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NHSCANCER                                                    NHS ImprovementDIAGNOSTICS   Making connections with the     ...
How big is the problem? Definition of Urgent Care: A condition that requires an assessment and planned intervention within...
Understand the real issues before you put in solutions14 COMMON ISSUES1. VARIATION IN CLINICAL PRACTICE 2. NO CLEAR DEFINE...
Triage, Treat, Transfer – Developing the right  response to meet the needChallenge: Do you know if patients are assessedap...
Test the urgency of the symptoms = Patient self-managementChallenge: Do you know how you can encourageyour patients and ca...
NHS 111 – When it’s less urgent than 999Challenge: Are your services aligned to the localDirectory of Service that informs...
Contact - Response - Action = Timely senior clinical decision makingChallenge: Do you have a communication alertprocess in...
Delivering safe care - seven days a weekChallenge: Would extending your services acrossseven days improve your outcomes? D...
Achieving integrated careChallenge: Is their willingness and determinationto achieve integrated care across whole systemsw...
NHSCANCER                                                                                                         NHS Impr...
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The challenges of unscheduled care

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Urgent and emergency care remains a high priority across the NHS as demand, length of stay and variation in practice continues to increase. NHS Improvement has worked with a number of acute hospital sites to understand the complexity of urgent and emergency care attendances, and admissions. “Making connections with the challenges of unscheduled care” shares the issues, the outcomes and identifies some tried and tested solutions that can ease the burden of unscheduled care

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Transcript of "The challenges of unscheduled care"

  1. 1. NHSCANCER NHS ImprovementDIAGNOSTICS Making connections with the challenges of unscheduled careHEART Sharing knowledge - Delivering benefitsLUNGSTROKE
  2. 2. How big is the problem? Definition of Urgent Care: A condition that requires an assessment and planned intervention within seven days, or which is likely to lead to an emergency within four weeks Definition of Emergency Care: Not always life threatening, but needs prompt assessment and a planned intervention within 24 hours 5,135,794 emergency hospital 35% over a 37% increase 40% of rising emergency admissions in England in third are in emergency admissions can be explained 2009/10 (Hospital Episodes classified as hospital by the ageing population Statistics (HES) emergency admissions hospital over the last admissions 10 years The majority of accident and Patients admitted as an emergency at emergency attendances are weekends have a higher mortality than those for medical conditions admitted on weekdays - Is this a failure to rescue or failure to access? For cancer patients - There is significant variation Haematological, Lung and in emergency admissions, Urological tumours are the bed days and length of stay highest users of emergency between NHS Trusts and cancer bed days between PCT’s Resouces and references www.rightcare.nhs.uk/atlas/downloads/nonPBC_AoV_2011.pdf www.cqc.org.uk/sites/default/files/media/documents/ip11_national_summary_final.pdf www.kingsfund.org.uk/document.rm?id=9524 www.ncepod.org.uk/2007report1/Downloads/EA_report.pdf www.rcplondon.ac.uk/sites/default/files/documents/hospitals-on-the-edge-report.pdf
  3. 3. Understand the real issues before you put in solutions14 COMMON ISSUES1. VARIATION IN CLINICAL PRACTICE 2. NO CLEAR DEFINED PATHWAYS OFCARE 3. OUT OF HOURS ACCESS, KNOWLEDGE AND INFORMATION4. VARIATION IN TIMELY SENIOR CLINICAL DECISION MAKING AT THE POINTOF ENTRY 5. MULTIPLE ENTRY ROUTES OF SINGLE ACCESS 6. LACK OFINTEGRATION AND COORDINATION ALONG THE CARE PATHWAY, LONG LENGTHSOF STAY 7. DISEASE SILOS, DISEASE THINKING ‘V’ WHOLE PATIENT, PERSONAPPROACH 8. LACK OF SYMPTOM BASED PATHWAYS 9. REACTIVE CARE –CRISIS MANAGEMENT, FOUR HOUR WAITS 10. POOR RISK MANAGEMENT/RISK STRATIFICATION BEFORE AND AFTER ADMISSION 11. THE EMERGENCYMINDSET CAUSING A NUMBER OF MISCONCEPTIONS 12. FREQUENTATTENDERS, READMISSIONS 13. LACK OF OWNERSHIP OF CASE MANAGEMENTACROSS BOUNDARIES, PRIMARY, COMMUNITY AND ACUTE CARE14. PATIENTS KNOWN TO THE SYSTEM BUT THE SYSTEM DOES NOT KNOWTHE PATIENTS6 COMMON POOR OUTCOMESDEATH: COMPLAINTS: PATIENT DISSATISFACTION, LOSS OF CONFIDENCE,WASTED RESOURCES: COMPLICATIONS: STAFF DISSATISFACTION
