IMPROVING ED PERFORMANCE
Delivering improvements across the entire
patient journey
ED Improvements
Avoiding ED Attendances and Admissions by developing Integrated Care Communi-ties
Improving Ambulance Hand-overs at RLI
Redesigning Triage at FGH
Tackling patient flow cross bay, implementing SAFER
Helping Patient Discharge-Hospital Home Care
A small excerpt of what have tak-
en forward, and what we continue
to develop…..
INTRODUCTION
A WHOLE SYSTEM APPROACH
The health community of Morecambe Bay have a long history of working in part-
nership, born in part, as a result of the challenging geography & topology of
Morecambe Bay. From rural South Cumbria, to the industrial hub of Barrow and
the University city of Lancaster delivering sustainable health services to the com-
munity has been at the heart of “Better Care Together “. A strategy in which,
health care partners clearly set out the roadmap for improved patient services.
This has been further supported through the establishment of Bay Health &
Care Partners collaborative.
This collaborative approach was demonstrated, when it was recognized that fail-
ing to achieve the 4 hour 95% ED target, was not simply a problem for ED, but
more symptomatic of wider system pressures and flow. And that a whole system
response was needed to help deliver improved performance.
The initiatives highlighted in this Improvement leaflet briefly illustrate some of
the changes that have been implemented across the whole patient journey, com-
mencing with admission avoidance through ED and inpatient wards, to discharge.
They are not exhaustive, and there are many other initiatives which in turn, will
also contribute towards a step change in performance.
Our Work Programme
The A&E Delivery Board sanctioned a work programme which drew together dis-
crete workstreams across the primary, community, secondary and social care sys-
tems of Morecambe Bay. All of which will ultimately contribute towards delivering
the 4 hour quality standard.
The approach has been to structure the programme utilizing a cross bay / cross or-
ganizational PMO lite, rapid improvement approach supported by improvement
colleagues. Task groups have been established, which report to project / operation-
al boards, and through to the A&E Delivery Group. The workstreams are;
Admission Avoidance
Improving ED
Enhancing Pathways
In Hospital Flow (SAFER)
Pre / Post Hospital
Reducing Delayed Transfers of Care
ICC Headlines
Barrow ICC - Respiratory illness is a concern for the locality, with joint UHMB & community respiratory clinics planned for November. Practice nurses & HCA’s are being upskilled in spirometry reading & interpretation to support the new clinics.
Kendal ICC - created care plans for a number of frail elderly residents. This ena-bles the ICC team to support the patient in their home or care home and prevent un-necessary hospital admissions.
Garstang ICC assessed 175 patients. Early analysis shows a reduction of at least 20% in hospital admissions over a 12 month period.
Bay ICC in partnership with secondary care, reviewed paediatric frequent attend-ers to A&E. This demonstrated a 31% re-duction in hospital attendances for the 16 children involved.
Ulverston & East ICCs have estab-lished MDT meetings to review vulnerable patients; those contacting out of hours ser-vice, NWAS, or who have presented in Pri-mary/ Secondary care. Early indications are that these are proving useful
STARTING WITH ADMISSION AVOIDANCE
Integrated Care Communities (ICCs) are integrated teams of health and care work-
ers, practicing population health with a mobilised population. Based on natural
communities of between 10,000 and 70,000 people, ICCs bring together primary,
community and social care workers into one single integrated team working to a
common purpose: improving the health and well-being of the local population.
Each of the 12 ICCs across Morecambe Bay have targets relating to avoidance of
emergency admissions. Fundamental to achieving this is early recognition of people
who are vulnerable because of ill health or other social issues; ICC staff undertaking
a detailed assessment and taking actions to optimise health and care needs includ-
ing support to self-care. This includes admission avoidance plans including consider-
ation of future preferences in relation to care.
ICCs are using the eFrailty tool to identify these patients. The ambition is that this
Care Plan is generated electronically and visible across the system. We are working
together with colleagues in primary, community and secondary care to ensure that
the assessment templates contain key information to support any future episode of
care.
The ICCs
ED Improvements
Integrated Care Communities
Contact: [email protected]
Millom East
Alfred Barrow Carnforth
Barrow Town Bay
Dalton & Ulverston Lancaster
Grange & Lakes Queen Square
Kendal Garstang
ED Improvements
Set up a joint ED / NWAS improve-
ment group
Senior Paramedic on the corridor
Reworked handover processes
“Fit to Sit” implemented
Paramedic review of ambulance
attendances
What we did…..
