Acute Medicine: The Scottish perspective Essential actions, flow - - PDF document

10/5/2018 1

Acute Medicine: The Scottish perspective

Essential actions, flow and a touch of realism

@djbeckett

10/5/2018 2

10/5/2018 3

10/5/2018 4

Why SAM Scotland?

10/5/2018 5

“The Scottish Patient Safety Programme marks Scotland as leader, second to no nation on earth, in its commitment to reducing harm to patients dramatically and continually”

Donald M Berwick, MPP Former President and CEO Institute for Healthcare Improvement

Fill rates

0% 20% 40% 60% 80% 100% Scotland England

Fill rates, A(I)M, 2015

0% 20% 40% 60% 80% 100% 2013 2014 2015

Acute (Internal) Medicine fill rates, Scotland

Unfilled Filled

10/5/2018 6

SAM Scotland

• Hosted by RCPE
• Route of entry through SAM UK, initially with no

additional cost (regional representation)

• Annual conference (next is December 14th 2018 at

FVRH…)

@weeSAMScotland

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 2013 2014 2015 2016 2017 2018

Acute (Internal) Medicine fill rates, Scotland

Unfilled Filled

10/5/2018 7

Scottish Government

• ‘Acute Physicians play a key role in the Unscheduled

Care process and we are keen to see a vibrant and representative SAM Scotland work with us and the

• ther key partners to improve patient and staff

experience which are inextricably linked’ Alan Hunter, Director of Performance,

10/5/2018 8

Emergency Access Standard

• The Emergency Department cannot deliver

this target alone

• It requires a whole system response to ensure

capacity meets demand - by hour of the day and day of the week

• Whole system barometer

Charles Goodhart

10/5/2018 9

Crowding

There is an association between ED crowding and:

• Mortality
• Increased length of stay both in ED and I/P
• Reduced quality of care
• Poor patient experience
• Staff burnout
• Difficulty recruiting and retaining staff

10/5/2018 10

5.1% 3.6% 5.4% 1.3% 4.6% 2.0% 3.0% 6.1% 0% 1% 2% 3% 4% 5% 6% 7% 8% 9% 10% 11% 12% 13% 14% 15%

08/11/2009 22/11/2009 06/12/2009 20/12/2009 03/01/2010 17/01/2010 31/01/2010 14/02/2010 28/02/2010 14/03/2010 07/11/2010 21/11/2010 05/12/2010 19/12/2010 02/01/2011 16/01/2011 30/01/2011 13/02/2011 27/02/2011 13/03/2011 06/11/2011 20/11/2011 04/12/2011 18/12/2011 01/01/2012 15/01/2012 29/01/2012 12/02/2012 26/02/2012 11/03/2012 11/11/2012 25/11/2012 09/12/2012 23/12/2012 06/01/2013 20/01/2013 03/02/2013 17/02/2013 03/03/2013 17/03/2013 31/03/2013 14/04/2013 28/04/2013 12/05/2013 26/05/2013 09/06/2013 23/06/2013 07/07/2013 21/07/2013 04/08/2013 18/08/2013 01/09/2013 15/09/2013 29/09/2013 13/10/2013 27/10/2013 10/11/2013 24/11/2013 08/12/2013 22/12/2013 05/01/2014 19/01/2014 02/02/2014 16/02/2014 02/03/2014 16/03/2014 30/03/2014 13/04/2014 27/04/2014 11/05/2014 25/05/2014 08/06/2014 22/06/2014 06/07/2014 20/07/2014 03/08/2014 17/08/2014 31/08/2014 14/09/2014 28/09/2014 12/10/2014 26/10/2014

Scotland: weekly, self-reported acute inpatient boarding rates, Nov 2009 to Oct 2014

Proportion of estimated staffed acute inpatient beds reported occupied by boarded patients, %

Sources: (i) SG weekly monitoring submissions; (ii) hospital-level ISD(S)1-derived ISD IR2012-00483 and hospital bed statistics publications Notes: (i) interpretation of inpatient boarding definition may vary between Health Boards, hence caution should be taken when interpreting trends; (ii) reported measure changed from Mon census in 2009/10 to bed day usage from 2010/11; (iii) data imputed where required, except for Highland Health Board, for which no consistent data are available; (iv) results are intended for management information only

