Acute Admissions Management at the Royal Derby Hospital - PowerPoint PPT Presentation

Loading...

PPT – Acute Admissions Management at the Royal Derby Hospital PowerPoint presentation | free to download - id: 6a303e-OWY3N



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Acute Admissions Management at the Royal Derby Hospital

Description:

Acute Admissions Management at the Royal Derby Hospital Dr David Staples MBiochem(Oxon) BMBCh(Oxon) MRCP MMedSci(ClinEd) FRSA Consultant Physician in Acute Medicine. – PowerPoint PPT presentation

Number of Views:24
Avg rating:3.0/5.0
Slides: 62
Provided by: David46
Learn more at: http://www.aesclepius.co.uk
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Acute Admissions Management at the Royal Derby Hospital


1
Acute Admissions Management at the Royal Derby
Hospital
  • Dr David Staples
  • MBiochem(Oxon) BMBCh(Oxon) MRCP
  • MMedSci(ClinEd) FRSA
  • Consultant Physician in Acute Medicine.
  • Lead Consultant for Service Development.
  • TPD, Acute Medicine (East Midlands North).
  • Director, Aesclepius Ltd.


2
The Royal Derby Hospital
3
(No Transcript)
4
Hit the 4 hour target
Improve patient experience
Train the trainees
Discharge patients earlier
Save money
Get the right patient to the right ward
5
The old process
Patient referred for acute medical assessment.
All patients put in a bed. Observations may not
be done by a qualified nurse.
Patient waits to be clerked by a junior
doctor. Patient waits for review by registrar or
consultant.
Patient waits for specialty physician review.
Patient waits for bed on medical specialty ward.
Patient moved to (any) bed on a base ward.
6
First assessment by least experienced staff.
7
(No Transcript)
8
GP
Ambulatory Care
Triage
AE
Home
Clinic
Short Stay / ..ology
9
AMU Triage
F1s chair
Consultants chair
10
Acute Medical Unit Triage
  • Band 6 nurse led.
  • Collate referral story.
  • Observations, EWS, allergies, pain score.
  • Bloods, ECG, microbiology.
  • Prioritisation for clerking.
  • Transfer to ambulatory care.
  • Alert specialty teams.

11
Analysis of intervention
  • Pre and post March 2010.
  • 600 cases.
  • June, October February before 03/10
  • June, October February after 03/10
  • 100 patients from each month.
  • Wide range of quantitative and qualitative
    measures.

12
Process time results
13
Reduction in re-attendance
14
Summary of Outcomes
  • Reduction in waiting time to see the first
    practitioner.
  • Reduction in time to see a senior doctor.
  • Reduction in time to receive an agreed management
    plan and pathway allocation.
  • Reduction in admissions to base wards.
  • Reduction in re-attendance rates.
  • Increase in proportion of patients completing
    care on AMU.

15
GP
Ambulatory Care
Triage
AE
Home
Clinic
Short Stay / ..ology
16
Principles of Hospital Ambulatory Care
  • Ambulatory care means they sit on a chair

17
GP
Ambulatory Care
Triage
AE
Home
Clinic
Short Stay / ..ology
18
Comfortable environment
19
Ambulatory Care Centre consultation rooms
20
Ambulatory Care
21
Who Do We Want in ACC?
  • High number of easy wins
  • Well
  • Mobile
  • Self Caring
  • Sane (?)
  • Rule Outs for unlikely but serious conditions
    (PE / ACS)

22
Process
23
  • Abnormal LFTs
  • Adult First Seizure
  • Anaemia
  • Anaphylaxis
  • Asthma
  • Cardiac Chest Pain
  • Cellulitis
  • COPD
  • DVT
  • Headache
  • Pleural Effusion
  • Pneumothorax
  • Pulmonary Embolism
  • Seizure in a Known Epileptic
  • Syncope
  • SVT
  • Upper GI Bleed
  • Generic ambulants