TACKLING THE FRONT DOOR
IMPROVING AMBULANCE HANDOVERS AT THE RLI
Recognising the national challenge for NWAS around wasted notify to handover
hours in ED, the ED Improvement Group at the Royal Lancaster Infirmary have been
working hard to improve their compliance with the 15 minute standard.
ED RLI ended December with an average notification to handover time of over 22
minutes. Extensive work was undertaken through the following months to develop
a process on the ambulance corridor which enabled quicker handover of patients.
An ED Improvement Group was established which involved the trust and key NWAS
staff. The group meet regularly, and it has enabled both organisations to develop
solutions which can be localised.
The work began initially with checking the appropriateness of ambulance arrivals. A
senior paramedic on the corridor for a week long test period to gather data around
ambulance arrivals and challenge presentations to ED which could more suitably
have been managed elsewhere. Data and anecdotal evidence from the senior para-
medic found that most presentations were appropriate.
The team followed this work up with the implementation of the “ fit to sit” initiative
which resulted in increased space on the corridor in times of pressure, in addition to
a change in mind set for both patients and staff. This initiative is now common prac-
tice with NWAS and ED teams.
Alongside this, the group developed a new process for ambulance handover which
removed the time consuming duties performed by the CSW which weren’t necessary
for triage e.g. cannulas. The new process was tested and analysis of data with NWAS
proved it to be effective at reducing the notify to handover time. With a supernu-
merary nurse with a keen interested in ambulance triage, the process was rolled out,
and is currently being fully embedded. By August, the RLI notify to handover times
had reduced to 17.03 minutes.
Contact: [email protected]
December 2016: notify to hando-
ver times of 22 minutes
April 2017: notify to handover
times reduced to 15.49 minutes
Key Facts:
ED Improvements
Contact: [email protected]
PDSA 1
Not a resounding success, with mixed feed-
back;
the size and height of the reception desk
obscured the view of the patient for the
triage nurse
Queues for triage built up
There were concerns for privacy /dignity
Queues led to staff feeling overwhelmed
PDSA 2
The team maintained focus and quickly
scheduled another trial, this time they were
more prepared.
Alterations were made to desk height
Room was identified for privacy
Patients seated in waiting room whilst
awaiting triage
When under pressure, the ED Nurse In
Charge triaged ambulance patients
NOTE: staff demoralized by whiteboard
recording of data (in the red!)
Redesigning Triage at FGH The clinical staff at Furness General Hospital felt that there were opportunities to
improve their triage times, and for them to better reflect the work of the team.
Following a visit to York Hospitals, clinical staff from Furness General Hospital were
keen to trial the navigator triage model, which they had seen demonstrated.
The model sees a senior triage nurse in reception undertaking a rapid triage assess-
ment, supported by a health care assistant for observations/tests. A
DOING THINGS DIFFERENTLY…..
It took a couple of attempts to really nail the process, and the team had a num-
ber of issues with each of the PDSA’s, however the one consistent factor, was
that the team were able to see that they were improving triage times for the
patient.. The approach is now adopted consistently, with performance regularly
improved (see below). Within triage target, times recorded in GREEN.
02
4
68
10
12
1416
18
20
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
FGH Monthly Triage Performance
% in 15 mins Median Minutes
ED Improvements
Implemented Red to Green on medicine wards
Board rounds structured around a patient checklist
Instigated fortnightly meetings to investigate reasons for patient de-lays
Developed and implemented a patient flow dashboard
Reinstated Discharge Lounge xbay & set targets for use
Engaged with wards re target for earlier discharge - league table.
Held a xbay “End PJ Paralysis day”
What we did…..
ACHIEVING PATIENT FLOW
SAFER BUNDLE
Addressing all of the elements that constitute patient flow is unexpectedly, a large
piece of work. The programme of work commenced in [date] and was principally
focused on Red to Green as a means of engaging staff in identifying and understand-
ing patient delays, and was the precursor to a full implementation of the SAFER bun-
dle.
The focus has been on xbay medicine wards, a roll out to Surgery wards is planned
for the near future. Some common themes and areas have been uncovered, and
which would benefit from further engagement with clinicians and nursing staff.
ECIP colleagues have helped structure board rounds by asking “4 key questions” that
a patient would expect to ask or know. Board rounds are further supported by 3pm
huddles.
