DRAFT
Draft Phase 1 Report
Northern Health & Social Care Trust
Review of Emergency Care & Medical Specialities –
Phase 1 A&E and MAU
Patricia Kilpatrick
23rd June 2010
Content
1
The Scope and Objectives for the Review
2
2
The Review Process
5
3
The Current Emergency Care System
8
4
Opportunities for Improvement using UK Best Practice
31
5
Appendices
41
1
1
The Scope and Objectives for the Review
2
Scope and Objectives for the Review
Background and Scope
All aspects of
unscheduled care
including the flow
through A&E, MAU
and specialities are
included in the review
The Northern Health and Social Care Trust engaged Tribal Consulting to undertake a major review of the provision of Unscheduled Care in order
to:
 Achieve increased performance
 Improve the quality of the patient experience
 Create a more efficient care process
 Deliver optimum utilisation of healthcare resources.
The review focussed on the specialities and services provided from the following hospitals:
 Antrim Area
 Causeway
 Whiteabbey
 Mid Ulster
In addition the Dalriada, Moyle, Robinson and Braid Valley community hospitals were also reviewed.
The review included all aspects of non elective patient flow and with a particular focus on:
 Accident & Emergency (A&E) Acute medicine
 Medical specialties
 Intermediate and
 A & E services in terms of achieving and sustaining the 4 hour access target
 Medical Assessment Units (MAU)
 Medical specialities
 Care of the Elderly
 General Medicine
 Cardiology
 Respiratory Medicine
 Gastroenterology
 Neurology
 Stroke
 Rehabilitation
 Pharmacy and medicines Management team
 Intermediate and step down care with a clearly defined diagnosis and robust assessment of the current problem
The review process involved:
 an appraisal of the current models of care
 evaluation against UK best practice
 recommendations on the future design and configuration of these services
3
Scope and Objectives for the Review
Objectives
The main objective is
to improve the triage
and streaming of the
patient flow in order to
build a more efficient
model of emergency
care.
The Review aimed to:
 Reduce rate of presentations and to provide alternatives to A&E and reduce physical congestion
 Segment flows and define appropriate resources to improve quality and reduce waiting and congestion
 Match staffing with peaks in demand reduce breaches
 Create alternatives to admission by increasing slots in imaging ,scopes, outpatient services, direct referral to rapid access clinics and
reduce numbers in A&E
 Exploit ambulatory emergency care and bed reduction at both sites
 Reduce the number and categories of patients who will have their detailed assessment and work up in A&E e.g. Ambulatory Care Service,
GP referred medical patients, urgent / emergency Gynaecology, miscarriages, early pregnancy bleeds – eradicate congestion and
breaches.
 Reduce length of stay in MAU where appropriate
 Benchmarking current performance with peer group and best practice
 Review current intermediate care arrangements and performance
 Prepare and plan for implementation of change to new models of care.
 Plan for the recourses needed to implement and run the new model of care.
The review process developed:
 An unscheduled care model focussed on bringing together the key elements within the service to create an integrated emergency care
department
 An emergency ambulatory care reflecting UK best practice and supporting any existing “see and treat” functions within the Trust.
 A bed model for the Trust based on achieving rapid access to streaming, assessment and specialty based care in line with Department of
Health (DOH) guidance, UK best practice in the design of emergency care and the requirements of the Royal College of Physicians.
 A resource plan to provide a sustainable solution that includes proposals to deliver the efficiencies required in the context of
Comprehensive Spending Review (CSR)
 A detailed implementation plan that focuses on the costs and timeframe by which the proposed models may be implemented
4
2
The Review Process
5
The Review Process
Clinical Engagement
Frequent meetings
and workshops
enabled involvement
and participation from
all clinical groups.
A range of methods where used to meet and engage with clinicians on all sites including meetings with the following:
 The clinical director for emergency care.
 The emergency and specialty clinical teams.
 The Multi Disciplinary Teams from the Community Hospital sites.
Though these meetings we have ensured involvement and participation of consultants, clinical leads, senior nurses, senior
managers, AHP leads, diagnostic teams in lab, imaging, pharmacy, CDs and Executive Directors.
Each phase of the review process is followed by a workshop to further strengthen the clinical engagement:
 Phase 1: A&E & MAU - 28th June 2010
 Phase 2: Bed Models for Speciality Based care – 17th June 2010
 Phase 3: Resource Planning and Implementation – 21st July 2010
This report covers the first phase of the report – the review of A&E and MAU.
6
The Review Process
Timescales & Reporting
Phase one of three
has now been
finalised.
A Project Plan has been developed covering all phases and is shown below for phases two and three these cover the following:
 Phase two - 7th June- 5th July - new bed models
 Phase three 5th July – 2nd of August - resource and implementation
7
3
The Current Emergency Care System
8
The Current Emergency Care System
Model of Care at Antrim Hospital
A&E and MAU have
together 42 beds
The diagram opposite indicates the current
model of care and capacity on the Antrim site.
The size and capacity of the site indicates:
All GP referrals,
except chemotherapy
go through A&E
 Antrim is a high volume site the around 65000
DEMAND
A&E Department - Triage
attendances per year
 Short stay is managed by A&E consultants and
has 10 spaces - 8 bays & 2 single rooms.
 Ambulatory care has 6 beds and MAU outliers
are often boarded into these beds which results
in excessive LOS.
 The MAU has 26 beds and is managed by MAU
Ambulatory 6 Beds
Short Stay Ward
A & E 10 Beds
SSW
Assessment 26 Beds
Antrim B1
consultants on a weekly rota this includes:
–
1 dedicated MAU posts – 0.5 wte
–
Locum support for 0.5wte
PULL
 There are 166 medical specialty beds where
patients are transferred to from the MAU.
Front Door
Specialty 166 Beds
 There are no collaborative care teams at the LOS Benchmarking
front door. Rapid Assessment teams are
available but currently underutilised.
Sum of LOEs by HRG
within spell
 All GP referrals, except chemotherapy go
through A&E.
 GP services are not collocated on site.
Ratio All Admissions (Excl. Obstetrics & Neonatal) To A&E Attendances 16 % - UK Benchmark 17 %
9
The Current Emergency Care System
Antrim A&E Attendances
There has been
limited change in
number of
attendances over the
last two years.
60% of attendances
are self referred
45% of attendances
are triage 4 & 5
A&E attendance trends across the Trust
 The table opposite indicates very minimal changes across the last
two financial years with overall 0.8% increase across the 4 sites in
the Trust.
 Specifically on the Antrim site there has been a 1% growth
between 2008/09 and 2009/101.
The analysis presented below is in relation to 2008/09 as this was the
most complete and up-to-date year when the work commenced.
Antrim A&E Attendances by source
In 2008/09 there were around 65,000 attendances; on average 178
per day. The source of the A&E referral is shown opposite which
indicates:
 60% Self
 40% GP/Ambulance/HP/Transfer
Triage and Streaming
The triage method currently used is nurse judgement backed up by
written protocols. The Antrim site do not currently use the
Manchester triage system. Appendix 2 provides a definition of the
triage system used.
The chart opposite indicates the A&E attendances by triage category
which indicates 45% are triage 4&5.
Year
2008/09
2009/10
% change
Antrim
64,858
65,535
1.04%
Causeway
41,033
42,045
2.47%
Mid Ulster
19,056
18,444
-3.21%
Whiteabbey
22,563
22,697
0.59%
Total
147,510
148,721
0.82%
1%
1
Appendices 1provides
further data on presentation
to A&E
1%
Self
999 Ambulance
17%
GP/HP Referral
Transfer
Not Known
Other
57%
21%
Disposal from A&E
Analysis of the main disposal route after A&E is shown in Appendix 3
this indicates::
 87% Discharged
 4% to Ward
 7% to Short Stay Ward (SSW), MAU or CCU
Performance against 4h target 2010:
Analysis against the 4 hour target is shown in Appendix 4 indicating
between 60% to 70% compliance, considerable below the Northern
Ireland target of 98% within 4 hours.
 Jan: 65%
 Feb: 70%
 March: 60%
3%
Not Known, 0.4%
Triage 1, 10%
Triage 1
(Paediatrics), 6%
Triage 4/5, 45%
Triage 2/3, 38%
10
The Current Emergency Care System
Antrim A&E Workload
