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Northern Health & Social Care Trust

Review of Emergency Care & Medical Specialities – Phase 1 A&E and MAU

Patricia Kilpatrick

23rd June 2010

DRAFT

Draft Phase 1 Report

DRAFTDRAFTDRAFT

2

Co

nte

nt 1 The Scope and Objectives for the Review 2

2 The Review Process 5

3 The Current Emergency Care System 8

4 Opportunities for Improvement using UK Best Practice 31

5 Appendices 41

3

1 The Scope and Objectives for the Review

4

Background and ScopeScope and Objectives for the Review

All aspects of unscheduled care including the flow

through A&E, MAU and specialities are

included in the review

The Northern Health and Social Care Trust engaged Tribal Consulting to undertake a major review of the provision of Unscheduled Care in order to: Achieve increased performance Improve the quality of the patient experience Create a more efficient care process Deliver optimum utilisation of healthcare resources.

The review focussed on the specialities and services provided from the following hospitals: Antrim Area Causeway Whiteabbey Mid Ulster

In addition the Dalriada, Moyle, Robinson and Braid Valley community hospitals were also reviewed.

The review included all aspects of non elective patient flow and with a particular focus on: Accident & Emergency (A&E) Acute medicine Medical specialties Intermediate and A & E services in terms of achieving and sustaining the 4 hour access target Medical Assessment Units (MAU) Medical specialities Care of the Elderly General Medicine Cardiology Respiratory Medicine Gastroenterology Neurology Stroke Rehabilitation Pharmacy and medicines Management team Intermediate and step down care with a clearly defined diagnosis and robust assessment of the current problem

The review process involved: an appraisal of the current models of care evaluation against UK best practice recommendations on the future design and configuration of these services

5

Objectives

The Review aimed to: Reduce rate of presentations and to provide alternatives to A&E and reduce physical congestion Segment flows and define appropriate resources to improve quality and reduce waiting and congestion Match staffing with peaks in demand reduce breaches Create alternatives to admission by increasing slots in imaging ,scopes, outpatient services, direct referral to rapid access clinics and

reduce numbers in A&E Exploit ambulatory emergency care and bed reduction at both sites Reduce the number and categories of patients who will have their detailed assessment and work up in A&E e.g. Ambulatory Care Service,

GP referred medical patients, urgent / emergency Gynaecology, miscarriages, early pregnancy bleeds – eradicate congestion and breaches.

Reduce length of stay in MAU where appropriate Benchmarking current performance with peer group and best practice Review current intermediate care arrangements and performance Prepare and plan for implementation of change to new models of care. Plan for the recourses needed to implement and run the new model of care.

The review process developed: An unscheduled care model focussed on bringing together the key elements within the service to create an integrated emergency care

department An emergency ambulatory care reflecting UK best practice and supporting any existing “see and treat” functions within the Trust. A bed model for the Trust based on achieving rapid access to streaming, assessment and specialty based care in line with Department of

Health (DOH) guidance, UK best practice in the design of emergency care and the requirements of the Royal College of Physicians. A resource plan to provide a sustainable solution that includes proposals to deliver the efficiencies required in the context of

Comprehensive Spending Review (CSR) A detailed implementation plan that focuses on the costs and timeframe by which the proposed models may be implemented

Scope and Objectives for the Review

The main objective is to improve the triage and streaming of the

patient flow in order to build a more efficient model of emergency

care.

6

2 The Review Process

7

Clinical Engagement

Frequent meetings and workshops

enabled involvement and participation from

all clinical groups.

The Review Process

A range of methods where used to meet and engage with clinicians on all sites including meetings with the following: The clinical director for emergency care. The emergency and specialty clinical teams. The Multi Disciplinary Teams from the Community Hospital sites.

Though these meetings we have ensured involvement and participation of consultants, clinical leads, senior nurses, senior managers, AHP leads, diagnostic teams in lab, imaging, pharmacy, CDs and Executive Directors.

