Review of the Cardiff Masters EU Projects with Aneurin Bevan University Health Board

Danny Antebi, Paul Harper, Julie Vile & Janet Williams Masters students: Elizabeth Allkins, Yiwen Fu

Overview

Background on links between Cardiff University & ABUHB Brief overview of the two Unscheduled Care Masters Projects Project feedback to the Health Board Outcomes and sustainability of the work Questions

ABUHB – Aneurin Bevan University Health Board

14 hospitals in total, 2 major A&E Serves an estimated population of over 639,000, approximately 21% of the total population of Wales Employing over 13,000 staff, two thirds of which are involved in direct patient care

ABCi – Aneurin Bevan Continuous Improvement

The Modelling Unit

John Frankish – Service Lead/Improvement Coach Dr Tracey England – Mathematical Modeller Dr Penny Holborn - Mathematical Modeller Dr Izabela Komenda – Mathematical Modeller Dr Julie Vile - Mathematical Modeller Terry Watkins – Improvement Coach Mr Hiro Tanaka – Clinical Liaison/Support Steve Elliott – Financial Support

Functions

Range from informal advice to analytical support Variety of mathematical techniques permit best option approach for any project:

Simulation Statistics Forecasting Demand and capacity planning Optimisation Scheduling Queueing theory

Training sessions

Focus - Current Projects

Unscheduled care:      Modelling demand and capacity for OoH services Improving the accuracy of predictions for RGH ED Aligning staffing profiles to peaks and troughs in demands for RGH ED Improving patient flow Evaluating the effect of individuals presenting in ED under the influence of alcohol Mental health:    CHMTs skill mix and staffing levels Developing caseload management tool Analysis of CHC packages over a 5 year period Pathology: The effects of changing the shift patterns in the laboratory at the RGH Primary care: Evaluating the introduction of a Patient Access system for GPs scheduled care Scheduled care: Development of a fracture neck of femur database tool Informatics: Digitalisation of Health Records

Masters Projects

Short-term projects (3 months)

Outputs:

Presentation Executive summary 20,000 word dissertation!

TOO MUCH DEMAND

Unscheduled Care

PROCESSES ARE TOO SLOW IN HOSPITAL LACK OF CAPACITY TO TAKE PATIENTS OUT OF SYSTEM

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Admission avoidance strategies

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Better community model

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Role of WAST

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Consultant at front end

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Alternative pathway for elderly/ frail patients

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Co-locate MIU

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Better computational facilities

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Discharge patients earlier

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Bring in elective patients later

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24/7 working

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Patient boarding

Modelling patient flow in ED to better understand demand management strategies.

Elizabeth Allkins Sponsor Supervisor – Danny Antebi University Supervisors – Dr Julie Vile and Dr Janet Williams

Aims

Gain insight into the functioning of the Emergency Department in the Royal Gwent Hospital Explore the effect on the system of actions to redistribute demand, reduce overcrowding and long waiting times

Background

25 20 15 10 5 0

4 hr Breaches & Death Rate

4 hour breaches Death rate 4 1 0 3 2 7 6 5

Two complementary approaches

Reduce attendance at ED Improve flow through ED

Stats analysis: Length of Stay

DES Simulation model

Input Parameters – easily changed via spreadsheet Resources Staff     Nurses Doctors Call handler Receptionist Beds   Beds for Majors and wards Rooms for Minors Xray machine Validation and Verification processes completed

Final model

What-if scenarios

CDU  Use as a ‘fast-track’ stream  Use as an additional ward with 12 extra beds.

Comparative average LOS for discharged Majors patients 2012 baseline Introduction of CDU Earlier routing to CDU Split beds (50%<1 day, 50% <3 days) Increase routing to CDU 195 200 205 210 215 220 225 230 235 240 245 LOS (minutes)

What-if scenarios

WAST pre-hospital streaming  Streaming ambulance patients direct to the MAU GP trial  Streaming GP referrals to a bed in the MAU Reduction in WAST conveyance rates  Reduction of 10% reduced waiting times

Conclusions

Detailed analysis of ED data Cost saving of CDU  Reduction in Majors LOS Simulation  Demonstrated the power of modelling   Explored scenarios to improve waiting times Built a solid foundation for future research

Assessing the impact of an ageing population and the effects of frailty programmes on RGH

Yiwen Fu Sponsor Supervisor – Danny Antebi University Supervisors – Dr Julie Vile & Prof. Paul Harper

Aim and background

Aim  Evaluation: Impact of aging population on RGH   Evaluation: Indirect effectiveness of Newport frailty team on ED Simulation models and scenarios: Estimate impact on patient flow in ED resulting from realisation of operational LoS and attendance targets Background    Pressure from ageing population in ED Newport frailty team: Established at 11 th at 1 st Sept 2011 April 2011; Further developed Main patients source: GP and secondary care

Attendance

Arrival modes

2/3 of patients 65+ arrive by ambulance 2/3 of those under 65 come in a private vehicle

Over 65

N/A (Planned Follow-up) 3% Other 2% Police Car 0%

Ambulance 65% Private Vehicles 27%

Walked 1% Public Transport 2%

Under 65

N/A (Planned Follow-up) 4% Other 4% Police Car 1%

Ambulance

Ambulance

19% Private Vehicle 66%

Walked 3% Public Transport 3%

Newport population projection

The Frailty programme

Joint service provision across ABHB and the 5 local authorities Set up in April 2011 Provide intermediate care services  Keep people happily independent in their own home   Services within Community setting Services within the hospital Aims  Reduce bed days   Avoid ED and MAU admissions Reduce need for Continuing Health Care Packages

Impact on ED/MAU attendance ratios

The baseline population is increasing and ageing.

