Unscheduled Care Task Group

Patient Flow workstream

ED Streaming

Inflow & Outflow

Seamus O Reilly – ED Consultant, CAH

Barry Conway – Assistant Director Acute Services

Friday 12 December 2014

Background

Strong 12 hour position in CAH

4 hour position in CAH on a downward trend

Increasing complaints

Need for a greater focus on quality

All agreed - need for a fresh focus

Approach

Discussions with frontline staff – doctors,

nurses, AHPs, clerical staff etc..

Focussed on strengths and weaknesses of

our existing processes in ED and beyond

Needed a new focus on inflow and a new

focus on outflow

Opportunity

Major changes in Acute Medicine in CAH

from August 2014

Pure Acute Physician model in MAU

Twice daily ward rounds in medical wards

Improved senior medical cover at weekends

across CAH medicine

Time was right for a fresh focus

2013/14 – monthly range for 4 hours 61% to

77%

2013/14 – 68 patients over 12 hour

breaches (56 in April 13)

2014/15 (to date) – 2 patients over 12 hours

Highest ‘recent’ 4 hour monthly figure was

Sep 12 – 82%

CAH baseline position – 4 and

12 hours

Discharge before 1pm

- Largely unchanged – around 20% before 1pm

Internal ward transfers

– There was no formal monitoring of internal ward

transfers

CAH baseline position –

discharge before 1pm and

internal transfers

Inflow

Streaming

Feedback from Users

10,000 voices

Complaints

Reported incidents (via datix)

Feedback from staff

Quality Indicators

Emergency Department

engagement

Main receiving wards for medicine and

Surgery – timely admission and transfers

Medical and surgical base wards – timely

transfer and discharge

Discharge before 1pm

Patient Flow Team (24 hour period)

Wider hospital engagement

CAH Emergency Department

‘60 minute plan’

Triage processes (including ambulance)

Direct streaming to ENP

Frontloading investigations

Using eEMS functionality for doctor and

ENP pick up times

Senior Doctor / Nurse walkaround

Senior management presence

Inflow - The 60 minute Quality

Improvement Plan

Triage performance

Time to first assessment (focus on 60

minutes)

DTA within 2.5 hours

Unplanned re-attenders

Left without being seen / treatment complete

4 hour position

The 60 minute Quality

Improvement Plan - KPIs

‘simple’ triage for minor cases – triage

complete at point of registration

Additional nursing support at triage

Understanding the numbers – 13 per hour is

manageable, >15 needs action

Monitor and report on triage performance

Improving triage

For patients requiring full Manchester

Triage:

PGDs for pain relief

Investigations frontloaded where possible –

bloods, ECG, x-ray (guidance in place)

Band 3 in place to support the triage nurse

in a separate cubicle nearby

Improving triage

Dedicated space in Majors 1 for ambulance

triage

Same principles apply as per previous slide

Focus on trying to improve ambulance

turnaround times and minimising risk

Maximising the flows between Majors 1 and

Majors 2

Improving triage

ENP (from ‘simple’ triage)

Minor illness (minors)

Majors 1(trollied majors)

Majors 2 (ambulatory majors)

Clinical Decision Unit

Resus Room

Streaming

Trying to see patients in line with triage

category

Focus on pick-up times

Using eEMS functionality to allocate Doctor

or ENP initials to each patient

Pick up times

Designated consultant in charge

2 Band 6 nurses on duty (one focuses on

flows at triage / Minors and other focusses

on Resus / Majors / CDU)

Regular senior doctor and senior nurse

walkthroughs to assess flows and address

pressures

Links with Patient Flow or senior

management were necessary

“Managing the floor”

Existing dashboards were numbers based

and difficult to see at glance what the key

issues were

Paul Kerr produced a new ED patient

journey dashboard focussing on admitted

patients

Reviewing how we are

performing

ED ATTENDANCES WITH A DTA – TRIAGE /

ASSESSMENT / DTA / LEFT DEPARTMENT

ED ATTENDANCES WITH A DTA – TRIAGE /

ASSESSMENT / DTA / LEFT DEPARTMENT

Change to overnight ED medical rota from

August 2014 – 3 doctors on duty all night

one of which must be at least a CT1

Major improvements in Outflow - INFLOW

AND OUTFLOW BOTH MUST GO HAND

IN HAND

Other changes that have helped

Outflow

Creating ‘ready beds’ in main receiving

wards to maintain outflow from ED

Focus on discharge before 1pm

Focus on timely transfers:

Objective: putting the hospital to bed by

8pm and avoid the usual build up of

admissions in ED in the early evening

Focus three key areas - on

discharge before 1pm and transfers

Impact of the work on Inflow

and Outflow

Craigavon- Triage

Performance

Overall, Triage Performance is

similar to 4hr performance,

highly variable and increasing

overall, but the parallel between

the measures seems almost exact

for June to July, with both

underperforming in June and

both suddenly improving on July

1st…

Craigavon- Decisions To Admit < 2.5hrs

• The overall

pattern for DTA

< 2.5hrs is

similar to 4hr

Performance;

increasing

overall whilst

being highly

variable, with

November

outperforming

the last months.

• However, DTA <

2.5hrs is

significantly

lower in

September…

• Continual improvement in all key measures from June to

Novembe

Note – focus started in June 2014have a DTA <2.5hrs

• G2G three times higher in June

• Over double the number of medical discharges before 1pm

Craigavon flows

Craigavon- 4hr progression

60 minute plan introduced plus changes to overnight ED staffing has

improved performance as well as improved variance

We have made some progress

BUT - We have much more to do…..

In summary