what’s wrong with emergency care in aneurin bevan health board? dr danny antebi & dr julie...
Post on 30-Dec-2015
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What’s wrong with emergency care in Aneurin Bevan Health Board?
Dr Danny Antebi & Dr Julie Vile
“We have seen an increase in the 85+
age group”
“The acuity of our patients is increasing”
What do we know / think?
TOO MUCH DEMAND
PROCESSES ARE TOO SLOW IN HOSPITAL
LACK OF CAPACITY TO TAKE PATIENTS OUT
OF SYSTEM
“The system is in crisis”
With increased demand, bed cuts and no immediate prospect of additional funding, we need a FUNDAMENTAL change if we hope to deliver a high quality service
Demand for A&E services
Demand by age band
A&E age profile (adults)
A&E outcome – admitted
Hospital profile: co-morbidities
Hospital profile: age & beddays
Projections for 65+ AB residents with dementia
The 4 hour target
0.5
0.55
0.6
0.65
0.7
0.75
0.8
0.85
0.9
0.95
1Ja
n/08
Mar
/08
May
/08
Jul/
08Se
p/08
Nov
/08
Jan/
09M
ar/0
9M
ay/0
9Ju
l/09
Sep/
09N
ov/0
9Ja
n/10
Mar
/10
May
/10
Jul/
10Se
p/10
Nov
/10
Jan/
11M
ar/1
1M
ay/1
1Ju
l/11
Sep/
11N
ov/1
1Ja
n/12
Mar
/12
May
/12
Jul/
12Se
p/12
Nov
/12
95% Target
ABHB Performance
NH Performance
RG Performance
The 8 hour target
0.5
0.55
0.6
0.65
0.7
0.75
0.8
0.85
0.9
0.95
1A
pr/1
0M
ay/1
0Ju
n/10
Jul/
10A
ug/1
0Se
p/10
Oct
/10
Nov
/10
Dec
/10
Jan/
11Fe
b/11
Mar
/11
Apr
/11
May
/11
Jun/
11Ju
l/11
Aug
/11
Sep/
11O
ct/1
1N
ov/1
1D
ec/1
1Ja
n/12
Feb/
12M
ar/1
2A
pr/1
2M
ay/1
2Ju
n/12
Jul/
12A
ug/1
2Se
p/12
Oct
/12
Nov
/12
Dec
/12
ABHB Performance
NH Performance
RG Performance
4 hr Breaches & Death Rate
0
1
2
3
4
5
6
7
0
5
10
15
20
25A
pr/
08
Jun
/08
Au
g/0
8
Oct
/08
De
c/0
8
Fe
b/0
9
Ap
r/0
9
Jun
/09
Au
g/0
9
Oct
/09
De
c/0
9
Fe
b/1
0
Ap
r/1
0
Jun
/10
Au
g/1
0
Oct
/10
De
c/1
0
Fe
b/1
1
Ap
r/11
Jun
/11
Au
g/1
1
Oct
/11
De
c/11
Fe
b/1
2
Ap
r/1
2
Jun
/12
Au
g/1
2
Oct
/12
De
c/1
2 Em
erg
en
cy
A&
E d
ea
th r
ate
by
da
y o
f a
dm
iss
ion
A&
E %
4 h
ou
r b
rea
ch
es
4 hour breaches
Death rate
Ideas for modelling/ alleviating the problem
TOO MUCH DEMAND
PROCESSES ARE TOO SLOW IN HOSPITAL
LACK OF CAPACITY TO TAKE PATIENTS OUT
OF SYSTEM
• Admission avoidance strategies
• Better community model
• Role of WAST
• Consultant at front end
• Alternative pathway for elderly/ frail patients
• Co-locate MIU
• Better computational facilities
•Discharge patients earlier
• Bring in elective patients later
• 24/7 working
• Patient boarding
50%
22%
14%
7%7%
21/03/2013
MAU Assessment
Deferred to Hot Slot
Admission Avoided
Diverted RGH-YYF
Referred Frailty
Ideas for modelling/ alleviating the problem
TOO MUCH DEMAND
PROCESSES ARE TOO SLOW IN HOSPITAL
LACK OF CAPACITY TO TAKE PATIENTS OUT
OF SYSTEM
• Admission avoidance strategies
• Better community model
• Role of WAST
• Consultant at front end
• Alternative pathway for elderly/ frail patients
• Co-locate MIU
• Better computational facilities
•Discharge patients earlier
• Bring in elective patients later
• 24/7 working
• Patient boarding
Choluteca Bridge
The problem
Evidence of repeated escalation, increased clinical incidents, stories of poor care, queues of ambulances.
So… Case for change
Organisational focus
Conceptual framework
Case for change
Internal to health, partners in delivery, public and politicians
Making the case Data Hearts and minds Patient safety
Organisational focus
Leadership
Whole system approach
Prioritise Emergency Care
Safe
Timely
Effective
Efficient
Equitable
Patient Centred
Systemic
Collaborative
Dialogue
Improvement Innovation
Conceptual framework
Flow
Complexity
Networks and Matrices
Flow
Poor flow harms and kills (Kate Sylvester-mortality by day of admission)
Poor flow wastes resources
Demoralises staff
Impacts on other departments
Complicated or complex
Simple - following a recipe
Complicated - building a space rocket First 48 hours CVA, cardiac surgery
Complex - raising a child Chronic conditions, plus dementia plus NOF
Slide on differences
Production lines and pathways
Acute chest pain Expertise, latest equipment, excellent process, minimal collaboration, safe environment
Complicated pathway/Organisational ownership
Chronic cardiac failure and cognitive impairment
Stay at home, response, support, advice when I need it, a lot of collaboration, engage my family, friends and the milkman, occasional high tech
Complex approach/Shared ownership
Networks and matrices
Resilient communities
public/private/3rd sector – with a shared agenda and priority
? integration IT, budgets, management
Research and modelling
Flow - patient safety, risk, right person, right place, right time, right expertise, pull not push
Complexity – process measures less outcome measures, dignity, patients who can’t report
Networks – organisational collaboration, resilient and robust community and primary care, risk assessment and management, EOL/anticipatory care.
Thank you for listening!
Email:Danny.antebi@wales.nhs.ukjulie.vile@wales.nhs.uk
Any questions?
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