Emergency Access 4-hour Q3 2008/2009 Performance Review

(February 2009 update)

Introduction

This paper provides a review of factors affecting performance against the 4-hour emergency access target during Q3 of 2008/2009, and actions taken to address this, in response to concerns raised by Monitor. In a letter of the 10th February, the Trust was asked to provide:

1)  A full explanation of the reasons for the failure to achieve the 98% standard in Q3 2008/2009

2)  Evidence that the Board took appropriate action following the failure to achieve the standard in Q3 2007/2008

3)  Details of the Trust’s plans to ensure ongoing achievement of the target

1. Reasons for the failure to achieve the 98% standard in Q3 2008/2009

During both Q1 and Q2 in 2008/2009, the Trust achieved the 98% standard. However, during Q3 performance dipped to 96.3% (including Walk in Centre (WIC) attendances). At the end of November year to date compliance was 98.0%[1] including WIC attendances. Performance deteriorated during December 2008 but improved significantly in January 2009, which represents a significant improvement in performance over the same period last year (Figure 1).

Figure 1. Performance against the 4-hour standard during 2008/2009 and 2007/2008.

1.1. Factors affecting the deterioration in 4-hour performance in Q3

The seasonal pattern of performance in 2008/2009 has been similar to that of 2007/2008, with the exception of the improvement seen in January 2009. In 2007/2008 an improvement in performance was seen in the latter half of February. However, in 2008/2009 performance improved from the second week in January, despite a significant outbreak of norovirus.

The deterioration in performance in 2008/2009 coincided with a significant rise in emergency admissions (Fig 2), and a change in the pattern of those admissions over the week. There was also an uncharacteristic drop in performance at the Bristol Children’s Hospital. Details of the key factors affecting performance in Q3 2008/2009 are set-out below:

1.1.1 Levels of emergency admissions

Analysis of Bristol Royal Infirmary (BRI) activity data continues to confirm the strong association between bed availability and 4-hour performance. Breaches against the 98% target are consistently due to capacity and the subsequent impact of timely bed availability, with 80 % of breaches falling into this category. This includes beds within the Medical Assessment Unit (MAU), Observation Unit (ward 19) as well as inpatient wards.

Figure 2. The number of emergency admissions (first FCEs) per month in 2007/2008 and 2008/2009

There are a number of factors that affect bed availability, including 1) our ability to avoid un-necessary admissions (including levels of senior decision making); 2) length of stay (elective and emergency); 3) daily levels of elective admissions and discharges, and how these correspond with peaks in emergency admissions over the week and 4) bed closures due to norovirus.

Figure 3. The number of emergency admissions (first FCES) and percentage of breaches of the 4-hour standard per month during 2008/2009

Despite a significant increase in emergency admissions relative to 2007/2008 during the first two quarters of 2008/2009, the Trust was able to sustain the 98% standard. However, during Q3, the number of emergency admissions increased further (Figure 2). In contrast to 2007/2008, performance in 2008/2009 has been positively correlated with the level of emergency admissions (Figure 3). This suggests that the increase in emergency admissions has now become the constraint on performance. Despite analysis being undertaken by both the Trust and the PCT, the cause of the rise in emergency admissions has not been elucidated. However, the increase in emergency admissions coincided with a significant increase in the number of emergency zero lengths of stay and the down-sizing of the local ambulance trust’s investment in Emergency Care Practitioner scheme at the start of the year. The ambulance trust data on ambulance conveyances suggests there has been also been a shift relative to previous years in the number of ambulances coming to the trust from areas on the boundary between ourselves and other acute trusts. The reason for this shift in the pattern of conveyances continues to be pursed with Great Western Ambulance Trust.

1.1.2 Patterns of Emergency Admissions

The recent increase in emergency admissions has not been evenly spread across the week (Figure 4). The most significant increases have been on Mondays and Sundays, with Mondays now being the busiest day for admissions. Compared with 2007/2008 we are now receiving an average of 10 more emergency admissions on a Monday and a Sunday.

