Unlocking gridlock in hospitals
Published in the June issue of the BGS Newsletter, we look at some startling results achieved through a couple of simple mechanisms as reported in to reports published by The Health Foundation.
The reports showcase programmes piloted in Sheffield Teaching Hospitals NHS Trust and South Warwickshire NHS Foundation Trust
The Flow Cost Quality improvement programme was set up to explore the relationship between patient flow, costs and outcomes by examining patient flow through the emergency care pathway and developing ways in which capacity can be better matched to demand.
Whereas the team at Sheffield focused on the trust’s geriatric medicine service, South Warwickshire chose the emergency care pathway for all adult patients.
In Sheffield, analysis of hospital data showed that on geriatric medicine wards, only 50 per cent of patients were receiving acute specialist medical, nursing or therapy care. The other half were waiting for discharge into a range of services including intermediate health and social care services. In Warwickshire, the driver came from one patient, a retired economist and management consultant who had written to the trust’s chief executive saying that while during his sojourn in hospital he had been treated well, he felt that his care had not been organised in an “optimal way”. He had been invited to come back to the hospital where, having prepared a process map of what had happened during his eight-day stay, it was discovered that only 18 per cent of that time had added value to his treatment and care. Using the finance department’s nominal cost, only £750 out of the £2,000 spent on the patient’s care, was needed to get him better.
One of the solutions implemented by Warwickshire was to change consultant working patterns from ‘post-take’ to ‘on-take’. Both Sheffield and South Warwickshire recognised that they needed to change the timetable of consultant activities and increase senior medical staff availability to meet patient demand as it occurred.
In Sheffield, it was recognised that existing work patterns (8 a.m. to 6 p.m., Monday to Friday), resulted in on-take physicians and surgeons seeing only around a third of patients on the day that they presented. The majority of patients arrived after 6 p.m. and had to be kept overnight on the assessment unit awaiting the arrival of the ward round the following morning. Following the ward round, there were further delays in the onward referral process, meaning that patients needing specialist review were often not seen until day three of admission. The mismatch between the daily variations in admissions and lengths of stay for patients requiring subspecialty care, and the variation in subspecialty bed availability, resulted in many patients being placed on the wrong specialist ward.
Meeting them at the front door
Consultants could see that current job plans were hindering provision of care and agreed to extend on-call service to 8 pm. and to increase weekend cover from 8 a.m. to 5 pm. This was achieved through the job planning process, releasing time by using clinic capacity more efficiently and timetabling periods of time back in lieu. This resulted in a higher number of older people being assessed on the day that they presented at hospital and prevented a build up of patients over the weekends.
In South Warwickshire, where the pilot had been focused on emergency care for all adults, the first benefits were seen in cardiology. However, because other pressures in the system made it difficult to free up beds to pull cardiology patients through to the ward, the Flow Cost Quality team realised that they needed to make the change across the whole system and geriatricians were drawn into the plan.
A dedicated consultant geriatrician worked alongside colleagues in the Medical Assessment Unit, providing an acute assessment as soon as diagnostic results were available. This earlier assessment identified much more quickly, those older patients requiring admission and ensured that they had the right care management plans that could be followed through their journey onto sub-speciality wards.
Like Sheffield, access to senior medical staff was extended from 8 a.m. to 8 p.m. to ensure that patients were assessed and put on the right care plan. One of the participants remarked: “The surprising thing was that although the symptoms were in A&E, we didn’t have to do anything in A&E at all. What we did was try to sort out the system from the back end - and the flow started improving.”
Reducing the time from admission to senior medical assessment required changes to the working patterns for junior doctors and by pooling the capacity of junior doctors from A&E and the Medical Assessment Units, Sheffield was able to meet peaks in emergency patient demand and eliminate repeated assessments which were not adding value.
In South Warwickshire, daily ward rounds were instituted. With early assessment on the MAU and the specialty ‘pull’ system overtaking the traditional bed management system, more of the right patients were on the right ward and the ward team could focus on carrying out the plan of care, actively moving each patient toward discharge and freeing up the ‘gridlock’ in the hospital.
With the new focus on getting investigations and their results within two hours of a patient presenting, some of the delays in junior doctors’ work were highlighted: “They reported running around, not sure where a patient was...and when they found them, not being sure what they needed to do with them.” An electronic work management system, run on mobile phone technology, was introduced. Upon arrival at A&E, a patient’s details were added to the system for assessment, flagging the key investigations to be done as a specific work list. On the wards, the electronic system was displayed on a large white screen, providing effective visual communication to support more efficient management of workflows.
Merging inpatient and outpatient care
A spectacular change was achieved after analysis of the patient pathway in Sheffield indicated significant delays for patients referred by GPs for an outpatient appointment. Sheffield’s improvements team challenged themselves to reducing the outpatient process time from 3 months to less than 8 hours. They instituted a small test with two GP referral letters, telephoning the patients to ask them to come in the next morning. For those two patients, all the issues identified by the GP were dealt with that day and unexpectedly, it was found that there was often no clinical difference in the severity of conditions for the older patients who presented (or were referred by their GPs) as an emergency case or those who were referred to the outpatient clinic. There was also no difference in the process of care they required.
“We realised that the divide of outpatients and emergencies is artificial because most patients being referred by GPs require secondary care consultation and in geriatric medicine, that’s usually sooner, rather than later.”
Results of Sheffield
The programme produced significant results in bed occupancy which was reduced from a mean in January 2012 of 312 (max 337) to a mean in early September of 246 (lowest point 245). The trust was able to close two wards, totalling 68 beds.
Results in South Warwickshire
In Warwickshire, the results are largely at a system level. Despite 11.5 per cent growth in emergency admissions over the past year, the trust has maintained A&E performance and reduced average length of stay and bed occupancy. An apparent non-linear relationship between emergency flow and subsequent mortality of patients admitted during periods of poor emergency flow was found. Following the changes introduced to improve flow, there was a reduction in the mortality rate.