Hospitals on the edgeCrisis in acute medical services

Dr Mark TempleConsultant Physician & Nephrologist

Acute care fellowRoyal College of Physicians

Overview: crisis in acute medical services Symptoms

• Hospitals on the edge

• Changing pts changing needs

• Out of hours care breakdown

• Weekend mortality• Imbalance of care

community / 2o care

The treatment

• The case for consultant delivered care

• Acute care toolkits – organisation of care & consultant working

• What type of consultant? generalists vs specialist

• 7 day working

• Hospitals on the edge – priority areas (summary)

Crisis : Hospitals on the edge September 2012

Clinical demand• 37% admissions (10yr) 33% acute beds (25yr)

Casemix/organisation• Age, co-morbidity &

expectation complex care available to all

• Changes to out of hours care. Over-reliance on secondary care OOH

Workforce crisis• pressure consultants

70% (3yr)

• 27% SpRs unmanageable workload

• Recruitment EM, elderly care, GIM training

• Pressure : Nurse, AHP staffing

Increased Emergency Admissions HEFT 07-09Increased Emergency

Admissions HEFT 07-09

Solihull Good Hope Heartlands Grand Total 0

2000

4000

6000

8000

10000

12000

14000

16000

18000

20000

Sep - Dec 07Sep - Dec 08Sep - Dec 09

Em

erg

ency

Ad

mis

sio

ns

(>0

day

s)

13.6% increase

Sept 07 – Dec 07

Sept 08 – Dec 08

Sept 09 – Dec 09

RCP Health Bill survey All members & fellows - March 2012

Top 5 Concerns – wider health agenda

1. Lack continuity of care2. Efficiency savings/funding3. Clinical staff shortages4. Health reforms5. Education training &

research

RCP: Members & Fellows survey• Recommend their hospital to family member?

– 1:10 NO, 1:4 not sure• Hospital’s ability to deliver high quality care 24/7?

– 34% average, 10% poor• Continuity or care the norm? 43% average, 25% poor• Stable teams care & teaching? 40% average, 21% poor• Discharge with realistic allocation responsibility for further

actions: 38% average, 21% poor

• Success of handover : 16% felt 80% handovers successful<10% felt 90% successful

Hospitals on the edge RCP September 2012

Fractured care • Lack of continuity of care

major concern March 12 • Multiple ward moves, handover, LOS

Outcomes:• mortality w/e (10%)

• NCEPOD – high quality care = consultant care

(time to intervene DNAR)

• Francis report (ii) - Mid Staffs – systematic failure of good care Inadequate staffing / patient centred care

• NHS financial climate

Medical workforceEmergency Medicine• 1:10 posts vacant• 1:5 SpR posts vacant• 1:8 trainees change to

another specialty in first 3yrs

Elderly care• 50% posts last 12/12

unfilled and of these 2/3 no applicants

GIM - unpopular undervalued

54% SpR dual accredit• Of these only 42% wish

practice GIM as cons

SpR“unmanagable workload” o/c Rota gaps SpR 10-15% NE England

Elephants in the room• Social care funding &

occupancy of acute medical beds.

7/7 admission 5/7 discharge

• NHS 7 day working = secondary careFailure to develop alternatives to hospital admission

Changing profile of patients changing needs

• 65% admissions > 65• Pts > 65 occupy 70%

of bed days– > 85 - 25% bed days

• Last decade :65% increase

admissions age >75[31% age 18-59]

• Mean LOSAge > 85 LOS 11 daysAge < 65 LOS 3 days

25% of all in-patients have dementia

Out of hours care breakdown Secondary care is the health service OOH

• Factors influencing decision to admit:– Lack of alternatives to admission - accessible 7/7– Less experienced staff (OOH) admit “senior review

mane”– “Momentum to admit” NH resident OOH carer

expectation– Baseline clinical status uncertain “less responsive”,

“not eating”, “off legs” – Minor illness/major social support issues -admit

“safe” option & perceived as only way to assess adequately

Weekend mortality for emergency admissions Aylin P et al (2010) Qual Saf Health Care; 19: 213-217

• 2005/6 emergency admissions England (4.3M)• In hospital deaths (medical, surgical, cancer)• 215,054 deaths crude mortality 5%

• Odds death admit at w/e compared with during the week-adjusted age sex comorbidity socio-economic status

& diagnosis

Weekend mortality increased - all admissions + 8/32 diagnostic groups with highest deaths

Number of admissions

Weekday Death % (no.)

