University Hospitals of Morecambe Bay NHS

Foundation Trust

Transforming Unscheduled Care

Background

This report is based on formative discussions with senior clinicians and managers

within the Trust over recent weeks. A review of previous external reports on

unscheduled care has also been undertaken.

It is acknowledged that considerable work is on going to address performance in

unscheduled care at RLI and that this report will cut across or duplicate plans already

in place. This is necessary to provide a complete picture and this plan will

deliberately focus on areas of potential improvement to ensure patient centred care,

improved delivery, timely access and improved patient experience across the whole

unscheduled medical and surgical pathway. (initial thoughts are provided on the

surgical pathway but these have not been discussed with clinicians)

Maintaining timely patient flow is the responsibility of each and every person on the

patient pathway and it is imperative that everyone understands the role they have

and what they need to do. They must own the systems and processes and put

patients at the centre of each and every decision.

Meeting the challenges of this requires engagement of all staff, not just those in ED

and assessment units. The Trust should develop a plan to engage and involve staff

through the provision of information, guidance and leadership. The whole issue

needs to become a high profile element of everyone’s day job.

Starting to make changes and building on the momentum this creates should be the

aim and the marketing/public relations department will need to be involved in this

to help develop a corporate message and start to develop the theme of “the way we

do things here”. This should help to create the right culture to deliver proposed

changes.

This report describes the way forward and follows clinical guidelines developed by

both the College of Emergency Medicine and the Royal College of Physicians. The

model of care is currently working in many hospitals nationally with significant

positive results in both patient experience and safety and resulting improvements in

organisational performance.

Implementation of the associated action plan will require detailed conversations

with clinicians who are primary to its success.

Analysis of length of stay at RLI

An initial assessment of length of stay (LoS) in medicine has been undertaken. The

average LoS in medicine at RLI is 6.7 days compared to a NHS national average of 5.4

days and top quartile performance of 4.9 days indicating that there is room for

increased efficiency.

Breaking the data down further shows that between 55% and 60% of patients move

through the hospital in less than 72 hours indicating effective systems within the

‘front end’ of acute medicine; ambulatory care and medical assessment. However

once patients move into the wider hospital LOS increases. In the group of patients

who stay 3 – 14 nights the average LOS is 6.7 days and those patients who stay over

15 nights the average LOS is 33.4 days.

The latter group of patients, (over 15 nights) constitute 12% of patients admitted to

medicine but they occupy 61% of available bed days.

This initial assessment indicates that whilst the front-end systems are efficient once

a patient moves into the hospital LOS increases dramatically. There are likely to be

multiple reasons for this related to the outlying of patients both within medicine and

across other specialties and delays in discharge processes. Whilst these will be

touched upon in this report further work will be required.

Demand and Capacity modelling on the patient pathway in medicine

Understanding demand and capacity is essential to gaining an understanding of

where the pressure points and blockages in the current medical pathway are. Any

planned changes must meet demand levels and allow surges and prolonged

increases in activity to be managed.

All modelling of demand is calculated at the 85th centile – planning on the average

means we will fail half the time - at this level we can build in capacity to allow peaks

to be managed, the rule of thumb being contingency to manage an increase of 15%

over a 6 week period.

This methodology for modelling is used throughout this report.

The Emergency Department at Royal Lancaster

Daily attendance at ED is between 192 and 227 patients (85th centile) and the daily

attendance is shown in figure 1 below.

ED daily profiles (at 85th centile)

Monday 220

Tuesday 204

Wednesday 196

Thursday 194

Friday 192

Saturday 213

Sunday 227

Figure 1: based on activity over the calendar year Dec 10 to Nov 11

This demonstrates a “normal” pattern of attendance, highest numbers being

experienced on Sundays and Mondays with attendance falling marginally through

the week to Friday. The figures currently include the majority of GP direct patients

referred for medical assessment who enter the pathway through ED. (The future

model will require these patients to go directly to MAU)

Figure 2 below shows the daily attendance by hour of the day (85th centile)

Figure 2: based on activity over the calendar year Dec 10 to Nov 11

0

2

4

6

8

10

12

14

16

Ax

is T

itle

85th centile by day & time band - RLI only

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

All work with the Emergency Department will be guided by the College of Emergency

Medicine report “The Way Ahead” (revised December 2011) and initially work will

analyse in greater detail the spread of the demand across each day, by hour of the

day and the capacity (staff resource) available to manage this.