Each phase of the review process is followed by a workshop to further strengthen the clinical engagement: Phase 1: A&E & MAU - 28th June 2010 Phase 2: Bed Models for Speciality Based care – 17th June 2010 Phase 3: Resource Planning and Implementation – 21st July 2010

This report covers the first phase of the report – the review of A&E and MAU.

8

Timescales & Reporting

A Project Plan has been developed covering all phases and is shown below for phases two and three these cover the following: Phase two - 7th June- 5th July - new bed models Phase three 5th July – 2nd of August - resource and implementation

The Review Process

Phase one of three has now been

finalised.

9

3 The Current Emergency Care System

10

Model of Care at Antrim Hospital

Specialty 166 Beds

DEMAND

Assessment 26 BedsAntrim B1

LOS BenchmarkingSum of LOEs by HRG

within spell

PULL

A&E Department - Triage

Ambulatory 6 BedsShort Stay Ward

A & E 10 BedsSSW

Ratio All Admissions (Excl. Obstetrics & Neonatal) To A&E Attendances 16 % - UK Benchmark 17 %

The diagram opposite indicates the current model of care and capacity on the Antrim site. The size and capacity of the site indicates: Antrim is a high volume site the around 65000

attendances per year Short stay is managed by A&E consultants and

has 10 spaces - 8 bays & 2 single rooms. Ambulatory care has 6 beds and MAU outliers

are often boarded into these beds which results in excessive LOS.

The MAU has 26 beds and is managed by MAU consultants on a weekly rota this includes:

– 1 dedicated MAU posts – 0.5 wte

– Locum support for 0.5wte There are 166 medical specialty beds where

patients are transferred to from the MAU.

Front Door There are no collaborative care teams at the

front door. Rapid Assessment teams are available but currently underutilised.

All GP referrals, except chemotherapy go through A&E.

GP services are not collocated on site.

The Current Emergency Care System

A&E and MAU have together 42 beds

All GP referrals, except chemotherapy

go through A&E

11

Antrim A&E Attendances Year 2008/09 2009/10 % change

Antrim 64,858 65,535 1.04%

Causeway 41,033 42,045 2.47%

Mid Ulster 19,056 18,444 -3.21%

Whiteabbey 22,563 22,697 0.59%

Total 147,510 148,721 0.82%


57%

21%

17%

3%1% 1%Self

999 Ambulance

GP/HP Referral

Transfer

Not Known

Other

There has been limited change in

number of attendances over the

last two years.

60% of attendances are self referred

45% of attendances are triage 4 & 5

Triage 1 (Paediatrics), 6%

Triage 2/3, 38%

Triage 4/5, 45%

Triage 1, 10%Not Known, 0.4%

1 Appendices 1provides further data on presentation to A&E

A&E attendance trends across the Trust The table opposite indicates very minimal changes across the last

two financial years with overall 0.8% increase across the 4 sites in the Trust.

Specifically on the Antrim site there has been a 1% growth between 2008/09 and 2009/101.

The analysis presented below is in relation to 2008/09 as this was the most complete and up-to-date year when the work commenced.

Antrim A&E Attendances by source

In 2008/09 there were around 65,000 attendances; on average 178 per day. The source of the A&E referral is shown opposite which indicates: 60% Self 40% GP/Ambulance/HP/Transfer

Triage and Streaming

The triage method currently used is nurse judgement backed up by written protocols. The Antrim site do not currently use the Manchester triage system. Appendix 2 provides a definition of the triage system used.

The chart opposite indicates the A&E attendances by triage category which indicates 45% are triage 4&5.

Disposal from A&E

Analysis of the main disposal route after A&E is shown in Appendix 3 this indicates:: 87% Discharged 4% to Ward 7% to Short Stay Ward (SSW), MAU or CCU

Performance against 4h target 2010:

Analysis against the 4 hour target is shown in Appendix 4 indicating between 60% to 70% compliance, considerable below the Northern Ireland target of 98% within 4 hours. Jan: 65% Feb: 70% March: 60%

12

Antrim A&E WorkloadWorkload Peaks and Troughs

The graph opposite indicates the number of A&E presentations by time period and day of the week indicating Presentations peak from 11am – 8.30pm Mondays have the most presentations – in

excess of 200 presentations Daily average number of presentations is

178/day .

