Formula 1 Frailty back on track (home) in the shortest possible time! Jyothi Nippani-Clinical Lead ECIST (midlands and East)

Transcription

1 Formula 1 Frailty back on track (home) in the shortest possible time! Jyothi Nippani-Clinical Lead ECIST (midlands and East)

2 2 Some facts about the frail older people

3 3 DATA TO SHOW THE NEED FOR EXTENDED DAY WORKING

4 Number A&E Arrivals Busiest period between 8am and 8pm Max +2std Avera ge

5 14.00% 12.00% 10.00% 8.00% A&E Arrival by referral source; 12 months (to GP July 25 th 2018) Self Self Referral peak GP Referral peak 12,890 arrivals in past year 73.2% Self Referral 8.5% GP referral 18.4% Other Referral 6.00% 4.00% 2.00% %

6 Patient may call GP in morning GP calls ambulance in afternoon Carer calls ambulance 6

7 7 Pre May 2018 EFFECT OF 0900 TO 1700HRS WORKING WITH ACTIVE FRAILTY PULL

8 8 5 days a week 0800 to 1700hrs Frailty team (MNP and consultant) access from ED triage Some MDT support Worked up in ADU when possible Admit under frailty even if pt. came OOH or on AMU (parallel take)

9 5 days a week 0800 to 1700hrs Frailty team (MNP and consultant) access from ED triage Bypassed ED and Ac. Medicine Admit under frailty even if pt. came OOH or on AMU (parallel take) Worked up in ADU if necessary Some MDT support FT 9 Community and social care response

10 Over 75s LOS Step change - decrease Released 14 beds in the organisation launc h PDSA Finish sustainability 8 to 8 10

11 11 PDSA MAY 14 TH TO 24 TH 2018

12 12 PDSA - Interventions

13 Consultant ACP Nurse HCA OT Physio Pharmacy Social work CERT Existed before New 13

14 OT ED Physio Ambulatory AMU Short stay Frailty Pharmacy Social ADU Nurse ACP Cons 14

15 PDSA working model OT ED ACP Physio Ambulatory AMU Short stay Frailty Pharmacy Social ADU FAU Nurse Aim to get the patient back home in the shortest possible time Cons 15

16 16

17 Junior Doctor replaced by ACP ACP CERT Nurse Voluntary sector Doctor Transport HCA Social care OT Pharmacy Physio 17

18 LOS - 10 days to 2 hours

19 Length of Time (mins) cons left Average of Arrival- Triage[Mins] Average of Arrival - ACP Decision [mins] Average of Arrival - FAA Arrival [mins] Average of Arrival - ACP Assessment [mins] 19

20 2% 2% Place Discharged To Usual place of residence 0% Admitted to Nicholas ward 24% 23% 49% Admitted to Squire ward Admitted to oken as no bed available on squire. Admitted to farries Admission to squire ward 20

21 2% 2% 2% 5% 4% 2% Discharge Outcome Care Admission Home CERT 38% 45% Admitted Inpatient on nicholas ward No changes Discharge home no outcome care O.T to order equipment 21

22 No Change in attendance of over 75s

23 23 Step Change in the admissions of over 75s

24 24 Was not the AIM of the PDSA!!!

25 25

26 Frailty PDSA Project Over the course of the PDSA the number of Medical admissions (75+) declined by 50%; from 18 per day to 9 per day. Since 2016 there have been 9 or fewer medical admissions in a day on 18 occasions, Over the 10 day course of the PDSA being in place this took place on 6 days. (75+ Cohort) 26

27 Frailty PDSA MADE 27

28 28 COLLATERAL BENEFITS ON OTHER AREAS

29 Effect on AMU bed occupancy Midnight Snapshot Ward had generally occupied around 25 patients+ and fully so at project start Ward dips below 25 as week 1 progresses with a rapid decline in those aged 75+ The increase in medical admits occurs over the weekend (no service); surgical inc slightly Overall Occupancy on AMU No. Med/Surg 75+ Total on Ward (All Ages) Medical O75 Surgical O75 weekend 29