It is clear from discussions with the lead ED consultant that there are real concerns

about medical staffing numbers and the Trusts ability to attract good calibre

applicants particularly for middle grade posts. This is a common problem nationally

and it is likely that the recruitment market will become more competitive, rather

than less. Work on capacity must address and work on solutions to these genuine

concerns.

It is recognised that plans are in place to develop an area to enable streaming of

minors, which should be available by late spring. Plans for staffing this, particularly

nursing skill mix, should aim to deliver a service where all “minor” patients are seen

in chronological order and no breaches of the 4-hour target occur. The further

development of the ENP service should be encouraged.

Timely review of patients in ‘majors’ may be problematic at times because of

capacity issues in the department but any wait over 15 minutes for first assessment

or delayed ambulance handover should be avoided. To support this all GP referred

patients should be taken directly to the MAU by the ambulance service. Using ED as

a holding area for these patients adds nothing to their pathway and blocks flow in

ED.

Rapid Assessment and Triage (RATS) model in emergency departments can be

particularly helpful at busy times and when flow slows and delays to first assessment

occur. A RATS model will enable patients with an obvious need for in-patient

specialist assessment to be referred as part of the initial assessment process. The

remaining patients need for specialist care only becomes obvious after more

detailed work by the ED team. This process will need to be agreed by Clinical

Directors across the Trust as a potential consequence of its introduction is that

patients will move on to care of the specialty with less clinical work up – leaving

more to be done in the specialist assessment facility but it should create a greater

‘pull’ from within the hospital and ease the pressure on space and consequent flows

in ED.

It is also suggested that the leadership team agrees performance metrics for ED in

relation to patients referred to specialties. This should encourage further

development of assessment areas and increased dialogue with specialties around

timely acceptance of referrals. (Specific recommendations for surgical

assessment/triage are included below.) Any referral made within two hours which

still breaches should be analysed and reported on by the receiving specialty and not

ED. These performance metrics should be shared with staff on a weekly basis; this

will promote increased engagement.

An essential element of managing patient flow is having an understanding of how

demand is developing hour by hour. It is better to know a patient may require

admission to a specialty or assessment bed as early in their journey as possible.

Evidence suggests (Prof. Matthew Cooke paper 2009) that about 70% of patients

who will need specialist assessment are obvious to a trained nurse within a few

minutes of their arrival in ED. Seeing patients in chronological order supports early

decision making, correct streaming and clinical assessment and triage. Added to this,

liaison between ED and assessment areas to provide alerts of required beds as soon

as possible is essential to smooth flow and in assisting assessment unit managers to

control the outflow and factoring of patients into beds in the wider hospital much

earlier. It is recommended that a system of Coordinator (ED) to Coordinator

(Assessment Area) referral should be developed to pre-emptively book beds, within

30 minutes of a patients arrival in ED

Whilst the 4-hour access target is focused on the emergency department staff can

only deliver this if all colleagues working in clinical services in the wider hospital

support them. Some work on this is developing through the ED ‘10 steps plan’. This

can be summarized into 5 clear commitments required from all clinical services:

1. They must support ED in the effort they are making to improve the service to

patients and achieve the 4-hour access standard and recognise that we all

have a part to play in this.

2. Staff must respond promptly (within 30 minutes) and pro-actively to expedite

effective care for patients and at all times maintain the highest standards of

professional collaboration with both the ED and specialty teams.

3. They must help and encourage the development of written care pathways,

referral guidelines and agreed processes through ED and must follow them

consistently.

4. They must facilitate the movement of referred patients to specialist

assessment units within an hour.

5. All our in-patients should have a care plan, which is reviewed daily by a

senior doctor which includes an expected date for discharge. Patient flow

should be measured routinely and delays should be analysed by the specialty.

Collaborative working between ED and specialties should be supported

through joint audit and governance reviews.

The Model of Care in Acute and Specialty Medicine The Medical Assessment Unit (MAU) provides the single portal for entry into

assessment for care for all medical patients whenever and from wherever they

arrive. It must become the single point of contact for GPs making emergency

referrals to medicine and all GP patients should arrive here. We must stop admitting

them through ED.

