Whittington Health Enhanced Recovery Health System Dr Martin Kuper Medical Director and Intensive Care Consultant Whittington Health, London Previously National Clinical Advisor to NHS Improvement Clinical Lead for Enhanced Recovery in London Presentation from Shaping the Future Direction of Enhanced Recovery Care Pathway Seven Days a Week workshop held in London on 5 December 2013

1. Whittington Health
Enhanced Recovery
Health System
Dr Martin Kuper
Medical Director and Intensive Care Consultant
Whittington Health, London
Previously…
National Clinical Advisor to NHS Improvement
Clinical Lead for Enhanced Recovery in London

3. Clinical strategy
Ambulatory
care
Enhanced
recovery
Integrated
care

4. Integrated Care
•
•
•
•
•
Coordinate health and social care
Patients targeted:
–
Complex
–
65+ / LTCs
–
Frequent ED attenders
–
High users of social services
Now 4 locaity MDT teams
Discussed more than 500 patients
Integrated Care MDT Teleconferences
•
GPs – the lead clinician
•
Community Health Teams (DNs, CMs)
•
Hospital Pharmacist
•
Social Services
•
Consultant physician (NMH or Whittington)
•
Consultant psychiatrist (BEH MHT)
Preliminary results – but risk regression to mean
•
17% reduction in A&E attendances
•
86% of the patients had fewer admissions
afterwards

5. All care should be
ambulatory or enhanced recovery

6. Ambulatory Care
8
7
6
•
•
•
•
•
•
•
•
•
Senior decision making, advanced diagnostics
Consultants - Acute Medicine/ ED
Ambulatory Care Coordinator
Community Matrons
Patient and staff designed area and pathways
Leverage community services
Avoid unnecessary admissions
Support discharges - reduce length of stay
DVT ADMISSIONS
Pharmacist
5
Total
4
median total
3
2
1
0
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

7. Ambulatory Care
Directory of Ambulatory Care - medical
NHS Institute of
Innovation &
Improvement,
Directory of
Ambulatory
Care, 2012
Average LOS for Directory of Ambulatory Care (Medical Conditions)
8
General
Medical
conditions only
7
6
Monthly
To August 2013
5
4
3
8/31/2013
6/30/2013
4/30/2013
2/28/2013
12/31/2012
10/31/2012
8/31/2012
6/30/2012
4/30/2012
2/29/2012
12/31/2011
10/31/2011
8/31/2011
6/30/2011
4/30/2011
2/28/2011
12/31/2010
10/31/2010
8/31/2010
6/30/2010
4/30/2010
2
Month
Reduction in LOS coincides with increase in Ambulatory Care in Summer 2012 (subset of overall Medical LOS
(see previous chart).
Directory of Ambulatory Care used as a proxy for conditions suitable for Ambulatory Care

8. Ambulatory Care
Throughput
Count of ED
attendances
where location =
“AEC”
900
Volume of Ambulatory Care attendances
800
700
Monthly data
To October 0213
600
500
400
300
200
100
Activity
Feb-14
Dec-13
Oct-13
Aug-13
Jun-13
Apr-13
Feb-13
Dec-12
Oct-12
Aug-12
Jun-12
Apr-12
Feb-12
Dec-11
Oct-11
0
Plan
Interim Model from March 2012, Initial implementation complete by summer 2012 with gradual increase to max capacity
Current activity is below plan
Increased activity in November 2013 to February 2014 -extended opening hours (620 pm)
Increased activity in March 2014 - scheduled opening of the new unit – increases in14/15 to 1650 pm.

9. Ambulatory Care
9

10. …getting better sooner
Enhanced Recovery
…getting better sooner
ENHANCED RECOVERY
HOSPITAL

11. IST
summary
GP referrals
MAU – multiple
handovers within
and between
day.
Social
care
Handover
Home
MAU
Specialist units
D+T OPA
A+E
Referrals
Churn
IC
Handover
Handover
Handover
Churn

12. Ambulatory care
Emergenc
y
Departmen
t
Ambulator
y care
Adult
Admissio
n Unit
Specialit
y Wards
Speciality
pathways
a) Medicine
Intensive
Care
Elderly
Care
Acute ER / Going home bundle
ACU

