good practice and address ongoing challenges.

It is essential that we maintain and build on the high levels of engagement and involvement of all

providers across the region as we move into phase two of the programme to ensure that good

practice is more widely implemented.

As part of phase two, we will also introduce dedicated Improvement Adviser support aligned to each

sub-region ,to provide hands-on support for providers in improving A&E performance. We welcome

and strongly encourage the continued involvement and engagement of all providers during the next

phase of the programme.

Good practice in the North region

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Our work with trusts across the region during phase one of the programme has identified a number of

areas where providers have implemented effective and innovative solutions to improve A&E

performance and patient experience in A&E. We wish to share this knowledge and for all providers to

implement effective solutions where not already in place.

Through our work with providers, we have identified eight “micro-systems” within the A&E patient

pathway where we have seen particular examples of excellent practice. This document captures just

a few examples of the fantastic and innovative work done by providers across the region that we

would like to see implemented more widely across the following area:

Minimise Ambulances Taking Patients

to A&E

Provision of Effective Patient

Information and Advice

Streaming of Patients at the Front

Door

Effective Ambulatory Care

Rapid and Effective Triage

Safely Minimise A&E Admissions

Discharge to Assess Models

Effective Internal Push and Pull

Mechanisms


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The following diagram shows examples of good practice in each “micro-system” already in place across providers in

the north region. We strongly encourage all providers to consider how they compare and to take action to ensure they

deliver best-in-class performance across each micro-system that makes up the patient journey.


Case Study One – Effective Ambulance Assessment

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33% of 999 calls now do not result in a transfer to A&E.

A further 8% of calls are transferred someone other than A&E where the needs of the

patient are better met. As a result, the number of patients attending local A&E

departments is being more effectively managed.

Good Practice: Ambulance trusts should have robust processes in place to support effective decision making and ensure that

patients are only taken to A&E when that is the best course of action for that patient’s needs. A culture needs to be established

within ambulance trusts that A&E should only be used when necessary and staff should be trained to be aware of and consider

alternative care and treatment options.

Key Challenges Faced

Outcomes Achieved

Action Taken – Example of

Good Practice in the Region

Patients will often dial 999 for an ambulance despite A&E not being the most appropriate

service for their health needs. Therefore, ambulance trusts face a significant challenge in

appropriately assessing patients and ensuring that they only transfer patients to A&E who

genuinely need it.

Mark Newton, Head of Service - [email protected] Contact Details

North West Ambulance Service (NWAS) NHS Trust has introduced a range of

measures to minimise the number of patients they transfer to A&E. This ensures that

patients receive the care that is most appropriate for their requirements and reduces the

burden of inappropriate A&E attendances at local EDs. Key action taken to achieve this

includes:

• implementation of a “clinical support hub” providing decision support and a single point

of access for care at home.

• a frequent caller initiative to identify individuals who make regular 999 calls and target

care accordingly, including targeted work with nursing homes.

• introduction of community specialist paramedics to support patients on community care

plans, provide public health advice and to support urgent GP home visits

mailto:[email protected]


Case Study Two – Effective Patient Information

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The North East Urgent and Emergency Care Network has piloted a phone system

whereby patients calling the 111 service are triaged by the call handler, and if the

necessary they are passed on to a ED consultant for further assessment and advice.

This has allowed better assessment of a patient’s care needs and has given patients

greater confidence in the advice they receive. As a result, there has been a genuine,

measurable impact on A&E attendance amongst the local provider population.

Having assessed the return on investment during the pilot phase, recognising the

expense associated with relying solely on ED consultants to provide additional advice,

consideration is being given to implementing a multi-disciplinary team approach with a

mix of consultants, pharmacy, dentists etc. to provide effective advice at a lower cost.

Good Practice: Patients should be provided with direct and effective information/advice in order for them to make a safe,

informed decision on whether A&E attendance is necessary and in the best interests of the patient. Patients should easily know

where to find such information and the information should be easily understood. Patients must have confidence in the

information received to allay any concerns over the need to attend A&E in inappropriate circumstances.


Outcomes Achieved

Action Taken – Example of Good

Practice in the Region

Inappropriate A&E attendance is a significant issue for acute providers nationally.

