Acceleration for ACS. NSTEMI Event 09 November. Outputs from Table Discussions

Transcription

1 Acceleration for ACS NSTEMI Event 09 November Outputs from Table Discussions 1

2 1. What mechanism do we need to have to identify patients early (within 6 hours of admission to hospital)? Have identification pathways and protocols in place in the ambulance, in the ED and also in in AMU ED-led triage / chest pain assessment / dedicated ACS nurses Need people with the correct skills to identify the patients dedicated ACS nurses / healthcare professionals Right person identifying patients with the right protocol (cardiology nurse, advanced nurse practitioner) They do the triage 24/7 availability Need to have chest pain pathways & clearly defined protocols that are universally followed Rationalise standards Improved taking / recording of chest pain history Better communication from ED doctors Use risk stratification tools (decision aid) to identify patients at the beginning of the patient journey Scoring Tool needs to be electronic (ipads?) Point of care testing (eventually) Who s role 1 st clinician who starts? Reduce waste Waste of time and resources in duplicating work i.e. how many times do we document patient? Troponin testing: Stop inappropriate Troponin testing introduces waste into the system and causes delays for those that genuinely need Troponin results quickly Troponin results taking 2 hours in some cases need to be processed as soon as lab receives the bloods High sensitivity troponin done in 20 mins Troponin / ownership of your own patient following triage Need to manage resistance from matrons / bed managers to secure beds for patient s return (they see the medical bed picture, not cardio). Extend the service at WWL to longer hours (beyond 5pm). WWL has a robust pathway in place and risk stratification with a flagging system in place at ED to identify patients early. Acute cardiac nurse practitioners review patients every hour in ED and AMU. WWL has short LOS. 2

3 Make sure that there is an understanding of high vs low risk patients troponin testing system as early point of care Robust pathways and appropriate triage criteria to determine what high, intermediate or low risk is. An on-call system to triage high risk patients Empowering of non-medical staff: NWAS: Need a change in thinking about who can refer a patient Understanding that non-medical staff (e.g. nurse/paramedic) can also directly refer a patient with chest pain to a major centre Education of front door staff (paramedics, cardiac nurses) 70% chest pains attend ED via ambulance **symptom onset** NWAS may pre-alert dependant on history Point of care testing / consider trial of point of care. NWAS view/ambition education sympathetic change Clinical examination Early diagnostics; ECG, CXR, Bloods, Tropinin, GRACE score, HEART score, TMACs People clinicians; cardiology in reach; 4hr ED target; which hospitals have high sensitive Troponin? Troponin pathway & Heart score currently used as discharge filter Mechanism needed to identify & then?redirect / referral to cardiology Replicate the Glasgow model (reduce assessment & duplication) Interim step needed (Keep hold of patients in ED on stretcher & then take to HAC if needed NWAS need to stay with patient) Education before the project starts of all stakeholders; AMUs, cardiologists, NWAS, C.C.U Front door (lessons from the past) 2. How will we facilitate fast transfer to the angio centre? (think about the referral process, the transfer process and the allocation to an angio centre) A system in place 24/7 would improve an early handover of the cardiac patients to the cath lab MRI and Wythenshawe to work alternate days to cover 24/7 service Developing specific shuttle ambulance services for transfer of cardiac patients between hospitals Ambulance may not always be required Own PCI Centre Ambulance Clear guidance on transfer to ambulance service Look at Liverpool model for patient transport between centres (already costed model) 3

4 CATS: Better access to CATS needed / easy and quick input onto CATS system 24/7 (more resource needed) Is CATS a barrier? So much information is needed! Access to CATS for all appropriate staff including CATS training High risk patients should be managed separaely from CATS Need to get the patient details updated promptly on CATS (e.g. blood results) Robust systems must be in place to capture data: A good electronic system (need an improvement to the current CATS system / modified version of CATS) User friendly/easy to use System needs to interface with DGH systems If it s a 7 day service, AMU consultants need to be making the referrals Skills for assessing referrals need to be supported by algorithms and decision-making tools Needs to be more proactive ( pulling patients) Communication is key ACU patients should only be referred by cardiologists Ward nurses to arrange NWAS transfers Direct referral from ED Develop a standardised protocol-driven chest pain / ACS pathway across GM to bypass ED so that patients go straight to the cath lab or regional chest pain units Activating referral from an ambulance; blood test on the stretcher Efficient technology is needed to support decision making Define a gold standard scoring system / referral service and direct discussion with cardiology Treat and discharge early with adequate support and information for a patient and family thereby releasing cardiac beds It is clear that the current system has a lot of waste. Identify the waste, identify what requires huge costs but produces poor outcomes. Obtain the buy-in from all clinicians / NWAS etc. Put in place the right processes/ pathways that are: Unique Easy to understand Not complicated Easy for MDTs to implement. For RAACS & other areas telephone call used dedicated referral line 24/7 7 days a week 4

