A Whole System Approach to Emergency Care Improvement The Ipswich Hospital NHS Trust
A Whole System Approach to Emergency Care Improvement Ipswich Hospital has one of the top-performing Emergency Departments in the country. Despite an 11% increase in non-elective admissions, it has delivered the 4-hour emergency access standard over eight consecutive quarters and has regularly been rated amongst the top 10 trusts in England. Emergency and urgent services at the hospital were rated as Outstanding overall by the Care Quality Commission, which had particular praise for the Emergency Department s innovative escalation protocol.
Earlier Decision Making A key component of this protocol is a unique trigger tool that the Trust has developed to warn senior staff of potential problems early on. While many early warning systems provide only minutes notice when patients are likely to breach the 4-hour emergency access standard, Ipswich Hospital s trigger tool provides three-hours warning of impending difficulties, giving staff and managers time to act. Chief Operating Officer, Neill Moloney, explained: When I first arrived at the hospital, I found it frustrating that I would receive a phone call letting me know that the Emergency Department was beginning to breach, at which point it was too late to do much about it. What we needed was a system that would trigger a warning much earlier on so that we had time to act before the issue became critical. Neill continued: We knew that problems occur in the Emergency Department when there is more demand than there is capacity to serve it but we wanted to find out if there was a pattern to the breaches. We set out to discover what information we had within the system that could inform us what was actually happening. We were actually relatively information-rich but we found that this information wasn t being used effectively. We had the paper-based coordinator s log, the patch bleep-holder staffing report, the electronic whiteboard that shows all patients in the department, the ambulance inbound screen, as well as the attendance, ambulance arrival and performance totals. Forward-Planning in Real Time Using this information, we assessed several months of ED attendance and identified any recurrent factors on days of poor performance. This showed that it was not just random, uncontrolled variation in attendance, but a combination of relatively few factors. For example, we
knew that if we had a higher than average number of patients arriving by ambulance in any given hour and that the number arriving did not level out over the next couple of hours, we were likely to experience problems. Identifying these triggers would allow us to predict, with some certainty, when there was an impending problem... and with enough time to do something about it. The hospital assigned each of these trigger factors a numerical weight and then set up a model tool on Excel which was tested and refined over subsequent weeks. Once managers were satisfied that they were using the right metrics the in-house Systems Developer created a webbased tool. Designed to Support a Culture of Forward-Planning Neill said: Primarily, this is not a tool for data analysts and managers. The ED trigger tool is designed to support a culture of forward-planning in real time by those on the shop floor. One of the keys to the trigger tool is its simplicity. It uses only a handful of basic data items which are clearly displayed in a spreadsheet format. Alerts are automatically emailed and texted to senior managers and executives and the trigger score is displayed in all operations centres across the Trust. A Whole-System Approach to Improving ED Performance The Trust-wide sharing of data reflects another key tenet of Ipswich Hospital s success in improving ED performance. The hospital believes in a whole-system approach to managing the demands on urgent and emergency care, as Chief Executive, Nick Hulme, explained: I believe that the commitment to see patients within four hours is the most important measurement of a well-functioning hospital. The entire hospital has to be functioning well for this measure to be achieved. Wards have to be safe, well-run and efficient. The same can be said for diagnostics. The bed management system needs to be effective and responsive. The relationship between managers and clinicians needs to be respectful, even though at times there can be areas of conflict.
When the ED trigger tool sends out a warning of potential problems, the response is Trustwide. Senior staff immediately assess the extent of the problem and consider whether there are sufficient resources within ED to handle it. If not, other departments are called on to send staff to provide additional support. Avoiding breaches is not regarded as the responsibility of ED alone. Neill added: If we can keep waiting times down and manage the risk of deterioration in vulnerable patients we reduce the impact across the hospital. In this way, we believe that everyone has a role in supporting these objectives. Operation Red to Green As part of its escalation protocol, Ipswich worked alongside ECIST (the NHS Emergency Care Intensive Support Team) to implement Operation Red to Green, a national programme that aims to identify where Trusts can work better in order to end the cycle of bed escalation (that is, having to make extra beds available to cope with spikes in demand). Red Days are designated as days when patients are in hospital without receiving any kind of clinical intervention or diagnostic test (in other words, when progress is delayed). Green Days are those days when interventions are made and the patient moves closer to being discharged. From 2014, Ipswich began assessing every inpatient using the Red Day and Green Day system. In March 2015, it decided to intensify its efforts to improve patient flow through the hospital and limit the requirement for escalation beds by launching Operation Red to Green Week. During this week, the whole system focused its efforts on resolving the issues that contribute to patient delays ( red days ). All non-essential meetings were cancelled to focus solely on patient care. Directors and managers made themselves available to support clinical and ward staff. All clinicians focused solely on clinical activity for the entire week.
Two Escalation Wards Closed The week produced some outstanding outcomes. During the course of the week, the hospital succeeded in closing two escalation wards. A proven red to green process was developed, which is capable of being deployed at short notice. Communication across primary, secondary and tertiary care was improved and the Trust gained a better understanding of how improvements could be sustained in the long term. Following the week, a number of red to green system changes have been adopted. Board rounds and daily huddle discussions ensure that all team members understand what has to be achieved that day. The hospital is investigating the idea of patients being able to receive intravenous antibiotics at home where it is medically appropriate to do so. A new TTA (medicines to take away) system has been introduced to ensure that TTAs can be written the day before discharge wherever possible. The hospital has also challenged itself to ensure that all patients referred from ED are moved within 30 minutes from acceptance by a ward regardless of breach time. Giving Patients Their Life Back Nick Hulme concluded: For many of our patients who face a limited future, every day that we can give back to them is precious. Therefore, we owe it to them to do whatever we can to improve system flow so that their time in hospital is the shortest it can be and they experience a smooth transition through the various treatments and diagnostics they need towards an early discharge. We have shown that, by taking a whole-system approach, of which red and green is an integral part, we can not only achieve this but also sustain it in the long term.
To find out more about the Emergency Care Improvement Programme please go to: www.ecip.nhs.uk or email nhs.ecip@nhs.net @ECIProgamme