Health Board variation

2010/11 onwards: total boarded bed days 2009/10: boarder census at Mon 23.59 Nov 2012 onwards: continuous collection of weekly monitoring submissions

Standardised results

Summary

Multilevel model standardisation

Expected values: Crude rates: Non- boarded, no sitespec boarding Non- boarded, site- specialty boarding present Boarded, site- specialty boarding present Non- boarded, no sitespec boarding Non- boarded, site- specialty boarding present Boarded, site- specialty boarding present Total

Spells 31.6% 59.2% 9.2% 981,798 1,836,546 285,688 3,104,032

days, n

3.2 4.3 5.3 1.7 4.5 9.4 4.1

99% CI

3.1 4.2 5.0 99% CI

3.4 4.4 5.6

7 days, %

3.7% 4.5% 5.2% 3.3% 4.8% 4.9% 4.3%

99% CI

3.6% 4.5% 5.0% 99% CI

3.8% 4.5% 5.3%

30 days, %

7.9% 9.5% 10.7% 6.4% 10.3% 11.5% 9.2%

99% CI

7.8% 9.4% 10.5% 99% CI

8.0% 9.5% 10.8%

7 days, %

2.1% 2.4% 2.6% 1.0% 2.8% 3.7% 2.3%

99% CI

2.0% 2.4% 2.5% 99% CI

2.1% 2.4% 2.7%

30 days, %

3.0% 3.4% 3.8% 1.5% 4.1% 5.6% 3.4%

99% CI

3.0% 3.4% 3.7% 99% CI

3.1% 3.5% 3.8%

Spell LoS: Emergency readmission within, of discharge: Death within,

• f discharge:

10/5/2018 11

Standardised results

Summary

Multilevel model standardisation

Expected values: Crude rates: Non- boarded, no sitespec boarding Non- boarded, site- specialty boarding present Boarded, site- specialty boarding present Non- boarded, no sitespec boarding Non- boarded, site- specialty boarding present Boarded, site- specialty boarding present Total

Spells 31.6% 59.2% 9.2% 981,798 1,836,546 285,688 3,104,032

days, n

3.2 4.3 5.3 1.7 4.5 9.4 4.1

99% CI

3.1 4.2 5.0 99% CI

3.4 4.4 5.6

7 days, %

3.7% 4.5% 5.2% 3.3% 4.8% 4.9% 4.3%

99% CI

3.6% 4.5% 5.0% 99% CI

3.8% 4.5% 5.3%

30 days, %

7.9% 9.5% 10.7% 6.4% 10.3% 11.5% 9.2%

99% CI

7.8% 9.4% 10.5% 99% CI

8.0% 9.5% 10.8%

7 days, %

2.1% 2.4% 2.6% 1.0% 2.8% 3.7% 2.3%

99% CI

2.0% 2.4% 2.5% 99% CI

2.1% 2.4% 2.7%

30 days, %

3.0% 3.4% 3.8% 1.5% 4.1% 5.6% 3.4%

99% CI

3.0% 3.4% 3.7% 99% CI

3.1% 3.5% 3.8%

Spell LoS: Emergency readmission within, of discharge: Death within,

• f discharge:

10/5/2018 12

Six Essential Actions Improvement Approach

• Launched in May 2015
• Developed in partnership with the Academy of Royal

Colleges, NHSScotland and Scottish Government

• Aims to improve the patient and staff experience of

Unscheduled Care

• Delivery of 95% target for all patients to be admitted,

discharged

• r

transferred from the Emergency Department within 4 hours.