Significant reductions in number of 65+ attending MAU (1 st contact):    1,995 (2011/2012) -> 1,884 (2012/2013).

Number of patients under 65 remained relatively stable over same period.

Early days – some natural variability in system, numbers increased in year frailty team was initiated. Need to re-evaluate in the future!

Lack of evidence to support a reduction in ED attendances:   Numbers and ratios fell for ALL patients except those aged 65-74 between the ‘during’ and ‘after’ period.

Possibly some evidence of a small impact - between 2012-2013 the ratios of patients aged 75+ fell at a more dramatic rate than those under 65.

 Need to re-evaluate in the future! Marginal (but not significant) reductions in the assessed-in rate

Newport LoS analysis

Simulation model

Results of simulation

Scenarios results are compared with baseline results  Relative large impacts on Major unit Scenario 1  Reduction on service time (65+ only)   Reduction rate is linearly related to performances Gradually improve all performances Scenario 2    Reduction on attendances (65+ only) Reduction rate is curvedly related to performances Mainly improve queuing size and queuing time

Simulation results

Conclusions

Small cohort of population but uses a non-equivalently large proportion of resources Impact of Newport frailty team – need to evaluate in future Better care management would benefit hospital and patients  Introduce a frailty consultant to ED?

Further research  Impact of Newport frailty team on MAU/quality of life    Apply same techniques to other Local Authorities Need IT software to capture the relevant data More detailed simulation model

Feedback to Heath Board

Aneurin Bevan Continuous Improvement and Cardiff University Event Developing Mathematical Models in Healthcare Wednesday 11 September 2013

Malpas Court, Whittle Drive, Malpas, Newport, NP20 6NS

Programme

From 13:00 13:30 13:40 Registration and Coffee Opening, Welcome and Introduction Prof. Paul Harper – Head of Operational Research, Cardiff University and Dr Danny Antebi – Director, ABCi How can the ABCi Modelling Unit support you?

Dr Julie Vile – Mathematical Modeller, ABCi Session 1 13:50 14:15 14:40 15:05 Session 2

Presentation 1

– Elizabeth Allkins “Admission avoidance strategies to redirect high demands for A&E services in ABHB ”

Presentation 2

– Yiwen Fu “The impact of an ageing population on unscheduled care services in ABHB”

Presentation 3

– Hannah Williams “Compliance with national guidelines for stroke in radiology” Coffee 15:35 15:40 16:05 16:30 Outcomes of Kayne Putman ’s 2012 Dermatology MSc Dissertation Prof. Alex Anstey – Director, R&D

Presentation 4

– Harriet Jones “Patient flow through hospital-based therapies for psoriasis at ABHB”

Presentation 5

– Bradley Hardy “Development of a model to simulate sample-flow through the Biochemistry Laboratory in ABHB ” Summing up & Close Dr Paul Buss, Interim Medical Director - ABHB

Outcomes and sustainability

 Extract from email to students from Dr Julie Vile: “

The buzz you created at the event was something rarely seen at the NHS and I've hardly been able to get any work done this morning, due to the large number of people coming in the office praising your work which has really helped to raise the profile of the Modelling Unit within our health board.

”

Outcomes and sustainability

 Quote from Dr Danny Antebi Director of ABCi (Aneurin Bevan Continuous Improvement) : “

Having seen some of the projects the mathematicians have been working on, senior managers in Aneurin Bevan University Health Board are becoming more and more convinced of the value of this approach. In my view we can

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t manage increasingly complex systems, be they in health or otherwise, without modelling as an integral part of our design and analysis.

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Outcomes and sustainability

Modelling patient flow in ED to better understand demand management strategies – Elizabeth Allkins

Built a solid foundation for future research and the model is to be used to explore future scenarios

Assessing the impact of an ageing population and the effects of frailty programmes on RGH – Yiwen Fu

Recommended that a frailty team be placed within ED and a pilot is now underway

Questions?

www.cf.ac.uk/maths/research/researchgroups/ opresearch/healthcare http://www.wales.nhs.uk/sitesplus/866/page/69767 Follow us on twitter @abciab Email: [email protected]

Other Masters Projects

Compliance with National Guidelines for stroke in radiology – Hannah Williams

The model identified a significant increase in compliance with revised guidelines and proposed changes to the initial plan for extended working hours

Modelling the provision of phototherapy services for dermatology clinics – Harriet Jones

The tool is to be further explored and recommendations on the location of future psoriasis centres are to be considered in South Wales Plan

Simulating the automated clinical biochemistry track system at RGH – Bradley Hardy

Identified reductions in cost and staff workload by removing/replacing analysers which are being considered for implementation