5 Beds: Breakdown barriers getting patients in the right beds ACS regional beds Treat and discharge patients given beds as a priority 3. How do we facilitate rapid transfer to the lab for PCI / angio centre patients? Not much to fix works well now sometimes a delay but not often Increase capacity and logistics in the Cath lab Number of cath labs low in UK as compared with the rest of Europe Have we got the right number of labs for the GM population? [e.g.- Denmark -10 labs:1.2m population (plus locality intervention pacemakers) (9+1 hybrid) 3000 PCIs] Need to benchmark like Denmark. Dedicated cath lab for emergency procedures - intervention lab Dedicated times for low and high risk patients Better scheduling Silver Heart Doctor in PAT General medical physician input required Identifying quickly/flagging to cardiology Models which work well cardiac nurse practitioner (look at whole group of cardiac contacts) Have a cardiac shuttle service - an ambulance may not always be necessary and ordinary transport may be sufficient Extending operational hours - have a dedicated lab available that is manned 24/7 Ideal infrastructure; green light when patient ready to be referred and cath lab ready to receive Could forget about beds and have immediate transfer to cath lab. Best practice tariff to facilitate ring fencing hot list / hot lab 24/7 ownership of a patient by the cardiology team Lower risk patients can be done the following day Rapid discharge and good follow-up. A quarter to a third of patients could be discharged directly home Standardised documentation to support the transfer Duplication of documents (different paperwork currently for MRI and Wythenshawe is not helpful) Need to balance elective / non-elective work Increase lab efficiency (e.g. scheduling of angioplasty lists) and lab capacity 5

6 CATS: Communication should be able to contact quickly via mobile (CATS a barrier) Phoning a specific number would be easier than using CATS Use CATS for flagging a patient - must be entered on CATS quickly Remove the difficulties of putting a patient on CATS Flow within hospital i.e. easy to get to the cath lab but a problem to move after procedure within the hospital Be able to be flexible in treatment Beds: Ring-fencing cardiac beds (not enough CCU beds) Increasing capacity outside Cardiology/ educating AMU to take patients. Unifying process in acceptance i.e. unifying process in referrals between different centres Ownership (ACS Nurses) Flexibility in cath lab staff Flexibility within cardiology work streams Demonstrate net gain to convince managers of the safety element. 4. What are the discharge pathways for these patients? Make sure patients are properly risk-assessed: Echo complete (should be standard and as accessible as having a chest X-ray. Consider having an echo prior to cath lab) Prioritising Echo for patients who will be discharged vs. patients with a longer stay on the ward, ring-fencing technician time for these patients Counselling arranged Clear mechanism to get the patient into a local pathway for follow-up / rehab This will prevent patients being discharged too early Criteria-led discharges Discharge summary: Standardise across both tertiary centres (one set of documentation) GP (need immediate links with GP via an Electronic Discharge Summary) Rehab pathway Discharge letters typed up (these sometimes take up to a month to come through needs to be much quicker!) Standardisation of chest pain pathway across GM AMU and EDs (so it is not consultant dependant) 6

