university hospitals of morecambe bay nhs foundation...
TRANSCRIPT
Background
This report is based on formative discussions with senior clinicians and managers
within the Trust over recent weeks. A review of previous external reports on
unscheduled care has also been undertaken.
It is acknowledged that considerable work is on going to address performance in
unscheduled care at RLI and that this report will cut across or duplicate plans already
in place. This is necessary to provide a complete picture and this plan will
deliberately focus on areas of potential improvement to ensure patient centred care,
improved delivery, timely access and improved patient experience across the whole
unscheduled medical and surgical pathway. (initial thoughts are provided on the
surgical pathway but these have not been discussed with clinicians)
Maintaining timely patient flow is the responsibility of each and every person on the
patient pathway and it is imperative that everyone understands the role they have
and what they need to do. They must own the systems and processes and put
patients at the centre of each and every decision.
Meeting the challenges of this requires engagement of all staff, not just those in ED
and assessment units. The Trust should develop a plan to engage and involve staff
through the provision of information, guidance and leadership. The whole issue
needs to become a high profile element of everyone’s day job.
Starting to make changes and building on the momentum this creates should be the
aim and the marketing/public relations department will need to be involved in this
to help develop a corporate message and start to develop the theme of “the way we
do things here”. This should help to create the right culture to deliver proposed
changes.
This report describes the way forward and follows clinical guidelines developed by
both the College of Emergency Medicine and the Royal College of Physicians. The
model of care is currently working in many hospitals nationally with significant
positive results in both patient experience and safety and resulting improvements in
organisational performance.
Implementation of the associated action plan will require detailed conversations
with clinicians who are primary to its success.
Analysis of length of stay at RLI
An initial assessment of length of stay (LoS) in medicine has been undertaken. The
average LoS in medicine at RLI is 6.7 days compared to a NHS national average of 5.4
days and top quartile performance of 4.9 days indicating that there is room for
increased efficiency.
Breaking the data down further shows that between 55% and 60% of patients move
through the hospital in less than 72 hours indicating effective systems within the
‘front end’ of acute medicine; ambulatory care and medical assessment. However
once patients move into the wider hospital LOS increases. In the group of patients
who stay 3 – 14 nights the average LOS is 6.7 days and those patients who stay over
15 nights the average LOS is 33.4 days.
The latter group of patients, (over 15 nights) constitute 12% of patients admitted to
medicine but they occupy 61% of available bed days.
This initial assessment indicates that whilst the front-end systems are efficient once
a patient moves into the hospital LOS increases dramatically. There are likely to be
multiple reasons for this related to the outlying of patients both within medicine and
across other specialties and delays in discharge processes. Whilst these will be
touched upon in this report further work will be required.
Demand and Capacity modelling on the patient pathway in medicine
Understanding demand and capacity is essential to gaining an understanding of
where the pressure points and blockages in the current medical pathway are. Any
planned changes must meet demand levels and allow surges and prolonged
increases in activity to be managed.
All modelling of demand is calculated at the 85th centile – planning on the average
means we will fail half the time - at this level we can build in capacity to allow peaks
to be managed, the rule of thumb being contingency to manage an increase of 15%
over a 6 week period.
This methodology for modelling is used throughout this report.
The Emergency Department at Royal Lancaster
Daily attendance at ED is between 192 and 227 patients (85th centile) and the daily
attendance is shown in figure 1 below.
ED daily profiles (at 85th centile)
Monday 220
Tuesday 204
Wednesday 196
Thursday 194
Friday 192
Saturday 213
Sunday 227
Figure 1: based on activity over the calendar year Dec 10 to Nov 11
This demonstrates a “normal” pattern of attendance, highest numbers being
experienced on Sundays and Mondays with attendance falling marginally through
the week to Friday. The figures currently include the majority of GP direct patients
referred for medical assessment who enter the pathway through ED. (The future
model will require these patients to go directly to MAU)
Figure 2 below shows the daily attendance by hour of the day (85th centile)
Figure 2: based on activity over the calendar year Dec 10 to Nov 11
0
2
4
6
8
10
12
14
16
Ax
is T
itle
85th centile by day & time band - RLI only
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
All work with the Emergency Department will be guided by the College of Emergency
Medicine report “The Way Ahead” (revised December 2011) and initially work will
analyse in greater detail the spread of the demand across each day, by hour of the
day and the capacity (staff resource) available to manage this.