Antrim A&E Average Daily Workload from Midnight - 8am, 8am - 4pm, 4pm - Midnight On
Days of Week (2008/2009)
4pm - midnight
The graph opposite indicates the number of A&E
presentations by time period and day of the week
indicating
8am - 4pm
Average Daily Presentations
 Presentations peak from 11am – 8.30pm
 Mondays have the most presentations – in
excess of 200 presentations
 Daily average number of presentations is
178/day .
250
Midnight - 8am
200
87
150
76
74
76
75
68
72
96
80
83
77
79
74
75
21
19
19
18
19
27
32
Mon
Tues
Wed
Thurs
Fri
Sat
Sun
100
50
0
Further work has been done to map the
presentations and department workload by hour
shown in the chart opposite
Current Staffing
Number of Presentations and Projected A&E Caseload (4 hrs) for Average Day (n = 178)
The current staffing provided is as follows:
 Consultants: 4wte cover Monday to Friday
Peak caseload between 1 pm and 9 pm)
9am-5pm and Saturday/Sunday 9am-1pm.
 Nurses: 1wte nurse from 9am-5pm. From
1pm -10pm there is a second nurse on shift.
The current hours are generally staffed for a 9-5,
Monday to Friday and there is a need to review
the staffing profile for out of hours and weekends.
.
45
12
 There are 2 band 5 posts who manage the
flow in minors and the supervisory physician
who will support where Emergency Nurse
Practitioners cannot treat the patient
50
14
40
10
35
30
8
25
6
20
15
4
2
Average Presentations (Primary Axis)
10
Department Caseload (last 4 hrs Secondary Axis)
5
Projected Caseload
Current staffing is
predicated on a
Monday to Friday
9am to 5pm and
further resources are
required to cover
weekend and
evenings.
Workload Peaks and Troughs
Presentations
Current peaks in A&E
on a Monday and
between 11am and
8.30pm.
0
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
24 Hour Clock (Before Hr)
11
A&E Case note study
A case note study of
19 records indicated ,
when excluding the
single outlier that the
total time from
registration to
treatment complete
was 3 hours 13
minutes.
26% of the patients
required to be
admitted to a hospital
bed
19 records were extracted from the Symphony A&E
system reviewing these indicates the following
findings:
 The chart below shows the split by triage type
 Of the 19 – 2 patients left before first seen
 4 patients required an x-ray
 1 patient required request for a consult with non-A&E
specialist and waited 1 hour 30 minutes
 12 records had time when decision to admit / discharge
made
 5 patient required a bed excluding outlier of 7 hours 33
the average wait was 1 hour 7 minutes for a bed
The key times between interventions is shown below. This
indicates overall from entering to treatment completion /
decision to admit or discharge the average time is over the
4 hour target however once the outlier (maximum) is
excluded the average is reduced to within the 4 hours (3
hours 13 minutes).
Triage and
Resuscitation
16%
Adult Majors
26%
Minors
21%
**MAJORS B**
37%
Average
Maximum
Average excluding outlier
Time from registration to triage
1:23
19:43
0:14
Time from triage to 1st consultation with medical staff
1:42
6.41
1:23
Time from consultation to x-ray
1:11
3:35
0:23
Time from 1st consultation or x-ray to 2nd consultation
1:38
6:56
1:15
Time from 2nd consultation to diagnosis
2:54
20:44
1:25
Time from entering to diagnosis
4:33
8:48
4:16
Time from entering to decide to admit /discharge
4:18
8:48
3:13
Time from enter to leave
6:57
1 day 3:31
5:52
12
The Current Emergency Care System
Antrim A&E Attendances to Admissions
For the specific
specialties under
review 95% were
directly referred from
A&E
Attendances to Admissions:
Antrim A&E Average Daily Admissions From Time of Present from Midnight - 8am, 8am 4pm, 4pm - Midnight On Days of Week (2008/2009)
4pm - midnight
Reviewing the attendances which results in an
admissions indicates in total 7458 admissions in
2008/09 within the following areas:
 54% MAU
 17% Short Stay Ward
 7% Ambulatory Care area
 22% Specialty Beds
Admissions from A&E by time of the day and day
of week is shown in the table opposite indicating
this greatest admissions are on a Monday (27 on
average) which is consistent with the analysis of
attendances .
Admissions For Specialties in Scope Only
8am - 4pm
Average Daily Presentations
54% of patients
admitted from A&E
where admitted to the
MAU
30
Midnight - 8am
25
20
10
9
9
10
10
10
11
10
5
4
4
Mon
Tues
Wed
8
8
10
7
7
4
4
5
5
Thurs
Fri
Sat
Sun
15
10
5
0
12
Reviewing the medical specialties within the
scope of the review indicates around 7,500
admissions per annum, on average 20 per day.
Of these the referral source indicates:
 95 % via A&E
 5 % Direct GP/HP
13
The Current Emergency Care System
Antrim Medical Assessment Unit & Short Stay Ward
This included 4,045 episodes, 78% of which with a
stay up two days:
 14% with no overnight stay
50%
% Episodes of Care
The length of stay profile for patients either admitted to
the MAU ward or MAU specialty in Antrim is show
opposite.
42%
40%
30%
20%
22%
22%
Two Overnight Stays
LOE > 48 hrs
14%
10%
 42% 1 overnight stay
0%
 22% 2 overnight stays
LOE < 24 hrs
One Overnight Stay
The current target length of stay for the MAU is 2 days.
LOE Profile on Admission Under Medical Assessment Specialty, Admitted to Assessment Ward
(B1) or to Other Ward (n=3,316, n=249)
Further length of stay analysis of the patients admitted
under the MAU specialty by ward (either MAU or other)
is shown opposite.
This indicates 3,565 patients coded to the MAU
specialty with 3,3169 93% within the MAU ward and 7%
within other wards (likely to be the ambulatory care
area)
The length of stay analysis indicates a significantly
greater proportion of those within the MAU ward stay up
to 2 days (82% of total) compared to those who stay in
other wards only where only 51% stay up to 2 days with
49% staying over 2 days.
Admission to Assessment Unit
60%
Admission To Other Ward
50%
% Episodes of Care
49% of activity coded
to MAU consultants
but not in the MAU
ward stayed over 2
nights.
LOE Profile on Admission Under Medical Assessment Specialty or Admitted to Medical
Assessment Unit B1 (n=4,045)
Medical Assessment Unit
49%
45%
40%
30%
26%
22%
20%
19%
17%
15%
8%
10%
0%
LOE < 24 hrs
One Overnight Stay
Two Overnight Stays
LOE > 48 hrs
LOE Profile on Admission Short stay Ward (n=1,280)
Short Stay Ward
Analysis of the short stay ward activity indicated:
 1280 patients were coded to the ward
 82% stayed up to 2 days with:
–
28% no overnight stay
–
42% 1 overnight stay
–
12% 2 overnights stays
50%
% Episodes of Care
Around 80% of
patients coded to
either MAU specialty,
MAU ward or Short
stay ward stayed up
to 2 nights.
42%
40%
30%
28%
18%
20%
12%
10%
0%
LOE < 24 hrs
One Overnight Stay
Two Overnight Stays
LOE > 48 hrs
14
The Current Emergency Care System
The Current Model of Care at Antrim Hospital A & E
The access to
speciality beds is not
fast enough
The social worker
response time is good
.
A&E attendances are streamed into three areas:
 Majors
–
Patients arrive by self referral, GP or ambulance.
–
Protocols exists for triage,
–
There is a point of care testing in place and some delays due to pathology.
 Minors
–
Self referred patients will on arrival choose against a list of conditions (minor/majors).
–
Minors move to a separate area with 7 cubicles available.
–
An Emergency Nurse Practitioner (ENP) manages minors with the supervision of a physician (any grade).
 Paediatrics
–
There is a separate area for children.
–
A dedicated nurse from majors and a physician covers this area in conjunction with A&E.
–
They have not all received paediatric specific training.
Access to clinics
 Elective clinics should allow for acute management of patients within specialities. The rapid access clinics with a 2 week wait are not
‘rapid’ enough.
 There is a direct access to Stroke and Cardiology, admission from A&E to MAU.
 Gynaecology is a particular problem and the teams are working to identify a clear pathway to Gynaecology services to reduce response
times
Occupational Therapy/Physiotherapy/Social Care support in A&E and Short stay:
 Physiotherapy and Occupational Therapy are available on weekdays and for a few hours in the morning on weekends.
 Social worker is on call at weekends and dedicated in the department weekdays
 The response time is good
15
The Current Emergency Care System
Current Model of Care Antrim Hospital A & E
Access to mental
health acute beds is
an issue
Mental Health
 Crisis response from Mental Health is excellent.
 Daily presence in the mornings and good response time
 Access to Mental Health acute beds is an issue and can cause delays for up to a day where patients are admitted to the ward/short stay
until a bed can be found within the region if none available at Holywell.
The role of the flow
coordinator should be
expanded to better
manage breaches
