Joint Board Meeting 12.10.12 Unscheduled Care Report originally prepared for Quality & Safety Committee in September 2012 1
This report provides a broad summary for the Quality & Safety Committee on the position relating to unscheduled care. The report gives an overview of the All Wales position and the situation across the University Health Board, but then goes on to focus on the delivery of quality services for patients at the Ysbyty Glan Clwyd hospital site. Emergency Department (ED) performance over time by site - 4hour breaches The Welsh Government routinely monitors how long patients wait for admission, discharge or transfer in Emergency Departments. The official Welsh Government target states that 95% of patient should wait less than four hours. The chart below sets the context for Performance across the University Health Board. It shows performance against the four hour target by month since April 2010 to July 2012. Each hospital Emergency Department is shown separately. Four Hour Emergency Department Performance April 10 to July 12 The performance shows that on average over the last 12 months, Ysybty Glan Clwyd performance has been 79%, Ysbyty Gwynedd has been four percent higher at 83% and Ysbyty Wrexham Maelor has eleven percent higher at 90%. Historically, the annual pattern of performance typically shows higher levels of performance across the summer months. The reasons for this are multifactorial, however a significant cause is the number of high volume but low acuity cases attending Emergency Departments. This means that in the summer there is a higher volume of patients with less complex needs, which are treatable within four 2
hours. In contrast, typically winter periods may have fewer patients, but with more complex needs. This pattern of summer improvement can be seen in Wrexham Maelor s pattern of performance in summer 2010 and summer 2011. For Ysbyty Gwynedd the pattern is visible in 2010 and again, to a lesser extent in 2011. For Glan Clwyd hospital, the pattern stopped after 2010. Ambulance Attendances Approximately 1/3 of patients arriving at Glan Clwyd s Emergency Department do so by ambulance. The remainder arrive by their own transport or other public transport. It has been reported by the Welsh Ambulance Service Trust (WAS) that the change in Card 35 to record GP requests for ambulance conveyance to hospital and in particular the creation of the immediate category ( which is treated like an 8 minute 999 response) has resulted in an increase in patients arriving at ED in batches and may well have increased the pressure on both ambulance services and WAST. The chart shows that since the new response model was introduced, there has been an increase in the number of immediate ambulances requested by GPs. This chart illustrates WAST s Category A incidents by month since April 2010. The pink area is the Card 35 proportion (3394) of the total Category A incidents (25246) which is 13% 3
Mortality Rate within Emergency Department - BCU compared to Wales Deaths in the Emergency Department are very rare. This section looks at the numbers of deaths within Emergency Departments and the crude rate of mortality. The information here is to be treated cautiously. Figures on mortality are collected from the Emergency Department s data systems across Wales. A picture of deaths in Major Emergency Departments across Wales emerges. Only patients who die in the department are included, therefore this excludes patients who are deceased on arrival at the department, and also excludes patients who die when they are subsequently admitted to a ward. In the twelve month period between May 2011 and June 2012 some 1,355 patients died across Wales in Emergency Departments. Of these, 236 patients died within North Wales. The full data can be seen in Appendix 1. The crude rate of mortality is calculated by dividing the number of deaths by the number of attendances. This is multiplied by 1,000 to present a rate of deaths per 1,000 attendances at each Emergency Department. The summary table, showing rates across the Health Boards in Wales over the last 12 months is shown below. Crude mortality rate per 1,000 - died in department 2011 2012 12m LHB Name 06 07 08 09 10 11 12 01 02 03 04 05 HB 1 HB 2 BCU HB 3 HB 4 HB 5 0.68 1.21 1.81 1.79 1.45 0.00 1.61 2.25 2.41 1.27 1.77 1.42 1.59 2.03 1.22 1.06 1.72 1.82 2.67 3.16 2.08 3.31 2.05 2.14 1.80 2.07 1.24 0.65 1.64 1.27 1.73 1.28 1.82 0.91 1.73 1.42 1.36 1.40 1.37 1.72 1.48 2.24 1.34 1.50 1.62 2.89 2.83 2.29 2.18 2.45 2.12 2.05 1.87 1.77 2.00 1.16 2.00 2.23 3.25 2.43 2.70 2.62 1.77 1.55 2.12 1.37 1.63 0.79 1.25 0.83 1.98 1.52 1.72 1.47 1.38 1.07 0.78 1.30 The period for the full twelve months is also shown. As the following chart shows, BCU reports the second lowest mortality rate across Wales in ED. 4
