Emergency Flows -Urgent Care Services Wye Valley NHS Trust Neil Doverty Chief Operating Officer Trust Board – 29 May 2014
Demand • A&E attendances show year on year increase with activity in 2013/14 3.1% (1467 actual) up against previous year. • Attendances in April 5.7% (234 actual) up against the corresponding month in 2013. This equates to on average an additional 8 patients per day with the daily average being 145 attendances. Worth remembering that the design build of the department was just 125. • May attendances forecast to be in the region of 10% up against the same month last year and just short of the highest number of monthly attendances recorded in July 2013. • Emergency admissions following similar pattern and 3.4% (443 actual) up against previous year and with April 294 admissions up against April 2013. • WMAS has confirmed an increase of 161 ambulance conveyances from the beginning of April 2014 to • mid-May, compared to same period in 2013
Demand • April 2014 saw an increase in those patients attending A&E but leaving without being seen (228 actual). • Of those patients only 7 patients returned to the A&E department on the same day which suggests that the remaining patients did not require urgent medical attention by an A&E doctor. • Of the 228 patients only 41 returned to A&E at some point between their original visit to date, therefore 82% of them have not re-attended to A&E.
Impact • A&E department too small and limited capacity to cope with demand, design build 125 but April average 145. • Unrelenting pressures of patient demand on the department with failure of the 4 hour A&E waiting time standard. • Planned capacity full resulting in increased numbers of cancellations and failure of the national standard for elective access • Very high bed occupancy level rates resulting in restricted flow to main acute bed base • Bed waits constitute about 65% of all our breaches of the 4 hour standard • Trust has been contracting the previous historic reliance on extra-capacity outlying areas • CCG commissioned Winter pressure capacity schemes came to an end towards end of March but partly re-opened to support rising demand • Increased pressure on 18 week admitted pathways targets with failure against the standard in a number of specialties • Higher acuity of admitted patients resulting in more complex discharge plans and longer lengths of stay for some cohorts of patients • Medical outliers • Mixed sex accommodation breaches
Actions taken within the Trust • Emergency Ambulatory Care introduced to Herefordshire through new CAU • Hospital at Home (Virtual Ward) commenced autumn 2013 • Proposed capital development scheme changes to the design / layout of the A&E Department • Changes in patient flows required within Trust: agreed bed reconfiguration plan with all specialties and planned for August 2014 • EPOD is Consultant Physician 8am-8pm 7 days per week, complemented with 7-day extra diagnostic support • Attempting to resolve the Powys delayed transfers of care (5-10 patients at any point in time over the last 6 months) with support from CCG, Area Team and Wales Community Health Council. Various contractual levers being pursued and short term use of Discharge to Assess scheme in Hereford City for their patients • Opened new Discharge Lounge late April 2014 – staffed with dedicated discharge team • Strategic workforce review performed with help of A&E Nurse Consultant from HEFT • 1 new Consultant with an interest in Acute Medicine – the search continues for others • GPs with experience of emergency medicine introduced to A&E Department • Revised TechFund bid for EPR / electronic prescribing test site
Actions taken across the health economy • Review of falls pathway • Primecare support in A&E / CAU • Personalised care planning development • Anticipatory care planning across all environments • Social networking type approach to connect patients and health care professionals • LTC pathways – COPD, Heart failure etc • Dementia implementation group • End of life forum • Development bed to 7 day primary care working • Risk Stratteam in Community working closely with GPs & Hospital at Home • CCG funded GPs in A&E • WVT / multi-agency discharge function improvements • CCG / Council - Rapid Access to Assess beds • WRVS pilot in Leominster • Older persons psychiatry liaison service for A&E • Psychiatry liaison (RAID) • Memory clinic
CAU • Small temporary CAU opened from November whilst full refurbishment undertaken and fully operational from March 2014 • The expectation was that certain patient groups would be seen, treated and discharged within the same day rather than being admitted into an acute ward and staying in hospital for several days • Average number of daily admissions showing a stepped increase month on month • Average number of patients going through the Unit in April 15 per day • Average length of stay for CAU patients between 5 and 6 hours • Discharge rate from CAU has seen an increase but currently falling just short on the 80% threshold set nationally
EPOD • Marked increase in 0 length of stay patients month on month since EPOD implemented • % of 0 LOS patients increased from on average 13% prior to EPOD to 27% during March 2014 (note this includes an element of CAU)
Length of Stay • Average LOS for emergency medical patients has seen a downward trend over the last couple of years. • Reducing the LOS from 6.1 days in April 2012 to 3.5 during April 2014
If we didn’t do anything ? • Demand has already outstripped the performance improvement schemes already developed and continues to increase further • CAU and EPOD has freed up on average 18 beds per day across the winter months. Without these then the impact on services would have been far greater: • Worse A&E position • Increased cancellations • Higher occupancy • Patients treated in no designated ward areas • Adverse to patient experience and quality of care • Since the Virtual Ward went live in October 2013 the number of patients receiving Intravenous Antibiotics (IV) in the community is 40 patients. This has equated to number of days of treatment delivered of 442 days which has crudely saved an average between 2-3 beds per day since October 2013. Without the introduction of the Virtual Ward these patients would have typically been admitted and therefore put more pressure on the bed stock than was experienced during this period.
Future • Ageing population with greater, more complex healthcare needs • Continued growth and demand • Increased GP opening hours coming soon to Herefordshire • New housing developments planned for next decade • Potential further population expansion • Financial constraints