Flow Management/Coordinator:
 This post does exist but it is not working optimally. It is felt this role would significantly improve the management of patient flow and
managing breaches within the department and allocating resource where required.
.
Delays downstream
 MAU is unable to create capacity.
 Wards are not discharging enough to allow pulling from MAU to release capacity.
Information/Monitoring of the target:
 An electronic system, Symphony, is in use and flags patients when they are coming up to breaching. Symphony shows: Name of Patient,
Registration time, pre streamed (ED1), ED2, Decision to Admit, Depart.
 Performance against 4 hours / 12 hours high level of breaches. - waiting for breach report from Seamus
 There are full admitting rights to surgery therefore no delays in terms of response times
 There is unlimited access to CT, ultrasound and X-ray in hours and unlimited access to X-ray out of hours. However access to ultrasound
and CT out of hours is by patient demand and on call. There is access to a morning endoscopy list
16
The Current Emergency Care System
Model of Care Antrim Hospital MAU
All patients , except
cardiology, go from
A&E to MAU.
The Model
 All patients, except Cardiology, go to MAU and are coded to the single consultant regardless of whether it is their rotaed week on
 There are 26 beds and one extra bed without call buttons or gas/air.
 There is no high dependency unit in the MAU
 Length of stay is longer than needed due to capacity issues in specialty beds
 It is a push model rather than a pull from MAU to specialist or discharge.
 There are no electronic boards to track A&E waits
 The discharge services are poor at weekends.
Staffing
 1wte consultant post (work each 2nd week in MAU)
–
0.5 Respiratory
–
0.5 Locum –The recruitment for this post is delayed.
 Nurses work over 3 areas to increase flexibly (MAU, Clinical Decision Unit, Short Stay Ward)
 The nursing skill mix in MAU is high (3 qualified to 1 non)
 Receiving arrangements
–
Consultant rota between 8am-5pm
–
On call Physician of the day working a 1 in 11 rota.
–
There is no Rheumatology in rota
–
Cardiology, Renal & Haematology have separate rotas
 There is in reach from Cardiology and Stroke but not Gastrointestinal (GI)
 Typical 5 days service across MAU and hospital with limited consultant input at weekend
–
50% reduction in discharges at weekend
17
The Current Emergency Care System
Model of Care Antrim Hospital MAU
Difficult to discharge
within 72 hours due to
lack of specialty beds.
Systems and Processes
 There are 2 ward rounds a day during Monday -Friday
–
am ward round followed by review
–
pm white board round with Multi Disciplinary Team (MDT).
 There is one daily (am) ward round during Sat & Sun
 MDT including occupational therapists, physiotherapist and social worker, are meeting daily at 10.30
 The post take round is done by a MAU consultant – either from respiratory or locum (geriatric medicine)
 The goal is to discharge within 72 hours where possible but this is currently difficult due to lack of specialty beds
 The current general model is to hold patients in MAU awaiting correct specialty bed rather than put in other specialty
 There are is treatment plan proforma in use except for stroke Integrated Care Pathway (ICP)
 Estimated date of discharge is set in MAU together with date of admission, details of any investigations, referral and discharge. The status
of each patient is kept up to date on a whiteboard. All patients in BAY1,2,3, 4 and side room 1 and 2 are tracked.
 Nurses are currently not able to order Radiology or Diagnostics.
 MAU staff have access to A&E system to identify patients
Improvements and issues
 There has been recent improvements to CT that allows early am session and weekend session for strokes
 Blockage in the process appears to be diagnostics in particular Endoscopy
–
A solution could be setting up early 8am session Monday to Friday.
18
The Current Emergency Care System
Current Emergency Flows Antrim Hospital
A summary of the
current emergency
flows at Antrim
Hospital is shown in
the diagram opposite
Self Referred Walk-ins,
Blue light emergencies
Acute Medical Patients triaged In A&E those
requiring assessment to MAU
Children's
A& E
Paediatric
Adm ission
Wards
A&E
178 att endances
per day
Triage &
Assessment
Treatment >4 Hours
Not
admitted
Obs Short
Stay 1.6 days
ACS
ALOS
0.31
Triaged Medical
Patients
MAU
Transfer
to AMU
Ward B1
ALOS 1.5
20% >48hrs
SSW
10 beds
Am bulatory
6 beds
Not
admitted
Medical Specialty Wards
Discharge /Referral to GP/ OP Referral/
Comm unity Services
19
The Current Emergency Care System
Antrim Hospital: Issues emerging from the review
A standardised triage
method would reduce
risk of clinical
variation.
.
Front Door
 High level of Urgent Care cases presenting at A&E in 08/09
–
Triage 4/5 = 29,043 represents 45% of total, a daily average of 80 patients per day
 Lack of protocols for streaming patients to minors and majors (self referral only) – at present this is based on patient’s own allocation at
reception according to a list of conditions. This could result in inappropriate use of resources should patient’s default to the wrong stream.
 Triage is undertaken using protocols and nursing judgement. There needs to be a standardised mechanism for triage to reduce clinical
variation practices.
 The self referred & GP referred medical patients are being managed through A&E. this is not UK best practice. On average 80% of the
breaches are related to medical assessment of self referred cases with lower admission rate.
Admissions
 There were 7,458 non-elective admissions for all medical specialties admitted; excluding Stroke and MI there are 6910
 Of these 54% are subsequently admitted to MAU, 17% admitted to Short Stay Ward, 7 % to Ambulatory and 22% to specialty beds
 Of the 4045 admitted to MAU, 15 % are discharged within 24 hours
Staff
 Significant problems recruiting to junior doctors and also managing to cover these posts with locums. With the merger across Whiteabbey
and Mid Ulster there is funding available for 3.5 middle grades. The suggestion is to use this funding for 2 additional consultant posts in
order to plan medical workforce in line with demand peaks.
Length Of Stay
 Average length of stay in MAU is 1.5 days; compared to the UK average of 0.8 days
 532 admission in A&E related to ante natal not related to delivery or an event of which 63 were discharged same day
Suggestions to improve flow:
 Active streaming & minors can be managed in a separate area by emergency nurse practitioners
 All GP referred cases should go direct to MAU
 All strokes following assessment and confirmed stroke should go to Hyper Acute Stoke Unit.
 All Myocardial Infarctions following confirmed diagnosis should go to Cardiology /Coronary Care Unit
 A care of the elderly service at the front door to manage patients through Care of elderly assessment beds in the community and
establishment of an older people rapid access clinics.
20
The Current Emergency Care System
Model of Care at Causeway Hospital
MAU and CCMMU
have together 26
beds.
All GP admissions go
through the A&E
The diagram opposite indicates the
current model of care and capacity on
the Causeway site.
The size and capacity of the site
indicates
 around 41000 attendances per year
 MAU has 12 beds
 Coronary Care Medical Monitoring Unit
(CCMU) with 14 beds
 71 specialty beds where patients are
transferred to from the MAU.
Front Door
The Causeway A&E department has
access to the following services:
 A Hospital Diversion Team to treat
patients at home
 a social worker on rota in A&E
 Two care of elderly physicians who
attend in the A&E
LOS Benchmarking
However there is no:
Sum of LOEs by HRG
within spell
 collaborative care team at the front door,
no rapid assessment team
 minor injuries unit / walk in centre in
primary care
 community hospitals with inpatients
providing any walk in type services
 older person rapid access clinics that
pulls from the acute assessment unit
DEMAND
1. A&E Department - Triage
Coronary Care/Med
Monitoring 14 Beds
MAU 12 Beds
PULL
Specialty 71 Beds
GP admissions
 All GP referred patients are managed
through A&E
 GP is co-located out of hours
Ratio All Admissions (Excl. Obstetrics & Neonatal) To A&E Attendances 16 % - UK Benchmark 17 %
21
The Current Emergency Care System
Causeway A&E Presentations
There has been
limited change in
number of
presentations over the
last two years.
80% of attendances
are self referred
60% of attendances
are triage 4 & 5
A&E Presentation trends across the Trust
Year
% change
The table opposite indicates very minimal changes across the last two
financial years with overall 0.8% increase across the 4 sites in the Trust.
Antrim
64,858
65,535
1.04%