It is the work place for all the clinicians contributing to the process, which responds

to about 45 patients per day and should be organised as a continuously flowing

process with a normal LOS of about 4 hours and a maximum of 12 hours.

The team is medically led by acute medicine but many others, including sub-specialty

physicians make vital contributions to delivery of care.

Patients’ expectations, researched internationally, are very consistent. They want:

Someone who knows what is wrong and explains this

Someone who knows what to do and makes it happen

Someone who respects their autonomy and is easy to get along with

Someone who works in a clean and dignified environment

(Research suggests that patients place emphasis on the perceived competence rather

than the grade or profession of the “someone”)

To this reasonable expectation our professional values also require us to:

Do no harm

Work together in teams to meet the patients’ needs

Avoid duplication, waste and delay in the use of our resources

Avoid discrimination and sustain equity in access to appropriate care 24/7

Sustain recognised professional standards of organisation and delivery of

clinical care

From these principles it follows that assessment in an acute medical context is only

complete when a senior competent doctor has:

1. Explained the working diagnosis to the patient

2. Outlined and agreed with them a plan for their care

3. Advised them whether an inpatient stay is required and if so whether it will

be short (1 or 2 nights) or rather longer

4. Identified the care pathway and any specialty inputs required

It is good practice to clearly identify this element of the case note and routinely audit

the elapsed time from arrival to it being signed off by a consultant. (The RCP

guidance is that this should normally be within four hours and certainly within 12

hours every day of the week).

Delivery of this consistently must be our number 1 goal. This will help in ensuring

robust implementation and continued development of the model of care to the

absolute benefit of patients.

Length of stay data indicates that whilst the assessment process in medicine is

efficient the flow of patients slows considerably as they move into the wider hospital

with outlying a regular occurrence both within and out of specialty. This creates

additional work for specialty physicians and is not good for patients. The option of a

short stay facility is being actively considered and it is recommended that this is

progressed quickly with the aim of developing an acute medicine model of care in

the Trust.

From data provided by the Trust we can calculate the demand for acute medical

assessment each day as follows:

Medical Assessments (at 85th centile) – Assess to admit

Monday 45

Tuesday 45

Wednesday 43

Thursday 44

Friday 47

Saturday 35

Sunday 33

The weekend figures are lower as the patients referred from GPs are reduced

significantly.

To manage patients more efficiently, following assessment, in medicine a revised

model of care is proposed based on a linear pathway as described in figure 3 below.

This will be the subject of wide ranging discussions in the Trust and in particular with

the clinical directors and physicians currently providing the service. This model must

be clinically owned and managed.

The Model of Care

Figure 3: Revised model of care

The model is based on a requirement for 45 assessment each weekday. Around 15 of

these patients will come from GPs and this pathway is reversible. Patients may be

ambulant on presentation and can be treated and return home ‘in day’ or may

require follow up through an urgent out-patient appointment or diagnostic

procedure. The majority of these patients will be managed through the ambulatory

care unit.

Note: It is essential that all GP referred patients arrive at the assessment unit whilst

staffing resources are available – preferably between mid day and 6pm – this will

need further discussion with both GPs and NWAS.

The remaining 30 patients will enter the pathway through ED – 2 to 3 each day will

require immediate admission to CCU/ITU or Stroke care leaving 27 to move to the

assessment unit. With the 5 GP patients this means 32 patients each day are likely to

need in patient care through this pathway.

The new short stay unit (SSU) fulfils two key roles, firstly to manage patients with a

LOS of up to 72 hours and secondly it acts as a buffer (of up to 24 hours) for patients

who require a specialist bed which is not available at the time of their admission –

this reduces the number of outliers and thus reduces the length of stay of patients.

Medical Assessment

45 per week- day

Short Stay Facility 72 hours max LoS

35 bed max- 20 short stay, 15 buffer

CCU/ITU Stroke Unit

Respiratory Unit

Gastro

Care of the Elderly

Cardiac Unit

Metabolic Unit

Complex care pathway

ED

GP

In Reach

Out Reach

15 10

2/3

32

27

8-10

The model requires a heavy emphasis of acute physician time in the

MAU/assessment process and the management (with specialist input as required) of

patients staying less than 72 hours. With only two acute physicians at present

specialty colleagues will need to provide general medical support to the unit,

particularly the short stay element. Benefits of providing this support are twofold,

firstly the number of ‘general medical’ patients on specialty wards should decrease

and those patients who need a specialty bed should get to the right ward on a more

regular basis thus reducing fragmentation of rounds etc.