Weekend Death % (no.)

p OR (95% CI)

AllEmergencyAdmissions

4, 317,866 4.9%162, 639

5.2%52,415

<0.001 1.10 (1.08 - 1.11)

AMI 68932 13.5%6803

14.4%2650

0.002 1.081.03 - 1.14

AKI & other Renal Failure

14134 25.6%2924

33.3%909

<0.001 1.451.32 -1.60

Aylin P et al (2010) Qual Saf Health Care; 19: 213-217

10% higher odds death admitted w/e

• 3369 “excess” deaths – – 3201 all road deaths 2006

• “excess mortality may reflect differences in standards of care”

• Pts should expect same standard of care irrespective of day of week admitted

• Recommendation - Hospitals revise:– patterns of care – Level of service provision at w/e

Mortality: patients admitted on a weekday vs weekend – preliminary data 2012

Diagnostic group Weekday weekendAcute and unspec. Renal failure 19.5% 25.1%

Aneurysms: Aorta, peripheral, visceral 27 36.5

Carcinoma of bronchus 28.4 34.2

Carcinoma of pancreas 25.1 34.4

Secondary malignancies 16.3 20.9

Congestive cardiac failure 14.6 16.5

Pneumonia 19.9 20.9

Acute cerebrovascular disease 19.2 22.2

Dr Foster

Rate of diagnostic procedure on the day of admission Dr Foster 2012. Expressed: % admissions including the diagnostic procedure

DiagnosticProcedure

Weekday Weekend

CT 54% 52%

MRI 19% 11%

Upper GI endoscopy 13% 8%

Dr Foster

Benefits of consultant delivered care. Academy Royal Medical Colleges 2012

• Rapid, appropriate decision making(endorse DNACPR where CPR futile)• Improved outcomes• More efficient use of resources• GP access to fully trained Dr• Pt expectation of access to

appropriately skilled clinician & info• Benefits to training junior doctors

Benefits of consultant delivered careAcademy Royal Medical Colleges• Increased mortality & morbidity associated

with delay in consultant involvement – range of fields (acute medicine)

• Increased mortality at w/es attributed to reduced consultant input in care

• Studies designed to improve pt care incorporating earlier consultant involvement – improved outcomes

Consultant presenceRCP Position statement 11/2010

• Hospitals undertaking the admission of acutely ill medical patients should have a consultant physician on site for at least 12 hours per day, seven days a week, at times relating to peak admission periods. The consultant should have no other duties scheduled during this period.

• Currently - average hospital consultant cover gap:– Weekday 4.4 hrs - requires 35% increase cons hrs – Weekend 7.3 hrs - 60% increase consultant hours

RCP initiatives : consultant delivered care/ organisation of care

Consultant care: AMU

Consultant care : wards

Deteriorating patientdetection / escalation

Clinical decision making include CPR decisions

Acute Care toolkit 2 - 2011Evaluation consultant working 2011Acute Care toolkit 4 – Oct 2012

Toolkit 2 – High Quality Acute Care

NEWS – July 2012Toolkit 6:The medical patient at risk

Effective Ward Round – Oct 2011 Early cons. Review 7/7 – Toolkits 2,4

Future Hospital Commission

ACT 2: High quality care for acutely ill patients

1: AMU• Consultant on site 12 hours day without conflicting

duties • At least 2 consultant WRs during 12 hrs• In period AMU staffed by consultant all newly

admitted patients should be seen within 6-8 hrs. • Patients admitted overnight seen within 12-14 hrs• The staffing, resources and specialist support

services involved in the care of medical emergencies should be organised on the basis of 7 day working

AMU: Support for patterns consultant working: RCP survey Feb-April 2010: Association pattern of cons cover acute medical admissions & patient outcomes :

• Admitting cons > 4hrs/day, 7 days a weeklower 28/7 re-admissions rate

• Consultant on call no other fixed commitmentslower adjusted case fatality rate

• Consultants conducting >2 WRs / day on AMU lower adjusted mortality pts LOS > 7days

• Consultant on call works blocks of >1 day, < 7dayslower overall week-end mortality

Clin Med 2011 (11) 1: 17-19

ACT 2: High quality care for acutely ill patients Improving care - Medical and surgical wards

Particular risk: Transfer out of AMU within 48 hrs – evolving acute illness

Move to a different landscape!From AMU : enhanced staffing (cons) organisation of careTo wards:

– Unfamiliar with pt/acute care– Uncertainties about diagnosis & management – Quality monitoring /response pt deterioration?

