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Mark Poulden Lead Consultant in Emergency Medicine Andrew Carruthers Directorate Manager Medicine ABM University NHS PowerPoint Presentation
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Mark Poulden Lead Consultant in Emergency Medicine Andrew Carruthers Directorate Manager Medicine ABM University NHS - PowerPoint PPT Presentation

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“Making the front door work!”. Mark Poulden Lead Consultant in Emergency Medicine Andrew Carruthers Directorate Manager Medicine ABM University NHS Trust. COMPETING DEMANDS & TARGETS. Reduce emergency admissions. Emergency Department 95% 4 hour. Waiting time IP/OP/DC.

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Mark Poulden Lead Consultant in Emergency Medicine Andrew Carruthers Directorate Manager Medicine ABM University NHS

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“Making the front door work!”

Mark Poulden

Lead Consultant in Emergency Medicine

Andrew Carruthers

Directorate Manager Medicine

ABM University NHS Trust

competing demands targets

Reduce emergency admissions

Emergency Department 95% 4 hour

Waiting time


ED Saphte scores within acceptible limits

Reduce LOS

Achieve EWTD


Reduce DTOCs

Evidence based clinical effectiveness

Financial Stability

Reduce cancellations due to lack of bed

where do we start
Remember the patient

We work hard and don’t succeed

We don’t work together

It feels like a mammoth task… do nothing

New approach to team-work

What do you do – can it be done differently

Where do we start?
how did it start
How Did it start?
  • Accept that 95% was hospital (system) not ED target.
  • Realisation that it should drive/derive from better patient care.
  • Streaming patients in the hospital as well as at the front door – learning and sharing things previously thought of as separate!
  • Form following function – processes changed before the geographical change – do not wait until the new build
  • A leap of faith that this could work WITHIN current recurrent resources – it would otherwise never have been done
  • Along came WECAC…………..
bro morgannwg emergency services transformation best programme ingredients for success
Bro Morgannwg Emergency Services Transformation (BEST) programme:Ingredients for success
  • Strong, enthusiastic clinical leadership
  • Supported and driven by committed management team
  • Executive champion
  • Mapping processes/pathways: identifying constraints, delays, duplication
  • Focus – determine what will make a difference, not what may be interesting…….
  • Use information/tools/techniques/evaluation
  • Learn from others/share good practice
  • Small step changes (PDSA cycles), Theory of constraints, LEAN methodology etc.
key diagnostic work
Key Diagnostic Work
  • Process Mapping
      • Key elements of process mapped during August / Sept
  • 7 day ED analysis
      • August 2004 – yielded limited information
  • Breach analysis
      • From September 2004 – over 5000 individual breaches analysed
  • In patient flow analysis
      • February 2005 – helped understand admission / discharge gap
  • In patient ‘snapshot’ audit
      • May 2005 – helped understand issues associated with clinician review, diagnostic delays and discharge planning
collaborative approach
Model for improvement

Specific aims

Measurement – where are the problems?

What will lead to improvement?

Ask why? - all the time

Plan-Do-Study-Act cycle

Simple things

Incremental change


Collaborative approach
success factors
Success factors
  • Streaming
  • Frontload Decision Makers
  • Clinical Pathways
  • Some easy wins
  • Access to diagnostics
  • Clinically driven IM&T
  • Minimise Duplication
  • Joined up working
  • Continual Processing
  • Bed management
  • Discharge planning
early success minors streaming
Early Success – Minors Streaming





  • Triage removed
  • Team
  • All patients for assessment
  • Assessment
  • Initiate treatment
  • Initiate Investigations (Recipe Book)
  • Who can see
  • Where can go
bratz issues
BRATZ Issues……..
  • Big investment
  • Safer
  • Increase use of XR
  • Difficult
  • How much time
  • 24/7
  • Peak times
  • Consultant & middle grade shortages
traditional patient pathway
Traditional Patient Pathway

Arrive & Book in


Emergency Dept SHO

Have a think

Do some tests

Consultant Discharge

Do take homes

Have a think

Results available

Take homes ready

Refer to Specialty

Specialty Tests

Can go home

Serum rhubarb

Transfer to “ology” ward

Care package cancelled

Plan “senior review”

Seen by consultant “ologist”

Seen by Specialty SpR

Refer to “ologist”

Decision to Admit

Seen by on call consultant

Transfer to MAU


Segregated Silo Working

Uniform Efficient Collaborative Team

clinical pathways duplication
Clinical Pathways - Duplication
  • High Impact (numbers/problems/evidence)
  • Multi-specialty
  • Diagnostic support
  • Beware “best fit”
  • Documentation from front door
  • Pooled juniors – 1st one completes
  • Added value at each step
new patient pathway
New Patient Pathway

