Vincent Connolly
Clinical Lead ECIST
Emergency Care is a ‘wicked
problem’
 A social or cultural problem
that is difficult or impossible to
solve because:
 of incomplete or contradictory
knowledge;
 of the number of
people/opinions involved;
 of the large economic burden;
and
 of the interconnected nature of
this and other problems
Russell L. Ackoff wrote about complex problems as:
"Every problem interacts with other problems and is
therefore part of a set of interrelated problems, a system
of problems…. I choose to call such a system a mess."
Care Coordination
The health system delivered the required
care, but was it in a time frame that
suited the patient, carer or staff ?
Queue
Demand
Capacity
Can’t pass
time
unused capacity
forward to next week Reducing waiting times in the NHS: is lack of
capacity the problem?
Bevan et al Clinician in Management (2004)
12:
When do medical patients
arrive?
Organise beds to improve patient flow
 Arrange beds around patient
streams:
 Clinical Decision Unit (CDU) /
Ambulatory Emergency Care
(AEC), Acute Assessment Unit
(AAU), short stay, specialty,
complex discharge
 Minimise handovers
 Combat outliers
New medical model for urgent care patients
All non elective activity at the 85th percentile
Route and process
Activity
Discharge
Admissions Minors
Admissions Majors
Ambulatory and
observation patients
(28% total)
Patient
review/referral/discharg
e from CAU (55% of
CAU)
Patient
review/referral/discharg
e from CAU (45% of
CAU)
Expected
LOS
Minors
248
230
18
Short Stay
Acute
Admission
Assessment
183
97
78
Discharge
Specialist
referral/
Admissions
CAU and short
stay Bed
requirement
96
27
5
64
19
19
26
zero LOS
1
midnight
2
midnights
3 midnights can not be
managed by CAU
3 LOS+
19
6
6
So How Many Beds?
(50 Assessments and <40 patients sleeping over)
Estimated Requirement
Assessment
16-20 spaces
Short Stay
60 beds
Specialty total
@ 10 nights = 200
@ eight nights = 160
@ seven nights = 140
@ six nights = 120
What type of
system?
Admit – but where?
Respiratory
Unit
Decision
to admit
Stroke Unit
Acute Bed Pool
two nights
GastroIntestinal
Unit
Acute
Rehabilitation
Unit
Metabolic
Unit
Critical
care
Cardiac
Unit
‘In-reach’ Case Management
Respiratory
Unit
Decision
to admit
Specialist “inreach”
Stroke
Unit
Acute Bed Pool
two nights
GastroIntestinal
Unit
Acute
Rehabilitation
Unit
Metabolic
Unit
Critical
care
Cardiac
Unit
Outreach Model of Care
Respiratory
Unit
Stroke Unit
GastroIntestinal
Unit
PCT
Decision
to admit
Acute Bed Pool
two nights
Acute
Rehabilitation
Unit
Metabolic
Unit
A&E
Critical
care
Cardiac
Unit
The right people are more
important than the right system
as long as it is
 Well described
 Addresses patient care requirements
 Everybody understands their role
 Appropriate support from other services
 Location is fit for purpose
 Adequately scoped
 Supported by staff
Managing the Streams
Identify the stream
 Short stay
Sick specialty
Sick general
 Allocate early to teams skilled in that stream
Complex
Number of patients
250
Short stay – manage to the hour
Maximise ambulatory care
200
150
100
50
Clarity of specialty criteria
Specialty case management plan at
Handover – no delays
Green bed days vs. red bed days
Minimise handover
Decompensation risk
Early assertive management
Green bed days vs. red bed days
Complex needs – how
much is decompensation?
Detect early and design
simple rules for discharge
0
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59
Length of stay (days)
Pareto Analysis
Complex
5% of demand:
Red stream: Rare Strangers
Cumulative Demand
100%
20
15%
Short Stay
30%
50% of demand
= 7% of types:
Green stream: ‘Runners’ \
80
0
LOS
Sick Specialty
Sick General
Glenday Sieve
LOS Cumulative Profile
Excl Paeds, Obstetrics and Midwifery, Zero LOS
ANHST
Top 25
50% =
3 midnights
2 midnights
80% =
10 midnights
7 midnights
95% =
29 midnights
midnights
23
Cumulative OBD by LOS
Excl Paeds, Obstetrics and Midwifery , Zero LOS
ANHST
%OBD
<50% =
3 midnights
10.8%
<80% =
10 midnights
35.3%
<95% =
29 midnights
69.4%
>95% =
>29 midnights
30.6%
Focus on discharge
 Consistently prioritising discharge activities can
significantly reduce length of stay in elective or
emergency clinical care pathways.
 Prioritising discharge activities only when beds are
full may have little impact on patient throughput or
average length of stay.
 Increasing beds may increase length of stay with no
benefit to patient throughput.
Simulation of patient flows in A&E and elective surgery Discharge Priority: reducing length of stay and bed
occupancy
Michael Allen, Mathew Cooke & Steve Thornton, Clinical Systems Improvement 2010
Focus on discharge
 Every patient should be reviewed every day by a senior
decision maker
 Use expected date of discharge (EDD) to support case
management for all inpatients
 Ensure all patients have criteria for discharge
 Implement morning check-outs so that patients are
‘home for coffee’
 Focus on early supported discharge
Which type of doctor?
Acute Physician
General Physician
 Specific training
 Generic training
 Focus on acute med
 Holistic approach
 Assessment & 1st 48 hours
 Long ward rounds
 Will develop acute med
 Office hours
 Out of hours
The doctor needs to have:










Team worker
Humility
Discipline
Measures performance
Service improvement
Challenges the orthodoxy
Accepts and embraces peer challenge
Concerned about quality not volume
Can describe the system
Builds service around the needs of patients
Redesign
 Focus on decisions, tasks and workflows to optimise
care
 Sort out the high variation
 Reconfigure the supporting infrastructure to match
the redesigned clinical processes
 Design structures and processes to help learning
from daily work

Fixing Healthcare from Inside and Out, Harvard Business Review
Does daily senior review work?
Twice weekly consultant ward rounds compared with
twice daily ward rounds
Impact:
Over study period, no change in length of stay on ‘control’
wards
Average length of stay (ALOS) on study wards fell from 10.4 –
5.3
The impact of twice-daily consultant ward rounds on the length
of stay in two general medical wards
No deterioration in other indicators (readmissions, mortality,
bed occupancy)
The impact of twice-daily consultant ward rounds on the length of
stay in two general medical wards
Aftab Ahmad, Tejpal S Purewal, Dushyant Sharma and Philip J Weston
Clinical Medicine 2011, Vol 11, No 6: 524–8
Continuity of care and regular reviews
 Hospitals with two or more AMU ward rounds per day on
weekdays AND admitting consultants working blocks of
more than one day had a lower adjusted case fatality
rate.
 Where the admitting consultant was present for more
than four hours, seven days per week they had a lower
28 day readmission rate
RCP Taskforce 2007
Internal Professional Standards for AAU
 Time to first review
 Completion of clerk in
 Middle grade review in
 Consultant
 Diagnostics within
 Referral response
15 mins
Two hours
Four hours
Two-three hours day
time, 12 hours out of
hours
Four hours
half a day
Quality measures
 Mortality
 Mortality & morbidity (M&M) meetings
 24 hour discharge rate
 Delivery of Internal Professional Standards (IPS)
 Readmissions seven days
 Adverse events
 A&E flow
 Patient experience
Admission avoidance & early discharge
Strong evidence
 Admission prevention from nursing
homes
 Ambulatory emergency care (e.g. 6090% reduction in overnight stays for
pulmonary embolism (PE))
 Improve urgent access to primary care
 Intermediate care in-reach to
emergency department (ED) and
assessment units
 Assertive case management of frail
patients with dementia
 Continuity of care with a GP
 Hospital at home as an alternative to
admission
 Assertive case management in mental
health
 Early senior review in A&E
 Multidisciplinary interventions and telemonitoring in heart failure
 Integration of primary and secondary
care
Weak evidence
 GPs in ED
 Walk in centres (WICs) and urgent
care centres (UCCs) (unless colocated with EDs with integrated







governance)
Public education
Pharmacist home-based medication
review
(Unfocussed) intermediate care
Community-based case management
(generic conditions)
Early discharge to hospital at home
on readmissions
Nurse-led interventions pre- and
post-discharge for patients with
chronic obstructive pulmonary
disease (COPD)
Telemedicine (except for heart failure)
An example of success
No of patients with LoS
> 14 days
Crude Mortality
Hospital Falls
2011/12 Target - A 20% reduction in the number of
actual cardiac arrests, based on 2010/11 data
Cumulative Serious Harm Falls
Cumulative Ward Cardiac Arrests 2011/2012
Target
March
February
January
December
November
October
September
August
July
June
May
100
90
80
70
60
50
40
30
20
10
0
April
March
February
17
January
September
CQUIN Target YTD
14
December
13
November
12
October
11
August
May
April
8
June
4
July
45.00
1
A&E – Wait to
treatment time
Ward cardiac arrests
CQUIN Target/Cumulative Serious Harm Falls 2011/12
50.00
45.00
40.00
35.00
30.00
25.00
20.00
15.00
10.00
5.00
0.00
A&E - Time to be seen
The Ten Commandments
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Ensure timely access and continuity in primary care
There should be early senior review of all patients along all parts of the pathway,
to maintain the momentum of care – there should be a senior review of every
inpatient’s care plan every day
Get patients on the right pathways – Concentrate on patient flow
Work together across the whole system to systematically and predictably –
implement internal professional standards – to minimise variation
Plan and manage capacity to meet demand
Avoid unnecessary overnight stays – implement ambulatory emergency care
There should be a relentless focus on discharge
Develop clear models of care for assertive management of the frail elderly
Measure the effect and impact of interventions using SPC and follow up with
further improvements
Remember this will all be delivered by people so talk, engage, lead, follow &
LISTEN