Refining and Redefining Emergency Flows Dr Veronica Devlin

Refining and Redefining Emergency Flows Dr Veronica Devlin Programme Lead Service Improvement and Clinical Governance Emergency Care

Defining flows • Resus <5% • Majors 40 -45% • Minors 55 -60% • • • Admitted, by specialty Assessment majors Minors Planned returns Ward work

Patient Numbers Accident & Emergency March-May 2009 (3 months) No Follow Up NHSL Overall # 28, 302 54. 0% GP follow up Avg. 107 min # 7, 912 52, 398 A&E Minors 32, 388 61. 8% Medical 8, 620 16. 5% Acute ass. 7, 713 Surgical Deaths 0. 2% 3, 595 15. 1% Avg. 113 min 14. 7% 6. 9% 82 Emergency Receiving Unit Admission # 7, 973 15. 2% Avg. 144 min # 5, 190 9. 9% Avg. 137 min # 3, 021 Other* 5. 8% Avg. 81 min *e. g. Other Hospitals, Primary Care Emergency Centre

Theory…. .

Practice….

• • • History of specialty 3 ED’s Fewer middle grades Recruitment issues Retention issues Casemix challenge Access block Audit Scotland Quality standards Delivery

Theory….

Practice…

Lean in emergency flow

Lean principles • • • Specify value Map the value stream (patient flow) Implement flow Establish pull where you can’t flow Work to perfection • Voice of the customer

Lean tools • • • Standard work Standard operating procedures Managing variation Metrics Dashboards

In God we trust all others must bring data

Deming • You can’t manage on visible figures alone • Figures on the most important areas of management may be unknown or unknowable, and successful managers must nevertheless manage those areas.

Vital Signs - measurement • ED • • • TTFA DNW’S Unplanned returns Planned returns Delays to care

Vital Signs - measurement • Admission/discharge • balance • Discharges before • noon • Diversions • • 8 and 12 hour delays • to care • Boarders • • Additional beds • • Delayed discharges Length of stay on Medical Receiving Unit Total hospital length of stay Diversions Cancelled electives due to lack of capacity Surge capacity Use of off site beds

Monklands • • Minors flow Majors pitstop ACE GP assessment bay

minors

Minors flow Monklands • • • Maintaining operation Timing of stream operation Staffing Operational set up Monitoring Follow up arrangements

reception store xray Patients had to go outside after registration

store reception xray Patients’ journey contained within the department – and no compromise in Waiting Room space

Majors Pitstop • Proof of concept • Dedicated approach for assessment of majors • Negotiated diagnostics • Senior decision-making • Average tat 102 minutes during trystorm

Majors pitstop

GP assessment bay • • Complete team based assessment Meds rec Admission avoidance Decide to admit vs admit to decide

Implement ASSESSMENT BAY and ACE

Hairmyres • • STATUS CHANGE Medical Assessment bay Minors flow CPAU pathway Stroke pathway

LENGTH OF STAY AMRU Dashboard Key Performance Indicators Patient moves am/pm Ward Round Start Times Ward Pull Before noon Parent Specialty Mix Porter Response Times Admissions vs. Discharges & Transfers MAB Performance Surge Beds

Medical Assessment Bay (MAB) Sustainability Change Detail 4 Trolley bay in AMRU for the review of GP referred medical patients between 9 am and 7 pm weekdays) Key Performance Indicators 25% of patients Discharged from MAB Consistent staffing, bed availability Ambulance Service/ERC Criteria for access.

Medical Assessment Bay (MAB) Change Detail Sustainability 4 Trolley bay in AMRU for the review of GP referred medical patients between 9 am and 7 pm (weekdays) Key Performance Indicators MAB journey time 37 mins Consistent staffing, bed availability ? Senior Decision Maker availability in MAB Was 9% Now 18% admitted in <2 hrs less than A&E MAB TTFA 30 mins less than A&E From 48% to 33% Admitted between 210 & 240 mins

Change Detail • • • Visual management Target driven Updated and reviewed daily Also for surgical and medical flow Monitors individual ward performance Daily Dashboard Sustainability

Positives Excellent clinical engagement Data driven Perceive the service from customer viewpoint But….

Reshaping Emergency Medicine • • Clinical Director Consultant appointments Review of skillmix Standard operating procedures Quality Standards Safety Brief Roles and Responsibilities redefined

Consolidate core service

Non core ED work