www.england.nhs.uk

SW SCN & Senate Annual Conference 27 November 2014

Bigger Better

Faster?

www.england.nhs.uk

Urgent and Emergency Care Review 2013

2

NHS England Business Plan 2014-15 to 2016-17

www.england.nhs.uk

Emergency stroke admissions 2010-13

92% go to closest hospital* 95% go to hospital within 5miles of closest hospital* *Bristol hospitals combined

Differences in the process of care for patients admitted in normal working hours and out of hours

Eligibility for and compliance with process measures for normal hours and out of hours patients (adjusted odds ratios)

SINAP unpublished data 2010-2013

How does the size of a unit influence process of care? Arrival to tPA/scan times

Thrombolysis volume per annum

0-24 25-49 ≥ 50 p

Median arrival to scan (mins)

30 (18-49) 27 (16-45) 20 (13-31) <0.0001

Median arrival to tPA (mins)

78 (57-105) 72 (50-101) 50 (33-75) <0.0001

Arrival to tPA within 1 hour (%)

30.4 38.4 63.3 <0.0001

SINAP unpublished data 2010-2013

30 day mortality of patients admitted at weekends, by ratio of registered nurses per 10 beds on the weekend

Hazard ratios adjusted for patient casemix, organisational characteristics, staffing and care quality

www.england.nhs.uk

Variations in service quality 2014

www.england.nhs.uk

Variations in service quality 2014

www.england.nhs.uk

Variations in service quality 2014

CQC Risk Indicator SSNAP Stroke Unit ranking

‘Risk’ ‘Elevated Risk’

www.england.nhs.uk

Standards used for stroke reconfigurations so far

• 600-1500 stroke admissions per year • Maximum 45 minute travel time • 6 consultants with stroke expertise on rota • 7-day consultant ward rounds • Nursing input: 2.9 WTE nurses per bed for HASU

(ratio 80:20 qualified to unqualified) and 1.35 (ratio 65:35) for ASU

• Therapy input: 0.73 WTE Physio, 0.68 OT, 0.68 SALT per 10 beds (HASU)

www.england.nhs.uk

Standards used for stroke reconfigurations so far

• 100% patients continuous physiological monitoring

• 95% of patients admitted directly to HASU from A&E

• Scanning standards (100% urgent patients scanned next slot and all within 24 hours)

• 50% appropriate patients thrombolysed within 30 mins; 90% within 45 mins of arrival

www.england.nhs.uk

Impact of centralisation of hyperacute stroke: London Stroke Survival vs Rest of England

Hazard ratio for survival in London 0.72 95%CI 0.67-0.77 p<0.001

www.england.nhs.uk

Demographic pressure

14

Forecast increase in number of people with stroke 2012-35

+6% +20% +36% +53% +70%

www.england.nhs.uk

Current situation: should patients travel elsewhere?

If door-to-needle times, rather than just travel times, are taken into account, then the decision on which hospital to take a patient to would be different for ~30% of patients. For those patients the average delay ~8 minutes.

www.england.nhs.uk

Time is survival in Primary PCI For every minute of delay in treatment in the first 3 hours of an acute MI - a life is lost (per 1000 STEMIs)

N Engl J Med 2007;357:1631-1638

www.england.nhs.uk

Standards for Primary PCI Primary PCI must be available 24 hours a day, 7 days

a week, 365 days a year with contingencies to deal with broken cath lab, staff illness etc

PPCI centres should be treating 300 or more PPCI patients per annum (catchment popn. ≈1 million). Absolute minimum of 100 PPCI procedures/year