It is clear from discussions with the lead ED consultant that there are real concerns
about medical staffing numbers and the Trusts ability to attract good calibre
applicants particularly for middle grade posts. This is a common problem nationally
and it is likely that the recruitment market will become more competitive, rather
than less. Work on capacity must address and work on solutions to these genuine
concerns.
It is recognised that plans are in place to develop an area to enable streaming of
minors, which should be available by late spring. Plans for staffing this, particularly
nursing skill mix, should aim to deliver a service where all “minor” patients are seen
in chronological order and no breaches of the 4-hour target occur. The further
development of the ENP service should be encouraged.
Timely review of patients in ‘majors’ may be problematic at times because of
capacity issues in the department but any wait over 15 minutes for first assessment
or delayed ambulance handover should be avoided. To support this all GP referred
patients should be taken directly to the MAU by the ambulance service. Using ED as
a holding area for these patients adds nothing to their pathway and blocks flow in
ED.
Rapid Assessment and Triage (RATS) model in emergency departments can be
particularly helpful at busy times and when flow slows and delays to first assessment
occur. A RATS model will enable patients with an obvious need for in-patient
specialist assessment to be referred as part of the initial assessment process. The
remaining patients need for specialist care only becomes obvious after more
detailed work by the ED team. This process will need to be agreed by Clinical
Directors across the Trust as a potential consequence of its introduction is that
patients will move on to care of the specialty with less clinical work up – leaving
more to be done in the specialist assessment facility but it should create a greater
‘pull’ from within the hospital and ease the pressure on space and consequent flows
in ED.
It is also suggested that the leadership team agrees performance metrics for ED in
relation to patients referred to specialties. This should encourage further
development of assessment areas and increased dialogue with specialties around
timely acceptance of referrals. (Specific recommendations for surgical
assessment/triage are included below.) Any referral made within two hours which
still breaches should be analysed and reported on by the receiving specialty and not
ED. These performance metrics should be shared with staff on a weekly basis; this
will promote increased engagement.
An essential element of managing patient flow is having an understanding of how
demand is developing hour by hour. It is better to know a patient may require
admission to a specialty or assessment bed as early in their journey as possible.
Evidence suggests (Prof. Matthew Cooke paper 2009) that about 70% of patients
who will need specialist assessment are obvious to a trained nurse within a few
minutes of their arrival in ED. Seeing patients in chronological order supports early
decision making, correct streaming and clinical assessment and triage. Added to this,
liaison between ED and assessment areas to provide alerts of required beds as soon
as possible is essential to smooth flow and in assisting assessment unit managers to
control the outflow and factoring of patients into beds in the wider hospital much
earlier. It is recommended that a system of Coordinator (ED) to Coordinator
(Assessment Area) referral should be developed to pre-emptively book beds, within
30 minutes of a patients arrival in ED
Whilst the 4-hour access target is focused on the emergency department staff can
only deliver this if all colleagues working in clinical services in the wider hospital
support them. Some work on this is developing through the ED ‘10 steps plan’. This
can be summarized into 5 clear commitments required from all clinical services:
1. They must support ED in the effort they are making to improve the service to
patients and achieve the 4-hour access standard and recognise that we all
have a part to play in this.
2. Staff must respond promptly (within 30 minutes) and pro-actively to expedite
effective care for patients and at all times maintain the highest standards of
professional collaboration with both the ED and specialty teams.
3. They must help and encourage the development of written care pathways,
referral guidelines and agreed processes through ED and must follow them
consistently.
4. They must facilitate the movement of referred patients to specialist
assessment units within an hour.
5. All our in-patients should have a care plan, which is reviewed daily by a
senior doctor which includes an expected date for discharge. Patient flow
should be measured routinely and delays should be analysed by the specialty.
Collaborative working between ED and specialties should be supported
through joint audit and governance reviews.
The Model of Care in Acute and Specialty Medicine The Medical Assessment Unit (MAU) provides the single portal for entry into
assessment for care for all medical patients whenever and from wherever they
arrive. It must become the single point of contact for GPs making emergency
referrals to medicine and all GP patients should arrive here. We must stop admitting
them through ED.
