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LLR Urgent & Emergency Care Improvement Plan

Rachna Vyas, Cluster Unscheduled Care Lead

29th September 2011

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Governance

LLR Emergency Care Network (ECN) set up Jan 2011

Senior Executive membership, both managerial & clinical with

clear links to each Clinical Commissioning Group

Multi-agency plan with timescales & leads

Weekly performance dashboard Other stakeholders bought in as

required

Local Authorities

LPT

GEH EMAS

UHL

Clinical Comm.Groups

PCT

ECN

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Key multi-agency challenges tackled through the ECN

1. Management of attendance levels to ED/Bed Bureau 2. Management of Mental Health Patients in ED3. EMAS Patient Transport Service; Service delivery &

cancellations4. Tackling delayed discharges 5. Robust winter planning6. Systems design7. Delivering reablement services8. Pathways for Frail Older People9. Improving Discharge processes10. UHL internal processes & workforce development11. Creating a LLR Single Point of Access

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Challenge 1: Rising demand on acute services affects service delivery in the ED

Actions:1. Cluster-led streaming project initiated in June 2010 to reduce the number of patients

treated in the ED by up to 10% (at additional cost). 2. Every GP practice across LLR monitored weekly against an agreed target to reduce

usage of acute care, inc. both ED attendances and admissions. 3. Targeted communications/social marketing work launched in certain areas of Leicester

City showing highest inappropriate use of ED.

Progress: LLR current position is -1.4% against planned activity

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Challenge 2: The response to ED by the Crisis Response Team causes delays in the patient journey

Actions:1. LPT undergoing a full review of the acute adult mental health pathway2. Enhancing the Adult Liaison Psychiatry Service to:

– Increase out of hours liaison psychiatry presence within ED in UHL between 5pm – 12pm seven days a week

– Provide dedicated Mental Health expertise at point of admission– Reduce waiting times– Provide improved care pathway for the acute medical units (15 & 16) and short stay units

(33)– Divert patients from ED to the Urgent Care Centre where they can be assessed in a more

appropriate environment – Improve the transfer of patients requiring crisis intervention or admission to LPT– Support the redesign of Acute Mental Health Care Pathway

Progress:The enhanced service is due to go live in Oct 2011

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Challenge 3a: The ‘re-bedding’ of patients causes unnecessary delays in the patient journey

Actions:1. Re-specify Patient Transport Service contract to provide a fit-for-purpose service within the

current financial envelope2. Increase communication channels between UHL-EMAS3. PTS crews will be made available earlier to transport those patients who are made ready before

midday4. Earlier escalation to UHL to ensure that mitigating actions can be enabled if delays arise5. Re-issue PTS Eligibility criteria to city and county General Practices, as well as all UHL wards.

Progress:

Average number of rebeds per week for 11/12 has been 9.

10/11 Q3/4 average was 12 per week.

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Challenge 3b: Late cancellations of PTS services reduces availability of crews and interrupts service delivery

Actions:1. Root cause analysis of

cancellations by reason 2. Targeted multi agency teams

tackling specific issues

Progress:The number of ambulance

cancellations has dropped across all categories, taking the total number of cancellations to over half of that in Jan 2011

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Challenge 4: Multi factorial delays in discharging medically fit patients block beds – reportable & non reportable delays

Actions & progress:In talks with community equipment provider to

reduce waits for community equipment to less than 24hrs where possible, esp. in periods of surge

Discharge planning principles discussed earlier are also being applied to community provision to ensure patient flow is not disturbed due to delayed/late discharges

Work continues with nursing and residential homes to improve quality of care at points of admission and to ensure timely discharge

LPT undergoing an acute pathway review, with a view to ensuring that delayed discharges due to access to beds are minimal for patients transferring to LPT inpatient beds

Review of bed capacity agreed across LLR. Toby Sanders is the SRO

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Challenge 5: Winter planning needs to be both innovative and meticulous to ensure a robust urgent care system through winter 11/12

Actions:• Specific holiday period service availability planner prepared across primary care,

secondary care & social care• Agreed escalation & de-escalation process agreed across all LLR agencies• Joint multi-agency public signposting & communication• Weekly communications from Sept 1st to the Health Protection Agency re Flu • Director to Director contact for any closure/stop• Multi agency ‘Plan B’ being drafted – what do we need to do over and above what

we have already prepared?

Progress: • LLR Escalation plan re-engineered with full stakeholder support following

comments from IMAS and learning from winter 10/11• ‘Plan B’ options being modelled ready for winter 11/12

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Challenge 6 – Application of ‘Systems thinking’ to ensure that we work across agencies to deliver an innovative and tailored system of care for LLR

STREAMING

999Walk In

URGENT CARE SERVICE

SERIOUS ILLNESS &

INJURY

Integrated Governance & Training

Shared Diagnostics / Staff

Shared Social Care

Psychiatric Care

AMBULATORY EMERGENCY PATHWAYS

Clinical Decisions Unit –Paediatrics/Geriatrics &

Ambulatory Emergency Pathways

Assessment Wards & RehabINTEGRATED DISCHARGE

Minor Illness

Minor Injuries

DISCHARGE +/- FOLLOW UP

Ambulance

Out of Hours Face to Face

EMERGENCY DEPARTMENT (A&E)

Actions & progress:

1. The Urgent care pathway across LLR is currently being modelled in conjunction with the CCG’s & UHL, but will be geared towards multi agency partnership working to deliver an integrated, safe and consistent service.