  4. 4. Triage, Treat, Transfer – Developing the right response to meet the needChallenge: Do you know if patients are assessedappropriately prior to the decision to admit?There are a selection of tried andtested solutions, e.g. senior clinical Whole Pathway Approachdecision making, defined symptom TRIAGEpathways, communication alerts,seven day services that allow Patient self Test the urgency of your symptoms Single call management numberpatients to be assessed and treated NHS 111in a timely way; which has an impacton quality improvement, efficiency TREAT Senior clinical decision making Defined symptom pathwaysand the patients experience. Communication alerts Ambulance Out of Community General Seven day services services hours services e.g. practice Emergency care Walk in District Nurse, Unscheduled admissions practioners Social Care should be the exception not the norm TRANSFER Hospice Day Rapid Straight Assessment Emergency or care case or access to test unit department 8,000 strokes per year home inpatient clinic 24 hours 4 hours ward outpatients could be prevented by DISCHARGE HOME using the GRASP-AF tool - Avoid unnecessary admission Proactive clinical decisions improve outcomes Reduce length of stay and readmissions This could save the NHS £96m Resouces and references www.improvement.nhs.uk/communicationalerts www.improvement.nhs.uk/definedemergencypathways
  5. 5. Test the urgency of the symptoms = Patient self-managementChallenge: Do you know how you can encourageyour patients and carers to self-manage ?Patient and carers need to know about their condition Neutropenic sepsis CDand symptoms to encourage self-management, choice Blackpool, Fylde and Wyre Hospitals NHSand to know who, where and when to access services. Foundation Trust Tested solution – Patient informed of symptomsWHY by use of DVD.• Empowers patient and carers to act• Increases knowledge to understand symptoms Stratified Pathways of Care and make choices Survivorship test sites from five acute trusts tested• Manages patients and carers expectation stratified pathways of follow up care and discovered• Increases independency an expected 70% of breast cancer patients were• Increases confidence predicted to be suitable for a supported self-• Reduces patient/carer anxiety management pathway• Reduces professional dependency Pleural effusion symptom alert card: Case study Peterborough and Stamford Hospitals NHS Aligning patient expectations with those Foundation Trust Tested solution – Patients with recurring pleural who are delivering the service is critical effusions from lung cancer are given an alert card to success informing them of symptoms. Impact • Inpatient length of stay for pleural effusion Resouces and references ranged from 0 to 4 days - is now managed as an Eight top tips for patient empowerment attendance. www.improvement.nhs.uk/documents/eight_top_tips.pdf NHS Improvement Case Studies www.improvement.nhs.uk/urgentcare/casestudies Fulfilling the Potential: A better journey for patients and a better deal for the NHS Eight Top Tips for Patient Empowerment - www.improvement.nhs.uk/documents/er_better_journey.pdf www.improvement.nhs.uk/documents/patientempowerment.pdf Stratified Pathways of Care My role and my responsiblities in helping to improve my recovery www.improvement.nhs.uk/documents/survivorship/ www.improvement.nhs.uk/documents/er_my_role.pdf Stratified_Pathways_of_Care.pdf
  6. 6. NHS 111 – When it’s less urgent than 999Challenge: Are your services aligned to the localDirectory of Service that informs patients where togo to access services in your area?NHS 111, the urgent care number for patients, will berolled out across England in 2013. NHS Pathways is one Lung and Urology clinical reference groupsof a number of clinical management systems for assessing The development of symptom pathways for NHSpatients that delivers a single clinical assessment tool Pathways/NHS 111 has drawn on clinical expertisethat provides effective triage over the telephone. from around the country. Cancer Clinical AdvisorsNHS 111 will accommodate patients to go to the right place, from Lung and Urology (high cancer emergency bedfirst time, it is based on symptom pathways, not disease day users, HES) have been involved in developingspecific pathways, and it also aligns itself to patient specific symptom pathways for pain, shortness of breath,protocols. pleural effusions, retention of urine/renal failure, visible haematuria with or without retention andClinical Commissioning Groups (CCGs) will lead on the design catheter, cough and coughing up blood.of urgent care service provision accessible in each areathrough NHS 111. The choice of provider and clinical Patients who have been treated by chemotherapyassessment services available will be aligned to a local can also be identified. Some urgent admissions canDirectory of Service (DOS). be due to the effects of treatment, having a tagged question: “Have you had treatment for cancer in the last year?” ensures the patient is directed onto the right pathway and is seen by the right person. Ensuring the alignment and positioning of initiatives (e.g. 24 hour help lines) are critical; They need to be included in Resouces and references regional plans, Clinical Commissioning www.nhs.uk/NHSEngland/AboutNHSservices/Emergency andurgentcareservices/Pages/NHS-111.aspx Groups and local Directory of Services http://webarchive.nationalarchives.gov.uk/+/www.dh. (DOS) that link to NHS 111. gov.uk/en/MediaCentre/FAQ/DH_119189 ‘Getting to grips with integrated 24/7 emergency and urgent care’ - NHS Alliance, 2012
