How to streamline inter-hospital transfers Dr Richard Levy Wythenshawe Hospital, Manchester CHD...

How to streamline inter-hospital transfers

Dr Richard Levy

Wythenshawe Hospital, Manchester

CHD Collaborative

National Clinical Lead

“Real life” technical considerations ?

What is the evidence?

REASON FOR TRANSFER

Acute CoronarySyndrome Pacemaker

Urgent coronary surgery

Implantable CardioverterDefibrillatorValve surgery

Pacemaker with wire

Transplant assessment

Pericardial effusion

The majority of patients waiting for transfer were waiting with acute coronary syndrome (73%)

24 24 2217

14 126 6 6 5 5

A B C D E F G H I J K L M N

Number of patients reported awaiting transfer at each hospital Manchester Dec 2003

Hospitals

Inter-hospital transfer for revascularisation

At a CHD Collaborative Angina Workshop in September 2003 this was identified as national problem # 1

Organise a national survey and audit of current practice in patients with ACS

ACS Transfer

• Study from Manchester Royal Infirmary from May to October 2003 recorded 212 patients in 16 DGHs occupying 1755 bed days waiting for transfer

(N Curzen, Lancet letter 2004)

Inter-hospital transfers for revascularisation

“ view from-----

----- the DGH”

Inter-hospital transfers; view from the DGH

• We do all the right things• We triage the patients, identify the high risk

patients (Troponin testing etc)• We select the correct patients for angiography+/-

revascularisation and refer to the Centre• And then we wait• ----- and wait

----- and wait

“view from

the Ambulance Service”

Inter-hospital transfers;

view from the Ambulance service

• We have to match the type of vehicle, equipment and crew to needs

• This can have an adverse impact on category A calls

• The patient is never ready when we arrive• And then we wait• ----- and wait ----- and wait

“view from-----

----- the Centre”

Inter-hospital transfers; view from the Centre

• We must first meet our targets for elective revascularisation [PCI & CABG]

• This will dictate our “star rating” and application for Foundation status

• We have a “white board” for listing patients for transfer for non-elective revascularisation

• This is always full

Inter-hospital transfers; view from the Centre

• We do our best to deliver non-elective revascularisation --- and in time we do deliver

• After revascularisation we may need to transfer patients back to the DGH

• The DGH is always full• And then we wait• ---- and wait

---- and wait

• This is a major challenge for Cardiology

• Unrecorded waiting list

• Surge in referrals due to advances in clinical practice

• No indicator for non-elective revascularisation

CHD-C Survey and Audit

• National survey to scope the problem of interhospital transfer for the treatment of ACS

• Review of Central Returns (RoCR) insisted on voluntary contribution

• Collect baseline data about referring DGHs, transfer process and interventional/surgical centres across England

• Identify process redesign work already introduced and share best practice

CHD-C Survey and Audit

• Collect data about waiting times for transfer from DGH to referral centre for angiography and revascularisation in England over 4 weeks in March 2004

• These data provide a snapshot of our capacity to provide non-elective revascularisation

• Expose any limitations in the system

Sometimes Wythenshawe seems very far away……

ACS transfer

• Data suggest that at-risk patients with ACS benefit from early invasive assessment within 72hrs and this is recommended in local, national and international guidelines

A National Study of Transfer of Cardiac Patients

March 2004

Submitted Forms

• We tried to reach all the trusts in England

• 141/148 Trusts submitted forms

Team organisationTeam organisation

Admitted To DGH

Angiogram Referred Transferred Procedure

Inter-hospital Transfers Audit

Topline Average Waits

5.9 Days 1.6 Days 7.5 Days 1.5 Days

16.5 Days

15 Days

Admitted To DGH Angiogram Referred Transferred Procedure

Difference between PCI and Cardiac Surgery

CARDIAC SURGERY

5.9 Days 1.3 Days 7.6 Days 1.2 Days14.8 Days

18.7 Days

16 Days

22.2 Days

Admitted To DGH

Angiogram Referred Transferred Procedure

Intervention on site or transfer

INTERVENTION ON SITE

TRANSFERRED FOR INTERVENTION

3 Days 1.5 Days 3.8 Days 2.2 Days

8.3 Days

16 Days

DGH with a Catheter Lab 5.5 DaysDGH without a lab 8.2 Days

40.1% of the DGHs submitting data had a Cath Lab of some sort

Average waiting time betweenadmission and angio:

Wait after transfer to procedure

Number

0 1 2 3 4 5 6 7 8

Average wait (days)

CABGPCI

The North

Average wait from admission to PCI : 12.8Average wait from admission to cardiac surgery: 16.3Average wait from admission to procedure (all) : 12.9

The South and West

Average wait from admission to PCI: 23.5Average wait from admission to cardiac surgery:25.4Average wait from admission to procedure (all): 20.9

The Midlands and Anglia

Average wait from admission to PCI : 12.6Average wait from admission to cardiac surgery : 23.0Average wait from admission to procedure (all): 14.5

The South East & London

Average wait from admission to PCI : 15.5Average wait from admission to cardiac surgery:19.9Average wait from admission to procedure (all): 17.0

Geographical Differences In Average Waits (Days)

The North

Number of Interventional Cardiology Sites submitting data : 17

The South and West

The Midlands and Anglia

The South East & London

Number of centres submitting data

Average Wait In Days Per Patient By Trust For Angio +/- Proceed

0 5 10 15 20 25 30

709410114133555

67792920

1397253

1028981

10811478

10451741619

12180111

1323858

128368885903739759810511783113

1064513112052

138485492127103100648412515

133771152

9163135119110

857148211612

13710750

142182611

134129442297

1303417

6242591186187

12347131031219

1225643239335282773

126140

136764095

Average Wait (Days) Per Patient

Admission to Referral Referral to Transfer Transfer to Procedure

Average Wait In Days Per Patient By Trust For CABG

0 5 10 15 20 25 30 35 40 45 50

220707487

1095884141893369

10413955

12412629116679924101308397548

7511912515

13672383946115815061

100191

356398

13066854586117781126514

132123

5138133111496082

134131777

76121969256

108135

9410424410712823376822

Average Days Wait Per Patient

Average Wait In Days Per Patient By Trust For Definite PCI

0 5 10 15 20 25 30 35

Average Wait In Days Per Patient By SHA And Trust For Angio +/- Proceed

0 5 10 15 20 25 30

333913112013516

11784988352

1381553

1028063

1378754

134214079644

1245850891231357274121132113911411

14138712919

1339662616720

1429555

108572230251184327

12511042

1031001234781

1305693

1367851

1151162849368

8526603713

126482

10659106645

701391118890

11199775

1041281057718

127107140

61019244177376

DORSDURH

KENTLEICLINC

SWLSWPENSYORK

Average Wait In Days Per Patient By SHA And Trust For CABG

0 5 10 15 20 25 30 35 40 45 50

333913113584112117158398

13863875465

13412450586835891114727491

1211323871

14119296196

133206722304355

108234211012212569

100103123567581

13013624517811549116

84660853786

8210669445

7097111119139

5187799

104128

610717447692101109

DORSDURH

HAMPKENT

SWLSWPEN

SYORKTHAMETRENT

Average Wait In Days Per Patient By SHA And Trust For Definite PCI

0 5 10 15 20 25 30 35

Average Wait In Days Per Patient By SHA For Angio +/- Proceed

0 5 10 15 20 25 30

Admission To Referral Referral To Transfer Transfer to Procedure

Average Wait In Days Per Patient By SHA For CABG

0 5 10 15 20 25 30 35 40 45

Average Wait In Days Per Patient By SHA For Definite PCI

0 5 10 15 20 25 30 35

Admitted To DGH

Referred Transferred Procedure

Inter-hospital Transfers AuditAverage Admission to Procedure

Waits by Trust – 1 March to 28 March 2004

Angiography +/- PCI (with and without angiography)