It is the work place for all the clinicians contributing to the process, which responds
to about 45 patients per day and should be organised as a continuously flowing
process with a normal LOS of about 4 hours and a maximum of 12 hours.
The team is medically led by acute medicine but many others, including sub-specialty
physicians make vital contributions to delivery of care.
Patients’ expectations, researched internationally, are very consistent. They want:
Someone who knows what is wrong and explains this
Someone who knows what to do and makes it happen
Someone who respects their autonomy and is easy to get along with
Someone who works in a clean and dignified environment
(Research suggests that patients place emphasis on the perceived competence rather
than the grade or profession of the “someone”)
To this reasonable expectation our professional values also require us to:
Do no harm
Work together in teams to meet the patients’ needs
Avoid duplication, waste and delay in the use of our resources
Avoid discrimination and sustain equity in access to appropriate care 24/7
Sustain recognised professional standards of organisation and delivery of
clinical care
From these principles it follows that assessment in an acute medical context is only
complete when a senior competent doctor has:
1. Explained the working diagnosis to the patient
2. Outlined and agreed with them a plan for their care
3. Advised them whether an inpatient stay is required and if so whether it will
be short (1 or 2 nights) or rather longer
4. Identified the care pathway and any specialty inputs required
It is good practice to clearly identify this element of the case note and routinely audit
the elapsed time from arrival to it being signed off by a consultant. (The RCP
guidance is that this should normally be within four hours and certainly within 12
hours every day of the week).
Delivery of this consistently must be our number 1 goal. This will help in ensuring
robust implementation and continued development of the model of care to the
absolute benefit of patients.
Length of stay data indicates that whilst the assessment process in medicine is
efficient the flow of patients slows considerably as they move into the wider hospital
with outlying a regular occurrence both within and out of specialty. This creates
additional work for specialty physicians and is not good for patients. The option of a
short stay facility is being actively considered and it is recommended that this is
progressed quickly with the aim of developing an acute medicine model of care in
the Trust.
From data provided by the Trust we can calculate the demand for acute medical
assessment each day as follows:
Medical Assessments (at 85th centile) – Assess to admit
Monday 45
Tuesday 45
Wednesday 43
Thursday 44
Friday 47
Saturday 35
Sunday 33
The weekend figures are lower as the patients referred from GPs are reduced
significantly.
To manage patients more efficiently, following assessment, in medicine a revised
model of care is proposed based on a linear pathway as described in figure 3 below.
This will be the subject of wide ranging discussions in the Trust and in particular with
the clinical directors and physicians currently providing the service. This model must
be clinically owned and managed.
The Model of Care
Figure 3: Revised model of care
The model is based on a requirement for 45 assessment each weekday. Around 15 of
these patients will come from GPs and this pathway is reversible. Patients may be
ambulant on presentation and can be treated and return home ‘in day’ or may
require follow up through an urgent out-patient appointment or diagnostic
procedure. The majority of these patients will be managed through the ambulatory
care unit.
Note: It is essential that all GP referred patients arrive at the assessment unit whilst
staffing resources are available – preferably between mid day and 6pm – this will
need further discussion with both GPs and NWAS.
The remaining 30 patients will enter the pathway through ED – 2 to 3 each day will
require immediate admission to CCU/ITU or Stroke care leaving 27 to move to the
assessment unit. With the 5 GP patients this means 32 patients each day are likely to
need in patient care through this pathway.
The new short stay unit (SSU) fulfils two key roles, firstly to manage patients with a
LOS of up to 72 hours and secondly it acts as a buffer (of up to 24 hours) for patients
who require a specialist bed which is not available at the time of their admission –
this reduces the number of outliers and thus reduces the length of stay of patients.
Medical Assessment
45 per week- day
Short Stay Facility 72 hours max LoS
35 bed max- 20 short stay, 15 buffer
CCU/ITU Stroke Unit
Respiratory Unit
Gastro
Care of the Elderly
Cardiac Unit
Metabolic Unit
Complex care pathway
ED
GP
In Reach
Out Reach
15 10
2/3
32
27
8-10
The model requires a heavy emphasis of acute physician time in the
MAU/assessment process and the management (with specialist input as required) of
patients staying less than 72 hours. With only two acute physicians at present
specialty colleagues will need to provide general medical support to the unit,
particularly the short stay element. Benefits of providing this support are twofold,
firstly the number of ‘general medical’ patients on specialty wards should decrease
and those patients who need a specialty bed should get to the right ward on a more
regular basis thus reducing fragmentation of rounds etc.