  7. 7. Contact - Response - Action = Timely senior clinical decision makingChallenge: Do you have a communication alertprocess in place and do you know how timely yoursenior clinical decision making is?The provision of timely senior clinical decision makingcan have a significant impact on quality improvement,efficiency and the patients experience.Communication alerts let nominated clinicians knowthat patients have arrived, where they are, and wherethey may be admitted to. The key in any alert system is ensuring the responsibility for placing and taking of alerts and ensuring they get acted on. Alerts at Sandwell and Birmingham Hospitals released 3,500 bed days and reduced admission rates by 12% Resouces and references www.improvement.nhs.uk/documents/ CommunicationsAlerts.pdf
  8. 8. Delivering safe care - seven days a weekChallenge: Would extending your services acrossseven days improve your outcomes? Do you knowhow many deaths happen at weekends? Are youdoing enhanced recovery for your emergencypatients?Extending services across the whole week, improves Seven day whole care pathway approach toequality of treatment and outcome regardless of the enhance recovery of emergency and electiveday of the week. patients South Devon Healthcare NHS Foundation TrustNo ‘one size fits all’. There are different service models Emergency ward rounds carried out twice a day, sevento ensure flow of patients along care pathways from a days a week in medicine.whole hospital wide approach to a departmental Moving from a six to a seven day all day trauma list andapproach. identifying a surgical consultant of the week improved patient care, quality and efficiency. Clinical decision making through consultant presence Shouldn’t every one of us have provides earlier diagnosis, management and discharge. the best chance possible, no Impact • Earlier diagnosis with 24 hour radiology and matter what time of day or day reporting and timely decision making • Reduction in emergency fracture neck of femur of week it is? LOS from 10 to 5 days. Patient Representative Consultant led one-stop TIA service University Hospital of Leicester NHS Trust Patients are assessed and receive appropriate investigations, diagnosis and treatment, including Resouces and references referral for carotid intervention, in a single visit to www.improvement.nhs.uk/sevendayservices the hospital seven days a week. Impact • 70% of patients are now seen within 24 hours compared to baseline of 33%.
  9. 9. Achieving integrated careChallenge: Is their willingness and determinationto achieve integrated care across whole systemswithin your health community?Integrated care is what the NHS,social care and the voluntary sector The integration between hospital and community services for Whittingtonthrive for, however in reality it Health has made it easier to provide ambulatory care for people that previously may have needed an emergency admission. District nurses andstretches many organisations, and community matrons visit emergency departments and acute medical unitsis not easy to achieve. daily to identify patients who can be better managed at home. An example of this is providing IV antibiotics at home rather than as an inpatient. Celia Ingham Clark, Associate Medical Director, Whittington Health and NHS LondonRecommendations toachieve integration Communication: To ensure Direction: Establish engagement develop steering groups to drive robust communication the work mechanisms Time: Without Engagement and Evaluate and investment in time, ownership: Identify measure: Need to and people integration the common demonstrate outcomes is unlikely to be denominators across in quality, efficiency successful all organisations and patient Leadership: You Assumptions: Test need executive, them out, solutions operation and clinical that work in one area leadership across ALL many not work in organisations another, adapt Patients and carer Stability and Win - Win: Align involvement: Listen, sustainability: the integration to they know what Continue to test the organisations strategic happens, it happens strength of the objectives to them integration
  10. 10. NHSCANCER NHS ImprovementDIAGNOSTICSHEART NHS Improvement NHS Improvement’s strength and expertise lies in practical service improvement. It has Scan the QR code for quick and over a decade of experience in clinical patient pathway redesign in cancer, diagnostics, easy access to heart, lung and stroke and demonstrates some of the most leading edge improvement the enhancedLUNG work in England which supports improved patient experience and outcomes. recovery website. Working closely with the Department of Health, trusts, clinical networks, other health sector partners, professional bodies and charities, over the past year it has tested, implemented, sustained and spread quantifiable improvements with over 250 sites Scan the QR codeSTROKE for quick and across the country as well as providing an improvement tool to over 2,000 GP practices. easy access to the publication Fulfilling the NHS Improvement Potential. 3rd Floor | St John’s House | East Street | Leicester | LE1 6NB Telephone: 0116 222 5184 | Fax: 0116 222 5101 www.improvement.nhs.uk Follow us on: Publication Ref: NHSIMP/urgentcare001 - November 2012 ©NHS Improvement 2012 | All Rights Reserved Delivering tomorrow’s improvement agenda for the NHS

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