24
The Selection Process
25
(No Transcript)
26
Outcome
27
Outcome
28
GP
Ambulatory Care
Triage
AE
Home
Clinic
Short Stay / ..ology
29
GP
Ambulatory Care
Triage
AE
Home
Clinic
Short Stay / ..ology
30
GP Phone Triage
  • Discussion with senior generalist for all
    incoming medical patients
  • Reduce unnecessary admissions
  • Provide an accessible specialist advice service
  • Stream patients to the right place, first time
  • Improve patient flow from AE to MAU

31
GP Phone Triage
  • Options
  • Ambulatory Care (see but not stay)
  • O/P clinic
  • Service Navigation Team (Community beds / Rehab /
    Social)
  • Medical Assessment Unit
  • AE
  • Remain where they are with appropriate advice
  • Other Services
  • Planned investigation unit
  • Rapid access chest pain service
  • Stroke / TIA Service

32
Time of GP Calls
33
Results (n619)
34
What have we achieved?
39 reduction in overnight admissions from the
community (n1600)
35
Age Ranges
  • ACC
  • Avoided

36
Validation Avoided
  • Re-admission within 7 days n10
  • 2 straight to rehab from GP
  • 3 seen in AMU LOS 0 days
  • 1 vaginal pain
  • 1 admitted despite LCP agreed
  • 3 medical
  • LRTI (LOS 2)
  • GE (LOS 5)
  • UTI (LOS 1)

37
Validation ACC
  • n50 (from 184)
  • 7 admitted
  • 3 x CAP (LOS 1,3,6)
  • 1 x COPD (LOS 3)
  • 1 x PE (LOS 5)
  • 1 x CVA (LOS 3)
  • 1 x AML (LOS 50)

38
Intervention Components
  • Trialled using a LLP to provide consultant
    clinical expertise, migrating to job plan PAs
    when proved successful.
  • Change referral phone call management protocols.
  • Capital investment in upgrading Ambulatory Care
    Centre.
  • 80 increase in workload with up to ½
  • of the medical take now passing
  • through it.

39
Impact
  • 39 reduction in community admissions staying
    overnight
  • NOT creating unmet need.
  • 7 day and 30 day re-admissions low.
  • ? Increased LoS
  • ? Worse standardised mortality
  • Improved patient experience through
  • Improved environment
  • Clinical pathway standardisation, streamlining
    and redesign
  • Active management of patient expectation
  • Improved communications between primary and
    secondary care.
  • Smoothing the 1600h bump

40
90K Adult Attendances to ED
Urgent Care Pathway Adult, Medicine
Self Referrals Ambulance , 77K
Discharged or external transfer, 59K
ED
GP other, 13K
15K
Non-med internal transfer, 10K
Direct ad to Med ward, 6K
MAUT/ Amb. Assess
GP /BB, 11K
Discharged, 7K
19K
MAU
Discharged, 5K
Non-med internal transfer, 1K
13K
Base Wards
Discharged, 17K
2K
Rehab
Discharged, 2K
41
Urgent Care Pathway Adult, Medicine
Subject to 30 tariff
ED
Locally agreed price ED top up
GP /BB Locally agreed price more than ED due to
less work up.
MAUT/ACC
MAU
Admissions attract national tariff for an
inpatient stay
42
Financial Impact
  • Locally Agreed Tariff for MAU attendees
  • We do not attract ambulatory Best Practice
    Tariff (not counted as an admission)
  • Commissioners.
  • Pushing more activity through MAU triage
    increased cost, BUT saving made through avoidable
    admissions is greater.
  • Attractive to Commissioners
  • Hospital.
  • Increased activity paid at locally agreed tariff
    but major benefit because of increased patient
    throughput from ED and 4 hour target effects.
  • Attractive to Hospital Management