Specifically on the Causeway site there has been a 2.5% growth between
2008/09 and 2009/10.
Causeway
41,033
42,045
2.47%
Mid Ulster
19,056
18,444
-3.21%
Whiteabbey
22,563
22,697
0.59%
Total
147,510
148,721
0.82%
The analysis presented below is in relation to 2008/09 as this was the most
complete and up-to-date year when the work commenced.
Causeway A&E Attendances by source
In 2008/09 there were around 41,000 attendances 2; on average 112 per day.
The source of the A&E referral is shown opposite which indicates :

63% Self

16% GP/HP

19% 999 / Ambulance
2%
1%
16%
Self
Triage and Streaming
999 Ambulance

The Manchester triage system is used
GP/HP Referral

Triage team includes: SHO/locums, triage nurse, Consultant 9-5pm, (No
registrar)

Decision making at the front door – Senior house officer / Senior Nurse

3 flows: resuscitation, majors & minors

The physical layout of the department reflects the flow

29% of total limb problems; 57% of triage categories 4 & 5

5% of total wounds, 10% of triage categories 4 &5

68% Discharged

16% Admitted

8% to Clinic
Performance against 4h target 2010:
Analysis against the 4 hour target is shown in Appendix 4 indicating
between 85% to 90% compliance, below Best Practice of 98%
compliance.
Not Known
18%
Other
63%
Triage 1,
0.3%
Triage 5, 2%
Disposal from A&E
Analysis of the main disposal route after A&E is shown in Appendix 9
this indicates
5 and 6
provide an analysis of A&E
presentations by month, &
day of the week
2009/10

