Transcript Integrated Delivery Meeting

Emergency Flows Urgent Care Services
Wye Valley NHS Trust
Neil Doverty
Chief Operating Officer
Trust Board – 29 May 2014
Demand
A&E attendances - Acute Site
5000
G&A Emergency Admissions - Acute
1400
1200
4000
1000
3000
800
2000
600
400
1000
200
0
0
Jan
Feb
Mar
Apr
May
Jun
2012
2013
Jul
2014
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
2012
2013
Jul
2014
Aug
Sep
Oct
Nov
Dec
Demand
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A&E attendances show year on year increase with activity in 2013/14 3.1% (1467 actual) up
against previous year.
Attendances in April 5.7% (234 actual) up against the corresponding month in 2013. This equates
to on average an additional 8 patients per day with the daily average being 145 attendances. Worth
remembering that the design build of the department was just 125.
Average Daily Attendance
150
145
140
135
130
125
120
115
110
Apr 13 May 13 Jun 13 Jul 13 Aug 13 Sep 13 Oct 13 Nov 13 Dec 13 Jan 14 Feb 14 Mar 14 Apr 14: Apr 14:
1st 20 total
days
av daily attendance
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capacity level (125)
May attendances forecast to be in the region of 10% up against the same month last year and just
short of the highest number of monthly attendances recorded in July 2013.
Emergency admissions following similar pattern and 3.4% (443 actual) up against previous year and
with April 294 admissions up against April 2013.
WMAS has confirmed an increase of 161 ambulance conveyances from the beginning of April 2014 to
mid-May, compared to same period in 2013
Demand
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April 2014 saw an increase in those patients attending A&E but leaving without being seen (228
actual).
Of those patients only 7 patients returned to the A&E department on the same day which suggests
that the remaining patients did not require urgent medical attention by an A&E doctor.
Of the 228 patients only 41 returned to A&E at some point between their original visit to date,
therefore 82% of them have not re-attended to A&E.
Left without being Seen
April 2013 to April 2014
6.00%
300
5.00%
250
4.00%
200
3.00%
150
2.00%
100
1.00%
50
0.00%
0
Apr
May
Jun
Jul
Aug
Sep
Oct
Number left without being seen
Nov
Dec
% left without being seen
Jan
Feb
Mar
Apr
Demand - Outcome Measures
A&E
4hr waiting time Admissions
Attendances
standard
(G&A Acute
(Acute)
(Acute)
Emergency)
Average
Patients LOS 30
Number of
Bed Occupancy days and greater
Additional beds
(Acute)
(Average per
used per month
month)
(Acute)
Cumulative Bed days
Acute/patient numbers
Cumulative Bed days
Community/patient
numbers
Apr to Mar 2012/13
48094
93.72%
13123
81
22624
2541
37157
1148
Apr to Mar 2013/14
49561
91.72%
13566
80
23202
2562
34595
1116
Variance (No's)
1467
443
0
578
20
-2562
-32
Variance (%)
3.1%
3.4%
-0.1%
2.6%
0.8%
-6.9%
-2.7%
April 2013
4103
87.81%
1013
15
2120
225
3417
104
April 2014
4337
86.12%
1307
2
1921
207
2547
90
Variance (No's)
234
294
-14
-199
-18
-870
-14
Variance (%)
5.7%
29.0%
-89.3%
-9.4%
-8.2%
-25.5%
-13.5%
Impact
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A&E department too small and limited capacity to cope with demand, design build 125
but April average 145.
Unrelenting pressures of patient demand on the department with failure of the 4 hour
A&E waiting time standard.
Planned capacity full resulting in increased numbers of cancellations and failure of the
national standard for elective access
Very high bed occupancy level rates resulting in restricted flow to main acute bed base
Bed waits constitute about 65% of all our breaches of the 4 hour standard
Trust has been contracting the previous historic reliance on extra-capacity outlying areas
CCG commissioned Winter pressure capacity schemes came to an end towards end of
March but partly re-opened to support rising demand
Increased pressure on 18 week admitted pathways targets with failure against the
standard in a number of specialties
Higher acuity of admitted patients resulting in more complex discharge plans and longer
lengths of stay for some cohorts of patients
Medical outliers
Mixed sex accommodation breaches
Actions taken within the Trust
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Emergency Ambulatory Care introduced to Herefordshire through new CAU
Hospital at Home (Virtual Ward) commenced autumn 2013
Proposed capital development scheme changes to the design / layout of the A&E Department
Changes in patient flows required within Trust: agreed bed reconfiguration plan with all
specialties and planned for August 2014
EPOD is Consultant Physician 8am-8pm 7 days per week, complemented with 7-day extra
diagnostic support
Attempting to resolve the Powys delayed transfers of care (5-10 patients at any point in time
over the last 6 months) with support from CCG, Area Team and Wales Community Health
Council. Various contractual levers being pursued and short term use of Discharge to Assess
scheme in Hereford City for their patients
Opened new Discharge Lounge late April 2014 – staffed with dedicated discharge team
Strategic workforce review performed with help of A&E Nurse Consultant from HEFT
1 new Consultant with an interest in Acute Medicine – the search continues for others
GPs with experience of emergency medicine introduced to A&E Department
Revised TechFund bid for EPR / electronic prescribing test site
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Risk Strat team in Community working
closely with GPs & Hospital at Home
CCG funded GPs in A&E
WVT / multi-agency discharge function
improvements
CCG / Council - Rapid Access to Assess
beds
WRVS pilot in Leominster
Older persons psychiatry liaison service for
A&E
Psychiatry liaison (RAID)
Memory clinic
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Review of falls pathway
Primecare support in A&E / CAU
Personalised
care
planning
development
Anticipatory care planning across all
environments
Social networking type approach to
connect patients and health care
professionals
LTC pathways – COPD, Heart failure
etc
Dementia implementation group
End of life forum
Development bed to 7 day primary
care working
CAU

