THE AECU STORY.. Or how we put off the administrators!

Transcription

1 Milton Keynes Hospital NHS Trust THE AECU STORY.. Or how we put off the administrators!

2 March 2013 Waiting times at Milton Keynes Hospital s A&E department are some of the longest in the country. Department of Health figures show that between January 6 and March 31 this year, just 77% of patients at Milton Keynes Hospital A&E were seen in four hours or less. national average, is 91.1%.

3 June 2013 Shadow Health Secretary Andy Burnham visited the hospital to see how a new ambulatory care unit, giving patients a "short, sharp treatment", had helped turn around the department

4 For people who work for the NHS, I consider this to be the challenge of our time.. How do we deliver sustainable, unplanned, high quality emergency care to a growing, aging population in a time of austerity?

5 We CARE Why is the medical admission process failing? More patients, less beds Sicker, Frailer patients Rapidly changing expectation (Francis, CQC) Doctors in the community quickly become out of date about what a hospital can offer and so refer to hospital Doctors in hospital are unsure what can be offered in the community so keep the patient in Complaints and the worry of complaints generated by inaction Society believes we can cure everything Little tolerance for any delay in assessment or treatment Guidelines written by specialists (to increase specialist referrals) Junior team members are less confident to make decisions Mistakes are constantly highlighted leading to stagnated decision making.

6 Why are patients admitted to hospital? They are sick They are dying They need our scanners and diagnostics to exclude a diagnosis They need our diagnostics to confirm a diagnosis They want a second opinion or their ill health legitimised Their doctor wants a second opinion They cannot wait to see a specialist in clinic They need a procedure

7 We CARE Not a lot! In January 2013 this elderly lady was referred to hospital with delirium. She waited 8 hours on MAU before being sent home with some antibiotics for a chest infection. We have got to do better..

8 Dr Lindesay s rule for the medical take. The only acceptable reason for admission to hospital is that you are sick! FOR EVERYTHING ELSE THERE IS AEC

9 How can AEC impact on this? They are dying e.g. the jaundiced patient Confirm they are dying and provide counselling and community support They need our scanners and diagnostics to exclude / confirm a diagnosis e.g. stroke Decide which diagnostic is required and do it that day. They or their doctor wants a second opinion e.g. hyperventilation Give it and send them home ASAP They cannot wait to see a specialist in clinic e.g. heart failure force book them onto the specialists clinic They need a procedure e.g. chest drain or blood transfusion Change the admission from emergency to urgent elective

10 Spend time and design a unit around quality. What service do my patients deserve? What is stopping us achieving this?

11 From a vision comes a plan Our plan was simple Pick out zero length of stay patients and treat them as fast as possible

12 Why does this work? Ambulatory Patients on MAU Chaotic Centred around the sickest patients Well patients are left in a queue Cumulative patient numbers add to the chaos Good nurses will always prioritise sicker patients Ambulatory patients in AEC Calm Centred around processing stable patients Patients seen and discharged as quickly as possible with a plan Splitting the nursing staff provides welcome respite Care of sick MAU patients is better Removes pressure from the SpR / Medical team

13 We CARE Pilot Scoring protocol Ambulatory (AEC) Suitability Questions: Yes No 1. Do you think the patient is suitable to sit in a waiting room in a chair or wheelchair? If no, challenge the referrer to explain why? Explain the AEC concept including the unit s ability to give brief treatment interventions and daily outpatient review to monitor progress. 2. The patient should not be critical ill: (If not known assume Yes). Pulse <130. BP > 90 (systolic) (Don t accept systolic BP if pulse >100). Sats on usual oxygen > 92% or >88% if normally on home oxygen. GCS = 15 (or 14 in the case of known dementia). 3. The patient could cope being discharged with their current package of care. 4. Specific condition considerations: Cardiac Chest Pain: Should be assessed elsewhere (GP, ED) as low risk first. Patients should not have ongoing chest pain and a normal ECG (with a GRACE score probability of death at 6 months <2% - ED transfers only). Upper GI bleed: Patients should be aged <60, have a pulse<100 and systolic BP>100 without liver, cardiac, renal disease or cancer. Cancer Patients: The patient should not be potentially neutropaenic. How do we pick out zero length of stay patients? Telephone triage Nursing intuition If the answer to any of the above questions is No please send the patient to MAU. Suitable for: AEC Medical Admission Unit Emergency Department All questions = Yes Any question = No Ongoing cardiac ischaemia pain

