Transcript Admissions Avoidance and Reducing Emergency Bed Days …

Admissions Avoidance and Reducing
Emergency Bed Days
Focus on Stroke and Neurology
Steve Pollock.
SHA Clinical Advisor on Acute Care
Lead Neurologist, EKHUFT
Acute stroke and neurology;
what’s the problem?
 Very common cause of admissions
–
–
–
–
20% of medical admissions,
26% of medical admissions
29% presentations to Leeds AMU
Occupied 248/1189 acute beds
 About half are stroke
1987, (Morrow and Patterson)
2009 Bromley, Brex and Cai
April June 2008 Dunn
Audit Oct, 2009 EKHUFT
Methods
 The details of all medical patients admitted to PRUH
over a 2-week period (Sept 2008) were recorded from
daily handover sheets kept on EAU computer
 Patients were considered neurological patients if
– Main differential at most senior review was a neurological
diagnosis (e.g. CVA, seizure etc.)
– Unclear differential, but presenting complaint was neurological
(e.g. confusion with no identified cause)
– Social admissions due to problems arising principally from a
neurological condition (Alzheimer’s and failure to cope)
Number of patients by specialty
(n= 358)
Endocrine
4%
Misc
6%
Gastro
7%
Haem and
Onco
3%
Neurology
26%
Renal
9%
Respiratory
22%
Cardiology
23%
10th October 01:00 Bed Occupancy, with patients with neurological
problem as the main cause of admission, major, or as secondary illness,
minor.
major
minor
Probable stroke
A
75
10
SOL inc abcess
B
7 (5)
3
Brain infection, meningitis/encephalitis or similar
C
2 (2)
0
Brain inflammation without fever; eg MS
D
1 (1)
4
Problem in spinal column, chord or lumbar spine
E
12(3)
6
Peripheral nerve problem inc GBS
F
0
3
Headache ? cause
G
5 (2)
0
Dementia including confusion x 1 and head injury
x1
H
6 (2)
26
Walking problems, PD or similar
I
7 (3)
12
Possible Seizures
J
7 (3)
15
Weakness not listed above
K
4 (2)
5
Any other neurological problem not listed above
L
7 (7)
11
TOTAL
153
95
Figures in brackets are estimate of patients who could benefit from
transfer to EKNU
Care pathways
 Stroke, yes
– TIA clinics
– Thrombolysis
– Dedicated units
 Neurology, no
 Clinics swamped by
routine C&B, acute service
reduced
 Admitted general beds
 Usually not seen by
neurologist
In-patient management by
neurologists
 “very few neurological in-patients are even seen by a
neurologist”, Warlow et al , 2002
 “for epilepsy at least, diagnostic errors by non-neurologists
were common”, Chadwick and Smith, 2002
 Encephalitis Society, in a survey of 1188 members, who
had survived acute encephalitis, (28.5% response),
demonstrated that of those who saw a neurologist less
than half did so within the first day, while a third had to wait
more than three days. Less than half were managed by
nurses or therapists with specialist training in neurological
diseases and only a quarter of those were transferred to a
specialist ward on the first day. Easton, 2005
TIA Clinics- the theory




Incidence 0.25/1000
High risk of stroke,15% in 2/52 after
Risk can be stratified by ABCD2 score
Urgent investigation and operation reduces
risk of stroke
ABCD2 score
age
blood
pressure
clinical features
duration
diabetes
0
points
<60
years
normal
other than those
specified
less than 10
minutes
no diabetes
1
points
≥60
years
raised (blood
pressure
≥140/90)
speech disturbance
without weakness
10 to 59 minutes
diabetes present
unilateral (one-sided)
weakness
≥60 minutes
2
points
Risk of stroke
Score 1-3 (low)
2 day risk = 1.0%
7 day risk = 1.2%
Score 4-5 (moderate)
2 day risk = 4.1%
7 day risk = 5.9%
Score 6–7 (high)
2 day risk = 8.1%
7 day risk = 11.7%
TIA clinics, the theory
 Only work properly if there is;
– Same day MRI U/S
– RACE within 2 days
– Seven day service
– Patients seen within 24 hours
– Correctly triaged
TIA clinics- the practice
 Surrey “This exists in all four hospitals but is office hours only
and relies on a high level of admissions for ABCD2 of 4.” Agreed
move to 7 day working but infrastructure uncertain
 Sussex “All hospitals but only 5/7. No out of hour/weekend
service for U/S or MRI, therefore patients are admitted.”
 West Kent “Maidstone
5/7 urgent cases seen next day and
non urgent within a week but triaging difficult, not yet using MRI and
have some waits for U/S. Surgery improving but not upto National
Strategy standards. Darenth Valley 5/7 U/S same day + 2 MRI slots
per week.”
 East Kent “365 clinics with same day access to MRA and 2
day access to neurovascular surgery”, but 50% patients referred
not vascular but other neurological
Thrombolysis- the theory
 Suitable patients can have strokes reversed
by use of Alteplase
 “ Time is brain” must be done within 3 hours
 Requires good care pathway;
– SECAMB
– Reception area
– Rapid scanning and consultant opinion
Thrombolysis in 3 hours
Alive and
independent
100
80
30.2
44.3
60
40
51.4
38.4
Alive but
dependent
Dead
20
17.3
18.4
Thrombolysis
Control
0
Differences/1000:
141 extra alive and independent (P<0.01)
130 fewer dependent survivors (P<0.01)
NINDS Trial Data: N Eng J Med 1995; 333:1581
Thrombolysis- the practice
 Surrey “24/7 in each hospital except SASH. who are delayed
because of staff problems, (hopefully resolved) and are diverting to
Guildford with no local service.”
 Sussex Currently 24/7 in Brighton, alternating OOH diverts in east
sussex,24/7 Worthing and Chichester
 West Kent Alternating OOH diverts between 4 hospitals, “not
sustainable”
 East Kent OOH telemedicine with 3 hospital and 1 in nine rota
Telemedicine advantages
 Keeps service local
– faster
– reinforces local stroke unit
 No difference in outcome
 Only practical way to ensure rotas 24/7
Technology used in the service
consists of:Standard (H.323) video
conferencing hardware and
software
Standard Windows PC’s that
allow access to all and any
clinical information systems
Utilises existing networking
technologies including home
broadband
The unit illustrated operates
“wired” and “wireless”… that is
it can work on both wired and
wireless networks and has a
battery for power cuts!
Disadvantages
 Clinician Suspicion
 IT connectivity
 Requires clinical governance and
networking
Acute Neurology- some suggestions
 TIA clinics make the them urgent
neurovascular and neurology services
 Change clinic emphasis to include urgent
capacity
 Increase emphasis on in-patient work by
establishing liaison service and local beds
 Why should neurology patients be treated
differently to gastro-enterology?
Liaison neurology- the Leeds
experience
 What he does
– Daily consultation to acute medical service
– 3 liaison rounds to AMU
– 2 acute clinics with direct access for acute physicians
 How things have improved
– Better/faster diagnoses
– Noticeable improvement in management even when absent on leave of;
 Spinal cord problems, alcohol/other fits, NEAD, stroke mimics
 Better use of existing pathways and clinics
 Reduced admissions and shorter stay.
Length Of Stay
Over 31 days
15 to 31 days
14 days
13 days
12 days
11 days
10 days
9 days
8 days
7 days
6 days
5 days
4 days
3 days
2 days
1 day
0 days
Percent of Patients
Length Of Stay Comparison
Cumulative Percent of All Patients by Length of Stay
100%
75%
50%
Pre 0
Post
25%
0%