13. Improvement and information
• Improvement is not an accident and needs to be
resourced
• Information is key

14. Enhanced recovery from acute
illness
function
time

15. Common elements
•
•
•
•
•
•
•
•
Involvement
Clothes
Nutrition
Hydration
Mobilisation
Sleep
Pain
Discharge planning

16. Standardised condition
specific management
eg sepsis checklist
‘Variation is the enemy of Quality’
W Edwards Deming

17. ER training programme
• 09:10 What is Enhanced
Recovery?
• 09:55 Skills for supporting
patient engagement
• 10:15 The role of volunteers
• 10:45 Specific areas
– Mobility and Strength
(OT/Physio)
– Yellow Plan and links to
discharge checklist
– Pain
– Nutrition & positioning for
feeding
– Sleep
– Hydration
•
•
•
•
•
•
•
•
12:00 Going home bundle
Rationale for focusing on patient flow
Criteria for Discharge &EDDs
12:35 Board rounds & whiteboards
12:55 Morning Discharges
13:10 The discharge checklist
14:15 Delays escalation
14:30 Community Referrals (District
Nursing)
• 15:05 Working with social services
• 15:35 Continuing Health Care
• 15:55 Equipment

21. PROGRESS

22. Enhanced recovery after hip fracture

23. Emergency Medical LOS
Excludes
admissions to
ISIS Ward
under the ED
consultants.
Emergency Medicine Average LOS
10
9
8
7
6
Aug-13
Jun-13
Apr-13
Feb-13
Dec-12
Oct-12
Aug-12
Jun-12
Apr-12
Feb-12
Dec-11
Oct-11
Aug-11
Jun-11
Apr-11
Feb-11
Dec-10
Oct-10
Aug-10
Jun-10
Apr-10
5
Month
Interim model started mainly with Medical patients. See activity chart for Ambulatory Care – there is a drop in
Medical LOS at the same time as increased Ambulatory Care increased

24. ER in Medicine/Going Home Bundle
Average LOS for patients over 70 years
Average LOS
for discharged
patients aged
70 or over.
Average LOS Medical patients over 70 years
Excludes day
cases
14
13
Medical
Specialties only
12
The date period
is between April
2010 and
August 2013.
11
10
9
8/31/2013
6/30/2013
4/30/2013
2/28/2013
12/31/2012
10/31/2012
8/31/2012
6/30/2012
4/30/2012
2/29/2012
12/31/2011
10/31/2011
8/31/2011
6/30/2011
4/30/2011
2/28/2011
12/31/2010
10/31/2010
8/31/2010
6/30/2010
4/30/2010
8
Month
Increased in LOS in April & May 2013 breaks the run of data points. Nevertheless Los for older people has
come down

25. ER in Medicine/Going Home Bundle
95th Percentile Length of Stay
95th Percentile
LOS for Acute
discharges
Excludes day
cases
Excludes
Maternity,
Children &
Babies.
Excludes ED/ISIS
The date period is
between August
2011 and August
2013.
Reduced variation from July 2013 – Enhanced Recovery Programme commences on wards: ward
conversations, discharge escalation process, consultation on design of discharge checklist and Going Home
Bundle itself.

26. SHMI
SHMI
Outcome
Metrics
Threshold
100
Jul 11 - Jun12 Oct 11 - Sep 12 Jan 12 - Dec 12 Apr 12 - Mar 13
71.08
71.28
70.31
65
SHMI is Summary Hospitallevel Mortality Indicator
and measures whether
hospital deaths are higher
or lower than expected.
Methodology varies from
HSMR.
120
Apr 12 - Mar 13
Acute Myocardial Infarction
96.35
Integrated Cardiac Arrest and Ventricular Fibrillation
112.91
Care and Congestive Heart Failure, non hypertensive
70.22
Acute
Pneumonia
71.05
Medicine COPD and bronchiectasis
Acute and unspecified renal failure
34.11
100
80
60
40
Surgery,
Cancer and
Diagnostics
20
0
Jul 11 - Jun12
Oct 11 - Sep 12
SHMI
Jan 12 - Dec 12
Threshold
Apr 12 - Mar 13
Fractured Neck of Femur
79.81

27. Summary
• Enhanced recovery principles apply to acute illness
• Systematic implementation can drive change across
a hospital
• Ambulatory care is a key component of enhanced
recovery
• Maximal implementation depends on close
integration with local primary care and community
services
• These aspects have implications for the ‘future
hospital’ agenda

28. RCP commission