Analysis of the top 10 presenting conditions is shown in Appendix 7 for all
triage categories and Appendix 8 for categories 4 & 5; this indicates:
2 Appendices
2008/09
Triage 2, 5%
Triage 3,
34%
Triage 4,
58%
22
The Current Emergency Care System
Causeway A&E Workload
Average Daily Presentations
Due to the coastal location of the Causeway site analysis
has been undertaken separately for the spring/summer
and autumn/winter.
The graphs opposite indicates the number of A&E
presentations by day of the week and time period
indicating:
 Presentations peak 4pm to midnight
4pm to Midnight
150
21
100
21
52
19
53
51
64
61
57
Monday
Tuesday
Average Daily Presentations
Further work has been done to map the presentations and
department workload by hour shown in the chart opposite
indicating peak hours from 4pm to midnight spring/summer
and 5pm to 10pm in autumn/winter
25
6
4
15
3
10
5
Department Caseload (last 4 hrs Secondary Axis)
-
0
9
10
11
12
13
14
24 Hour Clock (Before Hr)
59
Friday
Saturday
Sunday
15
16
17
18
19
20
21
17
42
41
58
50
49
Monday
Tuesday
8am to 4 pm
Midnight to 8am
17
21
24
37
45
37
35
48
49
49
46
Friday
Saturday
Sunday
17
Wednesday Thursday
Peak caseload between 5 pm - 10 pm
30
25
20
5
4
15
3
10
2
Average Presentations (Primary Axis)
8
55
-
7
20
7
57
51
50
8
5
6
15
45
30
Presentations
6
5
18
100
35
7
4
44
Projected Caseload
Peak caseload between 4 pm - Midnight)
3
40
Causeway - Number of Presentations and Projected A&E Caseload (4 hrs) for Average
Day (September - February Inclusive) (Average Daily = 104)
8
2
48
46
4pm to Midnight
150
Causeway - Number of Presentations and Projected A&E Caseload (4 hrs) for Average
Day (March - August Inclusive) (Average Daily = 121)
1
23
Causeway A&E Average Daily Workload from Midnight - 8am, 8am - 4pm, 4pm
- Midnight On Days of Week, September - February (2008/2009)
the spring/summer and 104 in the autumn/winter.
1
25
17
19
Wednesday Thursday
 Daily average number of presentations :121 per day in
2
Midnight to 8am
-
137 per day in the spring/summer and 118 in the
autumn/winter
9
8am to 4 pm
50
 Mondays have the most presentations – on average
Projected Caseload
The peak hours within
A&E are 4pm to
midnight in the
spring/summer and
5pm to 10pm in the
autumn / winter.
Causeway A&E Average Daily Workload from Midnight - 8am, 8am - 4pm, 4pm Midnight On Days of Week, March - August (2008/2009)
Workload Peaks and Troughs
Presentations
There is a 16%
increase in the
average A&E
presentations in the
spring & summer
months due to the
coastal location of the
Causeway site
22
23
24
Average Presentations (Primary Axis)
1
5
Department Caseload (last 4 hrs Secondary Axis)
0
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
24 Hour Clock (Before Hr)
23
The Current Emergency Care System
Causeway A&E Attendances to Admissions
56% of patients
admitted from A&E
where admitted to the
MAU
For the specific
specialties under
review 92% were
directly referred from
A&E
Current Staffing
Admissions For Specialties in Scope Only
The current staffing provided is as follows:
Reviewing the medical specialties within the scope of the review
indicates around 3,800 admissions per annum, on average 10-11 per
day.
 Medical team includes physician of the week (8.30am-6.30pm
weekday and 8.30am-2pm on weekends).
 There is an on call rota for emergency work
Of these the referral source indicates:
 The Emergency Department team includes physiotherapist,
 92% via A&E
 5% Transfers
social workers, occupational therapists (using rotas)
 Access to specialist opinion Monday to Friday and on request at
 1% CCMU Fast-track
weekends.
 1 in 4 rota is used for advice
 Emergency Nurse Practitioners (ENPs) can make decision about
treatment.
 Nurse led discharge at weekends
Attendances to Admissions:
Reviewing the attendances which results in an admissions indicates
in total 3,859 admissions in 2008/09 within the following areas:
 56% Assessment
 34% CMU
 10% Specialty Beds
Admissions from A&E by day and time is shown below:
Causeway A&E Average Daily Admissions From Time of Present from Midnight 8am, 8am - 4pm, 4pm - Midnight On Days of Week, September - February
(2008/2009)
Causeway A&E Average Daily Admissions From Time of Present from Midnight 8am, 8am - 4pm, 4pm - Midnight On Days of Week, March - August (2008/2009)
4pm to Midnight
25
20
15
6
6
6
6
10
5
10
10
5
6
8
5
6
9
8am to 4 pm
5
5
9
6
4
8
Midnight to 8am
6
5
8
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Average Daily Presentations
Average Daily Presentations
As with attendances
the admissions peak
during the summer
months March to
August; circa 10-15%
higher.
4pm to Midnight
8am to 4 pm
Midnight to 8am
25
20
15
5
5
5
5
5
5
10
9
9
Monday
Tuesday
10
5
6
4
5
8
6
5
4
4
9
8
7
Friday
Saturday
Sunday
6
Wednesday Thursday
24
The Current Emergency Care System
Causeway Medical Assessment Unit & CCMU Ward
The length of stay profile for patients either admitted
to the MAU or the CCMU ward is show opposite.
LOE Profile on Admission to Medical Assessment Unit 2008/2009 (n=2,155)
This included 2,155 episodes, 52% of which with a
stay up two days:
 10% with no overnight stay
50%
 27% 1 overnight stay
40%
 15% 2 overnight stays
The current target length of stay for the MAU is 2
days.
% Episodes of Care
Just over 60% of
activity coded to
CCMU ward stay over
2 nights.
Medical Assessment Unit
CCMU
48%
27%
30%
20%
15%
10%
10%
0%
LOE < 24 hrs
Analysis of the CCMU ward activity indicated:
One Overnight Stay
Two Overnight Stays
LOE > 48 hrs
 1347 patients were coded to the ward
 61% stayed up to 2 days with:
–
15% no overnight stay
–
33% 1 overnight stay
–
13% 2 overnights stays
LOE Profile on Admission to CMU (n=1,347)
50%
% Episodes of Care
Just over 50% of
admitted to MAU stay
ward stay up to 2
nights.
39%
40%
33%
30%
20%
15%
13%
10%
0%
LOE < 24 hrs
One Overnight Stay
Two Overnight Stays
LOE > 48 hrs
25
The Current Emergency Care System
The Current Model of Care at Causeway Hospital A & E
Effective diagnostics
Use of Hospital
Diversion Team to
reduce admissions
A&E attendances are streamed into three areas:
 Resuscitation
 Majors
 Minors
There is effective diagnostics including the following features:
Clear pathway for
Gynaecology patients
 digital imaging and CT/ultrasound to support rapid decision making
 Lab results are sent to a printer within the A&E
 Ability for Nurses to request X-ray
Access to clinics
 Elective clinics should allow for acute management of patients within specialities. The rapid access clinics with a 2 week wait are not
‘rapid’ enough.
 There is a direct access to Stroke and Cardiology, admission from A&E to specialty beds.
 There is direct access to Palliative Care beds from A&E and from Community Hospital Transfers
 Gynaecology assessments are undertaken within Gynaecology ward. The area is used as an early pregnancy ward and managed by two
senior nurses
There is in reach to A&E from for the following specialties
 Stroke
 Care of Elderly
 General Medicine
 The decision to admit is made within one hour from the request of a surgical, orthopaedic, paediatric, gynaecologic expert opinion
Ambulatory Emergency Care
 Hospital diversion team are used 7am – 11pm to avoid admission
 There are no interventions provided by the Ambulance Service
 There is no clinical decision unit or surgical assessment unit
26
The Current Emergency Care System
Current Model of Care Causeway Hospital A & E
The diagnostic routine
is functioning well with
few delays
Access to mental
health acute provision
an issue
The role of the flow
coordinator should be
expanded to better
manage breaches
.
Mental Health
 The mental health provision can be improved as there is limited service provision out of hours is limited and the patients are kept in A&E
beds with no mental health medics on site
 The service is lead by Community psychiatric nurses who are available 9-5pm in A&E.