30 Type1_Breaches for South Warwickshire NHS Foundation Trust Data Avg (Back) Sig -3 Sig +3 Outside CL 2/3 outside 2sd /02/ /03/ /03/ /03/ /03/ /04/ /04/ /04/ /04/ /05/ /05/ /05/ /05/ /05/ /06/ /06/2018 4/5 outside 1sd 9 on one side Actual Prediction 30

31 /02/ /03/2018 Time to Treatment % for South Warwickshire NHS Data Foundation Trust Avg (Back) Sig -3 13/03/ /03/ /03/ /04/ /04/ /04/ /04/ /05/ /05/ /05/ /05/ /05/ /06/ /06/2018 Sig +3 Outside CL 2/3 outside 2sd 4/5 outside 1sd 9 on one side Actual Prediction 31

32 32 Effect on discharges from other wards

33 Other potential savings not quantified yet Savings on over investigations CT scans Bloods 33

34 Red in Admissions per day Days Service Runs Over 75 LOS Averag e LOS Reduction In Bed Days (5 Day LOS) Reduction In Bed Days (8.2 Day LOS) ??? Beds 12 beds based on Frailty PDSA??? Beds saved due to improved efficiency in AMU and Nicholas. 34

35 Ambulatory -We were able to concentrate on Ambulatory, could pull patients faster Nicholas could get on with the regular work and concentrate on discharges The ED seemed much quieter and felt manageable ADU - We were able to pull sicker patients from ED GPs: its was good to be able to get help in managing complex patients Frailty Team: - We enjoyed it very satisfactory 35

36 36 The speed in which the care was done. Assessment by the nurse and then the doctor was excellent. Communication was a two way thing. Action plan was explained clearly and precisely by the doctor. So much better than A&E(Although they do a fantastic job too). Thank you for looking after my mum. I was treated as a queen, I could not fault anything Absolutely wonderful (and you can have a laugh and a joke) Came in with my mother and found this ward better and faster for her needs Did not have to wait too long in A&E Very courteous, helpful, informative and generally excellent

37 37 Consultant ACP Nurse HCA OT Physio Pharmacy Social work CERT Transport Nicholas Ward Staff Nicholas Ward Staff Some control will be good Existing Happy to do extended hours Can share with AMU and AEC and ED New consultants from Sept. Can CERT accept until 8.00 pm?

38 38

39 Breakout session 2 Bedside handover in a community hospital including the patient in the conversation (Rolls Suite: First floor) Transforming A&E using single clerking and innovative staffing solutions (Royce Suite: First floor) How to develop a home first model with new roles (Lancaster Suite: First floor) Developing a frailty model (Stanley Suite: First floor) Collaborative approach to SAFER and Red2Green in the North (Victoria Suite: Lower ground floor) Treating staff fairly and consistently when care doesn t go to plan: NHS Improvement s Just Culture guide (Fairclough Suite: First floor)

40 Formula 1 Frailty back on track (home) in the shortest possible time! Jyothi Nippani Clinical Lead ECIST (midlands and East

41 41 Some facts about the frail older people

42 42 DATA TO SHOW THE NEED FOR EXTENDED DAY WORKING

43 Number A&E Arrivals Busiest period between 8am and 8pm Max +2std Avera ge

44 14.00% 12.00% 10.00% 8.00% A&E Arrival by referral source; 12 months (to GP July 25 th 2018) Self Self Referral peak GP Referral peak 12,890 arrivals in past year 73.2% Self Referral 8.5% GP referral 18.4% Other Referral 6.00% 4.00% 2.00% %

45 Patient may call GP in morning GP calls ambulance in afternoon Carer calls ambulance 45

46 46 Pre May 2018 EFFECT OF 0900 TO 1700HRS WORKING WITH ACTIVE FRAILTY PULL

47 47 5 days a week 0800 to 1700hrs Frailty team (MNP and consultant) access from ED triage Some MDT support Worked up in ADU when possible Admit under frailty even if pt. came OOH or on AMU (parallel take)