Further work has been done to map the presentations and department workload by hour shown in the chart opposite

Current Staffing

The current staffing provided is as follows: Consultants: 4wte cover Monday to Friday

9am-5pm and Saturday/Sunday 9am-1pm. Nurses: 1wte nurse from 9am-5pm. From

1pm -10pm there is a second nurse on shift. There are 2 band 5 posts who manage the

flow in minors and the supervisory physician who will support where Emergency Nurse Practitioners cannot treat the patient

The current hours are generally staffed for a 9-5, Monday to Friday and there is a need to review the staffing profile for out of hours and weekends.

.

Number of Presentations and Projected A&E Caseload (4 hrs) for Average Day (n = 178)

0

2

4

6

8

10

12

14

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

24 Hour Clock (Before Hr)

Pres

enta

tions

0

5

10

15

20

25

30

35

40

45

50

Proj

ecte

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selo

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Average Presentations (Primary Axis)

Department Caseload (last 4 hrs Secondary Axis)

Peak caseload between 1 pm and 9 pm)

Antrim A&E Average Daily Workload from Midnight - 8am, 8am - 4pm, 4pm - Midnight On Days of Week (2008/2009)

21 19 19 18 19 27 32

96 80 83 77 79 74 75

8776 74 76 75 68 72

0

50

100

150

200

250

Mon Tues Wed Thurs Fri Sat Sun

Ave

rage

Dai

ly P

rese

ntati

ons

4pm - midnight

8am - 4pm

Midnight - 8am


Current peaks in A&E on a Monday and

between 11am and 8.30pm.

Current staffing is predicated on a

Monday to Friday 9am to 5pm and

further resources are required to cover

weekend and evenings.

13

A&E Case note study

19 records were extracted from the Symphony A&E system reviewing these indicates the following findings: The chart below shows the split by triage type Of the 19 – 2 patients left before first seen 4 patients required an x-ray 1 patient required request for a consult with non-A&E

specialist and waited 1 hour 30 minutes 12 records had time when decision to admit / discharge

made 5 patient required a bed excluding outlier of 7 hours 33

the average wait was 1 hour 7 minutes for a bed

The key times between interventions is shown below. This indicates overall from entering to treatment completion / decision to admit or discharge the average time is over the 4 hour target however once the outlier (maximum) is excluded the average is reduced to within the 4 hours (3 hours 13 minutes).

Adult Majors26%

**MAJORS B**37%

Minors21%

Triage and Resuscitation

16%

Average Maximum Average excluding outlier

Time from registration to triage 1:23 19:43 0:14

Time from triage to 1st consultation with medical staff 1:42 6.41 1:23

Time from consultation to x-ray 1:11 3:35 0:23

Time from 1st consultation or x-ray to 2nd consultation 1:38 6:56 1:15

Time from 2nd consultation to diagnosis 2:54 20:44 1:25

Time from entering to diagnosis 4:33 8:48 4:16

Time from entering to decide to admit /discharge 4:18 8:48 3:13

Time from enter to leave 6:57 1 day 3:31 5:52

A case note study of 19 records indicated ,

when excluding the single outlier that the

total time from registration to

treatment complete was 3 hours 13

minutes.

26% of the patients required to be

admitted to a hospital bed

14

Antrim A&E Attendances to Admissions

Antrim A&E Average Daily Admissions From Time of Present from Midnight - 8am, 8am - 4pm, 4pm - Midnight On Days of Week (2008/2009)

5 4 4 4 4 5 5

1210 11 10 10 7 7

109 9 10 10

8 8

0

5

10

15

20

25

30


Aver

age D

aily P

rese

ntati

ons

4pm - midnight

8am - 4pm

Midnight - 8am


Attendances to Admissions:

Reviewing the attendances which results in an admissions indicates in total 7458 admissions in 2008/09 within the following areas: 54% MAU 17% Short Stay Ward 7% Ambulatory Care area 22% Specialty Beds

Admissions from A&E by time of the day and day of week is shown in the table opposite indicating this greatest admissions are on a Monday (27 on average) which is consistent with the analysis of attendances .