Flow Management/Coordinator:
 This post does exist but it is not working optimally. It is felt this role would significantly improve the management of patient flow and
managing breaches within the department and allocating resource where required.
Outlying to Surgical beds
 Recently Surgery stopped taking outliers in last 2 months after removed surgery from Mid Ulster and only permits if an Estimated
Discharge Date (EDD) and a discharge letter are provided
 The A&E could benefit from creation of surgical assessment room for transfers
Information/Monitoring of targets
 A manual system is used for bed management information
 There are delays in accessing both assessment beds and specialty beds
 Twice daily emails regarding bed availability are sent across the Trust
 There are online printed manual for all conditions but no tick box pathway protocols
 A discharge date is set on admission (where possible).
 Performance against 4 hours are close to 90%
 The trust has set a 1 hour limit for the surgical specialties to respond within
 No reported delays in waiting for a surgical opinion (orthopaedics, paediatrician, gynaecology) obstructs the flow
 Operational policies are perceived as success
 There are however inappropriate nursing home admissions including end of life care.
27
The Current Emergency Care System
The Current Model of Care Causeway Hospital MAU
All patients go from
A&E to MAU on
average 6 per day.
The Model
 There are 6 admissions to the MAU per day. This is 56 % of all medical admissions (34% go to CCMU and 10 % to Specialty Beds)
 All patients come through A&E
 There is no High dependency unit, Short stay ward or Clinical decision unit
 The Length of stay should be up to 48 hours.
Staffing
 1 wte Physician cover MAU according to a physician of the week model
 There are 4 band 7 nurses
 The physicians rota arrangement is 1 in 6 week but there is no acute physician.
 Specialists present at ward rounds:
–
Geriatrics present weekends only
–
All other specialities are present daily. (Stroke, Diabetes nurses, cardiac, respiratory, early discharge team.)
 The discharge pattern is even though the week with but low during weekends.
 Social worker is available but no dedicated Physiotherapist
 The community and step down beds doesn’t receive patients during weekends.
Systems & Processes
 Two daily rounds: morning and afternoon, coronary care unit is included in the round.
 Physicians for all areas except geriatrics participates on the ward rounds (Physician, Physiotherapist, Pharmacist, Social worker )
 There is a daily ward meeting with the board team.
 SOLVER System is used to get input from as many specialists as possible. This process is still in progress.
 If the patient is likely to be discharged within 72 hours they will be retained and managed on the MAU.
 There is a treatment plan pro forma in use in the MAU
 The estimated date of discharge is set in MAU, multi disciplinary team meetings are held morning and evening.
 There are no ICPs in use for treatment guidelines.
 The lack of isolation wards effects the patient flow
 There is a need for more speciality physicians in the intensive care unit so that all patients are seen by professional staff
28
The Current Emergency Care System
Current Emergency Flows Causeway Hospital
A summary of the
current emergency
flows at Causeway
Hospital is shown in
the diagram opposite
GP & Self Referred Walk-ins,
Blue light emergencies
Acute Medical Patients triaged In A&E
those requiring assessment to MAU
Children's
A&E
Paediatric
Admission
Wards
Not
admitted
Not
admitted
A&E
Triaged Medical
Patients Transfer
to AMU
Triage &
Assessment
MAU 12 Beds
Resus , Majors,
Minors
48 Hrs Target LOS
Treatment >4 Hours
RATS Team
Hospital
Diversion
Team
Medical Specialty Wards
Discharge /Referral to GP/ OP Referral/
Community Services
29
The Current Emergency Care System
Causeway Hospital – Issues Emerging from the Review
The key object of the
review is to assess
the efficiency of triage
and streaming of
patients in the A&E.
.
Front Door
 High level of Urgent Care cases presenting at A&E in 08/09Triage 4/5 = 24,000 represents 60% of total a daily average of 65-70 patients
per day
 Use of the Manchester triage system ensures standardised mechanism for triage to reduce clinical variation practices.
 The self referred & GP referred medical patients are being managed through A&E which is not UK best practice.
 Self referred patients being managed through A&E
Admissions
 There are 3859 non-elective admissions for all medical specialties, excluding Stroke and Myocardial Infarction (MI) there are 3571; of
these 56% go to MAU
 10 % of the MAU admissions are discharged within 24 hours
 473 admissions in A&E were ante natal not related to delivery or an event of which 53 were discharged same day (11%).
Length of Stay
 Average Length of stay (ALOS) in MAU is 2.0 days compared to the UK average of 0.8 days
Suggestions to improve flow:
 Active streaming and management of minors by emergency nurse practitioners in a separate area
 All GP referred cases should go direct to MAU
 All strokes following assessment and confirmed stroke should go to Hyper Acute Stoke Unit.
 All Myocardial Infarctions following confirmed diagnosis should go to CCMU
 A care of the elderly service at the front door to manage patients through Care of Elderly assessment beds in the community and
establishment of an older people rapid access clinics.
30
4
Opportunities for Improvement using UK Best Practice
31
Opportunities for Improvement
Proposed Model of Care
CAU is a Combined
Assessment Unit for
both medical and
surgical assessments
All GP referrals direct
to CAU
• Self Referred Walk-ins, & Blue light
emergencies direct to A&E
• Acute Medical Self Referred Patients
triaged In A&E those requiring
assessment to CAU
Direct
Ambulatory
Treatment
A&E
Triage
See & Treat, Minors
Further Assessment
Observation Beds
Children's A&E
MIU Treatment
Triaged SR
Medical Patients
Rapid Transfer
to CAU
CAU
• All GP referred medical & surgical
patients direct to MAU
• Patient s admitted to A&E where
treatment is >4 hours transfer to
CAU
CAU
Triaged Self
referred Cases to
MAU for
assessment prior
to admission/
discharge
Not
admitted
Treated
within
CAU 24
hours
Short Stay Unit
Admitted to
Specialty Ward
with a treatment
plan/ EDD
Discharged
from specialty
beds
Collaborative
Care Teams
Discharge /Referral to GP/ OP Referral/ Community
Services
32
Opportunities for Improvement
Moving Forward
The new model of
care should reduce
attendances through
effective use of
alternatives, match
resources when most
needed and ultimately
improve patient
experience and
outcomes.
Using What We Know About Best Practice in the Design and Management of A&E
The Vision for the Emergency Department
 Appropriate practitioner, right skills and expertise
 Rapid access to diagnosis, assessment and treatment
 Paediatrics and Adults
 98% compliance on the 4 hour target
 Patient experience is good
 Clinical outcomes are optimum
 Readmission rate is low
The Model
 Reduce the number of attendances in the medium/ long term
 Utilise and create alternatives to admission
 Increase ambulatory emergency care
The Flows
 Segmentation and management of defined flows
 Staffing of the flows
 Process and systems Protocols and guidelines
Resources
 Understanding peaks and troughs
 Matching staffing resources with demand
 Appropriate skills and expertise
 Admission rights – responsive specialty input
 Availability of beds
33
Opportunities for Improvement
Key Issues to consider
The key features and
issues of the
proposed model of
care include
Best Practice Issues to be considered
The following strategy is suggested to optimise the flow:
Maximum stay in
MAU of 0.8 day
for assessment – the role of emergency medicine
 Self referred cases continue to be directed though A&E for
