Banes CCG Cluster meeting: Urgent Care, the beast …...2016/06/23 · Emergency Department Attendance •Medical Ambulatory Emergency Care provides a variety of clinical care, which

Banes CCG Cluster meeting: Urgent Care, the beast of many heads

23rd June 2016

Urgent Care, the beast of many heads

What is the beast of urgent care?

• Home visits audit: most done within 2 hours of request but the average time from request to face to face was 2 hours 12 minutes

• Transfer of patient to RUH adds an further delay in addition to the home visit response time

• Ambulance data shows that there is a peak in HCP calls between 12 – 3pm followed by a peak in arrival at hospital 3-6pm

• Ambulance emergency data shows an increase in 999 red calls from HCP peaking in the middle of the day and again at 5pm

What is the beast of urgent care?

• RUH A&E attendance for Banes rose by 2.8% above plan and NEL admissions rose 7.4% above plan in 2015/16

• Evidence shows the later in the day you are admitted, the longer your stay in hospital

• RUH data shows admissions and discharges are mostly happening after mid day with a peak between 3 – 4pm, admissions extending into the early hours of the morning.

• Growth in admissions mainly in older people but with a rise in under 9’s

2013-14 Hospital Episode Statistics

ENGLAND Royal United Hospital Bath

NHS Trust

Number Percentage Number Percentage

Number of A&E

attendances for

over 70’s

2,912,922 15.7% 17,405 25.1%

All age groups

arrival by

ambulance /

helicopter

4,419,919 23.9% 27,070 39.0%

All age groups

admitted became a

lodged patient

3,850,223 21.2% 27,261 39.3%

Mrs Andrews' story: Her failed care pathway

Medical Emergency Ambulatory Care Dr Sarah Gillett – Clinical Lead Medical Emergency Ambulatory Care

What Do We Do?

Consultant Review

Diagnostic Scans

Assessment

ECG

Blood Tests

Discharge

Infusions

Transfusions

Procedures

Vital Signs

Treatment

Referral to Specialists

• Delivering Same Day Urgent Care Preventing Hospital Admission and Emergency Department Attendance

• Medical Ambulatory Emergency Care provides a variety of clinical care, which includes assessments, diagnosis, procedures, and treatments, without admission to the hospital.

• We aim to provide assessment and / or treatment in a way that will enable patients to return home the same day

Ambulatory Care at the RUH

• Based in MAU

• 2 consulting rooms, 5 chairs, 3 trolleys, Office

• Reception area – 12 chairs

• Initially set up in 2005/6

• Band 3, Band 5, Band 7, receptionist

• Consultant cover 8am-7pm

• Initially more elective patients

• Increased focus on non elective patients

Ambulatory Care Development

• Focus on Ambulatory care sensitive conditions

• Publication of the Ambulatory Emergency Care directory in 2007

• Now 3rd edition – 49 ambulatory care sensitive conditions

• Ambulatory care-sensitive conditions account for one in every six emergency hospital admissions in England

• Emergency admissions for ACSCs cost the NHS £1.42 billion annually

19 Ambulatory sensitive conditions

What do we see?

Top 10 Others

DVT/PE Tonsillitis

Chest Pain SAH

Headache STEMI

LRTI Aortic dissection

Pneumonia Acute peritonitis

Cellulitis

Anaemia

AF/palpitations

CCF

Jaundice

What Do We

Do?

Consultant Review

Diagnostic Scans

Assessment

ECG

Blood Tests

Discharge

Infusions

Transfusions

Procedures

Vital Signs

Treatment

Referral to Specialists

Principals of ambulatory care

• Senior decision makers

• Clear exclusion criteria

• Timely assessment, treatment and discharge

• Management of patient expectations – Patient information leaflets

• Integrated primary and secondary care

– Appropriate patient streaming

– Meeting holistic patients needs

• Commissioners and Providers working together

• Assess the impact, quality and efficiency of service

How we work

• Medical Admission – tel 07824 334450

• GP liaison phone 8am-8pm

• Out of hours – medical SHO

• Consultant Advice line - tel 07818 013823

• 9am-7pm

• Emergency department referrals

• Self referrals

• Referrals from other specialties

• Referrals from within acute medicine

• Planned development to implement Urgent Connect

Activity FY2015/16

Activity FY 2016/17

Consultant Referred Cardiac Hot Clinics Introduced; Frailty Hot Clinics from June 2016

Improving our service

• Transformation plan as part of RUH Front Door Group

• Increased activity

– Increased opening hours

– Weekend working

– “Hot” Clinics – Consultant Referred

– Increased footprint of RUH service

– Explore opportunities within primary care and community

Ambulatory Care 2016 Transformation Ideas

• Extension of opening hours to cover hours 8am - 10pm

• Weekend opening 8am - 8pm

• Full staffing with nursing staff rotations through MAU and HCA cover and admin support - leaving managerial role with band 6 and MNPs free to support medical staff

• Training environment for SHOs and junior medical staff/MNPs

• Emphasis on acutely unwell patients - no elective work coming through amb care - all to go to MTU

• Further community links - development of shared pathways for community patient management

• Enlarged footprint - (or upgraded current footprint)

Ambulatory Care 2016 Transformation Ideas

• Hot clinics (either within ACU or with direct access to urgent reviews) - in all specialties

• Frail elderly pathway through ACU - with provision of DAT/community liaison

• Improved waiting area - with refreshment facilities for patients

• Increased support from diagnostics - more timely access to reports

• Low risk UGIB pathway

• Improved IT - Email or ICE referrals from community/ED

• Dedicated portering staff

Frailty @ the RUH

Dr Robin Fackrell Head of Medicine

Getting the assessment of older people right has the

potential to improve outcomes, reduce inappropriate

hospitalisation, and potentially reduce the need for long-

term care

Frail and Elderly Pathways

• Preventing admission key priority

• The “stranded patient”

– number of beds occupied by patients who have been in hospital 7 days or more

– Why does this patient need to remain in hospital? • What is being done and by whom to get this patient home?