In the longer term SSU will need to be supported by specialty ‘in reach’ from
consultants on a daily basis and this will need discussion and agreement. Because of
higher numbers (8 – 10 each day estimated) the Care of the Elderly could helpfully
develop arrangements to identify complex care patients early in the process and
may be in a position to provide a full consultant session of input each day in SSU.
Again this will need further discussion.
Core principles of the model of care:
1. The demand for care must drive the way we organise resources to respond
effectively
2. Assessment is a key component of the process which determines the onward
path of care and must precede any presumption about the need for an in-
patient stay. We have a single portal for medical assessment.
3. The assessment process must be consistent, irrespective of day of week or
time of arrival of the patient and must meet the RCP recommendations for
timely senior doctor supervision
4. We will only be able to deliver consistently safe, timely and effective care if
all our resources are co-ordinated into an integrated response based on the
model of care which becomes the culture or “the way we do things around
here”
Specialty Care
Whilst some excess bed days can be attributed to delays in discharge it is too easy to
attribute all the problems in this direction and miss some other internal actions
which need to be taken.
It is imperative that each and every patient (and therefore ward) has input from a
senior doctor on a daily basis, preferably in the morning.
It is recommended that each patient leaving the assessment facilities (both medical
and surgical) has an expected date of discharge with an associated care plan. Where
this is not appropriate an internal standard is set to ensure the EDD and care plan
are agreed within 24 hours of admission to the specialty.
The role of the ward manager in achieving robust patient flow cannot be
underestimated and all need to be fully engaged. Their responsibility extends
beyond patient care to direction of medical staff, particularly juniors, bed
management, nurse-led discharge and the accurate analysis of bed availability on a
daily and hourly basis. This will require them to plan ahead and the use of expected
date of discharge and care planning processes should be the norm. The development
of standards for each ward is recommended which focus on the timeliness and
quality of patient care, are agreed collectively and shared widely. Similar standards
should also be developed for allied professions providing direct input to the patient
pathway, which also concentrate on timeliness and quality of inputs.
In general, hospitals tend to operate around 30% slower over a weekend/bank
holiday period when discharge rates fall. This leads to “Mad Monday”, Terrible
Tuesday” and sometimes “Woeful Wednesday”. As discussed above the resolution
to this is in increased regular senior medical input, use of EDD, care plans and Nurse-
led discharge particularly over the week-end.
Reducing variation should be the aim and with this patient flow will improve.
Bed management
The Trust must establish a daily patient flow control system supported by
contemporary information on the bed state and activity levels. There is a site based
meeting to consider the bed position in the Trust held each morning but evidence
from conversations is that this provides little in terms of action to maintain flow. Site
based bed meetings should be held daily at 9.00am, 1.00pm and 4.00pm with a
number of agreed actions emanating from each one. The meetings should be chaired
by a senior manager (the responsibility should be shared around) and attendance
will be required from Lead Matrons in Medicine and Surgery and MAU, Bed
Management, Discharge facilitation teams etc.
One of the key issues the bed meeting must drive is early, in day discharges. One
tactic which has been found to work well is the development of a ‘Home for Coffee’
policy which can create improved flow from MAU to specialty wards and the
discharge lounge earlier in the day. Support can be provided to develop this idea.
In addition to this the bed meeting must manage escalation (and more importantly
de-escalation) at times of pressure within the parameters of the Trust and wider
community escalation policies.
The table below provides examples of the type of information which should be
considered at daily bed meetings.
The output from each bed meeting should be an agreed list of 6 – 10 actions which
address the identified issues. The aim of the meeting is to galvanise the clinical
teams to focus on pinch points during the day and develop a corporate/team
approach to resolving issues.
The main tool for managing beds and flow in the future must be IT based. It is
acknowledged that the Lorenzo system is in development and this needs to be
implemented as part of this project.
