In November 2014 Sherwood Forest Hospitals was the second to the bottom in the ED 4 hour target performance in England. The ED department had been rated as ‘inadequate’ for safety in 2015 and the trust had seventeen patients breach 12 hours during December 2014 and January 2015. We recognised that this was not just a problem for ED to solve and so created the Emergency Flow Programme, which is organisation wide. Our most significant improvement has been to become the best performer of the 4 hour ED target in England in October 2016.
Challenges
•Non achievement of the 4 hour target. Our performance was 88.52% in quarter 3 for 15/16
•Poor use of our Ambulatory Care Unit.
•Seventeen patients breached the 12 hour ED target.
•A lack of flow and engagement with the rest of the organisation, with an average length of stay (LOS) of over 8 days (when critical care, neonates and paediatrics are excluded).
•Sepsis compliance at 46%.
Actions
•Established the Emergency Flow Programme. This was an organisational wide group, sponsored by the Chief Operating Officer and Clinical Director for Emergency Care and Medicine. It recognised emergency care would only be successful if flow was improved by enabling safe and timely discharges of patients from base wards.
•Worked with primary care to improve diversion and introduced the single front door model.
•Establish a Short Stay Unit that provides quality care for patients and ensures discharges happen within 72 hours of admission.
•Agreed availability of a social worker in ED, seven days a week.
•Increased consultant cover to 7 days a week 8am – 11pm.
Results
•Achieved the four hour target and sustained that improvement. We are currently at 96.67% for quarter three 16/17.
•Increased sepsis compliance from 46% to over 95% consistently. There are graphs to demonstrate the improvement in the supporting material.
•Increased the number of patients diverted to primary care. It is now at 20% of the total ED attendances, which saves the health economy £1.28m gross.
•Reduced the number of patients who breached 12 hours. There has been one in April 2016 and this was a patient who was at the Minor Injuries Unit at Newark and who should have been transferred to Kings Mill Hospital. This is not technically a breach, but was reported to NHSE in the spirit of being open and transparent.
•Increased the number of patients who are discharged from the Short Stay Unit from 25 per week to over 90 per week.
Value
•Fewer patients were attended ED due to better diversion at the front door, giving a gross saving to the health community of £1.28m per annum.
•More patients have been seen in ambulatory care meaning fewer patients have been seen in EAU. This is forecasted to save the health community £500k per annum, but will increase as more patients are admitted to an ambulatory care pathway.
•As a consequence of improving flow we have managed to close 94 funded beds which has saved the organisation £2.75m Cost Improvement Plan (CIP) recurrently.
•Staff sickness rates have reduced from an average of 3.68% in 2015/2015 to an average of 2.12% for 2015/2016. For the year to date we have an average of 1.77% sickness rate in ED.
•Sepsis compliance has increased from 46% to over 95%
•More patients are seen in ED within 4 hours. We have increased our performance from 88.52% in Q3 of 2014/15 to 96.67% Year To Date (YTD).
In detail
AMBITION
Whilst the main objective of the Emergency Flow programme was to ensure more patients were treated within 4 hours in ED, we recognised that the only way to do this was to improve the flow of patients across the whole hospital and specifically to ensure patients were discharge back to their usual place of residence in a safe and timely manner. Our length of stay was significantly higher than the national average and so we knew there was an opportunity to safely improve our performance. Other key performance indicators included reducing the number of patients who waited in the department more than 12 hours and increasing the sepsis compliance in ED.
The programme focused on increasing diversion of patients to primary care; working with community and social care partners to increase the number of patients where we safely avoided an admission; increasing the number of patients admitted onto an ambulatory care pathway; increasing the number of patients admitted to the short stay unit and reducing the average LOS. All of this improvement work has been undertaken in conjunction with our CCG colleagues, staff from the local authority (specifically housing department) and social care, third sector organisations and community health colleagues.
Important teams within the community health organisation are the ‘Call for Care’ team which operates a single phone number 24/7 that emergency care staff can access in order to secure care that will enable the patient to be discharge back home; the Emergency Department Avoidance Support Scheme (EDASS) and the Frailty Intervention Team (FIT) both of which are a combination of staff from health (acute and community) and social care and who work within ED and EAU to help prevent admission where possible by initiating and/or bridging packages of care.
The programme informs and is informed by the Better Together vanguard work to ensure we reduce the number of patients who actually arrive at ED. Our plan was informed by best practice guidance from the Ambulatory Emergency Care Network, Royal College of Emergency Medicine, the Primary Care Foundation, 5 Year Forward Plan, the relevant policy briefings from the Nuffield Trust, appropriate reports from the Kings Fund, and NHS England’s publications on improving urgent care.
OUTCOME
This programme of work has already achieved its original plan to ensure we achieved the 4 hour target more consistently. We have moved from second bottom to being the best in October 2016. The sickness level has fallen to an average of 3.68% in 2014/15 to 1.77% YTD 16/17 and we currently have 100% of our ED nursing posts filled with permanent members of staff. As a consequence of the targeted work in ED we have increased the sepsis compliance from 46% to over 95% consistently. This has aided the significant reduction in HSMR from 118 to 90. There are graphs to demonstrate our improvement in the supporting material.
SPREAD
The Emergency Flow Programme started in ED and EAU and focused on medicine wards and then became an organisational and system wide programme. We included diagnostic departments, facilities team and then the wider health and social care colleagues. We have recently been visited by University Hospitals of Leicester who are interested in understanding how we manage to consistently achieve the 4 hour target.
VALUE
The programme has seen savings to the health community of £1.28m gross through increasing diversion of patients to primary care and £500k as more emergency activity being put through ambulatory care rather than being admitted to an inpatient bed. The organisation has seen an increase in admitting and discharging patients from our short stay unit, from an average of 25 per week at the start of the project, to over 90 per week now. We have also improved our use of the discharge lounge from 55 patients per week to over 100 per week, which helps the flow of patients in the hospital especially earlier in the day.
The improvement in flow was achieved by reducing the LOS which in turn enabled the closure of 94 funded and 20 unfunded beds, which has saved the organisation £2.75m CIP recurrently. At the same time the organisation has reduced its length of stay by almost 2 days; closed 94 unfunded beds with no elective surgical cancellations for beds; seen an 11% increase in ED attendances and achieved its CIP targets for 15/2016 and is on track to deliver it for 2016/2017. This is unique within the NHS in the timescales involved against the required cost savings.
INVOLVEMENT
As a consequence of being unable to prevent seventeen patients breaching the 12 hour target in winter 14/15, the ED department we keen to learn lessons and one of the actions they undertook was to video and record the stories of two of the patients who had endured a 12 hour wait in ED in January 2015. This was shared with staff in the organisation and those from our CCG and community colleagues.
It was a reminder of why we needed to make the improvements that were so necessary. Internally matrons from the wards now attend the four daily flow meetings which are designed to understand the performance in ED and how the organisation can respond to any problems to ensure patients are treated in a safe and timely manner. When we are on black alert our medical heads of service attend the flow meetings.
The radiology team committed to undertake any CT request made on any day before 8pm on that day. ED and EAU could not have improved their performance as well as it has without the support of colleagues from the community health provider, social care, third sector, local authority colleagues and our CCG.
The EDASS and FIT teams are multi-agency teams whose complete focus is to ensure we avoid admitting any patient that could safely return to their usual place of residence on the same day as they attend ED. A similar multi-agency team meet on a daily basis to discuss patients who are in delay on the base wards, which is designed to improve the flow of the emergency pathway.
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