Many patients attend A&E every day who would be better treated through other means

– such as through primary care, mental health or pharmacy. It is estimated that a 30%+

reduction in A&E attendances could be achieved if inappropriate attendances were

eliminated.

The introduction of the phone-line has resulted in 76% of patients who call not

attending A&E and there has been an overall 2.5% fall in admissions. 34% of patients

receiving advice from the ED consultants over the phone are referred for self-care.

This has been helped relieve the pressures on local EDs in the face of increasing

demand.

Contact Details Gary Collier, Senior Programme Lead – [email protected]



Case Study Three – Streaming at the Front Door

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Central Manchester NHS Foundation Trust has implemented processes that allow

them to stream 25% of patients at the front door of the ED to alternatives –

predominantly an on-site walk-in centre and local GP practices. Key action taken

includes:

• implementing new, much clearer signage, speaking in a language the patient

understands, directing them to the most appropriate place and ensuring the physical

environment does not funnel all patients through A&E.

• ensuring the walk-in centre has the appropriate skill mix (including a GP under the

trust’s management) to prevent unnecessary streaming of patients back to A&E.

• basing a clerk on the front desk who can make GP appointments for patients directly

when that is the most appropriate source of care.

Good Practice: Patients should be streamed to the most appropriate place for them to receive care as soon as possible on

arrival at the ED – which is often primary care, community services, mental health services or pharmacy. A cultural shift is often

required within EDs to recognise that streaming of patients is both in their best interests and in the best interests of those

patients most in need of emergency care.


Outcomes Achieved



Patients often attend EDs despite it often not being the best place to meet their care

requirements. This can be exacerbated when patients have long waits for GP

appointments or do not have easy access to information or advice on alternative

services.

Streaming 25% of patients at the front door clearly significantly reduces the demands

on the ED, but has also had other significant tangible benefits. Since implementing

direct GP bookings, A&E re-attendance rate has also fallen dramatically from 11% to

3%. Patient experience is also enhanced through care needs being met in the most

appropriate way.

Contact Details Marie Rowland, Associate Director Performance – [email protected]



Case Study Four – Effective Ambulatory Care

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Mid Cheshire Hospitals NHS Foundation Trust therefore introduced a new

ambulatory care unit (ACU) to provide a dedicated area for non-elective medical

patients to receive medical assessment. The service includes the daily allocation of a

senior clinician enabling a one-stop service for patients with the ethos that “no medical

patient will stay in hospital if they can be treated and go home the same day”. Through

this unit, the trust now offers an ambulatory care service from Monday to Friday 8am-

10pm combining the skills of a range of staff.

The trust has set specific targets and KPIs for the ambulatory care service by which

they could measure the impact and success of the unit and has continuously

developed its ACU service through, for example, widening its ACU criteria to treat a

greater number of patients and trialling an ACU nurse within ED triage

Good Practice: Effective ambulatory care is essential to ensure that, where appropriate, patients are assessed and treated in a

more appropriate setting than an emergency care bed, and ensure that inappropriate or unnecessary admissions to A&E are

avoided. Patients who are identified as suitable for assessment by ambulatory care during triage should be assessed in this

way, rather than relying on the A&E service and adding further unnecessary demand pressures to the ED.


Outcomes Achieved



In May 2016 Mid Cheshire Hospital closed 28 medical beds as part of the service

redesign. Prior to that, the ambulatory care service was run from a day room on the

bedded primary assessment unit which was not providing the optimum environment for

the service to run effectively.

The actual percentage of acute medical take treated by the ACU in the last 25 weeks

was 33% and the discharge rate from the ACU to patients’ homes over the last 25

weeks has been 53%, both ahead of target. Furthermore, there has been rapid decline

in the number of hours medical patients referred from GPs spent waiting in ED.

Contact Details Tony Mayer, Divisional Medical Director – [email protected]



Case Study Five – Rapid and Effective Triage

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Doncaster and Bassetlaw NHS Foundation Trust has put qualified nurses on the

front-desk within the A&E department to simultaneously clerk and triage patients on

arrival at A&E rapidly. This has had a significant positive impact on the trust’s ability to

rapidly triage patients and has eliminated an unnecessary additional step in the patient

journey when attending A&E.