Average admissions per day
16.0
14.0
12.0

10.0
8.0
6.0
4.0
2.0
0.0
November
December
January
February
March
April
CAU Discharge Rate
90.0%
80.0%

70.0%
60.0%
50.0%

40.0%
30.0%
20.0%

10.0%
0.0%
December
January
February
March
April
The expectation was that certain
patient groups would be seen,
treated and discharged within the
same day rather than being
admitted into an acute ward and
staying in hospital for several days
May to date
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November
Small temporary CAU opened from
November whilst full refurbishment
undertaken and fully operational
from March 2014
May to date
Average number of daily admissions
showing a stepped increase month
on month
Average number of patients going
through the Unit in April 15 per day
Average length of stay for CAU
patients between 5 and 6 hours
Discharge rate from CAU has seen
an increase but currently falling just
short on the 80% threshold set
nationally
EPOD
0 LOS Patients - Emergency Admitted (Not Including Obstetrics, Gynaecology and Paediatrics)
LOS (based on days)
0 los
1 day los
2 day los
3 day+
Grand Total
% 0 day LOS
% 0 & 1 day LOS
% 0-2 days LOS
Apr
123
197
117
555
992
12%
32%
44%
May
123
237
150
542
1052
12%
34%
48%
Jun
133
220
109
477
939
14%
38%
49%
Jul
143
226
135
563
1067
13%
35%
47%
Aug
161
220
127
577
1085
15%
35%
47%
EPOD Impact summary - LOS
Sep
134
182
125
564
1005
13%
31%
44%
Oct
183
219
138
584
1124
16%
36%
48%
Nov
199
206
120
521
1046
19%
39%
50%
EPOD Started
Dec
Jan
238
264
216
225
122
152
517
584
1093
1225
22%
22%
42%
40%
53%
52%
Feb
286
189
107
519
1101
26%
43%
53%
Mar
313
247
135
480
1175
27%
48%
59%
Trend April 2011 to March 2014
70%
60%
% 0 day LOS
50%
40%
30%
% 0 & 1 day LOS
20%
10%
0%
Apr
May
Jun
Jul
% 0 day LOS
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•
Aug
Sep
% 0 & 1 day LOS
Oct
% 0-2 days LOS
Nov
Dec
Jan
Feb
Mar
% 0-2 days LOS
3 day+
Marked increase in 0 length of stay patients month on month since EPOD implemented
% of 0 LOS patients increased from on average 13% prior to EPOD to 27% during March 2014
(note this includes an element of CAU)
Length of Stay
Emergency Average Length of Stay
Medical Specialties
7.0
6.0
5.0
4.0
3.0
2.0
1.0
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Apr-14
Mar-14
Feb-14
Jan-14
Dec-13
Nov-13
Oct-13
Sep-13
Aug-13
Jul-13
Jun-13
May-13
Apr-13
Mar-13
Feb-13
Jan-13
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
Jun-12
May-12
Apr-12
0.0
Average LOS for emergency medical patients has seen a downward trend over the last
couple of years.
Reducing the LOS from 6.1 days in April 2012 to 3.5 during April 2014
If we didn’t do anything ?
• Demand has already outstripped the performance improvement
schemes already developed and continues to increase further
• CAU and EPOD has freed up on average 18 beds per day across the
winter months. Without these then the impact on services would have
been far greater:
• Worse A&E position
• Increased cancellations
• Higher occupancy
• Patients treated in no designated ward areas
• Adverse to patient experience and quality of care
• Since the Virtual Ward went live in October 2013 the number of patients
receiving Intravenous Antibiotics (IV) in the community is 40 patients.
This has equated to number of days of treatment delivered of 442 days
which has crudely saved an average between 2-3 beds per day since
October 2013. Without the introduction of the Virtual Ward these
patients would have typically been admitted and therefore put more
pressure on the bed stock than was experienced during this period.
Future
• Ageing population with greater, more complex healthcare needs
• Continued growth and demand
• Increased GP opening hours coming soon
Herefordshire
• New housing developments planned for next decade
• Potential further population expansion
• Financial constraints
to