25-27 April 2004, Scarman House, University of Warwick

1. Evaluating a new Approach for Improving Care in an Accident and Emergency Department The NU-Care projectThe 2004 Healthcare Conference 25-27 April 2004, Scarman House, University of Warwick

2. NU-Care project • Significance of the NU-Care Project • Method of approach • Evaluation results • Wider implications

3. Government Policy • Make the NHS better for everyone • Improve in out-of- hours access to urgent care • improve in A&E completion times

4. Overall verdict • Response times improved  • Patient satisfaction • Staff endorsement partially met • Cost neutrality • Clinical assessment system

5. Basic structure of an A&E department

6. Overall verdict • Response times improved  • Patient satisfaction  • Staff endorsement partially met • Cost neutrality

7. Overall verdict • Response times improved  • Patient satisfaction  • Staff endorsement partially met • Cost neutrality

8. Overall verdict • Response times improved  • Patient satisfaction  • Staff endorsement partially met • Cost neutrality 

9. Key results Response times • Cut by half • Higher throughput • Fall in absconder rate • Overcrowding eliminated

10. March 2003 March 2002 Throughput and response times 180 170 160 150 140 daily throughput (patients discharged home) 130 120 110 100 90 80 2.00 2.50 3.00 3.50 4.00 4.50 5.00 5.50 6.00 average completion time

11. March 2003 March 2002 Absconders 180 170 160 150 140 daily throughput (patients discharged home) 130 120 110 100 90 80 2.00 2.50 3.00 3.50 4.00 4.50 5.00 5.50 6.00 average completion time

12. Ready reckoner

13. 09:00 08:00 March 1st- March 30th 2003 March 2nd-March 31st 2002 07:00 06:00 05:00 average completion time (hours:minutes) 04:00 03:00 02:00 01:00 S S M T W T F S S M T W T F S S M T W T F S S M T W T F S S day of the week Performance on matched days 2002/03

14. Patients’ comments on waits (before) • Terrible. Three hours waiting with a baby of one year old is beyond belief. • If you had more doctors we wouldn’t have to wait so long to be seen. First was 4 hours after arriving. Two hours later the medical team came…..We pay a lot of National Insurance.

15. Patients’ comments on waits (after) • Waiting times much better…… very nice doctors • Service was very good and prompt. The ambulance was quick. All services were very good. • I am happy to see a huge change in timing as I was seen sooner.

16. Bottlenecks Key issues -1 • Triage “Very dissatisfied -14 month child with head injury. Waited 2 hours to see triage nurse”.

17. Triage comparison 1:30 baseline 1:15 after 6 months 1:00 average wait (hours:minutes) 0:45 0:30 0:15 0:00 8-9 9-10 10-11 11-12 12-13 13-14 14-15 15-16 16-17 17-18 18-19 19-20 20-21 21-22 22-23 23-24 time of day

18. Managing Triage

19. Bottlenecks Key issues -1 • Triage “What’s the point of the triage nurse when after waiting an hour the sisters ask exactly the same questions then say exactly the same things. It seems like needless red tape”.

20. Streaming Key issues -1 • Triage

21. Bottlenecks Key issue -2 • Waiting for a clinician “If you had more doctors we wouldn’t have to wait so long to be seen. First was 4 hours after arriving. Two hours later the medical team came, and almost two hours later seen by ENT”.

22. Clinician waits 3:30 3:00 baseline 2:30 after 6 months 2:00 average wait (hours:minutes) 1:30 1:00 0:30 0:00 8-9 9-10 10-11 11-12 12-13 13-14 14-15 15-16 16-17 17-18 18-19 19-20 20-21 21-22 22-23 23-24 time of day

23. Staff on duty 30 25 20 staffing level 15 10 six-month stage A B A 5 baseline 0 00:00 12:00 00:00 12:00 00:00 12:00 00:00 12:00 00:00 12:00 00:00 12:00 00:00 12:00 S S M M T T W W T T F F S S time of day

24. People in the system

25. Bottlenecks Key issues -3 • Diagnostic tests “Waited four hours for blood results!”

26. Test waits 02:00 01:45 baseline after 6 months 01:30 01:15 average duration (hours:minutes) 01:00 00:45 00:30 00:15 00:00 8-9 9-10 10-11 11-12 12-13 13-14 14-15 15-16 16-17 17-18 18-19 19-20 20-21 21-22 22-23 23-24 time of day

27. Admissions to wards Key issue -4 • Admissions to wards “Whilst everyone who dealt with my mother was helpful and efficient it was the sheer time that upset. Arriving at 15:00 we are still waiting for a bed to be allocated at 22:00. We are thirsty and hungry”.

28. Ward admissions

29. Decision to admit 14 12 10 8 percentage frequency 6 4 2 0 time of day

30. Summary at 6 month stage - patients discharge home

31. Staff endorsement Staff views • A majority said that NU-Care had addressed or partly addressed their concerns • The views changed in 6 months from ‘more nurses’ to ‘more doctors (clinicians)’ • Senior clinicians were more critical

32. Economic evaluation Cost neutrality • Ongoing costs of £650k a year • Time savings to patients of £1.4m a year • No attributable impact on the wider health economy of NU-Care • Productivity improvements • No significant impact on pattern of repeat visits • Reduced overcrowding

33. Overall satisfaction (before) • A nightmare experience of uncertainty. • Very, very, very dissatisfied. • It’s too much like a third world country. • In general service poor. I hope the NHS improves for everyone.

34. Overall satisfaction (after) • Patient’s son is very impressed with the whole service.…..No complaints whatsoever. • All staff very polite and efficient, I am pleased with the service, many thanks. • Patient’s husband very happy with service. They don’t bother with GP as GP is not very good!

35. Queuing model

36. Scientific legacy • How to measure activity in A&E departments • Combining wide range of research techniques, quantitative and qualitative • Use of modelling techniques especially queuing theory

37. Outstanding issues • Sustainability • Further efficiencies • Model of service • Better use of information • Computer decision support systems

38. Overall verdict • Response times improved  • Patient satisfaction  • Staff endorsement partially met • Cost neutrality  • Clinical assessment system 