managing pressures in an acute setting grant archibald director emergency care & medical...
TRANSCRIPT
MANAGING PRESSURES IN AN ACUTE SETTING
Grant ArchibaldDirector Emergency Care & Medical Services
10TH JUNE 2011
A Short Introduction to Queuing Theory
AndreasWilligJuly 21, 1999
The subject of queuing theory can be described as follows:
consider a service centre and a population of customers, which at some times enter the service centre in order to obtain service. It is often the case that the service centre can only serve a limited number of customers. If a new customer arrives and the service is exhausted, he enters a waiting line and waits until the service facility becomes available. So we can identify three main elements of a service centre: a population of customers, the service facility and the waiting line.
Managing Pressures in an Acute Setting
Key Parameters
• NHSGGC - 9 Acute Hospital Sites
• 465,000 A&E attendences per year
• 161,000 emergency admissions per year
Managing Pressures in an Acute Setting
NHSGGC - UNSCHEDULED CARE COMPLIANCE BY MONTH - APRIL 2006 TO APRIL 2011
80%
82%
84%
86%
88%
90%
92%
94%
96%
98%
100%
Apr-0
6
Jun-
06
Aug-0
6
Oct-06
Dec-0
6
Feb-0
7
Apr-0
7
Jun-
07
Aug-0
7
Oct-07
Dec-0
7
Feb-0
8
Apr-0
8
Jun-
08
Aug-0
8
Oct-08
Dec-0
8
Feb-0
9
Apr-0
9
Jun-
09
Aug-0
9
Oct-09
Dec-0
9
Feb-1
0
Apr-1
0
Jun-
10
Aug-1
0
Oct-10
Dec-1
0
Feb-1
1
Apr-1
1
% C
OM
PL
IAN
CE
Managing Pressures in an Acute Setting
UCC Performance
Chart shows a steady build up of performance figures as improvement
work begins to take effect in the departments :
• April 2006 – 81% compliance • December 2007 – 98% compliance achieved for the first time • 98% achieved in 18 of the following 22 months as
improvements are embedded and sustained • Numbers of attenders and admissions increasing in A&E
across NGSGGC
However, it also shows a recent period of decline and then partial
recovery – what has changed?
Managing Pressures in an Acute Setting
System pressure builds through 2010/11 (1):
• Pressures re Delayed Discharges • Patients moving more slowly through the system
• ASR - Re-design of Services
• Winter Pressures – Extreme snow fall/freezing icy conditions– Increased number of H1N1/Flu like/Respiratory illnesses
Managing Pressures in an Acute Setting
System pressure builds through 2010/11 (2):
• Significant increase in emergency activity and admissions
• A&E attenders – 24th December to 7th January 2011: 5% increase on previous year
• Emergency Admissions – 25th December to 7th January 2011 : 9% increase on previous year– 1st to 3rd January : 17% increase on previous year– 3 days when emergency admissions exceeded 500 patients– 3 days when emergency medical admissions exceeded 300 patients
• Continued attender and admission pressures through most of January 2011
Managing Pressures in an Acute Setting
NHSGGC - TOTAL EMERGENCY ADMISSIONS BY DAY24 DEC - 07 JAN
200
250
300
350
400
450
500
550
24/1
2/20
11
25/1
2/20
11
26/1
2/20
11
27/1
2/20
11
28/1
2/20
11
29/1
2/20
11
30/1
2/20
11
31/1
2/20
11
01/0
1/20
12
02/0
1/20
12
03/0
1/20
12
04/0
1/20
12
05/0
1/20
12
06/0
1/20
12
07/0
1/20
12
DATE
EM
ER
GE
NC
Y A
DM
ITS
PE
R D
AY
2009-10
2010-11
Managing Pressures in an Acute Setting
Response to managing key pressures in system (1)
Immediate : •Implemented Escalation Policy•Opened additional capacity•Increased Home Visiting by GPs/Primary Care services
Longer Term :Understand Changes in Demand profiles
•Continuing to progress planned improvements in length of stay and bed usage•Ongoing management of delayed discharges•Reviewing plans to deal with any exceptional peaks in emergency activity•EDD•Reviewing Outcomes of A&E Patient Audit and Inequalities Audit•A Review of all out of hospital measures – HEAT 10 Work Programme
Managing Pressures in an Acute Setting
Response to managing key pressures in system (2)
•System wide Improvement Action Plan for Unscheduled Care (ATOS)
•March 2011 – Flow Mapping•Local team engagement to identify patient processes
•May 2011 – Stakeholder Engagement Event – whole system•Presentation of data analysis•Identified key priority issues to be addressed
•17th June 2011 – Stakeholder Event to agree future workplan
Reasons for breach
Beds = 39%
Waiting A&E = 16%
Waiting Specialist =
12%
Support Services =
15%
Clinical Exception =
14%
Transport = 9%
Bloods = 3.6%
Diagnostics = 1.3%
Radiology = 3.6%
Surgical = 3%
Ortho = 2.8%
Medical = 3%
Other = 2%
46% of admissions < 2
days ALoS
ALoS in Wards 4.7 days
40% of A&E admissions are
Surgical
12% of Surgical admissions
breach
8% of Medical admissions
breach
27% of Surgical processed in last 30
mins & getting worse
20% of Medical processed in last 30
mins & getting better
Issue Tree
Capacity vs Demand mismatch (1st Dr Assessment is 14%)
People & Process?
Footprint & routings (layout)
Managing Pressures in an Acute Setting
0
20
40
60
80
100
120
140
4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 0 1 2 3
Coun
t of
Brea
ches
Breach Hour (Arrival Hour + 4 Hours)
WIG - Waiting for Bed 01
Data 2009
Data 2010
Managing Pressures in an Acute Setting
Key Issues identified at Stakeholder Engagement Event
CAPACITY MANAGEMENT
• Improve accuracy and use of predictive tools • Match staffing and services to demand profile• Set capacity parameters for all service flows
Managing Pressures in an Acute Setting
Key Issues identified at Stakeholder Engagement Event
WHOLE SYSTEMS APPROACH
• Joined up performance targets for Acute services, Primary Care, SAS and NHS 24
• Re-emphasis on unscheduled care being a whole service target
• Review arrangements for chronic disease management / repeat admissions to reduce emergency hospitalisation
Managing Pressures in an Acute Setting
WAY FORWARD
• Essential to recognise this is not just a product of extreme winter
• A new paradigm in demand and capacity• Using structured analysis and tools to devise specific,
hard edged solutions• Develop a programme of sustained improvement• Achieve a new steady system-wide steady state, which
is also capable of managing demand variations