• Aiming towards a standard of 98%
• Ministerial objective

10/5/2018 13

Clinically Focussed Empowered Leadership Responsive Operational Management Whole System Escalation Triumvirate Leadership Team

• Site Director,
• Chief Nurse,
• Chief Doctor

Capacity and Patient Flow Realignment

Determining and utilising appropriate information and trend data for performance improvement to ensure correct resources are applied to meet demand and system need

Patient Rather Than Bed Management

Daily Dynamic Discharge Shifting the discharge curve left Developing a coordinated, multidisciplinary approach to discharge planning encompassing acute and community resources

Medical and Surgical Processes Aligned for Optimal Care

Designed to pull patients from ED through assessment and diagnostics process to be seen at right time, by right person in right place

7 Day Services

To reduce variation in access to all services across weekend and out of hours. Includes clinical assessment, diagnostics, and access to Senior Decision Makers. Also support services such as porters, cleaning and transport

Ensuring Patients Care for at Home

Pathways to reduce attendance, avoid admission and if admission necessary ensure home when ready

Basic Building Blocks

Improve rate of early in day and weekends Signposting and redirection to appropriate community services

26 Admissions Discharges

Emergency admissions with ED* LoS > 4 hr, % Scheduled and direct admissions Hospital discharges

with XRI AU LoS > 24 hr

10/5/2018 14

Daily Dynamic Discharge

Make sure we align the clinical and therapeutic pathways Creating the Plan

Dynamic MDT Planning from admission - EDD Effective Ward Rounds – management planning Daily Communication of Changes Dependant tasks considered

Executing the Plan

Rapid Daily Whiteboard Meetings (sick, discharge, new) x 2 per day Ordered ward rounds (sick, discharge, new) Non-slip task management Check, chase, challenge reinforcement In the moment escalation

Discharging when ready

Following criteria for discharge Escalation/expediting of delay causing tasks Discharge lounge? S H I F T T H E C U R V E

How we DDD on Ward 7C

IN THE MORNING:

• At 9am

We choose:

• A facilitator, task sheet scribe and

ward view updater We discuss:

• Sick patients/safety issues
• Patients for discharge today and

tomorrow

• Any relevant others (new patients/

urgent tasks) We agree:

• Things that need done TODAY, by

whom, by when (write on task sheet) We summarise:

• Bed numbers to be seen first

We finish:

• By copying the task sheet for each

team IN THE AFTERNOON:

• At 3pm

We choose:

• A facilitator, task sheet scribe, ward

view updater We discuss:

• Task sheet from this morning
• Plans for all patients – EDD, tasks etc

We agree:

• Any new tasks to be added to today’s

sheet (from ward rounds)

• Any changes to earlier tasks
• Escalations (preventing/possibly

preventing discharge) We summarise:

• What ELSE needs done TODAY

We finish:

• Agree to mark task sheet off before

leaving/handover to next shift SIGNED (SCN): SIGNED (CONSULTANT:

MANAGE TODAY PLAN FOR TOMORROW

10/5/2018 15

Noon

PRE-NOON

Noon 14% - February 2017 26% - February 2018 12% improvement in one year

PRE-NOON

10/5/2018 16

2pm 29% - Feb 2017 46% - Feb 2018 17% improvement in one year

PRE-2PM

3pm 60% - Feb 2018 42% - Feb 2017 18% improvement in one year

PRE-3PM

10/5/2018 17

10/5/2018 18

Variability Methodology

Analyse data to assess variability in patient flow Select flow priority based on

• pportunities to

reduce variation identified in analysis Develop standardised clinical processes to identify natural and artificial variation Implement and monitor standardised clinical processes. Collect data for modelling and benefits Construct model

• f improved flow

Use simulation and analysis to identify appropriate capacity to meet scheduled & unscheduled demand Select redesign recommendation and implement changes e.g. cohort homogenous groups Benefits Realisation

10/5/2018 19

10/5/2018 20

Variability: Daily Number of Surgical Cases

Elective Urgent Emergency Natural Variation Artificial Variation

10/5/2018 21

10/5/2018 22

10/5/2018 23

1500 1600 1700 1800 1900 2000 2100 2200 2300 2400 2500 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16