Figure 4. The mean number of additional emergency admissions by day of week

Many of the complex elective surgical cases are currently admitted on a Monday or Tuesday, due to the clinical need for a high level of medical cover during the immediate post operative phase. It is also evident that Monday bed availability is influenced by the ability to proactively discharge consistent numbers of patients over the weekend, due to reduced levels of senior medical cover available during this time (see actions taken appendix 1), and lack of community support for discharge at the weekend, as acknowledged by the Primary Care Trust’s GP Support Unit.

The pattern of emergency admissions is exacerbated by the pattern of elective discharges, with most being concentrated on Thursdays and Fridays. Analysis of the day of admission and length of stay of patients discharged on a Friday is currently being undertaken to establish how theatre sessions can be moved to enable patients to be discharged earlier in the week. A detailed audit of inhibitors to discharge is planned, to determine what factors are influencing the pattern of discharges.

1.1.3 Emergency Department capacity

The Children’s Hospital has up until November 2008 routinely exceeded the 98.0% standard. As a consequence, the same level of scrutiny has not previously been applied to levels and patterns of activity. Following the dip in performance the analysis that was undertaken demonstrated the highly predictable nature of levels of emergency attendances. In Q3 the seasonal peak in attendances resulted in a significant deterioration in performance. This started in mid November but has now fully recovered, in line with the forecast drop in attendances (Figure 5).

The high levels of emergency attendances at the Children’s Hospital made evident the shortfalls in junior doctor rota within the paediatric Emergency Department, as well as the pressures on ward staffing through high levels of sickness. Bed availability has also become a limiting factor due to ward staff sickness, and also due to the lack of senior decision making and therefore the tendency to admit more children. The predictable nature of emergency attendances provides an invaluable insight into the likely resource needs at different times of the year. This will be exploited to prevent future performance dips.

Figure 5. Numbers of emergency attendances at the Bristol Children’s Hospital during 2007/2008 and 2008/2009.

2. Action taken by the Board in response to failure to achieve performance during Q3 2007/2008?

Following the failure to achieve the 98% standard in Q3 and Q4 of 2007/2008 a revised action plan was developed and presented to the Trust Board. The South West Strategic Health Authority engaged with the Trust during this period and an action plan was developed and agreed. The action plan submitted to Monitor in the pre-authorisation stage encompassed all agreed actions. The strategy over the past twelve months has been on improving patient flow and capacity management, with key focus on:

·  Improving the way we use information to manage bed capacity pro-actively

·  Increasing support for early discharge

·  Ensuring escalation processes are robust and appropriate.

·  Increasing the engagement of senior clinical staff in managing patient flow on a daily basis

Progress against delivery of the action plan has been reviewed at weekly team meetings and reported monthly to the revised Emergency Access Steering Group, the Trust Executive Group and the Trust Board. The action plan (Appendix 1) provides a summary of key actions taken to date. It is felt that these actions have been critical in enabling the Trust to achieve the 98% standard in Q1 and Q2, despite the significant increase in emergency admissions above 07/08 levels.

3. Action being taken to further improve performance?

Whilst improvements have been made in the management of patient flow the Trust is fully aware that additional work is required to support sustainable improvements, specifically around timeliness of patient discharge. The Trust introduced the use of Estimated Date of Discharge (EDD) during the last year. The use of this tool has been variable up until the last two months, and has required a significant change in practice for clinical staff. More recently, this tool has been used on a twice daily basis to review patient flow and predict capacity over the following twenty four hours. The focus on EDD has helped to focus efforts to expedite discharges of individual patients, which may otherwise have been delayed due to external agencies not recognising the critical need for rapid discharge, both for the patient and the ongoing provision of an acute service.

The Trust constantly reviews progress and is highly conscious of the need to ensure the 98% standard is met as a minimum from both a patient care and experience perspective. It is clear from activity levels and the Trust’s ability to consistently comply with this standard, that capacity modelling for increased activity is critical to sustainability. The current situation has led us to review the medical model for acute medicine and the management of emergency admissions.

