Transcript Improving patient flows into and out of acute care The

Dr Dan Beckett
Consultant Acute Physician
NHS Forth Valley
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National recommendations for AMUs
◦ RCP Acute Medine Taskforce Report
 Recommendations to improve flow
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The current national picture
Outcome data
AMU Quality Indicators
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RCP Acute Medicine task force
recommendations published 2007
Blueprint for development
of acute medical services
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All hospitals admitting patients with acute
medical illnesses should establish AMUs as
the focus for acute medical care
The AMU should operate a number of streams
for patients related to clinical need
◦ Acutely unwell (level 1/2)
◦ Short stay – Ambulatory
◦ Complex needs patients
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‘Transfer of care planning should begin at the
time of initial patient assessment...and an
estimation of anticipated length of stay
should be recorded for all patients within 12
hours of admission’
‘Where patients require in-patient care within
the specialty bed base there should be no
barriers to patient transfer...’
Patient
Assessment
Stay
Diagnostic
uncertainty
Mobilisation
Care package
Multidisciplinary
Team
24 HR
24 - 48 HRS
Specialty Ward Transfer
ASAP if LOS > 48-72hrs
Pharm
OT
PCP
PT
Nurse
LOS ~ 48hrs
GP/A+E
36%
RIE
40% Home
24%
O/S
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‘The length of stay on an AMU should be
dictated by clinical need and not arbitrary
limits
◦ Typical LOS 24-72 hours
◦ Mean LOS 24-30 hours in established units
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Patients should be ‘pulled’ rather than
pushed
Number of patients
250
Alternatives to admission
200
Take ½ day off clinically unnecessary LoS
and it has a dramatic impact
150
100
Left shift
These patients may have more
complex support needs
50
0
1 3 5
7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59
Length of stay (days)
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‘An adequately sized and staffed AMU should
aim for a significant percentage (about 50%)
of acute medical admissions to complete
their episode of care within the AMU’
‘As a guide to size the minimum number of
beds will be equivalent to the number of
patients admitted over 24 hours plus 10%’
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‘There should be twice-daily, consultant-led
ward round/review of all patients in the AMU,
seven days per week’
‘The physician of the day model is strongly
discouraged as this is not conducive to
continuity of care’
‘We recommend dedicated blocks of work on
the AMU and cancellation of other
commitments’
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We recommend new models of working that
are predicated on ensuring adequate levels of
competent clinical decision makers are
present on the AMU and other front-line
services 24/7.
Specialty teams should...provide advice or
attend and review patients expeditiously on
the AMU within a maximum of 4 hours of a
request, or ideally sooner’
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‘The pace of life in the main hospital bed base
beyond AMU must be geared to respond
dynamically to changes in demand so as to
increase capacity during busy periods’
‘Real time monitoring of demand and capacity’
‘Robust escalation policies’
‘Daily clinical review of the entire bed base by
a competent clinical decision maker’
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Survey of 126 Acute Hospitals in England,
Wales and Northern Ireland
◦ October 2010
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Audit against national guideline standards on
service organisation and staffing
arrangements
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Number of hours admitting consultant
continuously present
◦ Weekday
 9 – 12 hours 49%
 >12 hours 13%
◦ Weekend
 9 – 12 hours 16%
 > 12 hours 4%
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Admitting consultants available for fewer
hours at the weekend
All admissions
4,317,866
4.9
(162,639)
5.2
(52,415)
<0.001
**
Acute renal failure (CCS 157)
14,134
25.6
(2,924)
33.3 (909)
<0.001
**
Acute cerebrovascular disease (CCS 109)
70,500
27.5
(14,451)
30.2
(5,437)
<0.001
**
Acute myocardial Infarction (CCS100)
68,932
13.5
(6,803)
14.4
(2,650)
0.002*
2,576
64.9
(1,238)
68.1 (455)
0.048*
Cardiac arrest and ventricular fibrillation (CCS 107)
Cardiac dysrhythmias (CCS 106)
Chronic obstructive pulmonary disease and bronchiectasis
(CCS 127)
86,134
106,951
1.9 (1,270) 2.4 (453)
7.7 (6,174) 7.6 (2,005)
0.840
Congestive heart failure non hypertensive (CCS 108)
56,394
17.9
(7,944)
Coronary atherosclerosis and other heart disease (CCS 101)
91,836
2.4 (1,676) 2.8 (583)
0.008*
Fluid and electrolyte disorders (CCS 55)
17,436
9.6 (1,359) 11.3 (365)
0.013*
Gastrointestinal haemorrhage (CCS 153)
57,937
7.3 (3,196) 7.8 (1,087)
0.042*
Liver disease, alcohol-related (CCS 150)
10,401
18.5
(1,576)
20.4 (382)
0.042*
102,465
24.3
(18,619)
25.4
(6,574)
Pneumonia ( CCS 122)
19.6
(2,351)
<0.001
**
<0.001
**
0.899
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Proportion of sites providing at least twice
daily ward round
◦ Weekday 61%
◦ Weekend 69%
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However ward rounds at the weekend less
likely to see all patients in AMU and more
likely to see only new patients, or those
thought to be unwell or possible discharges
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91% of sites still operate a physician of the
day receiving model, augmented by the
presence of Acute Physicians
48% of sites report that consultants with
first-on responsibilities still undertake other
duties during the acute take (eg out-patient
clinics)
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Mortality rates
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Within 48 hours of admission
HSMR
Weekend vs Weekday mortality rates
In-hours (0800-1900) vs Out of hours
Direct discharge rates within 24 or 48 hours
of admission
7 day readmission rate
Intermittent audit of tracker conditions
Patient experience
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Acute Medical Care: The right person, in the
right setting, the first time. RCP Acute
Medicine Task Force Report 2007
RCPE UK Consensus Statement on Acute
Medicine, November 2008