2. Key deliverables across the pathway: Integration of Urgent Care Centre and

ED “front door” Redesign of Loughborough walk in

centre, with more medical cover made available

Review of the Minor Injury provision across Leicestershire County

Increased capacity in the Emergency Department

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Challenge 7: Promoting independence and reducing demand through reablement

Action:

Collaborative proposals drawn up and currently going through governance processes

Summary of proposals for each area below:

Leicester City

1. Coordinated Community Reablement/RIT teams

2. Additional 10 Intermediate Care Beds in 11/12

3. Help at Home, Handy Person and Assistive Technology Service

4. Development of City Single Point of Access

5. Enhanced Hospital Team 6. Community

Coordinators/Demand Managers 12/13

Leicestershire County

1. Resourcing of IC teams

2. Resourcing of social care reablement teams

3. Development of Single Point of Access

4. Hospital at home scheme

Rutland County

1. On-going development of an integrated reablement & intermediate care service

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Challenge 8: Implementing pathways for Frail Older People to deliver a coordinated and high quality service

Progress:

Emergency Frailty UnitMay-Jul 2010 vs. May-Jul 2011

Number aged 85+ attending ED has increased by 10% (relative increase)

Overall discharge rate from ED for people aged 85+ has increased by 20% (relative increase)

90 day readmission rates have halved from 26% to 14%

Action:

Frail Older People service implemented with the aim achieving a 20% reduction in admissions to base wards for those patients referred to the service.

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Challenge 9: Improving UHL Discharge processes to facilitate patient flow through the system

Action:

‘Estimated Date of Discharge’ set and adhered to

‘To Take Out’ medicine & pharmacy mobilised

Coordination with EMAS Patient Transport Service

Earlier discharge from LPT community beds

Targets & Progress:

• Discharges by 1pm – Q1 targets achieved at both UHL and community sites

• Plans for continual improvement in place to ensure targets are met for the year.

DISCHARGES BEFORE 1PM - BASELINE Q1 11/12

24.1%

29.1%

19.6%

0%

5%

10%

15%

20%

25%

30%

35%

Medicine Respiratory Cardiac & Renal

DISCHARGES BEFORE 1PM - FUTURE PLANS

30%

35%40%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Q2 11/12 Q3 11/12 Q4 11/12

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Challenge 10a: Improving ED Processes to offer a streamlined and efficient pathway through the Emergency Department

Actions & Progress: – Transfer of Neurology services from Leicester General to Leicester

Royal site

– Closure of Emergency Medical Unit on LGH site

– Emergency Frailty Unit (EFU) established

– Introduction of Bed Bureau Triage in both Medicine & Surgery (33% admission avoidance)

– Ambulatory Pathways being implemented

– ‘See, Treat And Triage’ team introduced - senior decision maker supported by qualified nurse and Health Care Assistant. In place from 10.00am to 12 midnight daily - commenced in June 2011

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Challenge 10b: Development & mobilisation of a UHL workforce development strategy

Action:

Development of a workforce development plan in conjunction with the East Midlands Deanery & external guidance

Progress:

Appointments made to date: Substantive Consultants x 2 Locum Consultant posts x 2 Enhanced consultant cover 20.00hrs to 01.00hrs Advanced Practitioners (AP) 5/6 Physicians Assistants (PA) 3/5 Health Care Assistants 2 x 18 – accelerated training to band 3 in 6/12 GP recruitment x 5 (flexible with Urgent Care Centre) Speciality Doctor x 1 Geriatrician/Physician support to the Emergency Department in place Designated consultant of the week to cover Emergency Decisions Unit established

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Challenge 11: Integrate the current 11 ‘single points of access’ across health and social care to enable 1 single point of access across LLR

Actions & progress:

• Multi agency plans are being drawn up to agree a single overarching plan, detailing a phased approach to integration of the various projects across LLR, including those in the reablement proposals.

• NHS 111 pilots are currently running across Nottingham City and Lincolnshire, with plans for the rest of the region to pilot the service in April 2012.

• Discussions are underway across agencies to provide to a safe and effective pilot for the LLR region with each CCG.

Health SPA

Regional piloting of the NHS 111 project

Leics County LA

SPA

Leics City LA

SPA

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Critical issues to address in the next few months:

1. Designing a robust ED-UCC interface and ensuring that other urgent care provision across LLR is aligned to form an integrated service

2. Efficient patient flows out of ED into rest of hospital

3. Out of hours service delivery across providers to reduce inappropriate admissions

4. Single point for admissions into UHL5. Single Point of Access/111/bed bureau delivery

model

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Thank you for your time.

Please feel free to ask any questions.