Admissions For Specialties in Scope Only

Reviewing the medical specialties within the scope of the review indicates around 7,500 admissions per annum, on average 20 per day.

Of these the referral source indicates: 95 % via A&E 5 % Direct GP/HP

54% of patients admitted from A&E

where admitted to the MAU

For the specific specialties under review 95% were

directly referred from A&E

15

Antrim Medical Assessment Unit & Short Stay Ward

Medical Assessment Unit

The length of stay profile for patients either admitted to the MAU ward or MAU specialty in Antrim is show opposite.

This included 4,045 episodes, 78% of which with a stay up two days: 14% with no overnight stay 42% 1 overnight stay 22% 2 overnight stays

The current target length of stay for the MAU is 2 days.

Further length of stay analysis of the patients admitted under the MAU specialty by ward (either MAU or other) is shown opposite.

This indicates 3,565 patients coded to the MAU specialty with 3,3169 93% within the MAU ward and 7% within other wards (likely to be the ambulatory care area)

The length of stay analysis indicates a significantly greater proportion of those within the MAU ward stay up to 2 days (82% of total) compared to those who stay in other wards only where only 51% stay up to 2 days with 49% staying over 2 days.

Short Stay Ward

Analysis of the short stay ward activity indicated: 1280 patients were coded to the ward 82% stayed up to 2 days with:

– 28% no overnight stay

– 42% 1 overnight stay

– 12% 2 overnights stays


LOE Profile on Admission Under Medical Assessment Specialty or Admitted to Medical Assessment Unit B1 (n=4,045)

14%

42%

22% 22%

0%

10%

20%

30%

40%

50%

LOE < 24 hrs One Overnight Stay Two Overnight Stays LOE > 48 hrs

% E

piso

des

of C

are

LOE Profile on Admission Under Medical Assessment Specialty, Admitted to Assessment Ward (B1) or to Other Ward (n=3,316, n=249)

15%

45%

22%19%

8%

17%

26%

49%

0%

10%

20%

30%

40%

50%

60%


% E

piso

des

of C

are

Admission to Assessment Unit

Admission To Other Ward

LOE Profile on Admission Short stay Ward (n=1,280)

28%

42%

12%18%

0%

10%

20%

30%

40%

50%


% E

piso

des

of C

are

Around 80% of patients coded to

either MAU specialty, MAU ward or Short

stay ward stayed up to 2 nights.

49% of activity coded to MAU consultants but not in the MAU ward stayed over 2

nights.

16

The Current Model of Care at Antrim Hospital A & E

A&E attendances are streamed into three areas: Majors

– Patients arrive by self referral, GP or ambulance.

– Protocols exists for triage,

– There is a point of care testing in place and some delays due to pathology. Minors

– Self referred patients will on arrival choose against a list of conditions (minor/majors).

– Minors move to a separate area with 7 cubicles available.

– An Emergency Nurse Practitioner (ENP) manages minors with the supervision of a physician (any grade). Paediatrics

– There is a separate area for children.

– A dedicated nurse from majors and a physician covers this area in conjunction with A&E.

– They have not all received paediatric specific training.

Access to clinics Elective clinics should allow for acute management of patients within specialities. The rapid access clinics with a 2 week wait are not

‘rapid’ enough. There is a direct access to Stroke and Cardiology, admission from A&E to MAU. Gynaecology is a particular problem and the teams are working to identify a clear pathway to Gynaecology services to reduce response

times

Occupational Therapy/Physiotherapy/Social Care support in A&E and Short stay: Physiotherapy and Occupational Therapy are available on weekdays and for a few hours in the morning on weekends. Social worker is on call at weekends and dedicated in the department weekdays The response time is good


The access to speciality beds is not

fast enough

The social worker response time is good

.

17

Current Model of Care Antrim Hospital A & E

Mental Health Crisis response from Mental Health is excellent. Daily presence in the mornings and good response time Access to Mental Health acute beds is an issue and can cause delays for up to a day where patients are admitted to the ward/short stay

until a bed can be found within the region if none available at Holywell.