 Direct the GP referred admissions to MAU this would
potential take around 19 admission from Antrim and 13 from
Causeway per day from A&E to MAU
initial assessment and work up within four hour period
 Segment the flows in A&E
 DH Guidance supports 24 maximum LOS for effective
assessment function
Use of pathways
Creating alternatives
to admission
Key Issues to be Address in the Proposed Model of Care
 GP Referred acute medical patients are directed to the MAU
Segmented flows
GP referrals directed
to MAU
Key Issues
 UK ALOS for MAU is 0.8 days
 The Royal College of Physicians of England’s clear
objective is rapid access to speciality based care
 The stroke pathway – guidance from A&E to a Hyper Acute
Stoke Unit.
 Management of MI – Guidance supports from A&E to
Coronary care unit primary PCI
 Care of the Elderly consultant input at the front door with
options to transfer to assessment beds, intermediate care
beds, step down care
 Consider how best to manage the Minor Flow – which
constitutes 48% (Antrim) and around 60% (Causeway) of
the overall attendances at A&E – looking at the best practice
management of minor injury and minor illness
 Development of ambulatory emergency care – potential for
significant reduction in inpatient beds
 Development of Gynaecology Direct Referral system and
Early Pregnancy Assessment Unit
 Definitive list of ACS pathways which will be provided to
model the trolleys/couches etc this will reduce bed days and
inpatient beds.
 Creating alternatives to admission.
34
Opportunities for Improvement
Management of the A&E Flows
Key feature of the
model of care is
effective streaming
consisting of all GP
referred acute medical
patients direct to MAU
and clear flows for
remaining categories
including minor
attendances goes to a
form of primary care
Directing GP Referred Acute Medical Patients to MAU
 Relocate GP referred medical patients currently presenting at A&E to MAU
 This will free up capacity in the A&E
 Reduces overall wait time for assessment
 Reflects UK best practice
 Takes 19 admission from Antrim and 13 from Causeway from A&E to MAU for assessment & work-up
 Reduces duplication of function
 Emphasis on rapid assessment
 Creates a similar cohort of patients being managed by one team
Use of specific flows for the following patient groups
 Paediatrics: young patients are treated separately both for safety and efficiency reasons
 Minors: Estimate 50% of Trusts in the UK have some form of primary care service working with the emergency department.
Approximately 30% have been classified as “primary care” cases. There are three operational models for a GP managed minors flows:
1. A GP service located alongside or next to the emergency department.
2. GPs working at the front of the department screening attendees and either treating or diverting to other places – effectively acting as a
filter.
3. GP services fully integrated into a joint operation covering the whole range of primary care and emergency services. We came across
a small number of systems that offer a full primary care service to appropriate patients
 Ambulatory Care Service: predestined HRGs are treated in ambulatory care and kept separated from the A&E
 Majors: patients goes timely though A&E to appropriate bed (if admitted). Separate flow (not though A&E) for
– Cardiology
– Chemotherapy
– Complex Elderly
– Maternity
 Resuscitation: Separate area for resuscitation
35
Opportunities for Improvement
Options for the Management of the Care of Elderly
Care of the Elderly
improvements to the
model of care are
fundamental given the
aging profile and
significant pressure
this specialty has on
the unscheduled care
Care of the Elderly
 Options for the management of elderly patients
 Use of care of elderly – geriatrician led rapid access clinics
 Refer to care of the elderly assessment beds
 Use of intermediate care coordinators in- reaching to A&E / MAU
 Refer to intermediate care beds
 Refer to palliative care , end of life care
 Refer for social work assessment
 Collaborative care team / home care package
36
Opportunities for Improvement
Ambulatory Emergency Care
Ambulatory care
improvements are
recommended by a
number of
organisations
Analysis of the current inpatient data has been carried out to understand the impact of fully developing ambulatory care sensitive
(ACS) pathways.
This includes reviewing the 2008/09 admitted patient data and comparison of the proportion of patients with no overnight stay against the
recommended proportion from the Institute for Innovation & Improvement Directory of Emergency Care for Adult..
Full details are in Appendix 11 & 12 for the top 10 conditions however the summary results are shown below which provides analysis of the
spells and beds days associated with ACS conditions and indicate the potential bed savings at both the maximum and minimum % from the
report.
The key findings from this indicate:
 Overall 15% of ACS conditions are currently discharged with no overnight stay
 Between 7 and 14 beds spaces are required in Antrim and 5 to 10 beds spaces are required at Causeway for ACS conditions assuming 12
hour and 60% occupancy rate.
 Impact is between 27 and 55 bed reduction
Site
Total
Spells
Total bed
days
Indicative
Total %
beds
discharged
in day
Beds
saved max
Beds
saved
– min
Antrim
4,659
3,252
61
17%
(34)
(17)
Causeway
2,843
12,710
35
12%
(21)
(10)
Total
7,502
15,962
96
15%
(55)
(27)
37
The Scope for Improvement – Development of Early Pregnancy Assessment Unit &
Gynaecology Direct Referral system
Establishing an Early
Pregnancy
Assessment Unit in
Antrim to treat direct
Gynaecology referrals
 At Antrim, currently all early pregnancy patients and gynaecology emergencies are directed through the A&E. At Causeway there is an
Early Pregnancy Assessment Unit (EPAU)
 In 2008/09 there were 532 spells of antenatal admissions in Antrim not related to a delivery presenting through A&E utilising 1283
occupied bed days only 12% were discharged within 24 hours of admission.
 This HRG is clearly an ambulatory case sensitive (ACS) condition and the estimates based on the clinical evidence are that 30% to 60% of
those patients could be managed through an EPAU, reducing the Occupied bed Days (OBDs) by almost 2 inpatient beds, improving the
patient experience and reducing the burden on the A&E service by on average 2 cases per day.
Emergency gynaecology / Early Pregnancy Assessment Unit service
 A 24 hour consultant-led service for early pregnancy and emergency gynaecology that incorporates a 09.00 – 17.00 appointment service
for direct referral from GPs.
 Services provide assessment and management of early pregnancy problems, including early pregnancy bleeding up to 12 weeks’
gestation.
 Units are part of the gynaecology department
38
Opportunities for Improvement
Diagnostic Support
Improvements to
diagnostics
 Dedicated slots in imaging including Ultra Sound (US) and computerised tomography (CT) where delays are likely to contribute to
breaches
 Point -of -care -test (POCT) in A&E and MAU
 Dedicated slots for endoscopy emergencies and “urgents”
 Use of rapid access clinics
 Dedicated slots in OP clinics
 Care of the elderly consultant sessions in the A&E to “pull “ out from the A&E those patients who require assessment by a geriatrician
rather than admission to an acute medical bed.
 Use of the community hospital beds for , care of the elderly assessment step down and rehabilitation
 Longer term the development of collaborative care teams (CCT) and better utilisation of the existing Rapid Access Teams to pick patients
up at the front door & take home with support, home care packages.
39
Summary and Next Steps
Four key steps in
taking forward the
work
The diagram opposite summarises the next steps including:
 Agreement on the model of care covering
–
GP referrals routed straight to MAU
–
