ambulatory emergency care - change champions · 2015-07-03 · background ambulatory emergency care...
TRANSCRIPT
Ambulatory Emergency Care
Background
Ambulatory Emergency Care is a way of managing a
significant proportion of emergency patients on the same day
without admission to a hospital bed
It is a transformational change in care delivery – AEC has the
potential to be as significant to emergency care as day case
surgery is to elective care
Cohort One
• Calderdale &
Huddersfield
• Harrogate
• Hull
• Leeds
• Liverpool
• Nottingham
• Plymouth
• Tyne & Wear
• Weston
• Whittington
Cohort Two
• Bath
• Bristol
• Gloucester
• Imperial
• Milton Keynes
• North Cumbria
• North Lincs
• Pennine
• Pilgrim
• Stockport
• Warrington
Cohort Three
• Addenbrookes
• Ashford CCG
• Chester
• Dudley
• East Sussex
• Guys & St Thomas
• Heart of England
• Ipswich
• Kettering
• Peterborough
• Sandwell and West
Birmingham
• St Helens and &
Knowsley
• Worcester
Cohort Four
• Barnsley
• Basildon
• Croydon
• Epsom
• Heatherwood &
Wexham
• Herts Valleys CCG
• Kingston
• Northampton
• Northwick Park
• St Heliers
• St Georges
• Southport &
Ormskirk
• UCLH
Directory of AEC for adults
What’s in a name?
Ambulatory Emergency Care
Clinical Decisions Units
Same Day Emergency Care
What is AEC?
“Ambulatory care is clinical care which may include
diagnosis, observation, treatment, and rehabilitation, not
provided within the traditional hospital bed base or within the
traditional out-patient services that can be provided across
the primary/secondary care interface”.
The Royal College of Physicians – Acute Medicine Task Force & endorsed
by the College of Emergency Medicine, 2012
….What is it about?
• Improving patient experience
• Reducing waits for tests
• Early and frequent senior review
• Improving patient flow
And so better outcomes for patients
Emergency Care is a wicked problem A social or cultural problem that is difficult or impossible to solve because • Of incomplete or contradictory
knowledge • Of the number of people/opinions
involved • Of the large economic burden • Of the interconnected nature of this
and other problems • Solutions, depend on the framing
of the problem, may be only partially correct, lack evidence and are not definitive, they require an iterative approach.
What’s to blame?
• Patients • GPs • Staffing levels in emergency departments • Acuity • Admissions • Discharges • Finances
Bed occupancy is increasing
Acute admissions per bed per year
Solutions often: • Miss the point – e.g. focus on ‘minors’ • Are vigorously opposed • Lack clarity – ‘care closer to home’, ‘integration’ • Are misguided – opening more hospital beds
So what to do?
*See Purdy, S et al. Interventions to reduce unplanned hospital admissions, 2012
The evidence base for what does works is strong
Most studies suggest that admissions can be avoided in 20-30% of >75 year old frail persons
“Avoiding admissions in this group of older people depended on high quality decision making around the time of admission, either by GPs or hospital doctors. Crucially it also depended on sufficient appropriate capacity in alternative community services (notably intermediate care) so that a person’s needs can be met outside hospital, so avoiding ‘defaulting’ into acute beds as the only solution to problems in the community”. Mytton et al. British Journal of Healthcare Management 2012 Vol. 18 No 11
As well as tackling avoidable admissions, we must: Optimise hospital care:
• Systematic, early, multidisciplinary assessment of frail older people (CGA – comprehensive geriatric assessment)
• Improve patient flow through hospitals • Prioritise discharge planning • Discharge to normal residence– avoid bedded
destinations • Assertive short stay and ambulatory care
Non-elective admissions >65 years per weighted head of population. FT Network Survey .
Failure to assertively manage elderly people leads to rapid, in-hospital decompensation, extended inpatient stays and poor outcomes. See Silver Book.