– What could have been done in the first few days to prevent this patient becoming ‘stranded’

• Deconditioning

• Comprehensive Geriatric Assessment (CGA)

Falls

• Comprehensive Geriatric Assessment (CGA)

• Falls clinics in the community

• “Stranded patients” increased risk of falling and changing outcomes and place of ultimate discharge

Ambulatory Care Frailty Clinic at the RUH

• Consultant and Therapy led service

• PDSA June 2016 start date

• Patient Cohort (1st PDSA)

– Patients are referred from

– ACE Unit

– Geriatrician of the Day

– Ambulatory Care

– MAU

– ED

• Options for locations in the community?

• Advice and Guidance – Urgent Connect?

Frailty FLOW Programme

2016/17 Frailty CQUIN • The CQUIN for Frailty 2016/17 is based upon the National recommendation to develop a local CQUIN to “promote a system of timely identification and proactive management of frailty”.

• The indicator has been divided into three parts to achieve the following;

– Part 1: 85% of patients aged 75 and over who are frail admitted under Medicine screened for frailty.

– Part 2: 85% of discharged patients aged 75 and over referred to the Discharge Assessment Team (DAT) and/or admitted to the ACE short stay frailty ward where a Comprehensive Geriatric Assessment has been completed and, for those with a Clinical Frailty Score (CFS) of 5 or above, a summary of the outcome of the Comprehensive Geriatric Assessment should be included in the discharge summary to the patient’s GP.

– Part 3: Roll out the discharge passport to patients discharged from ACE Ward, building on the work completed in 2015/16 to improve the information provided to patients on discharge.

Clinical Frailty Scoring - Rockwood

Comprehensive Geriatric Assessment – Evidence for Use in Acute Care

Hospital At Home

Hospital At Home – Wiltshire Model

In Wiltshire greater interaction between primary care and secondary care Geriatricians has been

established to support more patients to live more independently at home

Planned Developments in Wiltshire

• More Geriatrician support to develop higher acuity care at home with virtual acute community beds and more step up provision to community hospitals or intermediate care beds where appropriate.

• Further development of ambulatory care models in community hospitals will also support admission avoidance.

• Further development of ambulatory care models in community hospitals will also support admission avoidance.

• Geriatricians to visit each larger practice to discuss patients and conditions directly rather than have patients referred to a traditional outpatient clinic

Dominic Williamson

Consultant Emergency Medicine RUH

Nursing Home Audit

Total BANES NH attendance

0

200

400

600

800

1000

1200

2012 2015

0

20

40

60

80

100

120

140

2015

2012

Referral source

GP referred

999

other

2012 2015

Disposal from ED

admitted

discharged

2012 2015

Slaying the beast

– Focus on key areas:

– Increase % of patients seen in ambulatory care

– Earlier home visiting by GPs

– Frail and elderly pathways including falls

Discussion groups

1) How can we get patients assessed by primary care earlier in the day?

2) How can the planned ambulatory care model work best for primary care and patients?

3) How can we improve the frail and elderly patient’s experience of the urgent care pathway?

Aqua – Catherine Room

Sulis – Stratton Room

Norton Radstock – Catherine Room

Chew Keynsham – Boardroom

End of presentation

Statement of Intent Results of the Survey

23rd June 2016

Q1

Answered: 95 Skipped: 0

Q2


Q3



Q5


Q6: To what extent do you agree with the following aspects within the Statement of Intent?

4.47 4.4 4.26

4.06 3.97 3.78

3.37

3.06

Building multi-disciplinary team

approaches

Maximising therole of technology

Supporting practicecollaboration

Developing newroles in the primary

care workforce

Securing highquality servicesthrough qualitymonitoring and

peer review

Developing anumber of

locations as MCPs(previously

referred to asintermediary CareCentres) to deliver

out of hospitalservices

Groups of mergedpractices that servelarger populations

Enhanced offer onevenings and

weekends

Weighted average

Q7: Is there anything important missing from the Statement of Intent?


Q8


Q9: What are these implications


Q10


Q11: Comments


Depends on detail, but anything

which leads to increased and

meaningful improvements in service

delivery should be welcomed

Q12: We have listed some of the unique selling points (USPs) that makes general practice in BaNES different from any where else. Please rank them in order of importance.


4.26

3.14 3.03

2.39

2.09

High quality generalpractice

Collaborative working Your care, your way Mix of urban and ruralareas

Population Growth

Score

Q13: Are there any other points we’ve missed?


Documents

Banes CCG Cluster meeting: Urgent Care, the beast …...2016/06/23 · Emergency Department Attendance •Medical Ambulatory Emergency Care provides a variety of clinical care, which