Flow Management/Coordinator: This post does exist but it is not working optimally. It is felt this role would significantly improve the management of patient flow and

managing breaches within the department and allocating resource where required.

Delays downstream MAU is unable to create capacity. Wards are not discharging enough to allow pulling from MAU to release capacity.

Information/Monitoring of the target: An electronic system, Symphony, is in use and flags patients when they are coming up to breaching. Symphony shows: Name of Patient,

Registration time, pre streamed (ED1), ED2, Decision to Admit, Depart. Performance against 4 hours / 12 hours high level of breaches. - waiting for breach report from Seamus There are full admitting rights to surgery therefore no delays in terms of response times There is unlimited access to CT, ultrasound and X-ray in hours and unlimited access to X-ray out of hours. However access to ultrasound

and CT out of hours is by patient demand and on call. There is access to a morning endoscopy list


Access to mental health acute beds is

an issue

The role of the flow coordinator should be

expanded to better manage breaches

.

18

Model of Care Antrim Hospital MAU

The Model All patients, except Cardiology, go to MAU and are coded to the single consultant regardless of whether it is their rotaed week on There are 26 beds and one extra bed without call buttons or gas/air. There is no high dependency unit in the MAU Length of stay is longer than needed due to capacity issues in specialty beds It is a push model rather than a pull from MAU to specialist or discharge. There are no electronic boards to track A&E waits The discharge services are poor at weekends.

Staffing 1wte consultant post (work each 2nd week in MAU)

– 0.5 Respiratory

– 0.5 Locum –The recruitment for this post is delayed. Nurses work over 3 areas to increase flexibly (MAU, Clinical Decision Unit, Short Stay Ward) The nursing skill mix in MAU is high (3 qualified to 1 non) Receiving arrangements

– Consultant rota between 8am-5pm

– On call Physician of the day working a 1 in 11 rota.

– There is no Rheumatology in rota

– Cardiology, Renal & Haematology have separate rotas There is in reach from Cardiology and Stroke but not Gastrointestinal (GI) Typical 5 days service across MAU and hospital with limited consultant input at weekend

– 50% reduction in discharges at weekend


All patients , except cardiology, go from

A&E to MAU.

19

Model of Care Antrim Hospital MAU

Systems and Processes There are 2 ward rounds a day during Monday -Friday

– am ward round followed by review

– pm white board round with Multi Disciplinary Team (MDT). There is one daily (am) ward round during Sat & Sun MDT including occupational therapists, physiotherapist and social worker, are meeting daily at 10.30 The post take round is done by a MAU consultant – either from respiratory or locum (geriatric medicine) The goal is to discharge within 72 hours where possible but this is currently difficult due to lack of specialty beds The current general model is to hold patients in MAU awaiting correct specialty bed rather than put in other specialty There are is treatment plan proforma in use except for stroke Integrated Care Pathway (ICP) Estimated date of discharge is set in MAU together with date of admission, details of any investigations, referral and discharge. The status

of each patient is kept up to date on a whiteboard. All patients in BAY1,2,3, 4 and side room 1 and 2 are tracked. Nurses are currently not able to order Radiology or Diagnostics. MAU staff have access to A&E system to identify patients

Improvements and issues There has been recent improvements to CT that allows early am session and weekend session for strokes Blockage in the process appears to be diagnostics in particular Endoscopy

– A solution could be setting up early 8am session Monday to Friday.


Difficult to discharge within 72 hours due to lack of specialty beds.

