Ben Rosling explains how information-led change focusing on patient flow helped Croydon Health Services Trust improve its A&E performance

Benrosling2

Ben Rosling

Ben Rosling

Croydon Health Services has one of the busiest emergency departments in southwest London. Having analysed patient flow over the past few years, from admission through to discharge and across the health economy, the trust was able to get a better understanding of patient flow and make significant improvements to emergency department waiting times and patient outcomes.

A detailed analysis found that patients were being sent to the Acute Medical Unit (AMU) as a priority from the emergency department in order to be assessed. However, they were not being assessed for a specific clinical reason and could have been treated in an appropriate consultant-led assessment unit and in a more appropriate outpatient environment.

In addition, transfers out of AMU typically occurred late in the day with increased risk of errors, potential for missed medications and additional complications. This cohort of patients were simply being admitted to be assessed.

Radical plan

As part of a radical plan to enhance the patient journey and redesign the front end model of care, the trust decided to co-locate acute assessment, ambulatory and comprehensive geriatric care services under one umbrella and in one single environment. These services now work collaboratively with the support of community and mental health services, creating a first-of-its-kind unit with one-stop consultant high quality care.

The trust had been struggling to meet the 95 per cent Emergency Access Target for some time due to exit blocks and patients not being treated in the most suitable environment for their care needs. In addition, the system did not lend itself to good ambulatory type care because of the delays inherent within the system from presentation to final discussion of patient needs with the consultant and capacity issues within.

The trust decided to co-locate acute assessment, ambulatory and comprehensive geriatric care services under one umbrella and in one single environment

In May 2015 we started an Emergency Care recovery programme with a number of work streams, one of which focussed on patient flow. The vision was to redesign the delivery of emergency care by developing new patient flow pathways as well as co-locating acute assessment, ambulatory care, and comprehensive geriatric care with rapid response services in a dementia-friendly and multidisciplinary unit.

We had been working on the premise that when we hit pressure points in activity throughout the year, by default, additional beds were opened. We realised this could not continue year in and year out.

We had to manage front-end flow more efficiently, prevent unnecessary admissions of our patients and ensure that our patients were provided with the most appropriate care in the most appropriate environment as early as possible in their patient journey.

Extensive analysis

The trust used a range of modelling tools and dashboards developed by Beautiful Information to carry out an extensive analysis of patient flow data through accident and emergency and downstream wards. It examined data over an 18 month period to highlight what needed to change and demonstrate the rationale.

This helped to model capacity need, bed reconfiguration requirements and measure as well as predict the impact of these changes and build the overall business case for change.

The analysis revealed the trust was being reactive rather than proactive in the management of its key emergency type services. It was sending patients to its AMU as a priority from the emergency department in to be assessed, rather than treated without any positive movement to their clinical pathway.

The analysis revealed the trust was being reactive rather than proactive in the management of its key emergency type services

The trust developed the Edgecombe Unit, opened in November 2015, to co-locate a range of emergency services including a new rapid assessment medical unit, a new acute care of the elderly short stay unit and at the same time brought together the existing services of the ambulatory care unit and acute care of the elderly in-reach, all as consultant-led services. The aim was to transform the models of care at the front end of the hospital.

The unit ensures patients are getting the right care at the right time. Whether this is rapid assessment of the patient’s complaints and their needs on arrival to ensure the right specialty is involved early, or meeting the increase in number of patients requiring ambulatory emergency care services.

It also means faster access to a specialty bed for all appropriate admissions. The Elderly Frail Unit (EFU) within Edgecombe is a quiet, well lit, dementia-friendly, 16 bed unit targeting emergency management of frail older people offering early elderly care consultant-led and multidisciplinary assessments while linking with community, social services mental health and voluntary teams.

Success so far

The recovery programme continues to be driven through the organisation with great success. The key successes to date being the reduction in number of admissions by over 20 per cent since the unit was opened in November 2015 compared to the same period last year coupled with the significant improvement in performance.

Patients who previously required extensive assessment in the emergency department, followed by referral to the medical team and subsequent admission are now being identified at an earlier stage and only admitted purely on clinical need, not operational pressure.

The unit is currently seeing over 2,000 patients per month, of these two thirds would have previously been admitted via the emergency department, incurring delays in assessment and potential subsequent admission. Earlier referral reduces the length of time patients spend undergoing assessment in the emergency department, waiting for medical review, and admission to a bed.

Ben Rosling is emergency care programme director at Croydon Health Services Trust and led the initiative to improve emergency department waiting times and patient outcomes