Targets, flow, exit block, stranded patients, red2green. What s any of this got to do with good patient care? Lee Dowson Divisional Director of Medicine Royal Wolverhampton NHS Trust Clinical Associate Emergency Care Improvement Program (ECIP)
Question If your relative was in the emergency department in your hospital with a significant medical problem would you feel the need to phone a friend to ensure they got the best care?
Flow, occupancy and mortality
Risks associated with crowded hospitals Full hospitals lead to poor outcomes Crowding in ED is associated with a 43% increase in mortality Outlying is associated with an increase in mortality Bed occupancy > 92.5% is associated with an increase in mortality
Risks associated with hospital admission Hospital Acquired Infections Deconditioning 10 days in hospital leads to 10 years of muscle wasting #EndPJparalysis #Last1000days
Solutions reduce demand Public health and General Practice Advance care planning and work with nursing homes Self management, case management Admission avoidance telephone advice, rapid response, HOT clinics, step up beds Ambulatory emergency care (AEC)
Solutions increase capacity The right bed base? Increase capacity Increase the number of hospital beds No funds and no staff Improve efficiency
Typical patient inpatient journey
Principles for improving internal capacity Early senior decision making Admit only patients whose care can t be delivered using an ambulatory approach Develop an intolerance of waiting and identify the commonest barriers Parallel processes Break down silos (pathways and culture) Innovate, PDSA, share Make it easier to do the right thing
Tools for improving internal processes Red2Green SAFER Stranded patient reviews Internal professional standards 6A s audits Ward round checklists
Theory of constraints
Red and Green Bed Days Visual management system to identify and address wasted time in a patients journey Short term - Todays work today Remove constraints from the system Easier to do the right thing Acute and community inpatients Not suitable for high turnover units eg ED, Assessment Units
A Red Day adds no value to a patient No senior review takes place The medical care plan lacks a consultant approved EDD There is no consultant approved physiological and functional clinical criteria for discharge (CCD) A planned investigation/assessment/procedure or therapy doesn't take place The patient is in receipt of care that doesn t require a hospital bed Patient is medically fit for discharge but doesn t go home
Green Day A patient receives value adding acute care progressing towards discharge Everything planned or requested gets done A patient receives care that can only be delivered in a hospital bed A GREEN day is of value for a patient
The Process Must be standardised within your trust Start the board round/huddle with all patients marked Red If an action occurs that progresses the patients care = Green Take immediate action to convert Red2Green Todays work today Escalate unresolved issues Collate Red reasons to identify common system constraints This is not a performance management tool. Red days are opportunities to improve care for patients
Arrow Park Effect on early discharges
SAFER Patient Flow Bundle The patient flow bundle is similar to a clinical care bundle. It is a combined set of simple rules for adult inpatient wards to improve patient flow and prevent unnecessary waiting for patients. If we routinely undertake all the elements of the SAFER patient flow bundle we will improve the journey our patient s experience when they are admitted to our hospital.
The Patient Flow Bundle - SAFER S - Senior Review before midday A - All patients will have an Expected Discharge Date F - Flow of patients will commence at the earliest opportunity (by 10am) Golden patient E Early discharge, 33% of our patients will be discharged from base inpatient wards before midday. R Review, a weekly systematic review of patients with extended lengths of stay ( > 7 days)
Patient Benefits Improved care co-ordination Key points Clinically owned Well planned, informed and timely discharge Less likely to be outliers May need local adaptations Consistent approach for greatest benefit Care delivered in less crowded wards and departments Joint working Management team Other directorates Community partners Social services
AMU discharges EDD
Stranded patients Patients who have been in hospital 7 days or more Most will be waiting unnecessarily due to internal and external delays have exceeded their EDD Some will be waiting for interventions that are inappropriate or no longer necessary waiting for interventions that could be performed as an outpatient waiting for social interventions which they will not qualify for What could have been done in the first few days to prevent this patient becoming stranded. Consider peer review and super huddles Collate constraints to inform service developments and D2A processes
Take home messages Hospital overcrowding is everyone s problem Improving efficiency is the best option for improving patient experience and outcome in the short-medium term Without clinical leadership the situation will not improve There are tools which have worked in UK hospitals and if implemented will improve outcomes directly and indirectly There is an urgent need for evidence based innovation and research into non-elective care systems (QIP) Improvement requires partnership working