Admissions to FVRH AMU

Patients

75% 80% 85% 90% 95% 100% Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16

FVRH compliance with the emergency access standard

Percent

80.9%

97.4%

10/5/2018 24

47

KEEP CALM

AND

MANAGE VARIABILITY

10/5/2018 25

10 20 30 40 50 60 70 80 WB21 (235) WA32 (407) WA31 (501) WB22 (192) WA11 (519) WA12 (574) WA21 (18) WB32 (551) WB12 (776) Card (421) WB11 (868) WA22 (373) WB23 (111) WB31 (356) Average AU LOS (Hours) Unit (Number of AU Admissions to Unit)

• 14. Average AMU LOS by Post-AMU Admitting Unit

in Hours with 10th/90th Percentile Error Bars NHS Forth Valley, [01-Jan-2014 to 30-Jun-2014], All Days Numbers in parentheses = Total AU admissions to unit

10 20 30 40 50 60 70 80 WB21 (235) WA32 (407) WA31 (501) WB22 (192) WA11 (519) WA12 (574) WA21 (18) WB32 (551) WB12 (776) Card (421) WB11 (868) WA22 (373) WB23 (111) WB31 (356) Average AU LOS (Hours) Unit (Number of AU Admissions to Unit)

• 14. Average AMU LOS by Post-AMU Admitting Unit

in Hours with 10th/90th Percentile Error Bars NHS Forth Valley, [01-Jan-2014 to 30-Jun-2014], All Days Numbers in parentheses = Total AU admissions to unit

10/5/2018 26

6.0 9.5 8.2 8.0 7.9 7.5 5.7 7.9 2.9 5.8 4.8 5.6 4.9 4.2 3.0 4.8 0.00 1.00 2.00 3.00 4.00 5.00 6.00 7.00 8.00 9.00 10.00 Sun (1.70) Mon (4.34) Tue (4.54) Wed (4.37) Thu (4.16) Fri (5.18) Sat (2.00) Overall (26.33)

Average/ Median LOS (in days)

DOW of Discharge/Transfer-out

LOS by DOW Of Discharge/ Transfer-out (Based on Actual Move Date)

NHS FV, Ward B32, Jan'13 - May'15, All Days

Average LOS Median LOS

Note: LOS calculated based on Date & Time

51 51

ADT Criteria

10/5/2018 27

Downstream Ward Median Discharge Times

2014 2015 2016 Median Discharge Time Median Discharge Time November A12 16:00 15:07 14:17 A31 16:03 15:00 14:47 B12 16:14 15:38 15:33 B32 16:00 14:34 14:30 Ward

3039 annualised bed days saved

10/5/2018 28

84 86 88 90 92 94 96 98 100 102 104 106 10 20 30 40 50 60 70 80 11/2/15 12/2/15 1/2/16 2/2/16 3/2/16 4/2/16 5/2/16 6/2/16 7/2/16 8/2/16 9/2/16 'Core' bed occupancy Number of boarders

FVRH 'core bed' occupancy and number of boarders

Core' bed occupancy Boarders 50 100 150 200 250 300 350 400 450 500

FVRH 'wait for AMU bed' breaches, Oct 2014-Sep 2016

10/5/2018 29

Sustained improvement New Temporary Median of 1.16 Provisional reduction of 54% 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 Jan 13 Mar 13 May 13 Jul 13 Sep 13 Nov 13 Jan 14 Mar 14 May 14 Jul 14 Sep 14 Nov 14 Jan 15 Mar 15 May 15 Jul 15 Sep 15 Nov 15 Jan 16 Mar 16 May 16 Jul 16 Sep 16 Nov 16 Jan 17 Rate per 1000 discharges

Cardiac Arrest Rate

NHS Forth Valley FVRH

10/5/2018 30

10/5/2018 31

Most people in Scotland with any long term condition have multiple conditions

23 13 7 5 48 31 23 22 18 14 13 9 7 6 3 22 21 17 13 20 23 21 24 19 20 21 16 13 14 9 18 21 20 18 12 16 17 19 17 19 21 19 16 18 14 36 46 56 64 21 29 39 35 47 47 46 56 65 62 74 0% 20% 40% 60% 80% 100% Depression Schizophrenia/bipolar Anxiety Dementia Asthma Epilepsy Cancer Hypertension COPD Diabetes Painful condition Coronary heart disease Atrial fibrillation Stroke/TIA Heart failure

Percentage of patients with each condition who have other conditions This condition only This condition + 1 other + 2 others + 3 or more others

10/5/2018 32

Public Finances – Fall in Government Expenditure

10/5/2018 33

Realism in Healthcare

• Doctors generally choose less treatment for

themselves than for patients

• Striving to provide relief from disability, illness and

death, modern medicine may have overreached itself – is it now causing hidden harm?