In the longer term SSU will need to be supported by specialty ‘in reach’ from

consultants on a daily basis and this will need discussion and agreement. Because of

higher numbers (8 – 10 each day estimated) the Care of the Elderly could helpfully

develop arrangements to identify complex care patients early in the process and

may be in a position to provide a full consultant session of input each day in SSU.

Again this will need further discussion.

Core principles of the model of care:

1. The demand for care must drive the way we organise resources to respond

effectively

2. Assessment is a key component of the process which determines the onward

path of care and must precede any presumption about the need for an in-

patient stay. We have a single portal for medical assessment.

3. The assessment process must be consistent, irrespective of day of week or

time of arrival of the patient and must meet the RCP recommendations for

timely senior doctor supervision

4. We will only be able to deliver consistently safe, timely and effective care if

all our resources are co-ordinated into an integrated response based on the

model of care which becomes the culture or “the way we do things around

here”

Specialty Care

Whilst some excess bed days can be attributed to delays in discharge it is too easy to

attribute all the problems in this direction and miss some other internal actions

which need to be taken.

It is imperative that each and every patient (and therefore ward) has input from a

senior doctor on a daily basis, preferably in the morning.

It is recommended that each patient leaving the assessment facilities (both medical

and surgical) has an expected date of discharge with an associated care plan. Where

this is not appropriate an internal standard is set to ensure the EDD and care plan

are agreed within 24 hours of admission to the specialty.

The role of the ward manager in achieving robust patient flow cannot be

underestimated and all need to be fully engaged. Their responsibility extends

beyond patient care to direction of medical staff, particularly juniors, bed

management, nurse-led discharge and the accurate analysis of bed availability on a

daily and hourly basis. This will require them to plan ahead and the use of expected

date of discharge and care planning processes should be the norm. The development

of standards for each ward is recommended which focus on the timeliness and

quality of patient care, are agreed collectively and shared widely. Similar standards

should also be developed for allied professions providing direct input to the patient

pathway, which also concentrate on timeliness and quality of inputs.

In general, hospitals tend to operate around 30% slower over a weekend/bank

holiday period when discharge rates fall. This leads to “Mad Monday”, Terrible

Tuesday” and sometimes “Woeful Wednesday”. As discussed above the resolution

to this is in increased regular senior medical input, use of EDD, care plans and Nurse-

led discharge particularly over the week-end.

Reducing variation should be the aim and with this patient flow will improve.

Bed management

The Trust must establish a daily patient flow control system supported by

contemporary information on the bed state and activity levels. There is a site based

meeting to consider the bed position in the Trust held each morning but evidence

from conversations is that this provides little in terms of action to maintain flow. Site

based bed meetings should be held daily at 9.00am, 1.00pm and 4.00pm with a

number of agreed actions emanating from each one. The meetings should be chaired

by a senior manager (the responsibility should be shared around) and attendance

will be required from Lead Matrons in Medicine and Surgery and MAU, Bed

Management, Discharge facilitation teams etc.

One of the key issues the bed meeting must drive is early, in day discharges. One

tactic which has been found to work well is the development of a ‘Home for Coffee’

policy which can create improved flow from MAU to specialty wards and the

discharge lounge earlier in the day. Support can be provided to develop this idea.

In addition to this the bed meeting must manage escalation (and more importantly

de-escalation) at times of pressure within the parameters of the Trust and wider

community escalation policies.

The table below provides examples of the type of information which should be

considered at daily bed meetings.

The output from each bed meeting should be an agreed list of 6 – 10 actions which

address the identified issues. The aim of the meeting is to galvanise the clinical

teams to focus on pinch points during the day and develop a corporate/team

approach to resolving issues.

The main tool for managing beds and flow in the future must be IT based. It is

acknowledged that the Lorenzo system is in development and this needs to be

implemented as part of this project.