Admitted To DGH

Inter-hospital Transfers AuditAverage Admission to Referral

Admitted To DGH

Inter-hospital Transfers AuditAverage Referral to Transfer Waits by Trust –

1 March to 28 March 2004

Admitted To DGH

Inter-hospital Transfers AuditAverage Transfer to Procedure

Admitted To DGH

Definite PCI

Admitted To DGH

Definite PCI

Admitted To DGH

Definite PCI

Admitted To DGH

Definite PCI

Interhospital Transfers - Tertiary Centre - Average days wait from transfer to procedure - All procedures - April

0 1 2 3 4 5 6

9417331955

1015824

1037998692067

1392989

116117136125

104548582

Average wait (days)

Transferred Procedure

Interventional Centres

Overall – All procedures

Interhospital Transfers - Tertiary Centre - Average days wait from transfer to procedure - Angio +/- proceed -

April 2004(Note Trusts 99,69 and 24 - no data provided/no procedures undertaken)

0 1 2 3 4 5

173355196758

117132

299820

1398153

116136

548285

104246999

Average wait (days)

Angiography +/- proceed

Interhospital Transfers - Tertiary Centre - Average days wait from transfer to procedure - CABG - April 2004(Note Trusts 24, 53, 79,19,17 and 94 - no data provided/no procedures

undertaken)

0 5 10 15 20

982058893369

104139136

117132

8182941719795324

Average wait (days)

Interhospital Transfers - Tertiary Centre - Average days wait from transfer to procedure - Definite PCI - April

2004(Note Trusts 79,19,94,82,81,117,125,54,101,99,67,116,29,103,136,139,104,69 and

58 - no data provided/no procedures undertaken)

0 0.5 1 1.5 2 2.5 3

3355981724

132858920535869

104139136103

125117

8182941979

Average wait (days)

Definite PCI

Average days wait in DGH 15.3 Days

Patients admitted to a DGH during 4 week audit period 2196

Occupied Bed Days for ACS pts 13295over 4 weeks based on 3 days forPossible proceed and 7 days for CABG

Summary

Clear unambiguous guidelines……

Interhospital Transfers

Redesign work

What are we doing to address this?

• Competencies for transfer• Treat and return• Transfer service• Working together across the network• Shared care of patients • Electronic communication• Jointly developed pathways / processes • Coordinator role• Optimise the patient - fit for procedure• Dedicated beds

Coordinator role

Middlesborough James Cook Hospital appointed Cardiology Pathways Coordinator Reduced DGH average wait from 12 – 6 days

• Co-ordinates transfers with 11 referring DGHs –single point of contact

• Arranges booking and scheduling of lists• Ensures consistent data management• Leads weekly meetings to review list based on

clinical priorities

Streamlining the Process

Walsall Hospitals NHS TrustReduced average times from decision to proceed

through to discharge following PCI from 19 to 5 days

• Faxed referral proforma• Tracking document across organisations from

referral to rehabilitation• Educational sessions for all staff on process• Patient information leaflet at DGH – patient better

informed before transfer.

Working across boundaries

11 referring hospitals in North East London and Essex with Barts and the London NHS Trust

Complete review of transfer process• Pre-schedule slots for DGHs according to demand• Prebook ambulance slots with private ambulance

provider• Plans to use NHS paramedic service to eliminate

the need for nurse escort

A redesigned service

West Yorkshire – 13 DGHs and Leeds general Infirmary

Previously median wait of 8.2 days to approx 2.5 days for PCI since 2001

• Cardiac Cath lab scheduler post• Ring fenced beds – DGHs and Centre• Common waiting list• Demand and capacity work which led to case specific

sessions, equalising the working day for all staff• Nurse led intervention beds

“I believe that public servants are working flat out but in a system that shrieks out for fundamental change…If we don’t get the systems and structures right we will never get to the roots of the problem, only prune its visible branches.

The key to reform is redesigning the system round the user.” Tony Blair

Prime Minister October 2002

• Agree a national standard for inter-hospital transfers eg 72hrs

• Repeat study planned for September 2005

The powerof freespeech!!

Britishintellectualsophistication!!

How to streamline inter-hospital transfers Dr Richard Levy Wythenshawe Hospital, Manchester CHD...

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