Trusts with early comprehensive geriatric assessment have 33% fewer admissions than those that don’t
Nine principles of great patient flow
• Early senior review
• Daily senior review
• A focus on discharge and case management
• Continuity of care
• Appropriate standardisation and matching capacity to demand
• Key services must run seven days a week and late evenings
Principles of great patient flow (continued)
• Standardise and manage response times
• Ambulatory emergency care as the ‘default’ position
• Cohort admissions into short stay, frailty and organ specialty streams, with minimal handovers, to optimise outcomes and resources (manage low volume, critically conditions, separately)
As well as tackling avoidable admissions, we must: Optimise hospital care:
• Systematic, early, multidisciplinary assessment of frail older people (CGA – comprehensive geriatric assessment)
• Improve patient flow through hospitals • Prioritise discharge planning • Discharge to normal residence– avoid bedded
destinations • Assertive short stay and ambulatory care
Home
Care Home
Home Care
home
Care Home
Home
Hospital
12.3 days
14 days
31.7 days
Initial residence
Discharge location
Hospital average length of stay
Avoid ‘bedded’ discharge destinations – we should ‘discharge to assess’.
FTN Benchmark March 2012
So, does emergency care need radical change? Likely trends • Centralising some services (stroke, heart attack, vascular) • Reduction in number of urban emergency departments • More investment in community health services • Confederation of primary care to work at greater scale • Confederation of hospitals • Vertical integration of hospitals, community services,
primary care confederations and social care But most change will be in a drive towards systematic implementation of good practice, particularly in hospitals
Managing byFlow Streams Identify the stream
Short stay Sick specialty Sick general Complex
Allocate early to teams skilled in that stream
Vincent Connolly
0
50
100
150
200
250
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59
Length of stay (days)
Nu
mb
er o
f p
atie
nts
Clarity of specialty criteria Specialty case management plan at
Handover – no delays Green bed days vs. red bed days
Short stay – manage to the hour Maximise ambulatory care
Complex needs – how much is decompensation? Detect early and design
simple rules for discharge
Minimise handover Decompensation risk
Early assertive management Green bed days vs. red bed days
Pareto Analysis
Glenday Sieve
30%
20
80 50% of demand = 7% of types: Green stream: ‘Runners’ \
15%
5% of demand: Red stream: Rare Strangers
Sick Specialty
0
100%
Cumulative Demand
LOS
Sick General
Short Stay
Complex
0%
20%
40%
60%
80%
100%
120%
1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 61 64 67 70 74 77 80 83 87 90 97 100103106110113130141147199233
Length of Stay (Days)
A Hospital: LOS Cumulative Profile –understanding LoS by Flow Stream
Excluding Obstetrics, Midwifery and Paediatrics Excluding zero LOS
50% 4 midnights 80% 10 midnights 95% 23 midnights
0%
20%
40%
60%
80%
100%
120%
1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 61 64 67 70 74 77 80 83 87 90 97 100103106110113130141147199233
% O
BD
Length of Stay (Days)
A Hospital: Cumulative Occupied Bed Midnights (OBD) by LOS - Understanding bed use
Excluding Obstetrics, Midwifery and Paediatrics Excluding zero LOS
4 midnights = 15.7% OBD 10 midnights = 41.1% OBD 23 midnights = 73.6% OBD
Capacity is decision makers & action takers
not
cubicles, beds, trolleys, chairs
etc – hold that thought.
Little progress
DSU vs Day Ward
Self-contained unit
Day surgery ethos
Functionally separate
Ringfenced
Efficient
Finite capacity
Duplication of skills
Duplication of resource
Ward-based day unit
Day surgery ethos
Relatively ringfenced
Easily expandable
Retains specialist (theatre) expertise
Flexible
Potential for mixed lists
Both models can be highly successful
Specialist Units
Model of care
Orthopaedics, 2005
Dedicated DSU
Inpatient “day beds”
Number of cases
634
642
Unplanned admission rate
13 (2.1%)
108 (16.8%)*
Fehrmann, et al. — J One-day Surg 19: 39, 2009
* p <0.01 from dedicated DSU
All day surgery, 2008
Dedicated DSU
Satellite DSU
6,419
1,015
64 (1%)
27 (2.7%)*
Written Information
What to expect
Wound care
Analgesia
Follow-up
Return to work
Warning signs
Emergency contact
Default to Day Surgery
Suitability for day surgery Pathway
Clearly suitable
Unsure
Clearly unsuitable
Day surgery Home if ok
Inpatient care ? Home if ok
Inpatient care Hospital stay
20–30%
5–20%
40–65%
Maintaining Quality & Safety
The aim is NOT shorter LOS
Better preparation
Better information
Better care
Less trauma
Less ill
Better recovery =
Shorter stay
Background • Ambulatory Emergency Care is a way of managing a significant proportion
of emergency patients on the same day without admission to a hospital bed
• It is a transformational change in care delivery – AEC has the potential to
be as significant to emergency care as day case surgery is to elective care
Updated version
VConnolly
Categories of Ambulatory
Emergency Care 1.Diagnostic exclusion group • Eg chest pain rule outs etc (many already in place) 2.Low risk stratification group • Eg low Rockall score GI bleed 3.Specific procedural group • Eg effusion drainage 4.Infra-structural group • Eg care home admissions
Model Of Acute Care
Ambulatory
and Short
Stay Unit
Home
Social
care
D+T -
OPA
IC
Discharge plan and case management
‘Making it Happen!’ – Publicise Performance
Specialist units
VS GIM >2 days
– don’t confuse!
