SW Strategic Clinical Network for
Maternity & Children
Reducing Avoidable
SCN Conference
Unplanned Hospital
Reducing Avoidable Unplanned
Hospital Admissions
Admissions
Long Term Conditions
Long term Conditions
th October
November
14
2014
2014 Exeter Rugby Club
Matthew Ellis
Associate Clinical Director
CYP Priorities
Working Groups
• Avoiding Unplanned Admissions
• Long Term Conditions
Themes
Smarter network thinking
• expertise earlier on pathways
Integrated working
• (1° / 2°/ 3°, Health/CYPS)
Making the Unplanned Planned
Parity of Esteem
NHS Outcome Framework areas for improvement
• 2.3 (2) Unplanned hospitalisation for asthma,
diabetes and epilepsy in under 19s
• 3 a Emergency admissions for acute conditions
that should not usually require hospital admission
• 3.2 Emergency admissions for children with LRTI
Scale of CYP patient flow on the
’emergency/urgent care pathway’
around the South West?
How
big
is
the
patient
flow
on
the
• >120,000 emergency department walkins
carecare
pathway’
• ’emergency/urgent
> 18,000 GP referrals for urgent
theassessed
South inWest
• around
> 25,000 CYP
specialist paediatric
assessment units (SPAUs)
>120,000
emergency department
walkins involve CYP around south
west annually
> 18,000 GP referrals involve CYP
around south west annually
Big 6 (account for >50% admissions) +
• abdominal pain
• asthma/wheezy child
• bronchiolitis
• feverish illness
• gastroenteritis
• head injury
• + self harm (up by 68% in the last 10 years)
Variation across the Region
eg Zero length of stay admissions
Zero days admissions
6
Provider responses (n=10 of potential 14)
Assessment Unit (SSPAU)
• 7 units report this provision
• variables where/when/who?
Rapid Access Clinic
• 6 units report this provision
• Variables how often?
Complexities of Systems
Taxonomy of Potential Pathways and Referral Routes
Primary Care
Home
2h
Incl MIU, Community Nurse,
CAMHS, Social services,
Midwives etc
2
GP
Home
3h e
2p
Home
2c
1g
5h
5e
ED
1e
Family
5a
7
5
3p
3
WARD
Paeds
1
7h
Home
5u
5c
1p
7c
4e
1s
3c
SWAST
6a
8a
8e
4p
Ambulance service
4
Home
4h
HOT CLINIC
4c
8a
e.g. Next Day Service
Home
8h
8
6c
IP PAU
6 OP
6i
6o
6h
Home
Advice and Guidance
8 (of 14) hospitals consulted ‘offer’ this service
• 3 - Consultant, 3 – ST, 1 - SHO,1 - ED,
Only 1 is formally commissioned and routinely
records the activity for this service
Commissioned @£100k PA
20% deflection
• Vast majority to ‘home care’
• Minority to ‘hot clinic’
“It’s Good to Talk”: Looking at the effect of a GP Phone Advice Service within a
Children’s Emergency Department
Dr Zoe Roberts, Dr Rosie Fish, Dr Jacqueline Seckley, Dr Will Christian
Introduction
Methods/Design
The Children’s Emergency Department has seen a significant increase in
yearly attendances, many of which could have been dealt with in the primary
care setting. With increasing pressures on acute paediatric services, the
Bristol Children’s Emergency department introduced a telephone advice line
for primary care providers in April 2012. The aim is for this to be delivered by
the ED consultant group in order to try and reduce unnecessary visits and
support primary care providers in their clinical practice.
A one-month pilot study was undertaken in May 2011 to inform the development
of the service. Following this a further, more detailed analysis was undertaken in
June 2011, looking at all phone referrals to the department. Details documented
included:
• Grade of person taking the call
• Brief history /examination
• Time of call
findings including vital signs
• Patient demographics
• Agreed Plan
• Referrer
• Outcome (including advice given
• Reason for referral
and disposal)
Following this a survey was distributed to all GPs involved in the pilot study for
feedback.
Results: Total of 350 calls in June (average 12 per day)
GP Feedback Survey
YES
NO
DON’T KNOW
Did you find speaking to the doctor helpful
87.5%
-
12.5%
Was it clear which grade of doctor you spoke to?
62.5%
37.5%
-
Did you think it enhanced the patient journey?
75%
12.5%
12.5%
Did you feel happy with the advice given?
87.5%
-
12.5%
If no to above, was this because you spoke to a junior?
-
66.7%
33.3%
Was it easy to contact the dept and speak to the right person
85.7%
14.3%
-
Should we continue to offer this service?
100%
-
-
Outcome of Call (by grade)
Conclusion: In _ out of _ cases, the call resulted in the avoidance of a same day ED attendance. There
was no obvious difference in outcome according to grade which may reflect on both the seniority of
the trainees taking the call and the availability of consultant advice during the hours of 0800 – 22.30.