• Focus on unwarranted variation in clinical practice

and outcomes

• Multiple conditions – management leading to
• ver-complex medical regimes?
• Clinicians have duty to acknowledge

powerlessness at times

JJ Gallo et al. Life-sustaining treatments: what do physicians want and do they express their wishes to others? J Am Geriatr Soc. 2003 Jul;51(7):961-9.

10/5/2018 34

Value Based Healthcare

10/5/2018 35

Reducing harm and waste

• Harm in healthcare not just missed diagnoses
• r under-intervention but ‘hidden harm’ exists

in over treatment, excessive interventions and medicalising normality.

– This is far harder to measure.

• Focus on better value care – including ‘the

gentle art of doing nothing’

– This isn’t always in the nature of Acute Physicians…

Gawande, A. (2014). Being mortal: Medicine and what matters in the end (First edition.). New York: Metropolitan Books.

10/5/2018 36

Over-investigation and over- diagnosis…

10/5/2018 37

10/5/2018 38

10/5/2018 39

Doctors and risk

• Managing risk is an inherent part of our

role

• There is risk associated with every clinical

decision, whether it is to do something or to do nothing

• The importance of positive risk taking –

avoidance raises anxiety rather than reduces it

• It is psychologically healthy to stimulate

and empower ourselves by taking risks

10/5/2018 40

So…‘Realistic Acute Medicine’?

How are we doing?...

10/5/2018 41

Variation between AMUs

• We all know it exists
• It’s very hard to measure
• Poor coding
• Activity data variably recorded

– Admission vs Attendance vs Ambulatory Care – In-patient vs Out-patient

10/5/2018 42

10/5/2018 43

Imison C and Vaughan L (2018) Acute medical care in England: Findings from a survey of smaller acute hospitals. Slide-set resource. www.nuffieldtrust.org.uk/research/acute-medical-care-in- england-findings-from-a-survey-of-smaller-acute-hospitals

10/5/2018 44

Variation within an AMU

40.0% 45.0% 50.0% 55.0% 60.0% 65.0% 70.0% A B C D E F G H I J K L M N O P Q R S T U V

Direct discharge rate from FVRH AMU, per consultant physician 2014-2016

Practising Realistic Acute Medicine is hard…

10/5/2018 45

10/5/2018 46

10/5/2018 47

Where do we start?

• Hunt out the dogma and the

pseudoaxioms

• Look for ‘Must’, ‘All’ and ‘Should’…

All admissions to an Acute Medical Unit need a set of baseline bloods

All admissions to an Acute Medical Unit need a baseline ECG

All patients with pneumonic consolidation must have follow up CXR

All patients admitted to an AMU with an overdose must be reviewed by psychiatry before discharge

All patients with ‘CT-negative’ thunderclap headache need a lumbar puncture…

All patients with ‘fast AF’ need to be admitted to hospital…AND on a cardiac monitor…

10/5/2018 48

10/5/2018 49

drlynndickson drlynndickson

10/5/2018 50

‘Right person, right place, right time’ #RightCareEveryTime

Acknowledgements

• Six essential actions (@6EAScot)

– Helen.Maitland@scot.gov, National Director – Andrea.Jamieson@scot.gov – Jacques.Kerr@scot.gov, National Clinical Lead for UC

• Patient flow program (@patientflowsg)

– Martin.Hopkins@scot.gov – Institute for Healthcare Optimization

• Realistic Medicine (@RealisticMed)

– @drgregorsmith, Deputy CMO – @CathCalderwood1, CMO – @damson29, National Clinical Lead for Realistic Medicine – @ChristineGregs5, ST7 in GIM and ID

10/5/2018 51

@djbeckett @weeSAMScotland #RightCareEveryTime