The trust has also implemented an easy-to-use IT system for triage, utilising numerous

drop-down menus that allow a patient’s condition to be quickly assessed and recorded.

Staff have been involved in the system design and trained to use the system effectively

and efficiently.

Good Practice: Patients should be triaged as soon as possible on arrival at A&E to allow their needs to be assessed quickly

and be directed to the most appropriate place to receive the care they require – whether that is admittance within A&E or

elsewhere. Staff responsible for triaging should be aware of, and trained on, the importance of rapid triage and the criteria for

A&E admittance. Rapid triaging of patients also increases patient safety through getting the patient to where they need to be

faster, and significantly improves the overall patient experience.


Outcomes Achieved



As a result, on average patients are now triaged in just 3.5 minutes from being seen at

the front desk. Assessing the patient’s needs rapidly maximises the time available to

meet the four-hour target and enhance the patient experience dramatically. Patients are

streamed to the most appropriate care setting faster.

Delays in triaging patients slows down patient flow through the department and can

reduce the time available to, where necessary, see and admit the patient within the

four-hour target. IT systems, staff skill mix, or departmental processes can hinder

patients being triaged quickly.

Contact Details Samantha Sidwell, Matron for Emergency Services – [email protected]



Case Study Six – Minimise Admission Rate

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County Durham and Darlington NHS Foundation Trust has implemented a range of

measures to minimise admission rates to A&E, with particular focus on the interaction

between the A&E department and the AMU. These measures include:

• ensuring all admissions are discussed with a senior decision maker prior to

admission, including out-of-hours admissions.

• developing processes to allow direct referrals to the AMU rather than requiring

admittance to A&E as a preliminary, unnecessary step.

• ensuring there is an regular, ongoing two-way dialogue between A&E and AMU staff

to ensure referral/admittance decisions are reviewed and challenged

• AMU consultants regularly coming into the A&E department to aid assessment and

“pull” patients from A&E where appropriate.

Good Practice: When possible (i.e. when safe and in the patient’s best interest), patients presenting at A&E should not be

admitted. Admitting patients unnecessarily generally leads to poorer patient outcomes and adds additional strain to already

stretched EDs. This can be particularly relevant for the frail and elderly, where outcomes are very often significantly better if

admittance can be avoided. All acute providers should therefore have robust processes, utilising multidisciplinary skills, for

assessing if A&E admission is in the patient’s best interest and apply them consistently.


Outcomes Achieved



The culture of an organisation can often be to admit patients as a default position, as

A&E is often, incorrectly, regarded as the safest place for patients to be. The risk

appetite of organisations or individual staff can result in admission rates being higher

than they need to be. Staff need to understand when admittance is absolutely

necessary and the impact on outcomes of admitting patients inappropriately.

Through implementation of these measures, the trust has admitted between just 10 -

19% of patients to A&E year-to-date. This has significantly reduced the demand

pressures within A&E and has ensured patients are treated in the most appropriate

setting.

Contact Details Kerry Dawson, General Manager Acute & Emergency Care – [email protected]



Case Study Seven – Effective Push and Pull

Mechanisms

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University Hospital South Manchester NHS Foundation Trust has implemented a

dedicated service (OPAL) within A&E to identify and treat frail older patients who would

benefit from specialist care from a geriatrician. The OPAL service has defined and

documented specific criteria to identify patients who would benefit from their care, and

proactively “pull” patients from A&E to provide specialist care.

The OPAL team has increased training and awareness both within the hospital and with

patients and their families about the benefits of the service. The team has also

strengthened links with local community services, recognising that these services are

critical in keeping frail older people out of hospital and achieving better patient outcomes

and experience.

Good Practice: A well-functioning A&E department is reliant on effective push and pull mechanisms to/from other hospital

departments to ensure that patients are moved to and are treated by the most appropriate department as soon as possible.

Effective processes should therefore be in place to “push” patients from A&E to the relevant departments, and for the relevant

departments to regularly and consistently “pull” patients in from A&E.