20

Current Emergency Flows Antrim Hospital

Discharge /Referral to GP/ OP Referral/ Community Services

A & E178 attendances

per day

Self Referred Walk-ins,Blue light emergencies Acute Medical Patients triaged In A&E those requiring assessment to MAU

Not admitted

Triage & Assessment

Treatment >4 Hours

Children's A&E

Triaged Medical Patients Transfer

to AMU

Paediatric

Admission Wards

MAU Ward B1 ALOS 1.5

20% >48hrs

Obs Short Stay 1.6 days

ACSALOS 0.31

Not admitted

Medical Specialty Wards

SSW10 beds

Ambulatory6 beds


A summary of the current emergency

flows at Antrim Hospital is shown in

the diagram opposite

21

Antrim Hospital: Issues emerging from the review

Front Door High level of Urgent Care cases presenting at A&E in 08/09

– Triage 4/5 = 29,043 represents 45% of total, a daily average of 80 patients per day Lack of protocols for streaming patients to minors and majors (self referral only) – at present this is based on patient’s own allocation at

reception according to a list of conditions. This could result in inappropriate use of resources should patient’s default to the wrong stream. Triage is undertaken using protocols and nursing judgement. There needs to be a standardised mechanism for triage to reduce clinical

variation practices. The self referred & GP referred medical patients are being managed through A&E. this is not UK best practice. On average 80% of the

breaches are related to medical assessment of self referred cases with lower admission rate.

Admissions There were 7,458 non-elective admissions for all medical specialties admitted; excluding Stroke and MI there are 6910 Of these 54% are subsequently admitted to MAU, 17% admitted to Short Stay Ward, 7 % to Ambulatory and 22% to specialty beds Of the 4045 admitted to MAU, 15 % are discharged within 24 hours

Staff Significant problems recruiting to junior doctors and also managing to cover these posts with locums. With the merger across Whiteabbey

and Mid Ulster there is funding available for 3.5 middle grades. The suggestion is to use this funding for 2 additional consultant posts in order to plan medical workforce in line with demand peaks.

Length Of Stay Average length of stay in MAU is 1.5 days; compared to the UK average of 0.8 days 532 admission in A&E related to ante natal not related to delivery or an event of which 63 were discharged same day

Suggestions to improve flow: Active streaming & minors can be managed in a separate area by emergency nurse practitioners All GP referred cases should go direct to MAU All strokes following assessment and confirmed stroke should go to Hyper Acute Stoke Unit. All Myocardial Infarctions following confirmed diagnosis should go to Cardiology /Coronary Care Unit A care of the elderly service at the front door to manage patients through Care of elderly assessment beds in the community and

establishment of an older people rapid access clinics.


A standardised triage method would reduce

risk of clinical variation.

.

22

Model of Care at Causeway Hospital

Ratio All Admissions (Excl. Obstetrics & Neonatal) To A&E Attendances 16 % - UK Benchmark 17 %

The diagram opposite indicates the current model of care and capacity on the Causeway site.

The size and capacity of the site indicates around 41000 attendances per year MAU has 12 beds Coronary Care Medical Monitoring Unit

(CCMU) with 14 beds 71 specialty beds where patients are

transferred to from the MAU.

Front Door

The Causeway A&E department has access to the following services: A Hospital Diversion Team to treat

patients at home a social worker on rota in A&E Two care of elderly physicians who

attend in the A&E

However there is no: collaborative care team at the front

door, no rapid assessment team minor injuries unit / walk in centre in

primary care community hospitals with inpatients

providing any walk in type services older person rapid access clinics that

pulls from the acute assessment unit

GP admissions All GP referred patients are managed

through A&E GP is co-located out of hours

Specialty 71 Beds

DEMAND

MAU 12 Beds

1. A&E Department - Triage

LOS BenchmarkingSum of LOEs by HRG

within spell

PULL

Coronary Care/Med Monitoring 14 Beds


MAU and CCMMU have together 26

beds.

All GP admissions go through the A&E

23

Causeway A&E Presentations Year 2008/09 2009/10 % change

Antrim 64,858 65,535 1.04%

Causeway 41,033 42,045 2.47%

Mid Ulster 19,056 18,444 -3.21%

Whiteabbey 22,563 22,697 0.59%

Total 147,510 148,721 0.82%


A&E Presentation trends across the Trust The table opposite indicates very minimal changes across the last two

financial years with overall 0.8% increase across the 4 sites in the Trust. Specifically on the Causeway site there has been a 2.5% growth between

2008/09 and 2009/10.