Engagement is underway with colleagues using the EDD more effectively to change
ways of working as well as “ready to go” to date and how this too, might support the
discharge process. Each site holds a fortnightly Red to Green meeting, which looks to
identify delays, pick out themes, which are then further investigated.
Achieving discharges earlier in the day are proving a challenge. The reasons for late
discharges are multi-factorial and are often difficult to unpick, ranging from assump-
tions that packages of care only start at tea time, to transport and issues with TTO’s.
The limitations of the discharge lounges at both sites are such, that they are only
able to take ambulatory patients, with capital investment needed for modifications.
Next Steps….
Further define EDD and “Ready to Go” dates & engage
Roll out on surgical wards
Possible business case to develop discharge lounge
Contact: [email protected]
What we learned!
Its not a good idea to start immediately following an ECIP visit; PLAN IT
It takes at least two weeks to inform every member of nursing staff - ENGAGE
To develop an implementation pack and guidelines, & don’t under estimate the
training/guidance required - SUPPORT
Consider using a core team to act as SAFER advocates - BE CONSISTENT
Delays are about unpicking reasons, and not about blame - ACT
ED Improvements
Contact: [email protected]
Staffing
1 x Manager, 2 x Admin, + 13 CSW’s
Response is demand driven, and co-
vers Barrow, South Lakes & North
Lancashire
2 x CSW’s joining in October ‘17
Aim for 5 staff (daily) potential for 80+
visits a day
Patient Using The Service
To date (4 Sept ‘17), a total of 561 pa-
tients have used the service
Bed Days
To date the impact on bed days are;
4911 bed days saved via sup-
porting /settling in patients
804 bed days prevented by avoid-
ing an admission
Helping to Achieve Patient Discharge The Hospital Home Care team (picture above) service was developed to provide hos-
pital outreach care for those patients waiting on a package of care to commence or
be restarted. The service commenced in October 2016 and operates across the
Morecambe Bay health area, with the aim of bridging short term gaps in provision, &
enabling patients to return home for end of life care life.
HOSPITAL HOME CARE
Hospital Home Care is a team of hospital clinical support workers who provide high
quality care at home. The service is provided free on the NHS and is a 7 day a week
service operating between 8:00-21:00hrs. They follow a tailor-made care package
which is established at the MDT assessment for discharge.
Duties include assisting with personal care including;
Toileting and incontinence
Bed routine
Bathing & oral hygiene, grooming & dressing
They can also ;
Provide household services including meal preparation
Assist patients to develop and maintain their daily living skills and inde-
pendence as part of their rehabilitation goals
Assist with medication reminders
Help with posture and positioning
And will undertake to promptly reporting any changes which may affect the health
or wellbeing of a patient.
KEY FACTS
Next Steps….
Scale up of the existing service
Enhancement of the service to support a discharge to assess model
What we have detailed ,is but a small selection of the initiatives that
will contribute towards achieving safe patient care in ED. It is clear
that no one single initiative will deliver 4 hour the target. Here at
Morecambe Bay we continue to be able to draw on the expertise and
support of health and social care colleagues from across primary,
community, acute and social care systems.
It is these relationships that are key to achieving system perfor-
mance and improving patient flow. The cumulative effect of the
work programme as detailed below have already begun, and will
continue to contribute to whole system improvement.
ED Improvements
Bay Health & Care Partners is a collaborative partnership of the
following organisations;
University Hospitals of Morecambe Bay Foundation Trust
Cumbria Partnership Foundation Trust
Blackpool Teaching Hospitals NHS Foundation Trust
Lancashire County Council
Cumbria County Council
North West Ambulance Service
Morecambe Bay CCG
Lancashire Care Foundation Trust
North Lancashire Medical Services
South Cumbria Primary Care Collaborative
For further information please contact:
“The best changes are
synergistic; each is a piece of the greater whole, aimed at integrated,
patient-centered care”
There’s more to do….
Admission avoidance ICC Work Frailty Strategy Step Up/Down Beds (Altham Meadows) Flow Within Hospital SAFER Red to Green Last 1000 days Bed Management Earlier Discharge Enhancing Pathways Ambulatory Care Signposting GP referrals Mental Health & Frailty
Front Door Primary Care Steaming Triage (FGH) Ambulance handovers (RLI) Capacity & Demand ED Co ordination Specialty Response Surge & escalation Back Door Home of Choice Policy Hospital Home Care Integrated Discharge Teams Discharge to Assess Trusted Assessor