Arrive & Book in & streamed to appropriate area/service

Senior decision maker plans care

Discharge as planned

Active bed management

Care Pathway with EDD

Discharge planned inc TTH & care

“Prescribed” investigations

Seen by appropriate team

Team “dooer”

Transfer to appropriate bed

process developments
Process developments……
  • Generic doctors or doctors with generic skills?
  • Clerking quality
  • Teamwork vs work avoidance
  • Clinical responsibility (senior & junior)
  • Communication with primary care
rapid diagnostics
Rapid Diagnostics
  • Access to diagnostics where decisions can be made on admission and discharge
  • Access to urgent out patient tests
  • Dedicated slots each day for previous days admissions
  • Access to tests 7 days a week
what pdm has delivered
What PDM has delivered
  • Introduced data entry as part of clinical process
  • Real time view of department status
  • Visual aid to pre-empt potential breaches
  • Patient whereabouts
  • Clinical usefulness
  • And demonstrated potential…
pims using technology as a tool to improve clinical processes
PIMS+: Using technology as a tool to improve clinical processes
  • Traffic light concept
  • Live view of Inpatients by:
    • ward
    • expected date of discharge (EDD)
  • Driven by simple, easy to use ADT functions
  • Helping to manage the discharge process
  • Managing beds in a live environment
  • The potential to use live information to streamline other processes
im t next steps
IM&T next steps……..
  • Dependance
  • Accuracy & timeliness
  • Confidentiality
  • ETOC – time/rapid enough
  • Stepwise EPR or wait???
  • Clinically useful vs beancounting
bed management
Bed Management
  • Bed finding
  • Critical level of occupancy
  • Forecasting tools (ADT matching)
  • Real time bed monitoring
          • Not just walking the wards
  • Ward rounds/discharge decisions 7days a week
  • Discharge planning from day 1 (pull rather than push)
  • Pharmacy
  • Discharge lounges
  • Early social care involvement
  • Discharge facilitators
in hospital process
In hospital process…….
  • Nurse facilitated
  • Weekend/OOH plan
  • Specialist nurse (DN, Resp, Card)
  • Patient to ward vs doctor to patient
  • Specialist vs generalist
  • Tertiary transfers
  • Elderly Care PDSA / NH Ward rounds?
Processes had to be in place BEFORE building work started – to compensate for the loss of space/facilities
clinical decision units
Clinical Decision Units
  • No size fits all (28 beds/trolleys?)
  • Personalities
  • Agreed clinical pathways
  • Rapid turnover - Continual “processing”
  • Multispecialty including ED
  • Joined up working
  • 24hrs / 7 days a week / 365 days a year
  • Location & Design

“By defining the top 10 presenting symptoms and developing pathways most hospitals could improve the care of 80-90% of their emergency admissions”



48 Hr

24 Hr

4 Hr


cdu next steps
CDU next steps…
  • CDU size
  • Suffers from effectiveness
  • Ineffective when inappropriate
  • Ambulatory evolution
  • Role of ACP vs OCP
  • Knock on effect on ward (LOS & dependency)










95 target
95% target…

92% Nov 2008

what s worked for us
What’s worked for us
  • No single factor responsible for improvements
    • Combined impact of multiple changes to processes including:
  • Changes to ED working
    • PDM – live information / breach prevention
    • Sieve and Sort / See and Treat
    • Majors assessment
  • Changes to Acute Assessment processes
    • Acute Care Physician
    • ED interface improvements
    • Improvements in diagnostics and discharge
  • Changes to inpatient flow management
    • PIMS+
    • Estimated dates of discharge
    • Transfer teams / discharge pull
effective resources
Effective resources?
  • Clinical engagement and lead from the start – involving several Directorates;
  • High profile Executive input and robust senior management leads;
  • Process issues addressed – detail (e.g. when Trop T taken/analysed) and staffing (identifying when required);
  • Empowering staff and encouraging PDSA cycles – have a go!
  • Reorganisation of job plans, leading to introduction of 2nd Acute Care Physician;
  • Reorganisation of Directorate structures to improve communication and remove any perceived barriers
  • Streaming – senior presence at extended triage, ambulatory streams, 24 and 48 hour areas, and also ward based working
  • Availability of “live” data – after breach takes place is too late!
  • Changes to geographical layout – bringing three separate areas together
  • Analyse impact – daily, weekly and monthly information – keep on top of things!
cannot be seen in isolation
Cannot be seen in isolation……..
  • Hawthorne Effect
  • Sustainability
          • (March madness)
  • Knock on effects
  • Generalisation
challenges for decs
Challenges for DECS
  • Consistent initial assessment & streaming pathway.
  • Realistic configuration of all UCS – safe, sustainable & clinically effective vs politically driven.
  • Balanced capacity.
  • Suitable & timely services for an ageing population.