Mortality Rate in ED, comparison over 12 months from June 2011 to May 2012. When the analysis of Emergency Department mortality is reported at Emergency Department level for BCU, there is some variation between the three sites. Ysbyty Wrexham Maelor reports the lowest rate of 1.08 deaths per 1,000 attendances. Ysbyty Gywnedd reports a rate of 1.47 and Ysbyty Glan Clwyd a rate of 1.63. It is important to note that this below other Health Boards in Wales. Emergency Department Mortality Rate by site, June 2011 to May 2012 2011 2012 Hospital 06 07 08 09 10 11 12 01 02 03 04 05 12m WMH 1.06 0.35 0.89 0.87 1.38 0.93 1.83 1.27 1.24 1.12 1.24 0.81 1.08 YGC 1.83 1.15 0.95 1.73 2.31 2.09 1.19 0.72 2.43 1.57 1.36 2.29 1.63 YG 0.75 0.46 3.41 1.30 1.53 0.85 2.55 0.57 1.69 1.70 1.52 1.17 1.47 In order to understand the reasons underlying the higher rate at Glan Clwyd hospital, a casenote level review of deaths within the Emergency Department at Glan Clwyd Hospital is underway. This review has been set up to give assurance regarding safe, sustainable quality care at the Emergency Department. Triage Each patient who arrives at an Emergency Department in North Wales is assessed using the Manchester Triage System. The Manchester triage systems is an internationally recognised method of prioritising patients when they attend an 5
emergency department. The table below gives a broad indication of the prioritisation categories and a patient s estimated waiting time. Colour Priority Example Estimated Patient Waiting Time Red Immediate Cardiac Arrest No Wait Orange Very Urgent Cardiac - Chest Pain Within 10 minutes Yellow Urgent Broken Bones Seen within 60 minutes Green Standard Abdominal Pain Seen within 120 minutes Blue Non-Urgent Minor Wounds Seen within 240 minutes The following charts shows the percentages of patients who arrive by triage category, by the way that they arrive in the department. Non Ambulance Arrivals Ambulance Arrivals 6% 9% Blue 28% 57% Green Yellow Orange Red Blank 32% 2% 6% Blue 10% 50% Green Yellow Orange Red Blank 6
The charts show that, as expected, ambulance arrivals are typically more urgent than those patients not arriving by ambulance. Whereas the majority of patients arriving not arriving by ambulance are triaged in the routine (green) category, the majority of patients arriving by ambulance are classified in the urgent (yellow) category. Utilisation of Ambulances by GP Practice This section looks at ambulance utilisation by GP practice. Two analyses of utilisation are undertaken. The first starts by looking a crude measure of ambulance utilisation. The second goes on to analyse utilisation by the relative size of the GP list. Further stages of analysis which are adjusted by age and socio-economic factors are yet to be undertaken. There is variation in the use of ambulances by GP practice. This analysis shows all patients who arrive at Glan Clwyd Hospital by ambulance. It includes all ambulances, including those called for either by the patient themselves or the patient s GP. The chart shows how many patients are using ambulances. This measure is relatively crude, in that no adjustment is made for the relative size of the GP practice. GP practices with larger lists are therefore more likely to have more patients using ambulances to arrive at hospital. The chart shows, as expected, the practices with the larger list sizes report higher ambulance utilisation. The following chart shows the utilisation of ambulances relative to the GP practice size using a funnel plot. The size of the practice population is shown on the horizontal axis. Practices towards the right have larger numbers. How many ambulances are called is shown as a percentage on the vertical axis. Practices towards the top have higher utilisation. 7
ED Attendances by Ambulance (April-May 2012) The funnel plot shows an average line across the middle, which can be regarded as the norm. Either side of the norm are dotted lines which show the limits within which practices would be expected to vary from month to month. These limits are referred to as Standard Deviations (SD) in the chart. As the funnel plot shows there are some practices above the third standard deviation line which are referring above the expected levels of patients to the Emergency Department by ambulance. Whilst the highest practice (indicated 1) refers a high percentage of patients, that practice s list size is relatively low so the impact on the Emergency Department is less. In contrast, the right-most practice above the third standard deviation (indicated 4) has a lower percentage of patients, but a significantly bigger list size, resulting in higher volumes of patients attending the Emergency Department. The practices indicated are anonymised in this report. Practice