48 5 days a week 0800 to 1700hrs Frailty team (MNP and consultant) access from ED triage Bypassed ED and Ac. Medicine Admit under frailty even if pt. came OOH or on AMU (parallel take) Worked up in ADU if necessary Some MDT support FT 48 Community and social care response

49 Over 75s LOS Step change - decrease Released 14 beds in the organisation launc h PDSA Finish sustainability 8 to 8 49

50 50 PDSA MAY 14 TH TO 24 TH 2018

51 51 PDSA - Interventions

52 Consultant ACP Nurse HCA OT Physio Pharmacy Social work CERT Existed before New 52

53 OT ED Physio Ambulatory AMU Short stay Frailty Pharmacy Social ADU Nurse ACP Cons 53

54 PDSA working model OT ED ACP Physio Ambulatory AMU Short stay Frailty Pharmacy Social ADU FAU Nurse Aim to get the patient back home in the shortest possible time Cons 54

55 55

56 Junior Doctor replaced by ACP ACP CERT Nurse Voluntary sector Doctor Transport HCA Social care OT Pharmacy Physio 56

57 LOS - 10 days to 2 hours

58 Length of Time (mins) cons left Average of Arrival- Triage[Mins] Average of Arrival - ACP Decision [mins] Average of Arrival - FAA Arrival [mins] Average of Arrival - ACP Assessment [mins] 58

59 2% 2% Place Discharged To Usual place of residence 0% Admitted to Nicholas ward 24% 23% 49% Admitted to Squire ward Admitted to oken as no bed available on squire. Admitted to farries Admission to squire ward 59

60 2% Admission 2% Discharge Outcome Care 2% 4% 2% Home 5% CERT 38% 45% Admitted Inpatient on nicholas ward No changes Discharge home no outcome care O.T to order equipment 60

61 No Change in attendance of over 75s

62 62 Step Change in the admissions of over 75s

63 63 Was not the AIM of the PDSA!!!

64 64

65 Frailty PDSA Project Over the course of the PDSA the number of Medical admissions (75+) declined by 50%; from 18 per day to 9 per day. Since 2016 there have been 9 or fewer medical admissions in a day on 18 occasions, Over the 10 day course of the PDSA being in place this took place on 6 days. (75+ Cohort) 65

66 Frailty PDSA MADE 66

67 67 COLLATERAL BENEFITS ON OTHER AREAS

68 Effect on AMU bed occupancy Midnight Snapshot Ward had generally occupied around 25 patients+ and fully so at project start Ward dips below 25 as week 1 progresses with a rapid decline in those aged 75+ The increase in medical admits occurs over the weekend (no service); surgical inc slightly Overall Occupancy on AMU No. Med/Surg 75+ Total on Ward (All Ages) Medical O75 Surgical O75 weekend 68

69 Type1_Breaches for South Warwickshire NHS Foundation Trust Data Avg (Back) Sig -3 Sig +3 Outside CL 2/3 outside 2sd /02/ /03/ /03/ /03/ /03/ /04/ /04/ /04/ /04/ /05/ /05/ /05/ /05/ /05/ /06/ /06/2018 4/5 outside 1sd 9 on one side Actual Prediction 69

70 /02/ /03/2018 Time to Treatment % for South Warwickshire NHS Data Foundation Trust Avg (Back) Sig -3 13/03/ /03/ /03/ /04/ /04/ /04/ /04/ /05/ /05/ /05/ /05/ /05/ /06/ /06/2018 Sig +3 Outside CL 2/3 outside 2sd 4/5 outside 1sd 9 on one side Actual Prediction 70

71 71 Effect on discharges from other wards

72 Other potential savings not quantified yet Savings on over investigations CT scans Bloods 72

73 Red in Admissions per day Days Service Runs Over 75 LOS Averag e LOS Reduction In Bed Days (5 Day LOS) Reduction In Bed Days (8.2 Day LOS) ??? Beds 12 beds based on Frailty PDSA??? Beds saved due to improved efficiency in AMU and Nicholas. 73