Patient transfer Friday pm (next cons round 72 hours +?)

ACT 2: Pts transferred out of AMU – receive a consultant review within 24 hrs – 7/7

Patients transferred out AMU: Enhanced review - Consultant of team responsible for continuing care – “Golden Hour” priority duty in first working hour– Template cons physician working 7/7 all wards

• “Buddy” arrangements : link medical teams to Surgical wards • Weekday: reschedule conflicting duties 8.30-10• Weekend: consultand rota for shared bed patch• Review all New + acutely ill

Facilitates:Reliable cons review critical time acute illness– Confirm: Diagnosis, Rx, discharge, ceilings of care,– Support ward nurses & covering med staff – Review newly transferred & acutely ill

Heartlands Hospital – Consultant duties 7 / 7

• AMU: 8am: 2 Consultants review pts

• All Medical and Surgical Wards:

8.45am (weekday) - 6 Consultant Physicians reviewing patients (new and/or sick) – all will provide ongoing care

9.15am (weekend) – 4 Consultant Physicians reviewing patients

[Previously 2 physicians “safari”of pts - no ongoing care responsibility ]

How to change consultant working The Physicians story - Paul Woodmansey (2011)• AMU consultant cover

12hrs w/d, 6-8hrs w/e• W/E Troubleshooting

Consultant visits all med wards : sick & quick d/c

• Increase early discharge

• Coincided reduction mortality (all and w/e)

• Major change working life : introduced with relative ease

• Consultant proposed tried & accepted

• Good for pt care• “Greatest challenge is

cons delivered (not led) service required”

• “Pace .. in hospital .. pts need daily senior input”

Clin Med 2011 (11) 1: 17-19

Acute care toolkit 4: Consultant 12 hour 7 day presence – October 2012

More consultants needed: - support acute take 7/7What type of consultant? Changing patients & needs

The generalist – Back to the future?DeLorean 1981

• GIM physician – once dynamic!• Now unpopular – flight to

specialty away from acute take

• < 25 % dual trainees (GIM /specialty) wish to practice GIM

• Pts now rarely present with a isolated single organ illness

Renaissance for GIM?

Supporting the consultant led 7 day ward round (1) : the 7 day Hospital

• Diagnostics • Assessment & treatment:

– Therapists, SW, specialist nurses

• Nursing culture monitoring progress – proactive use consultant decision making – ceilings of care (DNACPR)– Escalation enhanced care beds (level 1 – 1.5)

• Discharge support – pathways out (intermediate care, interim beds)

• Ambulatory care – default alternative to admission?

Supporting the consultant led 7 day ward round (2) : the communityRCP – Hospitals on the edge - admissions

Move focus from episodic care [crisis] – Kings Fund to:• Prevention – post d/c what to do in an emergency• Proactive management declining health: advanced

care decisions • Integrated care (COPD) - manage chronic disease • Consistent standards primary care - 7 day • Develop alternatives to admission that work 7/7 • Discharge pathways working consistently 7/7

Summary Hospitals on the edge – a time for action

10 priority areas (1-5)

• Dignity and patient centred care– Patient placement acuity of illness, staffing

• Redesign services / organisation of care– Design : maximise continuity, min. ward moves

• Medical education & training/ right skill mix – Right balance generalist / specialist skills– More extensive training elderly care skills– Re-invigorate GIM

Hospitals on the edge – a time for action Priority areas 6-10

• Improve availability of primary care – Integrated care– 7/7 services 2o care in community

• Revolutionise: use of information, EPR• Embed quality improvement

– Relevant, timely performance data• Renegotiate the new deal• Provide national leadership: implement national

standards & systems where this is in the interest of patient care

RCP - Future Hospital Commission www.rcplondon.ac.uk/futurehospital reports 3/13

Workstreams: • Place and process• Patients &compassion• People• Planning &

infrastructure• Data for improvement

Focus:• Patient centred care• Continuity of care• Staffing, skills &

organisation of care to match pts needs across community & 2o care [enhanced care beds 1-1.5]

• 7 day working