Bed Meeting Information Requirements

Bed Management Meeting – Information Requirements

Meetings held routinely at 9.00am, 1.00pm and 4.00pm

Medicine MAU

Medical patients to be seen/waiting for senior review

Patients to come in (from A&E or GP Direct)

Patients due to leave MAU

Empty beds on MAU

Beds available to use in Medicine

Beds available in the next 3 hours

Best case scenario (bed numbers)

Worst case scenario

Surgery EAU

Patients to be seen/waiting for senior review

Patients to come in (emergency admissions from A&E)

Ward rounds

Ward 1,2,3 etc

Specialist areas Available beds in ITU CCU Cardiology HDU Step Down

Elective Surgical Patients Today Tomorrow TCI Placed Tomorrow XXXXXXX Day case numbers

Community/non acute bed provision Facility 1 2 3

Paediatrics NICU beds Paeds beds Patients in Obs area

Bed Predictor Beds required today Beds required tomorrow Discharge running total @ 9.00, 1.00 and 4.00pm

Medical and Surgical outliers Escalation facilities Area 1 Area 2 etc

A&E Majors – Number of patients, time of next breach and destination of patient Minors – Number of patients, time of next breach and destination of patient

Discharge Lounge Patients through/booked in at 9.00, 1.00 and 4.00pm

NWAS Emergencies running Availability of discharge crews

Management O/C Director O/C Manager Lead Matron

The Emergency Surgical Pathway

The emergency surgical pathway relies heavily on bed availability in the Surgical

Assessment Unit (SAU). Delays do occur and it is evident that the SAU is a holding

area rather than a triage service.

Some Trusts now operate a full surgical triage service as described below and are

seeing significant benefits in terms of reduced delays and reduced bed days. It is

recommended that this model is given further consideration and visits to working

units can be arranged to support this.

Surgical Triage Unit

A Surgical Triage Unit (STU) is neither an admissions nor an inpatient ward for

surgical patients. It is an integrated unit where adult patients referred to the

emergency surgical take can undergo triage, investigation, treatment and

management planning.

Many of these patients can be managed in a safe and timely manner without the

need for admission. The STU should be viewed as a general surgical emergency

department for patients who have been assessed either by their GP or by the

emergency department.

The aim is to improve quality of care and patient experience by providing a “third

way” for acute referrals whose problem requires the input of an experienced

surgeon but does not need admission. The added value of this approach is a more

rational use of scarce surgical beds and nursing expertise.

The unit should be staffed by nurses experienced in the management of emergency

surgical patients and a senior middle grade doctor, available from 9am to 6pm. This

doctor will be supported by all members of the emergency surgical team with the

surgeon of the day/week playing an active role in all phases of management.

Surgical “hot clinics” and a dressing clinic will need to run every day. These allow

patients who do not require in patient admission to return the next day for review.

Patients that need to be monitored for a few days fall into this category.

Surgical referrals from GPs or the hospitals emergency ED can be directed to the STU

where nurses take patient details. This is an improvement on junior doctors being

bleeped to take the calls with no central record of the referrals.

General surgical patients should be triaged by a senior nurse on arrival on the STU

and initial observations taken. All patients should then be seen by a middle grade

surgeon or above within 2 hours of admission. Patients can be taken straight to

theatre, admitted to a surgical ward or discharged. Discharges can be to the hot

clinic, an elective list or home. Patients seen in the hot clinics can re-enter the

pathway by any of the above routes. Patients undergoing minor surgical procedures

can recover on the STU post op prior to same day discharge (day case urgent

surgery). This avoids unnecessary in patient admission.

Radiology can be requested to allocate 3/4 ultrasound slots per day which are

coordinated by the STU nurses in association with the vascular service.

A take home drug cupboard should be available for 24 hour dispensing.

Conclusion

It has been recognized for some time that a more effective integration of the

elements of the unscheduled care services is required across the NHS and

substantial investment of resources has been made over recent years in many

hospitals.

Despite encouragement and support some organisations and clinical teams have

struggled to find a way forward. External reviews from the teams such as the

National Emergency Care Intensive Support Team have proved a stimulus but whilst

ideas for change are helpful the implementation of required changes is always a

struggle. We must reinvigorate our determination that opportunities should now be

taken in line with this plan

Details of the implementation steps will continue to be discussed and planned and

since they influence the working lives of nearly a third of the consultant body and

cover the care pathways for an even greater proportion of our admitted patients this

is a substantial undertaking.

This is a challenging proposal, which asks a great deal of all our staff but it is

heartening to hear that the desire for change is widespread and recognition of the

scale of the task broadly understood and accepted.

Jeremy Pease

January 2012