How to streamline inter-hospital transfers

1. How to streamline inter-hospital transfers Dr Richard Levy Wythenshawe Hospital, Manchester CHD Collaborative National Clinical Lead

3. “Real life” technical considerations ?

4. What is the evidence?

5. The majority of patients waiting for transfer were waiting with acute coronary syndrome (73%)

6. Number of patients reported awaiting transfer at each hospital Manchester Dec 2003 Number of patients Hospitals

7. Inter-hospital transfer for revascularisation At a CHD Collaborative Angina Workshop in September 2003 this was identified as national problem # 1 Organise a national survey and audit of current practice in patients with ACS

8. ACS Transfer • Study from Manchester Royal Infirmary from May to October 2003 recorded 212 patients in 16 DGHs occupying 1755 bed days waiting for transfer (N Curzen, Lancet letter 2004)

9. Inter-hospital transfers for revascularisation “ view from----- ----- the DGH”

10. Inter-hospital transfers; view from the DGH • We do all the right things • We triage the patients, identify the high risk patients (Troponin testing etc) • We select the correct patients for angiography+/-revascularisation and refer to the Centre • And then we wait • ----- and wait ----- and wait

12. Inter-hospital transfers for revascularisation “view from the Ambulance Service”

13. Inter-hospital transfers; view from the Ambulance service • We have to match the type of vehicle, equipment and crew to needs • This can have an adverse impact on category A calls • The patient is never ready when we arrive • And then we wait • ----- and wait ----- and wait

16. Inter-hospital transfers for revascularisation “view from----- ----- the Centre”

17. Inter-hospital transfers; view from the Centre • We must first meet our targets for elective revascularisation [PCI & CABG] • This will dictate our “star rating” and application for Foundation status • We have a “white board” for listing patients for transfer for non-elective revascularisation • This is always full

18. Inter-hospital transfers; view from the Centre • We do our best to deliver non-elective revascularisation --- and in time we do deliver • After revascularisation we may need to transfer patients back to the DGH • The DGH is always full • And then we wait • ---- and wait ---- and wait

19. Inter-hospital transfers for revascularisation • This is a major challenge for Cardiology • Unrecorded waiting list • Surge in referrals due to advances in clinical practice • No indicator for non-elective revascularisation

20. CHD-C Survey and Audit • National survey to scope the problem of interhospital transfer for the treatment of ACS • Review of Central Returns (RoCR) insisted on voluntary contribution • Collect baseline data about referring DGHs, transfer process and interventional/surgical centres across England • Identify process redesign work already introduced and share best practice

21. CHD-C Survey and Audit • Collect data about waiting times for transfer from DGH to referral centre for angiography and revascularisation in England over 4 weeks in March 2004 • These data provide a snapshot of our capacity to provide non-elective revascularisation • Expose any limitations in the system

22. Sometimes Wythenshawe seems very far away……

23. ACS transfer • Data suggest that at-risk patients with ACS benefit from early invasive assessment within 72hrs and this is recommended in local, national and international guidelines

24. A National Study of Transfer of Cardiac Patients March 2004

26. Submitted Forms • We tried to reach all the trusts in England • 141/148 Trusts submitted forms

27. Team organisation

28. Inter-hospital Transfers Audit Topline Average Waits Admitted To DGH Angiogram Referred Transferred Procedure 5.9 Days 1.6 Days 7.5 Days 1.5 Days 15 Days 16.5 Days

29. Difference between PCI and Cardiac Surgery PCI 16 Days 14.8 Days 5.9 Days 1.3 Days 7.6 Days 1.2 Days Admitted To DGH Referred Procedure Angiogram Transferred 5.2 Days 2.4 Days 11.1 Days 3.5 Days 18.7 Days 22.2 Days CARDIAC SURGERY

30. Intervention on site or transfer INTERVENTIONON SITE 8.3 Days 3 Days 1.5 Days 3.8 Days 2.2 Days Admitted To DGH Angiogram Transferred Procedure Referred 6.3 Days 1.7 Days 8.0 Days 1.1 Days 16 Days TRANSFERRED FOR INTERVENTION

31. Average waiting time between admission and angio: DGH with a Catheter Lab 5.5 Days DGH without a lab 8.2 Days 40.1% of the DGHs submitting data had a Cath Lab of some sort

32. Wait after transfer to procedure

33. Geographical Differences In Average Waits (Days) The North Average wait from admission to PCI : 12.8 Average wait from admission to cardiac surgery: 16.3 Average wait from admission to procedure (all) : 12.9 The Midlands and Anglia Average wait from admission to PCI : 12.6 Average wait from admission to cardiac surgery : 23.0 Average wait from admission to procedure (all): 14.5 The South East & London Average wait from admission to PCI : 15.5 Average wait from admission to cardiac surgery:19.9 Average wait from admission to procedure (all): 17.0 The South and West Average wait from admission to PCI: 23.5 Average wait from admission to cardiac surgery:25.4 Average wait from admission to procedure (all): 20.9

34. Number of centres submitting data The Midlands and Anglia Number of Interventional Cardiology Sites submitting data : 10 The North Number of Interventional Cardiology Sites submitting data : 17 The South East & London Number of Interventional Cardiology Sites submitting data : 10 The South and West Number of Interventional Cardiology Sites submitting data : 6

38. AVON BEDS BIRM CHES CUMB DORS DURH ESS HAMP KENT LEIC LINC MANC NCL NEL NORF NWL SEL SHROP SURR SWL SWPEN SYORK THAME TRENT TYNE WMIDS WYORK

39. AVON BEDS BIRM CHES CUMB DORS DURH ESS HAMP KENT LEIC LINC MANC NCL NEL NORF NWL SEL SHROP SURR SWL SWPEN SYORK THAME TRENT TYNE WMIDS WYORK

40. AVON BIRM ESS HAMP KENT LINC MANC NORF NWL SEL SURR SWL THAME TRENT TYNE WMIDS WYORK

44. Inter-hospital Transfers Audit Average Admission to Procedure Waits by Trust – 1 March to 28 March 2004 Referred Admitted To DGH Transferred Procedure Angiography +/- PCI (with and without angiography)

46. Inter-hospital Transfers Audit Average Admission to Referral Waits by Trust – 1 March to 28 March 2004 Referred Admitted To DGH Transferred Procedure Angiography +/- PCI (with and without angiography)

48. Inter-hospital Transfers Audit Average Referral to Transfer Waits by Trust – 1 March to 28 March 2004 Referred Admitted To DGH Transferred Procedure Angiography +/- PCI (with and without angiography)

50. Inter-hospital Transfers Audit Average Transfer to Procedure Waits by Trust – 1 March to 28 March 2004 Referred Admitted To DGH Transferred Procedure Angiography +/- PCI (with and without angiography)