Whittington HealthEnhanced Recovery Health System

Dr Martin KuperMedical Director and Intensive Care ConsultantWhittington Health, London Previously…National Clinical Advisor to NHS ImprovementClinical Lead for Enhanced Recovery in London

Clinical strategy

Integrated care

Ambulatory care

Enhanced recovery

• Coordinate health and social care • Patients targeted:

– Complex – 65+ / LTCs– Frequent ED attenders– High users of social services

• Now 4 locaity MDT teams• Discussed more than 500 patients

• Integrated Care MDT Teleconferences• GPs – the lead clinician• Community Health Teams (DNs, CMs)• Hospital Pharmacist• Social Services• Consultant physician (NMH or Whittington) • Consultant psychiatrist (BEH MHT)

Integrated Care

Preliminary results – but risk regression to mean • 17% reduction in A&E attendances• 86% of the patients had fewer admissions

afterwards

All care should be ambulatory or enhanced recovery

Ambulatory Care• Senior decision making, advanced diagnostics • Consultants - Acute Medicine/ ED• Ambulatory Care Coordinator• Community Matrons • Patient and staff designed area and pathways• Leverage community services • Avoid unnecessary admissions• Support discharges - reduce length of stay• Pharmacist

0

1

2

3

4

5

6

7

8

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

Total

median total

DVT ADMISSIONS

Ambulatory CareDirectory of Ambulatory Care - medical

Reduction in LOS coincides with increase in Ambulatory Care in Summer 2012 (subset of overall Medical LOS (see previous chart).

Directory of Ambulatory Care used as a proxy for conditions suitable for Ambulatory Care

NHS Institute of Innovation & Improvement, Directory of Ambulatory Care, 2012

General Medical conditions only

MonthlyTo August 2013

Average LOS for Directory of Ambulatory Care (Medical Conditions)

2

3

4

5

6

7

8

4/30

/201

0

6/30

/201

0

8/31

/201

0

10/3

1/20

10

12/3

1/20

10

2/28

/201

1

4/30

/201

1

6/30

/201

1

8/31

/201

1

10/3

1/20

11

12/3

1/20

11

2/29

/201

2

4/30

/201

2

6/30

/201

2

8/31

/201

2

10/3

1/20

12

12/3

1/20

12

2/28

/201

3

4/30

/201

3

6/30

/201

3

8/31

/201

3

Month

Ambulatory CareThroughput

Interim Model from March 2012, Initial implementation complete by summer 2012 with gradual increase to max capacity Current activity is below plan Increased activity in November 2013 to February 2014 -extended opening hours (620 pm)Increased activity in March 2014 - scheduled opening of the new unit – increases in14/15 to 1650 pm.

Count of ED attendances where location = “AEC”

Monthly dataTo October 0213

0

100

200

300

400

500

600

700

800

900

Oct

-11

Dec

-11

Feb

-12

Apr

-12

Jun-

12

Aug

-12

Oct

-12

Dec

-12

Feb

-13

Apr

-13

Jun-

13

Aug

-13

Oct

-13

Dec

-13

Feb

-14

Vo

lum

e o

f A

mb

ula

tory

Car

e at

ten

dan

ces

Activity Plan

9

Ambulatory Care

…getting better sooner

Enhanced Recovery

…getting better sooner

ENHANCED RECOVERY HOSPITAL

Home

Social care

D+T - OPA

IC

Specialist units

MAU – multiple handovers within and between day.

ChurnHandover

Handover

Handover

GP referrals

A+E Referrals

Handover

Churn

MAU

IST summary

Elderly Care

Adult Admission Unit

Speciality pathwaysa) Medicineb) Surgery

ACU

Ambulatory care

Emergency Department

Speciality Wards

Intensive Care

Ambulatory care A

cute E

R / G

oing h

ome bu

ndle

Improvement and information

• Improvement is not an accident and needs to be resourced

• Information is key

Enhanced recovery from acute illness

time

function

Common elements

• Involvement• Clothes• Nutrition• Hydration• Mobilisation• Sleep• Pain• Discharge planning

‘Variation is the enemy of Quality’

W Edwards Deming

Standardised condition specific managementeg sepsis checklist

ER training programme

• 09:10 What is Enhanced Recovery?