Because there is a written record of the call, the consultant / senior trainee is often more aware of the
acuity presenting to the ED and in some cases this has resulted in escalation of the pre-hospital
management. Whilst we are succeeding in the overall aim of reducing emergency department
attendances and there appears to be support for this service from GPs, it has also brought its own
challenges namely consultants being drawn away from the shop floor during our busiest times and the
potential financial loss caused by the reduction in ED attendance tariffs. Therefore in order to ensure
its sustainability, we need to ensure adequate consultant availability and consider the potential for
financial recompense for this service.
Best Practice Network Standard
Advice and guidance
• An 8 to 8 service for GPs to access advice and
guidance from local paediatrician
SEE Revised Facing Future Standards: RCPCH in
consultation 2014
‘immediate telephone advice for acute problems
for all paediatricians for all specialties’
Advice and Guidance
• Use Network to leverage commissioned
advice and guidance by paediatricians for
primary care across the region in 2015
• Use Network to leverage specialist advice
and guidance for paediatricians by
specialist paediatricians across the region
in 2015
Assess what worksstandardise unit metrics
to allow more informed evaluation of
initiatives at unit level
• establish the simple core data needed
for evaluation of initiatives at local
level using unit trend data
• Pilot data collection in individual units
to ensure that data collection is
feasible in 2014
• Procede to a region wide evaluation
study in 2015
Long Term Conditions 0-16 years
Prevalence South West
• Diabetes: 2,000
• Epilepsy: 8,000
• Asthma: 40,000 boys 30,000 girls
• ‘Core’ Disability: 0-16 yrs 56,000
0-25 yrs 90,000
15 NHS 2013
2013 commissioned review 1990-2013
NHS 2013
16
• 2/3rds of deaths in
those with complex
needs
• Half of these
ie 1/3 of all deaths in
children with
neurodevelopmental
conditions
Making the unplanned planned –
Community Childrens Specialist Nursing
• Diabetes Nurse – HbA1C control
• Practice Nurse – asthma planning
• Epilepsy Nurse – AED compliance
emergency fit control
Epilepsy 12 audit
Category
Professionals
Assessment &
Classification
Investigation
Management &
Outcome
Title
Performance indicator
1
Paediatrician with expertise in
epilepsies
% of children with epilepsy, with input from a consultant paediatrician with
expertise in epilepsies by 1 year
2
Epilepsy Specialist Nurse
% of children with epilepsy, referred for input by an epilepsy specialist nurse
by 1 year
3
Tertiary involvement
% of children meeting defined criteria for paediatric neurology referral, with
input of tertiary care by 1 year
4
Appropriate first clinical assessment
% of all children, with evidence of appropriate first paediatric clinical
assessment
5
Seizure classification
% of children with epilepsy , with seizure classification by 1 year
6
Syndrome classification
% of children with epilepsy, with epilepsy syndrome by 1 year
7
ECG
% of children with convulsive seizures, with an ECG by 1 year
8
EEG
% of children who had an EEG in whom there were no defined
contraindications
9
MRI
% of children with defined indications for an MRI, who had MRI by 1 year
10
Carbamazepine
% of children given carbamazepine, in whom there were no defined
contraindications
11
Accuracy of diagnosis
% of children diagnosed with epilepsy whostill had that diagnosis at 1 year
12
Information & advice
% of females over 12 years given anti-epileptic drugs, who had evidence of
discussion of pregnancy or contraception
Epilepsy12 Performance results across
the South West Strategic Clinical Network
Paediatrician
with Epilepsy
Appropriate
expertise in specialist
Paediatric first clinical
Seizure
Syndrome
epilepsy
nurse neurologist assessment classification classification
Cornwall
Plymouth
Torbay
Exeter
North
Devon
Taunton
Yeovil
Bath
Bristol
Weston
Swindon
66.7
100
36.4
100
66.7
16.7
45.5
0
100
0
44.4
75
50
50
100
100
83.3
72.2
0
50
0
0
38.9
0
83.3
11.1
50
20
Gloucester
Key
Significantly better than England
No difference from England
ignificantly worse than England
No data available
100
50
100
100
33.3
50
ECG
EEG
Withdral Pregnancy or
of contraception
MRI Carbamazepine diagnosis
discussion
75.9
73.9
40
61.4
77.8
83.3
72.7
85.7
44.4
40 82.8
75
16.7 71.4 100
40
27.3
92 37.5
14.3 45.5 95.5 57.1
100
62.5
65.6
57.1
55.6
79.7
70
98.2
73.1
88.9
83.3
50
83.3
66.7
100
100
94.4
11.1
8.3
0
100
44.4
25
50
11.1
100
55.6
18.2
100
22.2
60
66.7
43.6
40.9
81.3
93.8
90.5
100
93.2
90
93
92.5
75
45.5
0
66.7
50
100
69.2
69.2
100
100
100
100
100
66.7
100
100
100
91.7
100
100
85.7
66.7
100
100
100
73.2
81.8
0
100
100
100
100
100
How can younetwork
help achieve
these three
ConcluSmarter
thinking
expertise earlier principles?
on pathways
Integrated
working
Smarter
network
thinking with expertise
(1° / 2°/
Health/CYPS)
earlier
on3°,
pathways
Making the Unplanned Planned
Integrated
working
sions
Making the Unplanned Planned
• Thankyou
• Questions?