HEAT 10

“An Emergency Medicine perspective”

HEAT 10

“An Emergency Medicine perspective”

Alasdair Gray Alasdair Gray Consultant in Emergency Medicine, EdinburghConsultant in Emergency Medicine, Edinburgh

Demand + activity Demographics

Disease chronicity

Front-door Emergency Activity at RIE, SJH and WGH, 2003-2007

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000

100,000

110,000

RIE Total Front Door SJH A&E WGH ARAUT

2003-2004 2004-2005 2005-2006 2006-2007 2007-2008

RIE Emergency Dept Activity, Referral Comparison - May 03 - Mar 08

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

May-03Jul-03Sep-03Nov-0

3Jan-04Mar-0

4May-04

Jul-04Sep-04Nov-0

4Jan-05Mar-0

5May-05

Jul-05Sep-05Nov-0

5Jan-06Mar-0

6May-06

Jul-06Sep-06Nov-0

6Jan-07Mar-0

7May-07

Jul-07Sep-07Nov-0

7Jan-08Mar-0

8

No.

of P

atie

nts 999 Emer

GPNHS 24Self-Ref

RIE Front-door Sources of Referral, Aug 07 - Jul 08

Self Referral to A&E45%

999 Emergency29%

GP / Bed Bureau13%

NHS 246%

Police1%

WGH - MIU1%

LUCS3%

Unplanned Return1%

Other/Unknown1%

RHSC ED, Sources of Referral, Aug 07 - Jul 08

Self Referral to A&E66%

999 Emergency5%

GP / Bed Bureau12%

NHS 245%

WGH - MIU1%

Other/Unknown4%

Hospital (not in LUHD)1%

Unplanned Return2%

SJH1%

LUCS3%

There is a story about a philosopher and a psychologist having a drink. The philosopher asks: why did the chicken really cross the road? The psychologist replied: well, as the chicken lacks any formal reasoning or decision making capabilities, it seems unlikely that its action was spurred by any conscious motivation, so I’d say it was instinct.

Culture + Expectations

System complexity

Community pharmacy

HEAT 10 + Emergency Medicine

NHS Lothian: Some small steps…….

• Direct transfer of patients to LUCS

or own GP

• Frequent attenders management

• Primary Care Physician in

Emergency Department

• Understanding of patient decisions

Emergency Department transfer to LUCS

0

100

200

300

400

500

600

Aug-08Sep-08Oct-08Nov-08Dec-08Jan-09Feb-09Mar-09Apr-09May-09

RIESJHNHS Lothian

Frequent attenders

• 57 patients attended ED >10 times in 6/12 h

(1.4% attendances)

• Median number of attendances 12

(interquartile range (IQR) 10–14)

• Following intervention median attendances

dropped to 6 (IQR 2–13, p<0.001)

• Total number of attendances dropped from

720 to 499 (31% reduction)

Skinner, J et al. Emerg Med J 2009;26:103-105

Multifactorial clinical presentations

Skinner, J et al. Emerg Med J 2009;26:103-105

Breakdown of case management into categories