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: Helen.Mcconville@morecambebayccg.nhs.uk

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: laurel.white@mbht.nhs.uk

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: joanne.mcguire@mbht.nhs.uk

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: Melanie.woolfall@mbht.nhs.uk

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: Pauline.turner@mbht.nhs.uk

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:

Kate.butterfield@mbht.nhs.uk

“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