In preparation for this current financial year the Trust modelled capacity requirements to sustain the elective workload, and manage the expected numbers of emergency admissions, using historical data. This modelling indicated, assuming all other things stay the same (e.g. length of stay) that the Trust required an increase in beds in both quarter 3 and again in quarter 4. This modelling exercise took into consideration the impact of Norovirus. However, whilst the Trust physically had capacity to meet the capacity demands identified for quarter 3, it was clear that the physical capacity was not there to meet the needs of quarter 4. It was therefore essential that the Trust took action to reduce length of stay and manage elective activity (against the 18 week target) to accommodate predicted activity. The establishment of a 23-hour facility to manage interventional radiology and non-complex inpatient surgery is one of the ways in which elective length of stay is being reduced. Length of stay for emergency patients has dropped from to 5.0 to 4.6 days, and elective from 3.8 to 3.7 days (comparing Q1 to Q3 both years[2]).

It is not yet clear whether the levels of emergency admissions the Trust has observed over the last three months will continue at similar levels. However, it is seen as necessary to remodel operational capacity for 2009/10, and make substantial changes to the acute medical model. This approach will focus on reducing admissions and further reducing length of stay.

The Trust emergency access team has worked with senior and junior medical staff from all clinical groups to review ways of working, along with recruiting external medical expertise to undertake a review of the emergency medical model of care. This work has identified the need to restructure the acute medical model of care and increase the senior consultant medical cover in the Emergency Department. The medical take is not currently set-up to support in full the levels of activity or efficiencies necessary to reduce length of stay, or avoid admissions. To support this in the interim, additional weekend medical consultant cover has been put in place and will be further rolled out during 2009/10. Work is in progress to change the acute medical model and an additional consultant appointment has been agreed for the BRI Emergency Department.

The capacity of the Medical Assessment Unit (MAU) in the University Hospitals Bristol NHS Foundation Trust has been acknowledged as inadequate in size and capacity for some years, via benchmarking and independent review. The MAU only currently has capacity for 11 beds plus a small number of trolleys/chairs. Increasing capacity is therefore seen as a high priority in 2009/10. The ability to increase the capacity of this facility is dependent on the implementation of a revised acute medical model of care and an increase and/or re-allocation of medical staff to support an extended unit. A ward has now been identified for this purpose and the Trust is currently reviewing the business case for adequate staffing levels to accompany this.

The Trust is aware from work undertaken this year that further efficiencies can be made. The Trust will once again review its operational capacity to manage levels of emergency admissions and support further efficiency gains to effect reductions in length of stay which underpin the longer term business plan of the Trust.

3.1  Actions to be taken

The Trust Board receives a monthly performance report which highlights current challenges and report performance against all targets. The 4 hour emergency access target has been discussed in detail throughout the last quarter and at the December and January meetings received and discussed a detailed report on cause, effect and actions. It was agreed at the last Trust Board that actions would be taken during quarter 4, to support achievement of the 4-hour standard, which included:

·  Proposal for a new model for acute medicine be finalised by the Division of Medicine, which should include the planned use of ward 7 (MAU expansion), any required changes to the physician rota/acute medical take, the role of the acute physicians

·  A revised staffing plan for the BRI Emergency Department at the weekend to ensure senior decision making, including the appointment of an additional consultant

·  Detailed audit of discharge management within the BRI, and Bristol General Hospital be undertaken, to identify inhibiters and understand what action must be taken to further reduce length of stay. It is planned that this audit is undertaken in tandem with North Bristol NHS Trust to ensure local health economy-wide actions can be taken.

·  A Divisional Patient Flow manager has been appointed to Surgery Division, and will be appointed to the Medicine Division shortly. These posts will support the pro-active management of patient flow at a Divisional level, ensuring that discharges match planned levels of admissions and therefore accommodate predicted levels of emergency admissions.