43
Barriers
  • Consultant resistance to new Role
  • Work from home
  • Linking shifts to locum payments
  • Only using those that wanted to do it
  • individualised job plans
  • Resistance from some GPs
  • Ensuring adequate call handling (better
    experience)
  • Positive message events and early consultation
    with GP leaders
  • GPs manning the unit
  • Management Buy In
  • Coordinators seeing the bigger picture

44
Factors for Success
  • Senior Decision Makers with good working
    knowledge of local services (not cheap medical
    decision makers)
  • Generalist Decision Makers with working clinical
    knowledge of a wide range of specialties (Elderly
    Care Acute Physicians)
  • Single point of access for community referrals
  • Supportive management able to see potential
    benefits
  • Well developed community services and pathways
  • Flexible dynamic department

45
Questions
Copies of presentation and slides
WWW.AESCLEPIUS.CO.UK
46
Consultant in triage 0800 to 1300
Consultant in triage 1300 to 1700
Consultant in triage 1700 to 2000
47
Consultant in triage 0800 to 1300
Consultant in triage 1300 to 1700
Consultant in triage 1700 to 2000
48
Consultant in triage 0800 to 1300
Consultant in triage 1300 to 1700
PTWR 1400 to 1600
Consultant in triage 1700 to 2000
PTWR 1700 to 1900
PTWR 2000 to 2200
49
Consultant in triage 0800 to 1300
Night take PTWR 0800 to 1200
Consultant in triage 1300 to 1700
PTWR 1400 to 1600
Consultant in triage 1700 to 2000
PTWR 1700 to 1900
PTWR 2000 to 2200
50
Consultant in triage 0800 to 1300
Night take PTWR 0800 to 1200
With night take team
Consultant in triage 1300 to 1700
PTWR 1400 to 1600
With early take team
Consultant in triage 1700 to 2000
PTWR 1700 to 1900
With late take team
PTWR 2000 to 2200
With late take team
51
(No Transcript)
52
(No Transcript)
53

Single point of access.
  • Primary care providers have a single telephone
    number for all urgent referrals.
  • The acute Trust will deliver clinically competent
    advice and direction for the most appropriate
    secondary care services.

54
Immediate triage on arrival.
  • All patients are triaged by a qualified nurse or
    midwife within 15 minutes of arrival.
  • This process will indicate the start of specific
    observations or physiological monitoring (EWS)
    where necessary.

55
Timely, senior-led assessment with all records.
  • All patients have a formal clinical assessment
    within 2 hours of arrival.
  • The outcome of assessment will be a diagnosis or
    explanation satisfactory to the patient of their
    circumstances.

56
Senior review within 4 hours.
  • Senior review of patients is indicated by the
    formal clinical assessment and subspecialty
    agreed protocols.
  • It will occur within 4 hours of arrival.

Care pathways may be completed without the
involvement of senior staff.
57
Ongoing care pathway - agreed, recorded and
communicated.
  • What happens next will be agreed with the
    patient,
  • detailed in the records and communicated to the
    next provider.
  • This includes handover to inpatient and
    outpatient teams.

58
Immediate electronic discharge summaries.
  • The timely provision of an accurate and
    appropriately detailed discharge summary is
    fundamental to successful continuity of care.
  • Similarly admitting providers need to supply
    accurate and relevant patient information.

59
Set criteria for specific care pathways.
  • Specific care pathways written for named
    conditions or patient groups should be evidenced,
    efficient, diagnostic, allow senior judgment and
    integrate and communicate with Primary Care.

60
Reassess when providers or condition changes.
  • Patients will recommence the assessment process
    if they are moved during urgent care or if their
    needs change.
  • Transfers will be appropriate, safe, and in the
    patients best interest.

61
Diagnostics and interventions have agreed timed
targets.
  • Subspecialty protocols will agree the timing of
    urgent access to diagnostic services.
  • All intravenous antibiotics will be given within
    30 minutes of the decision to treat severe
    sepsis.
About PowerShow.com