Complex
discharges –
detect early
Decision
to admit
Handover = Handoff = Increased LOS
Em
erg
en
cy N
ee
ds
As
se
ss
me
nt
Serv
ice
RA
T/S
TA
R +
/- S
IFT
Row Labels
Total current
ambulatory: 0 day
spells
Total ALL
ambulatory
spells
Minimum shift
Potential:0 Day
Spells
Maximum shift
Potential:0 Day
Spells
Ambulatory
Potential for all
non-0 Day Spells
Sum of
Opportunity
- Low (£)
Sum of
Opportunity
- High(£)
Ealing Hospital NHS Trust 792 1530 82 262.0 17.12% £47,112 £173,152
Northumbria Healthcare NHS Foundation Trust 1959 4502 313 1027.3 22.82% £213,940 £723,752
Newham University Hospital NHS Trust 804 1892 140 449.1 23.74% £73,386 £247,368
Southampton University Hospitals NHS Trust 1401 3290 254 831.8 25.28% £99,746 £459,594
Chelsea and Westminster Hospital NHS Foundation Trust 580 1413 100 366.1 25.91% £41,769 £155,899
Airedale NHS Foundation TrustAcute headache 14 9 * * 30 0.0 0% 4.0 13% £0 £0
Airedale NHS Foundation TrustAcute painful bladder outflow obstruction* 9 8 * 23 10.8 47% 17.7 77% £3,005 £7,217
Airedale NHS Foundation TrustAcutely hot painful joint * * 0 * 8 0.0 0% 1.6 20% £0 £0
Airedale NHS Foundation TrustAnaemia 0 * * 6 10 6.0 60% 9.0 90% £6,470 £10,356
Airedale NHS Foundation TrustAppendicular fractures not requiring immediate internal fixation* 7 * 11 25 12.0 48% 19.5 78% £6,336 £15,840
Airedale NHS Foundation TrustAsthma 6 8 * 16 * 0.1 0% 4.5 13% £0 £288
Airedale NHS Foundation TrustCellulitis * * 9 34 51 25.6 50% 40.9 80% £22,553 £37,762
Airedale NHS Foundation TrustChest pain 105 105 17 25 252 0.6 0% 46.2 18% £1,428 £2,856
It builds on existing NHS Institute offers Data that is available on the NHS Institute website shows the potential tariff savings related to the conditions in the directory for each NHS organisation
We also have the data down to condition level for each organisation
These data suggest that the potential tariff savings related to ambulatory
emergency care is in the region of £373 million per year
Which type of doctor?
Acute Physician General Physician
• Specific training
• Focus on acute med
• Assessment & 1st 48
hours
• Will develop acute med
• Out of hours
Generic training
Holistic approach
Long ward rounds
Office hours
Redesign
• Focus on decisions, tasks & workflows to optimise care
• Sort out the high variation
• Reconfigure the supporting infrastructure to match the redesigned clinical processes
• Design structures and processes to help learning from daily work
• Fixing Healthcare from Inside and Out, Harvard Business Review
Vincent Connolly
Vincent Connolly
Emergency Care is a complex problem!
@ECIST