Bed Meeting Information Requirements
Bed Management Meeting – Information Requirements
Meetings held routinely at 9.00am, 1.00pm and 4.00pm
Medicine MAU
Medical patients to be seen/waiting for senior review
Patients to come in (from A&E or GP Direct)
Patients due to leave MAU
Empty beds on MAU
Beds available to use in Medicine
Beds available in the next 3 hours
Best case scenario (bed numbers)
Worst case scenario
Surgery EAU
Patients to be seen/waiting for senior review
Patients to come in (emergency admissions from A&E)
Ward rounds
Ward 1,2,3 etc
Specialist areas Available beds in ITU CCU Cardiology HDU Step Down
Elective Surgical Patients Today Tomorrow TCI Placed Tomorrow XXXXXXX Day case numbers
Community/non acute bed provision Facility 1 2 3
Paediatrics NICU beds Paeds beds Patients in Obs area
Bed Predictor Beds required today Beds required tomorrow Discharge running total @ 9.00, 1.00 and 4.00pm
Medical and Surgical outliers Escalation facilities Area 1 Area 2 etc
A&E Majors – Number of patients, time of next breach and destination of patient Minors – Number of patients, time of next breach and destination of patient
Discharge Lounge Patients through/booked in at 9.00, 1.00 and 4.00pm
NWAS Emergencies running Availability of discharge crews
Management O/C Director O/C Manager Lead Matron
The Emergency Surgical Pathway
The emergency surgical pathway relies heavily on bed availability in the Surgical
Assessment Unit (SAU). Delays do occur and it is evident that the SAU is a holding
area rather than a triage service.
Some Trusts now operate a full surgical triage service as described below and are
seeing significant benefits in terms of reduced delays and reduced bed days. It is
recommended that this model is given further consideration and visits to working
units can be arranged to support this.
Surgical Triage Unit
A Surgical Triage Unit (STU) is neither an admissions nor an inpatient ward for
surgical patients. It is an integrated unit where adult patients referred to the
emergency surgical take can undergo triage, investigation, treatment and
management planning.
Many of these patients can be managed in a safe and timely manner without the
need for admission. The STU should be viewed as a general surgical emergency
department for patients who have been assessed either by their GP or by the
emergency department.
The aim is to improve quality of care and patient experience by providing a “third
way” for acute referrals whose problem requires the input of an experienced
surgeon but does not need admission. The added value of this approach is a more
rational use of scarce surgical beds and nursing expertise.
The unit should be staffed by nurses experienced in the management of emergency
surgical patients and a senior middle grade doctor, available from 9am to 6pm. This
doctor will be supported by all members of the emergency surgical team with the
surgeon of the day/week playing an active role in all phases of management.
Surgical “hot clinics” and a dressing clinic will need to run every day. These allow
patients who do not require in patient admission to return the next day for review.
Patients that need to be monitored for a few days fall into this category.
Surgical referrals from GPs or the hospitals emergency ED can be directed to the STU
where nurses take patient details. This is an improvement on junior doctors being
bleeped to take the calls with no central record of the referrals.
General surgical patients should be triaged by a senior nurse on arrival on the STU
and initial observations taken. All patients should then be seen by a middle grade
surgeon or above within 2 hours of admission. Patients can be taken straight to
theatre, admitted to a surgical ward or discharged. Discharges can be to the hot
clinic, an elective list or home. Patients seen in the hot clinics can re-enter the
pathway by any of the above routes. Patients undergoing minor surgical procedures
can recover on the STU post op prior to same day discharge (day case urgent
surgery). This avoids unnecessary in patient admission.
Radiology can be requested to allocate 3/4 ultrasound slots per day which are
coordinated by the STU nurses in association with the vascular service.
A take home drug cupboard should be available for 24 hour dispensing.
Conclusion
It has been recognized for some time that a more effective integration of the
elements of the unscheduled care services is required across the NHS and
substantial investment of resources has been made over recent years in many
hospitals.
Despite encouragement and support some organisations and clinical teams have
struggled to find a way forward. External reviews from the teams such as the
National Emergency Care Intensive Support Team have proved a stimulus but whilst
ideas for change are helpful the implementation of required changes is always a
struggle. We must reinvigorate our determination that opportunities should now be
taken in line with this plan
Details of the implementation steps will continue to be discussed and planned and
since they influence the working lives of nearly a third of the consultant body and
cover the care pathways for an even greater proportion of our admitted patients this
is a substantial undertaking.
This is a challenging proposal, which asks a great deal of all our staff but it is
heartening to hear that the desire for change is widespread and recognition of the
scale of the task broadly understood and accepted.
Jeremy Pease
January 2012