74 Ambulatory -We were able to concentrate on Ambulatory, could pull patients faster Nicholas could get on with the regular work and concentrate on discharges The ED seemed much quieter and felt manageable ADU - We were able to pull sicker patients from ED GPs: its was good to be able to get help in managing complex patients Frailty Team: - We enjoyed it very satisfactory 74

75 75 The speed in which the care was done. Assessment by the nurse and then the doctor was excellent. Communication was a two way thing. Action plan was explained clearly and precisely by the doctor. So much better than A&E(Although they do a fantastic job too). Thank you for looking after my mum. I was treated as a queen, I could not fault anything Absolutely wonderful (and you can have a laugh and a joke) Came in with my mother and found this ward better and faster for her needs Did not have to wait too long in A&E Very courteous, helpful, informative and generally excellent

76 76 Consultant ACP Nurse HCA OT Physio Pharmacy Social work CERT Transport Nicholas Ward Staff Nicholas Ward Staff Some control will be good Existing Happy to do extended hours Can share with AMU and AEC and ED New consultants from Sept. Can CERT accept until 8.00 pm?

77 77

78 Refreshment break Wifi: ECISTconferences Password: FLOWNHS710 Glisser: glsr.it/ecist2018 Twitter: #TBC

79 Breakout session 3 Bedside handover in a community hospital including the patient in the conversation (Rolls Suite: First floor) Transforming A&E using single clerking and innovative staffing solutions (Royce Suite: First floor) How to develop a home first model with new roles (Lancaster Suite: First floor) Developing a frailty model (Stanley Suite: First floor) Collaborative approach to SAFER and Red2Green in the North (Victoria Suite: Lower ground floor) Treating staff fairly and consistently when care doesn t go to plan: NHS Improvement s Just Culture guide (Fairclough Suite: First floor)

80 Formula 1 Frailty back on track (home) in the shortest possible time! Jyothi Nippani Clinical Lead ECIST (midlands and East

81 81 Some facts about the frail older people

82 82 DATA TO SHOW THE NEED FOR EXTENDED DAY WORKING

83 Number A&E Arrivals Busiest period between 8am and 8pm Max +2std Avera ge

84 14.00% 12.00% 10.00% 8.00% A&E Arrival by referral source; 12 months (to GP July 25 th 2018) Self Self Referral peak GP Referral peak 12,890 arrivals in past year 73.2% Self Referral 8.5% GP referral 18.4% Other Referral 6.00% 4.00% 2.00% %

85 Patient may call GP in morning GP calls ambulance in afternoon Carer calls ambulance 85

86 86 Pre May 2018 EFFECT OF 0900 TO 1700HRS WORKING WITH ACTIVE FRAILTY PULL

87 87 5 days a week 0800 to 1700hrs Frailty team (MNP and consultant) access from ED triage Some MDT support Worked up in ADU when possible Admit under frailty even if pt. came OOH or on AMU (parallel take)

88 5 days a week 0800 to 1700hrs Frailty team (MNP and consultant) access from ED triage Bypassed ED and Ac. Medicine Admit under frailty even if pt. came OOH or on AMU (parallel take) Worked up in ADU if necessary Some MDT support FT 88 Community and social care response

89 Over 75s LOS Step change - decrease Released 14 beds in the organisation launc h PDSA Finish sustainability 8 to 8 89

90 90 PDSA MAY 14 TH TO 24 TH 2018

91 91 PDSA - Interventions

92 Consultant ACP Nurse HCA OT Physio Pharmacy Social work CERT Existed before New 92

93 OT ED Physio Ambulatory AMU Short stay Frailty Pharmacy Social ADU Nurse ACP Cons 93

94 PDSA working model OT ED ACP Physio Ambulatory AMU Short stay Frailty Pharmacy Social ADU FAU Nurse Aim to get the patient back home in the shortest possible time Cons 94