Streaming of minors to GP service in A&E
–
Improvements to Care of the Elderly service
–
Roll out of all ambulatory care pathways
–
EPAU / GDR established in Antrim
–
Improvements to diagnostics
 Agree the planning assumptions underpinning the above
–
Agree the
planning
assumptions
Model the
changes
Including target performance for the specialty beds
 Factor in additional capacity required in Antrim as a result of the
reconfiguration of services at Mid Ulster and Whiteabbey
–
Agreement on the
model of care
Factor in the
additional activity
on the Antrim site
taking into the
reconfiguration of
service at MUH
and Whiteabbey
Including the impact to A&E, MAU and specialty beds
 Model the changes
–
Robust and bespoke bed model to take on board performance
improvements, new model of care and reconfigurations across
the Trust.
40
5
Appendices
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Antrim A&E Current Flows
Antrim Triage Categories
Antrim: Disposal from A&E
Antrim: Performance Against the 4 hour Target?
Causeway A&E Current Flows -1
Causeway A&E Current Flows 2
Causeway A&E Top Ten Presenting Conditions
Causeway A&E Top Ten Presenting Conditions – Triage 4&5
Causeway: Disposal from A&E
Causeway: Performance against the 4 Hour Target
Antrim – Ambulatory Care Sensitive Conditions
Causeway – Ambulatory Care Sensitive Conditions
42
43
44
45
46
47
48
49
50
51
52
53
41
Appendices
1. Antrim A&E Current Flows
Average A&E
Attendances 178 per
day. 95th Percentile in
excess of 240 per
day. Average A&E
Attendances Monday
203 per day.
Presentations
Average Daily Presentations (+/- 1.96 2 s.d) To Antrim A&E, Each Month During 2008/2009
Compared With Daily Average Over Year (178)
270
240
210
180
150
120
90
60
30
0
181
190
April
May
188
175
172
178
173
174
178
June
July
Aug
Sept
Oct
Nov
Dec
162
175
187
Jan
Feb
Mar
Presentations
Average Daily Presentations To Antrim A&E, On Days Of the Week During 2008/2009
Compared With Daily Average Over Year (178)
220
200
180
160
140
120
100
80
60
203
Mon
175
176
172
174
169
Tues
Wed
Thurs
Fri
Sat
178
Sun
42
Appendices
2. Antrim Triage Categories
Triage
Antrim Triage
Triage 1
Immediate Care (High Dependency)
Triage 1 (Paediatrics) Children Majors
Triage 2/3
Adult/Paeds **MAJORS A**
Minors, Primary Care Practitioners
Pre-Stream, Self Care Advice
Triage 4/5
43
Appendices
3. Antrim: Disposal where did they go from A&E?
SSW Ambul a tory, 1%
Wa rd, 4%
Intens i ve Ca re Uni t,
0.1%
Del i very Sui te, 0.1%
Corona ry Ca re Uni t, 2%
MAU, 2%
Di s cha rged
SSW Bed
SSW Bed, 3%
MAU
Corona ry Ca re Uni t
Wa rd
SSW Ambul a tory
Intens i ve Ca re Uni t
Del i very Sui te
Di s cha rged, 87%
44
Appendices
4. Antrim: What is the Performance Against the 4 hour Target?
90%
80%
70%
% 0-4 hours
% 4-12 hours
% 12 hours +
%
60%
50%
40%
30%
20%
10%
0%
Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10
45
Appendices
5. Causeway A&E Current Flows-1
Average A&E Attendances 112 per day but Seasonal Variation
Average Daily Presentations To Causeway A&E, Each Month During
2008/2009 Compared with Full Year Daily Average (112)
Presentations
140
120
115
127 120
119 122 112
103 105 105
100
80
60
40
96
108
116
20
0
April May June July Aug Sept Oct Nov Dec
Jan
Feb Mar
46
Appendices
6. Causeway A&E Current Flows-2
Average A&E Attendances 112 per day but Seasonal Variation
Average Daily Presentations To Causeway A&E, On Days Of the Week, March to
End of August (6 ms) Compared with Daily Average Over Full Year (112)
135
132
129
Presentations
130
123
122
125
117
120
115
113
111
110
105
100
Mon
Tues
Wed
Thurs
Fri
Sat
Sun
Average Daily Presentations To Causeway A&E, On Days Of the Week, Sept to
end of Feb (6ms) Compared with Daily Average Over Year (112)
Presentations
120
117
115
110
107
103
105
103
103
101
98
100
95
90
85
Mon
Tues
Wed
Thurs
Fri
Sat
Sun
47
Appendices
7. Causeway A&E Top Ten Presenting Conditions
2%
2%
3%
Limb problems
2%
Unwell adult
3%
Abdominal Pain
29%
3%
Wounds
Chest Pain
Head Injury
4%
Eye problems
Shortness of breath
6%
Back Pain
Unwell child
Falls
5%
General Discriminators
7%
10%
48
Appendices
8. Causeway A&E Top Ten Presenting Conditions – Triage 4&5
2%2%
3%2%
3%
Limb problems
Wounds
6%
Head Injury
Eye problems
6%
General Discriminators
57%
8%
Back Pain
Unwell adult
Local infections and abscesses
10%
Assault
Falls
49
Appendices
9. Causeway Disposal – Where did they go from A&E?
5%
3%
0.3%
8%
Discharged
Admitted
Clinic
16%
Blank
Transferred
MH
68%
50
Appendices
10. Causeway: What is the Performance against the 4 Hour Target?
100%
90%
80%
70%
% 0-4 hours
60%
% 4-12 hours
50%
% 12 hours +
40%
30%
20%
10%
0%
Apr-09 May-09 Jun-09
Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10
51
Appendices
11. Antrim – Ambulatory Care Sensitive Conditions
1,394
HRG Description
Unspecified Acute Lower Respiratory Infection
Transient Ischaemic Attack >69 Or W Cc
Lobar, Atypical Or Viral Pneumonia W/O Cc
Pleural Effusion W/O Cc
Pulmonary Embolis W/O Cc
Lobar, Atypical Or Viral Pneumonia W Cc
Chest Pain <70 W/O Cc
Pleural Effusion W Cc
Bronchopneumonia W Cc
Bronchopneumonia W/O Cc
Chest Pain >69 Or W Cc
Pulmonary Embolis W Cc
Deep Vein Thrombosis >69 Or W Cc
Asthma W/O Cc
Headache Or Migraine <70 W/O Cc
Deep Vein Thrombosis <70 W/O Cc
Transient Ischaemic Attack <70 W/O Cc
Asthma W Cc
Headache Or Migraine >69 Or W Cc
All spells
8,042
22
Movement in Beds
17%
OBDS
Reported Spells HRG
Ambulatory Episodes
Care HRG
Within Indicative % Discharged
Year 08/09
Spells
Beds
Same Day
331
3,252
9
2%
45
368
1
9%
93
847
2
2%
19
252
1
0%
25
217
1
4%
38
568
2
0%
410
692
2
37%
14
146
0
0%
15
225
1
7%
18
203
1
6%
144
346
1
28%
12
117
0
0%
24
117
0
8%
63
292
1
5%
81
167
0
22%
16
76
0
13%
21
45
0
5%
10
77
0
0%
15
35
0
27%
Best Practice Guidelines All Spells
Comparison
With
Ambulatory Ambulatory
Practice
Care
Care
Guidelines (<1 Day) Max (<1 Day) Min
<Min
60%
30%
<Min
90%
60%
<Min
30%
10%
<Min
90%
60%
<Min
90%
60%
<Min
30%
10%
Between
60%
30%
<Min
90%
60%
<Min
60%
30%
<Min
60%
30%
<Min
60%
30%
<Min
90%
60%
Between
90%
0%
<Min
30%
10%
<Min
60%
30%
Between
90%
0%
<Min
90%
60%
<Min
30%
10%
<Min
60%
30%
-
-11
-5
Max
5.13 0.82 0.65 0.62 0.51 0.47 0.44
0.36 0.33 0.30 0.30 0.29 0.26
0.20 0.17 0.16
0.11 0.06 0.03 -
Min
2.46
0.52
0.18
0.41
0.33
0.16
0.24
0.14
0.14
0.01
0.19
0.04
0.04
0.07
0.02
0.00
52
Appendices
12. Causeway - Ambulatory Care Sensitive Conditions
820
HRG Description
Unspecified Acute Lower Respiratory Infection
Transient Ischaemic Attack >69 Or W Cc
Lobar, Atypical Or Viral Pneumonia W/O Cc
Deep Vein Thrombosis >69 Or W Cc
Lobar, Atypical Or Viral Pneumonia W Cc
Pleural Effusion W/O Cc
Chest Pain >69 Or W Cc
Chest Pain <70 W/O Cc
Pulmonary Embolis W/O Cc
Headache Or Migraine <70 W/O Cc
Deep Vein Thrombosis <70 W/O Cc
Bronchopneumonia W Cc
Asthma W/O Cc
Pleural Effusion W Cc
Pulmonary Embolis W Cc
Headache Or Migraine >69 Or W Cc
Transient Ischaemic Attack <70 W/O Cc
Bronchopneumonia W/O Cc
All spells
3,912
11
Movement in Beds
14%
Reported OBDS
Spells
HRG
Ambulatory Episodes
Care HRG Within Indicative % Discharged
Year 08/09 Spells
Beds
Same Day
189
1689
5
3%
22
155
0
0%
72
428
1
0%
16
137
0
0%
33
326
1
0%
13
104
0
0%
135
224
1
23%
190
240
1
36%
14
67
0
7%
41
119
0
15%
15
57
0
7%
6
72
0
0%
38
155
0
5%
5
30
0
0%
4
26
0
0%
13
48
0
15%
7
15
0
14%
4
16
0
0%
3
4
0
33%
Best Practice Guidelines All Spells
Comparison
With
Ambulatory
Practice Ambulatory Care
Care
Guidelines (<1 Day) Max (<1 Day) Min
<Min
60%
30%
<Min
90%
60%
<Min
30%
10%
Between
90%
0%
<Min
30%
10%
<Min
90%
60%
<Min
60%
30%
Between
60%
30%
<Min
90%
60%
<Min
60%
30%
Between
90%
0%
<Min
60%
30%
<Min
30%
10%
<Min
90%
60%
<Min
90%
60%
<Min
60%
30%
<Min
90%
60%
<Min
60%
30%
Max
30%
10%
-
-6
-2
Max
2.65 0.38 0.35 0.34
0.27 0.26 0.23 0.16
0.15 0.15 0.13
0.12 0.11 0.07 0.06 0.06 0.03 0.03 -
Min
1.27
0.25
0.12
0.09
0.17
0.04
0.10
0.05
0.06
0.02
0.05
0.04
0.02
0.02
0.01
53