Warning signals and transition points across the whole system

1. Warning signals and transition points across the whole system Dr Dan Beckett Consultant Acute Physician NHS Forth Valley

3. Overview • Warning signals • Four hour emergency access standard • ED LoS - time profiles • Boarding • (Cancelled elective activity) • (Delayed discharges) • Whole system overview • NHSFV capacity and flow dashboard • Elective vs Emergency imbalance • Optimising patient flow by reducing its variability

4. Warning signals • Four hour emergency access standard • Useful as an indicator of whole system pressure • Poor compliance indicates with ED overcrowding • Associated with an increase in mortality both in patients admitted and patients discharged from the ED • Limited usefulness as an early indicator of pressure to trigger escalation

5. Warning signals • ED LoS distribution • Can demonstrate pressure in the system that is not evident when just looking at compliance with the four hour emergency access standard • ‘Crisis spike’

10. Warning signals • ED time curve • Useful for retrospective analysis • Crisis spike correlates with poor performance • Useful for proactive escalation? • Dynamic monitoring of the proportion of patients leaving the ED after 210 minutes?

11. BUT STILL 97% COMPLIANT AT THIS STAGE 27%

12. 91% 86%

13. 79% 77%

14. Warning signals • Boarders • Different models of boarding exist • Exclusively ‘front door’ • Exclusively ‘back door’ • Mixed model • Irrespective of model, increasing numbers of boarders indicates system pressure and should be monitored/controlled • Boarded patients have poor outcomes

18. Monitoring whole system pressure • NHSFV capacity dashboard • Real time information • Pressure vs Capacity • Admissions vs Discharges • Emergency vs Elective • Predicted vs Observed activity • Whole system vs Individual patient • Warning signals across the whole system as a trigger to escalation

23. Elective vs Emergency flow • Competition between emergency and elective flow ‘silos’ can directly lead to ED overcrowding • Perceived conflict between the 18 week RTT target and the 4 hour emergency access standard • Significant variation in numbers of patients admitted over the week

24. 131%

25. 54%

26. 131% BUT YOU CAN’T COMPARE WEEKENDS AND WEEKDAYS! 54% 3288%

28. 46% 16% 237%

29. Elective vs Emergency flow • Elective admissions display more variability (artificial variability) than emergency admissions (natural variability) • Counter-intuitive!

30. Elective vs Emergency Flow Imbalance • Difficult to plan staffing levels for such high levels of variation (largely artificial variation) • Invariably staffed for ‘average’ levels of activity resulting in periods of demand > capacity (leading to ED overcrowding and poor outcomes) and capacity > demand (waste of resources)

31. Queue Capacity Demand time Average demand = Average capacity Variation mismatch = queue Can’t pass unused capacity forward to next week Reducing waiting times in the NHS: is lack of capacity the problem? Bevan et al Clinician in Management (2004) 12:

32. Elective vs Emergency Flow • Need to eliminate artificial variation and manage natural variation

33. 14%

34. Eliminating artificial variation • Reduces overall variation • Reduces ED overcrowding • Less waste • Reduces patient boarding • In 2006 the IOM published a report asking hospitals to use operational management tools (queuing theory) to address patient flow issues that lead to ED overcrowding

35. Operational management of flow • Boston Medical Centre • Significant problems with ED overcrowding 2003 • Emergency work more predictable and less varied than elective work • Reprofiled elective cases Monday-Friday • Subsequently eliminated all block scheduling • Split elective and emergency surgical work • Used queuing theory to guide resources for emergency work

36. Operational management of flow • Boston Medical Centre • Reduced variability in demand for surgical HDU beds by 55% • Reduced nursing hours – saving $130K per annum • Reduced cancelled/delayed surgery from 334 to 3 (99.5%) for the same time periods April-September 2003/2004 (pre- and post-implementation) • Reduced ED waiting time by 50% and improved ED throughput by 45 minutes per patient

37. Operational management of flow • Now many examples of successful implementation • Cincinatti Childrens Hospital • Weekday OR waiting time reduced by 28% (despite an increase in case volume of 24%) • Weekend OR waiting time decreased by 34% despite an increase in volume of 37%) • Capacity boosted by equivalent of 100 bed expansion • Great Ormond Street Hospital

38. Operational management of flow • Assign responsibility for the patient flow problem • Chief Operations Officer or Vice President • Establish a multidisciplinary team • Collect and analyze data on bottlenecks • Eliminate or smooth artificial variation • Manage natural variation (queuing theory) • www.ihoptimize.org

39. References • Managing Capacity and Demand across the patient journey. Clinical Medicine 2010. 10:1 13-15 • Winter Pressures in NHS Scotland 2008-2009. A report for the Emergency Access Team, Scottish Government

40. Acknowledgements • Professor Derek Bell, Imperial College • Professor Eugene Litvak, Institute for Healthcare Optimisation • Dr Claire Gordon, NHS Lothian • Bas Gough, Scottish Government • Guy Blackburn, NHSFV • Thanks for listening...