Outcomes Achieved

Action Taken – Example of

Good Practice in the Region

Demand pressures within a hospital can often bottle-neck within the A&E department

whilst many patients within the department would benefit from care by other hospital

departments. In the case of frail older patients, once admitted within A&E the patient can

often decondition rapidly resulting in longer lengths of stay and poorer patient outcomes,

meaning an A&E bed is often not the optimum place for them to receive care.

The average length of stay for frail and older patients was reduced from 5.75 to 3.8 days

when treated through the OPAL service during the trial period, demonstrating tangible

benefits. The conversion rate for patients over 80 years was 37.5% during the first four

months compared to 57.9% NE and there has been a 21% increase in discharges for

patients over 90 years old.

Contact Details Dr Sally Briggs, Consultant Geriatrician – [email protected]



Case Study Eight – Discharge to Assess Models

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City Hospitals Sunderland NHS Foundation Trust has introduced multi-professional

teams, combining the skills of physios, OTs and assistant practitioners on a 7 day

basis, working across A&E, the emergency admission unit and emergency short stay

to identify and assess patients who are medically fit to go home and would benefit from

treatment outside of an acute setting. The team’s purpose is to ensure patients who

can be discharged home, are discharged same day with the essential support, and the

teams also act as the “Trusted Assessor” for community services to prevent repetition

of assessments.

The trust has also worked closely with partners to implement a “Recovery at Home”

service to smooth discharge across health and social care boundaries. Further work is

being undertaken to expand the discharge to assess process to back of house wards,

further reducing length of stay.

Good Practice: Patients very often have care needs that do not require them to be treated in an acute hospital bed. In these

cases, it may be most appropriate to discharge the patient to their home, or other community setting, and provide treatment

outside of an acute care environment. This can significantly improve the patient experience, often has a beneficial impact on

patient outcomes, and relieves demand pressures on A&E departments.


Outcomes Achieved



Patients continue to attend A&E despite the ED often not being the most appropriate

care setting to meet their needs. It is often challenging to quickly identify these patients

and to implement care packages at the patient’s home or within a community setting.

Once a patient is admitted to an acute bed for a prolonged period of time, it can be

particularly challenging to implement a discharge to assess approach due to patient

expectations and/or the deconditioning of the patient in an acute setting.

The interface team sees 100% of ED patients within 60 minutes, with an average

response time of 8 minutes. 71% of patients assessed in ED return to their own

home. The trust has achieved an additional 3% admission avoidance and an

increasing number of patients are being treated in a more appropriate care setting.

Contact Details Angela Gillham, Divisional General Manager - [email protected]


Best in Class Performance –

Please Share Your Achievements

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This document highlights just a few examples of good practice and innovative initiatives amongst the

very many we have identified through phase one of the Improvement Programme across the region.

We are very keen to continue to identify examples of best-in-class performance and share activities

that providers have found are making a genuine, measurable improvement to A&E performance.

Ensuring these examples are tailored to local needs and implemented more widely across the region

will form the basis of Phase Two of the programme.

Please continue to share your knowledge, experience and achievements with us:

[email protected]

Further Reading

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For more information on the many examples of excellent practice across the region, please refer to

the NHS Networks website. All presentations from the learning events and recent masterclasses

have been uploaded to the site which provides a wealth of further information.

To access the NHS Network:

If you haven’t already, you’ll need to register with NHS Networks:

https://www.networks.nhs.uk/@@register

You can then find our network either using the search function or by following this URL:

https://www.networks.nhs.uk/nhs-networks/ urgent-emergency-care-improvementcollaborative

Click “Apply To Join” just under the grey banner and enter your login details. We will then accept your

application and, once done, you’ll have access to the whole network.

Our sincere thanks to all providers across the region for engaging so well with the first phase of the

programme. The examples of good practice we have seen have been hugely impressive and inspiring

and we would like to see many of these initiatives implemented more widely across the region. We

ask that you continue to engage with the programme during the next phase.

Thank you to all providers who have spared their time to attend and present at events during

such a busy period. We are really grateful for your contributions.

Acknowledgements

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