• 09:55 Skills for supporting patient engagement

• 10:15 The role of volunteers• 10:45 Specific areas

– Mobility and Strength (OT/Physio)

– Yellow Plan and links to discharge checklist

– Pain – Nutrition & positioning for

feeding – Sleep – Hydration

• 12:00 Going home bundle• Rationale for focusing on patient flow• Criteria for Discharge & EDDs • 12:35 Board rounds & whiteboards • 12:55 Morning Discharges • 13:10 The discharge checklist • 14:15 Delays escalation • 14:30 Community Referrals (District

Nursing) • 15:05 Working with social services • 15:35 Continuing Health Care • 15:55 Equipment

PROGRESS

Enhanced recovery after hip fracture

Emergency Medical LOS

Interim model started mainly with Medical patients. See activity chart for Ambulatory Care – there is a drop in Medical LOS at the same time as increased Ambulatory Care increased

Excludes admissions to ISIS Ward under the ED consultants.

Emergency Medicine Average LOS

5

6

7

8

9

10

Apr-1

0

Jun-

10

Aug-

10

Oct

-10

Dec-

10

Feb-

11

Apr-1

1

Jun-

11

Aug-

11

Oct

-11

Dec-

11

Feb-

12

Apr-1

2

Jun-

12

Aug-

12

Oct

-12

Dec-

12

Feb-

13

Apr-1

3

Jun-

13

Aug-

13

Month

ER in Medicine/Going Home BundleAverage LOS for patients over 70 years

Increased in LOS in April & May 2013 breaks the run of data points. Nevertheless Los for older people has come down

Average LOS for discharged patients aged 70 or over.

Excludes day cases

Medical Specialties only

The date period is between April 2010 and August 2013.

Average LOS Medical patients over 70 years

8

9

10

11

12

13

14

4/30

/201

0

6/30

/201

0

8/31

/201

0

10/3

1/20

10

12/3

1/20

10

2/28

/201

1

4/30

/201

1

6/30

/201

1

8/31

/201

1

10/3

1/20

11

12/3

1/20

11

2/29

/201

2

4/30

/201

2

6/30

/201

2

8/31

/201

2

10/3

1/20

12

12/3

1/20

12

2/28

/201

3

4/30

/201

3

6/30

/201

3

8/31

/201

3

Month

ER in Medicine/Going Home Bundle 95th Percentile Length of Stay

Reduced variation from July 2013 – Enhanced Recovery Programme commences on wards: ward conversations, discharge escalation process, consultation on design of discharge checklist and Going Home Bundle itself.

95th Percentile LOS for Acute discharges

Excludes day casesExcludes Maternity, Children & Babies.Excludes ED/ISIS

The date period is between August 2011 and August 2013.

SHMI

SHMI is Summary Hospital-level Mortality Indicator and measures whether

hospital deaths are higher or lower than expected.

Methodology varies from HSMR.

Outcome Metrics

0

20

40

60

80

100

120

Jul 11 - Jun12 Oct 11 - Sep 12 Jan 12 - Dec 12 Apr 12 - Mar 13

SHMI Threshold

Apr 12 - Mar 13Acute Myocardial Infarction 96.35Cardiac Arrest and Ventricular Fibrillation 112.91Congestive Heart Failure, non hypertensive 70.22Pneumonia 71.05COPD and bronchiectasis -Acute and unspecified renal failure 34.11

Surgery, Cancer and Diagnostics

Fractured Neck of Femur 79.81

Integrated Care and

Acute Medicine

Threshold Jul 11 - Jun12 Oct 11 - Sep 12 Jan 12 - Dec 12 Apr 12 - Mar 13SHMI 100 71.08 71.28 70.31 65

Summary

• Enhanced recovery principles apply to acute illness• Systematic implementation can drive change across

a hospital• Ambulatory care is a key component of enhanced

recovery• Maximal implementation depends on close

integration with local primary care and community services

• These aspects have implications for the ‘future hospital’ agenda

RCP commission