95 95

96 Junior Doctor replaced by ACP ACP CERT Nurse Voluntary sector Doctor Transport HCA Social care OT Pharmacy Physio 96

97 LOS - 10 days to 2 hours

98 Length of Time (mins) cons left Average of Arrival- Triage[Mins] Average of Arrival - ACP Decision [mins] Average of Arrival - FAA Arrival [mins] Average of Arrival - ACP Assessment [mins] 98

99 2% 2% Place Discharged To Usual place of residence 0% Admitted to Nicholas ward 24% 23% 49% Admitted to Squire ward Admitted to oken as no bed available on squire. Admitted to farries Admission to squire ward 99

100 5% 2% 4% 2% 2% Admission Discharge Outcome Care 2% Home CERT 38% 45% Admitted Inpatient on nicholas ward No changes Discharge home no outcome care O.T to order equipment 100

101 No Change in attendance of over 75s

102 102 Step Change in the admissions of over 75s

103 103 Was not the AIM of the PDSA!!!

104 104

105 Frailty PDSA Project Over the course of the PDSA the number of Medical admissions (75+) declined by 50%; from 18 per day to 9 per day. Since 2016 there have been 9 or fewer medical admissions in a day on 18 occasions, Over the 10 day course of the PDSA being in place this took place on 6 days. (75+ Cohort) 105

106 Frailty PDSA MADE 106

107 107 COLLATERAL BENEFITS ON OTHER AREAS

108 Effect on AMU bed occupancy Midnight Snapshot Ward had generally occupied around 25 patients+ and fully so at project start Ward dips below 25 as week 1 progresses with a rapid decline in those aged 75+ The increase in medical admits occurs over the weekend (no service); surgical inc slightly Overall Occupancy on AMU No. Med/Surg 75+ Total on Ward (All Ages) Medical O75 Surgical O75 weekend 108

109 Type1_Breaches for South Warwickshire NHS Foundation Trust Data Avg (Back) Sig -3 Sig +3 Outside CL 2/3 outside 2sd /02/ /03/ /03/ /03/ /03/ /04/ /04/ /04/ /04/ /05/ /05/ /05/ /05/ /05/ /06/ /06/2018 4/5 outside 1sd 9 on one side Actual Prediction 109

110 /02/ /03/2018 Time to Treatment % for South Warwickshire NHS Data Foundation Trust Avg (Back) Sig -3 13/03/ /03/ /03/ /04/ /04/ /04/ /04/ /05/ /05/ /05/ /05/ /05/ /06/ /06/2018 Sig +3 Outside CL 2/3 outside 2sd 4/5 outside 1sd 9 on one side Actual Prediction 110

111 111 Effect on discharges from other wards

112 Other potential savings not quantified yet Savings on over investigations CT scans Bloods 112

113 Red in Admissions per day Days Service Runs Over 75 LOS Averag e LOS Reduction In Bed Days (5 Day LOS) Reduction In Bed Days (8.2 Day LOS) ??? Beds 12 beds based on Frailty PDSA??? Beds saved due to improved efficiency in AMU and Nicholas. 113

114 Ambulatory -We were able to concentrate on Ambulatory, could pull patients faster Nicholas could get on with the regular work and concentrate on discharges The ED seemed much quieter and felt manageable ADU - We were able to pull sicker patients from ED GPs: its was good to be able to get help in managing complex patients Frailty Team: - We enjoyed it very satisfactory 114

115 115 The speed in which the care was done. Assessment by the nurse and then the doctor was excellent. Communication was a two way thing. Action plan was explained clearly and precisely by the doctor. So much better than A&E(Although they do a fantastic job too). Thank you for looking after my mum. I was treated as a queen, I could not fault anything Absolutely wonderful (and you can have a laugh and a joke) Came in with my mother and found this ward better and faster for her needs Did not have to wait too long in A&E Very courteous, helpful, informative and generally excellent

116 116 Consultant ACP Nurse HCA OT Physio Pharmacy Social work CERT Transport Nicholas Ward Staff Nicholas Ward Staff Some control will be good Existing Happy to do extended hours Can share with AMU and AEC and ED New consultants from Sept. Can CERT accept until 8.00 pm?

117 117