7 Non-consultant dependent discharge, standardisation of discharge, empowering non-medics (practitioners, cardiac nurses) to discharge plus involve cardiac pharmacists in discharge Look at ways of freeing up ambulances - efficient transfers Post procedure patient to stay in 1 day Discharge home from the HAC where possible instead of cardiac transfer Discharge NSTEMI patients from cath lab when stable back to DGH (to a bed that has been held) Need copies of blood results / Echo (more info needed for the DGH cardiologists) Best interest meetings (Form 4?) Integrated IT service Best service would be: discharged from cardio bed- seen by cardiologist- echo done discharge from hospital In Stockport the cardiologist sees the patient before discharge, the waiting time for the cardiologist visit can block a cardiac bed and waste time in repatriation to the original hospital Education of patients: currently high level of re-admission is due to patients not taking advice seriously Consider patient experience Family / carers Taking in consideration family having fear of re-admission to hospital Family expectations: information leaflets, involving pharmacy in home delivery of the medication Provide 24/7 access for patients to the local hospital network after discharge Discharge during the weekend would release cardio-beds, currently too few doctors at the weekends Early discharge: discharge with a plan, empowering specialist nurses, cardiac rehabilitation team, physiotherapist, titration of medication and then regular visits High quality post-operational care: Identify people with early post-operation failure Have the facility to triage the patients. Capacity on the shop floor to educate these patients. Linking the Cardiac Units electronically across GM Create post MI clinics Create electronic patient records that can be shared across GM (Angiogram) Access to timely cardiac rehab 24 hr cardiac rehab units linked to DGH s Need to remove variation across GM Secondary prevention, refer to cardiac rehab linked to DGH 7

8 Cardiac nurse rehab: 2% prevention (stop smoking / exercise) and (medication / education) Networked approach Physio input rehab: prescribing opportunities (carers and families re-assurance, to prevent re-admission, community pharmacy involvement) Note Denmark follow-up with Physician + Nurse Cardiac Rehab. Education / information for GM population on what happens post-heart attack Medication Reduce delays by tackling TTO dispensing (pre-packed) hour discharge (discharge checklist) - can we titrate meds more efficiently? Surgical group 5. What are the operational, financial and manpower resources needed for this service? Adequate capacity within Cardiology to cope with the demand. Adequate manpower and flexibility (ANP, Chest pain practitioners, co-ordinators of CAT Lab activity) Use existing data (Right care/ RAACS/GIRFT) to determine resource requirements Invest in the workforce Core resources: extending roles for currently established roles, increased competencies Look at peoples roles and responsibilities- can we make changes using and adapting current resources. Invest to achieve longer term savings (ring-fence beds, dedicated ACS nurses /chest pain teams) Needs buy-in from senior leaders CEOs, Medical Directors, Clinicians Have re-investment directly into the area that is making the cost savings Share resources across the region Give people responsibility to make savings and reward good practice Address morale and make staff feel valued (culture in cardiology isn t great at the moment) Build trust through established pathways Empower staff & make them feel part of the team Training and development Adequately trained cardiology frontline staff Skill mix/ confidence/competency = standards = efficiency (increase) Education and awareness More engagement and better organisation 8

9 Bring back the cardiac network (re-invigorate this as the forum to drive combined change) Include tertiary centres, DGHs NWAS, CCGs, patients and carers Motivate staff (have study days) Bank staff / agency staff can be an issue due to high turnover this needs addressing Improvement of transport between hospitals Implement a 24/7 service; currently volunteering service: 90% Wythenshawe and 67% MRI Day working is a major limiting factor 7 day working Alter working patterns Cath lab manned 24 hours a day Need to invest in the resources needed to deliver this Changes to the tertiary centres (currently two) in the long term due to merger, one only planned. This will centralise all medics in one place and allow better organisation of 24/7 care Family friendly hours (but this is only possible with the right funding) GM-wide bed service Ring-fencing cardio-beds The GM-standardised pathway with the GM-wide IT support for this pathway (better communication) Reorganisation of cath labs Reduce duplication of documentation Multi sector agreed pathways (CCGs, NWAS and Hospitals) Align pre-hospital pathways (obtain buy-in from NWAS to deliver this and buy-in from all clinicians across GM) Ensure that there are people driving this that will force change Improved collaboration within GM Cardiac Network. Financial restrictions Capacity/demand bed modelling Ring fence beds Increase bed occupancy DNA CPR.frailty address OHCA pathway Rehab provision may have to increase Winter pressure on wards Look for waste in the system with resources Optimise cath labs IT information / data electronic data entry 9

10 Do we describe as a cardiac space Input. Output, Rehab? Align to Theme 3 Cardiac case for change Considerations 1. Where is the waste 2. Value for Patient = Outcome Cost 3. 80:20 principle: the because 4. Resistance: Why I diagnose 5. Change curve: Behaviours Next steps ACS for 24hr Angio s access Discussion paper for next steps and agree Use existing data saving money quality saves lives Articulate a work programme Clinicians, NWAS, OP managers, Data 10