names are known and the next step is to confirm the data is accurate before further discussions take place. It should be noted that this analysis is not yet adjusted for age or socioeconomic factors such as car ownership. Ambulance Arrivals by Patient s Usual Place of Residence This section of analysis looks at where ED Ambulance Arrivals usually live. This is typically the patient s home, but the definition is expanded to include patients usual residence. So, this could include a residential home, nursing home or caravan if the patient usually resides there. The image below displays a map of the North Wales coast line. The relative size of the dots shows how many patients are being transported to Ysbyty Glan Clwyd from that location. 8
Ambulance Arrivals by Usual Place of Residence Ysbyty Glan Clwyd April and May 2012 The chart clearly shows that the use of ambulances in Rhyl is significantly higher than other areas. Whilst this information is not adjusted for the relative population sizes, these cannot account alone for the variation in ambulance usage. Improvement Focus Work to improve the process at Ysbyty Glan Clwyd has identified three key themes which form the forward focus for improvement: 1. Medical Leadership Failure to repeatedly recruit to substantive posts in Ysbyty Glan Clwyd and reliance on locum and agency medical staffing. This posses a significant risk to the health board and leads to lack of clinical leadership. To mitigate against this risk some cross cover has been provided from the Wrexham Consultant lead and further discussion is underway to make this arrangement more robust. 2. Nurse Leadership & Scope of Practice Need to optimise the skill base of nursing staff working within the ED, particularly around the role of triage in the system. Refocus the nursing role on improving patient pathways for treatment. 9
3. Escalation and De-escalation processes Clarity of understanding and actions needed across the whole health system is key to ensuring improved response to times of peak pressure on the ED. Similarly the importance of de-escalation is when the position is stabilised is key to ensure all staff understand their responsibilities and contribute fully to improving the patient pathway. Further work is on-going to ensure consistency of approach and response to escalation and de-escalation processes. 4. Discharge planning and discharges before 11am The way that hospital wards manages discharges affects how well the Emergency Department can function. For patients who require admission to a hospital bed, the bed needs to be available. Typically, hospital discharges vary across the day, and only a very small number of discharges occur before 11am. The table below shows the percentage of discharges between 7am and 11am, compared to discharges at other times. Glan Clwyd Hospital Discharges by Time of Day Discharges 11am 7am- Discharges at other times Total Discharges Number 1,066 10,710 11,776 Percentage 9.05% 90.95% 100% The information shows that less than 9.05% of discharges occur before 11am at the Glan Clwyd Hospital site. Whole system approach Welsh Government announced 10m resource for improvement in unscheduled care. The Health Board has submitted a prioritised list of 20 schemes to the value of 5.3m which are presently being considered by the National Programme Board. In preparing the submission the schemes take a whole pathway approach and look to improve services pan-bcu. The highest priority has been attached to schemes such as Home Enhanced Care (HECs) which aim to maintain patients safely in a primary and community care setting, avoiding ED conveyance by ambulance and reducing acute hospitalization and the associated issues arising from this, such as delayed transfers of care when medically fit for discharge. Improvements within the pathway, once the patient arrives at ED are included through triage to primary and community care services, improved ambulatory care, 10
improved senior medical support from ED to Acute Medical Unit (AMU) and to discharge, improved supportive discharge services, and rapid response to home care adaptations required to enable prompt discharge of patients.. Recommendations The Quality and Safety Committee are asked to note the concerns in relation to the sustainability and performance of the ED service in Ysbyty Glan Clwyd and the actions being taken to support improvement in this service. The committee are asked to support the continuing focus on the top 3 priorities of medical leadership, escalation processes and discharge planning as key elements to improve the reliability of services over the next 3 months. The committee are asked to note the substantial submission made to Welsh Government to support whole pathway improvement across the Health Board. 11