A PPCI centre should have 2 or more cardiac catheter laboratories

Call-to-balloon time of 150 minutes or less for 75% European Cardiac Society standard for maximum call-

to-balloon time of 120 minutes Door-to-balloon time of 45 minutes or less

www.england.nhs.uk

Demographic pressure Forecast increase in demand for emergency PCI 2012-35

+5% +13% +21% +28% +33%

www.england.nhs.uk

Emergency Primary PCI admissions

90% go to closest hospital* 95% go to hospital within 5miles of closest hospital* *Bristol hospitals combined

www.england.nhs.uk

Emergency PCI patients

Trust Per year% Non-Local

patientsUHS BRISTOL NHSFT 933 16.7%ROYAL DEVON & EXETER NHSFT 562 4.9%PLYMOUTH HOSPS NHST 452 4.5%ROYAL CORNWALL HOSPS NHST 462 6.7%GLOUCESTERSHIRE HOSPS NHSFT 415 6.1%TAUNTON & SOMERSET NHSFT 330 10.7%S. DEVON H.C. NHSFT 293 7.7%ROYAL UNITED HOSP BATH NHST 255 4.9%GREAT WESTERN HOSPS NHSFT 263 8.5%N. BRISTOL NHST 112 2.9%SALISBURY NHSFT 106 25.9%All 4183 9.2%

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Ambulance – suspected STEMI

Number of emergency PCI 1.87x higher than number of suspected STEMI ambulance transfers (for hospitals in Cornwall, Devon & Exeter)

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Predicted vs actual admissions based on travel time

www.england.nhs.uk

Complex elective cardiology: Device standards – selected highlights 24 hour staffing cover for all device patients and should include device-

trained cardiologists Minimum of 2 active implanting ICD/CRT consultant cardiologists per

centre All implanters and physiologists will be fully competent in ICD/CRT

follow-up Appropriate CPD in ICD/CRT therapy including implications for driving Minimum of 30 new complex device implants per cardiologist per year

with a minimum total new device implant rate (including pacemakers) of 60 per year.

If an operator is implanting CRT devices, at least 20 of these devices should be CRT-D/P and if an operator implants ICDs, at least 10 devices should be ICDs.

Each centre will therefore perform a minimum of 60 new ICD or CRT implants per year, although 80 is desirable

www.england.nhs.uk

Complex elective cardiology: EPS standards – selected highlights

Standard ablation can be undertaken in a centre with only one EPS specialist (with arrangements for OOH cover)

Complex ablation - minimum of 2 trained specialists per centre

Minimum of 50 ablations/cardiologist/year

2 arrhythmia nurses and 2 EPS-trained techs per centre

‘In general’ complex ablation will be undertaken in centres with ‘co-localised’ cardiac surgery

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Effect of changing number of hospitals

www.england.nhs.uk

Dry run: where should the HACs be?

www.england.nhs.uk

Emergency stroke admissions

92% go to closest hospital* 95% go to hospital within 5miles of closest hospital* *Bristol hospitals combined 23

www.england.nhs.uk

Effect of changing number of hospitals

www.england.nhs.uk

A model of clinical impact

Dry run: where should the HASUs be?

CARDIAC and STROKE MAPPING PROJECT Project milestones

• AIM: To provide an appraisal of stroke and complex cardiac reconfiguration options to Network stakeholders by April 2015

31

Objective Timeline

Preliminary model presented at Cardiac and Stroke Commissioning Advisory Groups (CAGs) 11/12 Nov 2014

Revised model presented to CAGs Feb 2015

Options appraisal completed 31 March 2015

Final outcomes to be presented at CV SCN Steering Group and subsequently presented to commissioners April 2015

SW CV SCN: Priorities 2013-18 Cardiac

• Improving uptake of cardiac rehabilitation

• Reducing readmissions with heart failure

• Improving access to cardiac surgery after acute coronary syndrome

Renal

• Reducing Acute Kidney Injury in primary care and in hospital

• Improving renal health in Chronic Kidney Disease

Stroke • Improving prevention of

stroke in Atrial Fibrillation • Improving access to timely

acute care – thrombolysis, acute stroke units

• Developing cost-effective methods of follow-up

• Diabetes foot care and reducing amputation

• Improving provision and uptake of the NICE 9 key care processes

Diabetes