Managing and streaming of all admissions The Heartlands experience

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1 Managing and streaming of all admissions The Heartlands experience Dr Marwa Mattar, ST6 Acute Medicine Dr Ariyur Balaji, Clinical Lead Acute Medicine BHH

2 Why is this important? Unprecedented demand for beds this winter Cancelled elective operations Increased medical outliers Falling numbers of inpatient beds

3 2016 RCPE Visual patient care journey

4 How it works at BHH Tertiary Referral Centre with a catchment area of 1.3 Million 400 Attendances to A&E in 24 hours 110 Medical referrals in 24 hours 70 patients admitted to AMU in 24 hours patients seen in AEC in 24 hours Front door geriatrician and frailty unit Advanced Nurse Practitioners

5 AMU interface

6 Alternatives to Admission Hot Clinics Ambulatory Emergency Care Intermediate Care Beds Home- supported discharge

7 Available Hot Clinics Acute oncology Asthma outreach Cardiology admission avoidance slots Dermatology Diabetes Elderly care- rapid access clinics ENT Falls clinic Gastroenterology clinic HEFT TB service OPAT Parkinson s disease Renal rapid access TIA rapid access

8 Ambulatory Emergency Care patients reviewed daily Open 8:30am-9pm weekdays 11am-8pm weekends All GP referrals Pull patients from ED Day case procedures

9 AEC footprint

10 Suitable referrals for AEC Any ambulatory sensitive condition Mobile patients Mews<4 Can been seen, treated and discharged in AEC Suspected TIA Low risk ACS with no on-going chest pain DVT confirmed on USS

11 AEC Staff 1 Consultant 1-2 Middle Grades/GPs 1 SHO 1 Advanced Care Practitioner 3 Nurses 1 Administrator 1 Phlebotomist

12 Front Door Geriatrician Consultant Geriatrician based in A&E Monday-Friday 9am-5pm Provides advice to A&E for frail elderly patients Complex geriatric assessment Reduces replication of work

13 Front Door Geriatrician Close working relationship with A&E 70% of A&E admission aged 65 years Conversion rate of A&E attendances to medical referrals 30% Aged >85 becomes 75% Admission prevention Home with SID/REACT Early follow up in Medical Day Hospital Admission to Community Bed

14 NHS Benchmarking - Older People's Care in Acute Settings 2015/16

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17 BHH Total 2015/ A+E attendances Admitted Conversion rate 31% 58% 69% 78%

18 Front Door Geriatrician Average 8 patients seen daily 4-6 Discharged 2-4 Admitted

19 Frailty Unit 9 assessment beds, 18 long stay beds Improved mortality and morbidity More patients return to their own home Decreased length of stay as compared to GIM wards Minimises patient bed moves

20 AMU footprint

21 AMU Co-ordinator Senior nurse/matron Taking referrals (A&E, Urgent care, Bed Bureau, GPs, RMOs) Ensuring patient safety (Staffing levels, Nursing ratios) Pulling patients from A&E Allocating appropriate patients to specialty and short stay wards Co-ordinating beds on short stay wards

22 Early specialty review Respiratory/Cardiology/Stroke Gastroenterology Infectious Diseases Elderly Care Renal Haematology Oncology

23 AMU Quality Indicators Mortality rates Within 48 hours of admission HSMR Weekend vs Weekday mortality rates In-hours ( ) vs Out of hours Direct discharge rates within 24 or 48 hours of admission 7 day readmission rate Patient experience

24 Our data 70 patients admitted to AMU Discharge rate around 30% Average time on unit Admitted 24 hours Discharged 19 hours Crude mortality on AMU 0.97% 30 day readmission rate 13.36%

25 Supported Discharge 1 Advanced Nurse Practitioners Working with AMU and ED teams Admission prevention Reducing length of stay Access to community teams

26 Supported Discharge 2 Inclusion criteria Age >17 Birmingham GP Exclusion criteria Alcoholism main issue Mental Health problems main issue (not dementia)

27 Community Team Rapid response Intermediate care teams CMAU (Moseley Hall Hospital) Bedded rehab units The Willows (dementia) CU27 (GHH)

28 Intermediate Care Team Clinical Case Managers Advanced Nurse Practitioners District Nurses Therapists Dieticians SALT Podiatrists RMNs

29 Barriers to patient discharge Sick patients are prioritised Completing the ward round is prioritised Requesting investigations is prioritised Discharge summary seen as the final thing to complete once other jobs are completed

30 How to combat these barriers Discharge co-ordinators Use of the patient waiting room Discharge Lounge Timely completion of discharge letters and TTOs

31 The future.

32 Questions?

33 Acknowledgements Jo Drever ANP Dr Dariusz Rudzki Geriatrician and Front Door Elderly consultant James Robinson- Sister Sandra Kempson AMU sister