14 We CARE AECU Implementation Phasing Phase 1 (3 weeks) Analysis demonstrated that 65% of daily medical emergency admissions (85 th percentile) have a length of stay of 0/1 days equating to 19 patients per day Examine the process and engage the departments Blood tests are key (1 hour) CT and MRI scanning (Same day) Speciality HOT clinic spots Pharmacy stop TTOs, introduce FP10s, stock the drugs cupboard Nurses to think like doctors and predict what will be required Set mandatory expections Located the current DVT & OPAT service into the AECU = maximise impact of integrated service

15 We CARE AECU Implementation Phasing cont... Phase 2 (5 weeks) I d prefer we went down fighting - Just do it! It cant be worse than what's happening at the moment Chief Operating Officer Building work Ordering equipment Writing flow charts

16 We CARE Example Patient Ambulatory Emergency Flow Care Patient Flow In Hours GP Referral ED Referral Bleep holder completes AEC Scoring Protocol ED completes AEC Scoring Protocol ED AEC MAU ED informs AECU patient referred Patient arrives Stream to relevant Nurse DVT Nurse AEC Nurse OPAT Nurse See DVT Pathway AEC Nurse Led assessment See OPAT Pathway No Imaging required? Yes Book appointment with AEC Acute Physician T + 2 hours Patient attends imaging appointment T Patient sees AEC Acute Physician Admit patient Monitor & treat in AEC Discharge Discharge summary generated MAU Send patient home or admit Review next day in virtual Board Round Bring back for investigation / treatment / discussion Telephone follow-up clinic 1

17 The Unit Opens

18 Impact Data For AECU Opened 22 nd April 2013 No patients seen = 411 Admitted = 32 patients (8%) Admissions avoided = 193 (47%) this is based on clinical judgement. ALOS on the unit = 3.7 hours Re-admissions = 10 21% Increase in GP referrals 52% increase in the number of 0 LOS

19 We CARE The Team Acute Physicians, Matron, Ward Manager, Nurses, Specialist Nurses, Medical Assistant, HCAs, Ward Clerk & Project Manager

20 A day on AECU 9 AM. The Virtual Ward Round Review every case from the day before. Decide whether the patient needs: a return visit, a follow-up telephone call (nurse led or Doctor led) or discharge. Use the opportunity for case based discussion amongst the MDT. Review the notes of any overnight referrals to the unit and plan their care based on the notes. Review of the notes of any patient in the virtual ward who has been handed over from previous days. Encourage participation from: consultant, sister, staff nurse, consultant secretary, Ward clerk, VTE team etc.

21 Pathway for Medical Review on the AEC Referral taken from GP by experienced Nurse try to give advice to the nursing staff about which investigations should be requested at presentation. Some treatments can be started immediately upon arrival. E.g. for nausea and vomiting, then giving stat fluid and anti-emetics at the discretion of the nursing staff at the time of presentation is likely to significantly improve your chances of same-day discharge. Patient presents to receptionist. Patients seen by AEC nurses. Observations including lying and standing blood pressure and weight. Blood tests (ensure these are immediately podded in A&E). chest x-ray requested by nurses Urine pot provided to all patients Sputum pot provided to respiratory patients Patients encouraged to fill out some sections of their own medical clerking. (SH, FH, DH, PMH) decision made to be seen by Doctor either Immediately. (When cross sectional imaging is likely e.g. headache or for patients who need immediate treatments. E.g. rate control in AF) In two hours. (When patient can be seen by doctor in one stop with all relevant investigations reviewed.) The patient is encouraged to mobilise for their own x-ray. Pts are encouraged to return only at the agreed doctor consultation time. Advice patients to go and get a coffee Blood tests printed and filed in notes by receptionist. Patients seen by AEC consultant. All discharged patients will be reviewed in the next day virtual round

22 We CARE Ambulatory Emergency Care Unit (AECU) Key Challenges Clinician buy in and criticism Lack of belief in timely investigations in an outpatient setting Culture / mindset, shift from admission as the standard to focus on process & discharge within 4 hours Communication between a large team Sustainable working Spreading risk and supporting colleagues Next steps Integrate with the specialities through the speciality nurses developing pathways of care. Move to later opening hours ( ) to include weekends Establish Surgical ambulatory pathways