The analysis presented below is in relation to 2008/09 as this was the most complete and up-to-date year when the work commenced.

Causeway A&E Attendances by source

In 2008/09 there were around 41,000 attendances2; on average 112 per day. The source of the A&E referral is shown opposite which indicates : 63% Self 16% GP/HP 19% 999 / Ambulance

Triage and Streaming The Manchester triage system is used Triage team includes: SHO/locums, triage nurse, Consultant 9-5pm, (No

registrar) Decision making at the front door – Senior house officer / Senior Nurse 3 flows: resuscitation, majors & minors The physical layout of the department reflects the flow

Analysis of the top 10 presenting conditions is shown in Appendix 7 for all triage categories and Appendix 8 for categories 4 & 5; this indicates: 29% of total limb problems; 57% of triage categories 4 & 5 5% of total wounds, 10% of triage categories 4 &5

Disposal from A&E

Analysis of the main disposal route after A&E is shown in Appendix 9 this indicates 68% Discharged 16% Admitted 8% to Clinic

Performance against 4h target 2010:

Analysis against the 4 hour target is shown in Appendix 4 indicating between 85% to 90% compliance, below Best Practice of 98% compliance.

There has been limited change in

number of presentations over the last two years.

80% of attendances are self referred

60% of attendances are triage 4 & 5

Triage 3, 34%

Triage 4, 58%

Triage 1, 0.3%

Triage 5, 2% Triage 2, 5%

2 Appendices 5 and 6 provide an analysis of A&E presentations by month, & day of the week

63%

18%

16%

1%2%

Self

999 Ambulance

GP/HP Referral

Not Known

Other

24

Causeway A&E Workload

Workload Peaks and Troughs

Due to the coastal location of the Causeway site analysis has been undertaken separately for the spring/summer and autumn/winter.

The graphs opposite indicates the number of A&E presentations by day of the week and time period indicating: Presentations peak 4pm to midnight Mondays have the most presentations – on average

137 per day in the spring/summer and 118 in the autumn/winter

Daily average number of presentations :121 per day in the spring/summer and 104 in the autumn/winter.

Further work has been done to map the presentations and department workload by hour shown in the chart opposite indicating peak hours from 4pm to midnight spring/summer and 5pm to 10pm in autumn/winter


There is a 16% increase in the

average A&E presentations in the

spring & summer months due to the

coastal location of the Causeway site

The peak hours within A&E are 4pm to

midnight in the spring/summer and 5pm to 10pm in the

autumn / winter.

Causeway - Number of Presentations and Projected A&E Caseload (4 hrs) for Average Day (March - August Inclusive) (Average Daily = 121)

-

1

2

3

4

5

6

7

8

9

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24


Pres

enta

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s

0

5

10

15

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25

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35

Proj

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Peak caseload between 4 pm - Midnight)

Causeway - Number of Presentations and Projected A&E Caseload (4 hrs) for Average Day (September - February Inclusive) (Average Daily = 104)

0

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Pres

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Peak caseload between 5 pm - 10 pm

Causeway A&E Average Daily Workload from Midnight - 8am, 8am - 4pm, 4pm - Midnight On Days of Week, March - August (2008/2009)

64 61 57 51 57 55 59

52 53 51 46 48 40 44

21 21 1919 17 23

25

-

50

100

150

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Ave

rage

Dai

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ntati

ons 4pm to Midnight 8am to 4 pm Midnight to 8am

Causeway A&E Average Daily Workload from Midnight - 8am, 8am - 4pm, 4pm - Midnight On Days of Week, September - February (2008/2009)

58 50 49 48 49 49 46

4542 41 37 45 37 35

1815 17 17

17 21 24

-

50

100

150


Ave

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Dai

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ntati

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4pm to Midnight 8am to 4 pm Midnight to 8am

25

Causeway A&E Attendances to AdmissionsThe Current Emergency Care System

Current Staffing

The current staffing provided is as follows: Medical team includes physician of the week (8.30am-6.30pm

weekday and 8.30am-2pm on weekends). There is an on call rota for emergency work The Emergency Department team includes physiotherapist,

social workers, occupational therapists (using rotas) Access to specialist opinion Monday to Friday and on request at

weekends. 1 in 4 rota is used for advice Emergency Nurse Practitioners (ENPs) can make decision about

treatment. Nurse led discharge at weekends

Attendances to Admissions:

Reviewing the attendances which results in an admissions indicates in total 3,859 admissions in 2008/09 within the following areas: 56% Assessment 34% CMU 10% Specialty Beds

Admissions from A&E by day and time is shown below:

56% of patients admitted from A&E

where admitted to the MAU

For the specific specialties under review 92% were

directly referred from A&E

As with attendances the admissions peak

during the summer months March to

August; circa 10-15% higher.

Admissions For Specialties in Scope Only

Reviewing the medical specialties within the scope of the review indicates around 3,800 admissions per annum, on average 10-11 per day.

Of these the referral source indicates: 92% via A&E 5% Transfers 1% CCMU Fast-track

Causeway A&E Average Daily Admissions From Time of Present from Midnight - 8am, 8am - 4pm, 4pm - Midnight On Days of Week, March - August (2008/2009)

10 10 8 9 9 8 8

6 6 6 6 54

5

6 65 5 5

66

-

5

10

15

20

25


Ave

rage

Dai

ly P

rese

ntati

ons

4pm to Midnight 8am to 4 pm Midnight to 8am

Causeway A&E Average Daily Admissions From Time of Present from Midnight - 8am, 8am - 4pm, 4pm - Midnight On Days of Week, September - February

(2008/2009)

10 9 9 8 9 8 7

5 5 5 56

4 4

5 5 5 46

6 5

-

5

10

15

20

25


Ave

rage

Dai

ly P

rese

ntati

ons 4pm to Midnight 8am to 4 pm Midnight to 8am

26

Causeway Medical Assessment Unit & CCMU Ward

Medical Assessment Unit

The length of stay profile for patients either admitted to the MAU or the CCMU ward is show opposite.

This included 2,155 episodes, 52% of which with a stay up two days: 10% with no overnight stay 27% 1 overnight stay 15% 2 overnight stays

The current target length of stay for the MAU is 2 days.

CCMU

Analysis of the CCMU ward activity indicated: 1347 patients were coded to the ward 61% stayed up to 2 days with:

– 15% no overnight stay

– 33% 1 overnight stay

– 13% 2 overnights stays


Just over 50% of admitted to MAU stay

ward stay up to 2 nights.

Just over 60% of activity coded to

CCMU ward stay over 2 nights.

LOE Profile on Admission to Medical Assessment Unit 2008/2009 (n=2,155)

10%

27%

15%

48%

0%

10%

20%

30%

40%

50%


% E

piso

des o

f Car

e

LOE Profile on Admission to CMU (n=1,347)

15%

33%

13%

39%

0%

10%

20%

30%

40%

50%


% Ep

isode

s of C

are

27

The Current Model of Care at Causeway Hospital A & E

A&E attendances are streamed into three areas: Resuscitation Majors Minors

There is effective diagnostics including the following features: digital imaging and CT/ultrasound to support rapid decision making Lab results are sent to a printer within the A&E Ability for Nurses to request X-ray

Access to clinics Elective clinics should allow for acute management of patients within specialities. The rapid access clinics with a 2 week wait are not

‘rapid’ enough. There is a direct access to Stroke and Cardiology, admission from A&E to specialty beds. There is direct access to Palliative Care beds from A&E and from Community Hospital Transfers Gynaecology assessments are undertaken within Gynaecology ward. The area is used as an early pregnancy ward and managed by two

senior nurses

There is in reach to A&E from for the following specialties Stroke Care of Elderly General Medicine The decision to admit is made within one hour from the request of a surgical, orthopaedic, paediatric, gynaecologic expert opinion

Ambulatory Emergency Care Hospital diversion team are used 7am – 11pm to avoid admission There are no interventions provided by the Ambulance Service There is no clinical decision unit or surgical assessment unit


Effective diagnostics

Use of Hospital Diversion Team to reduce admissions

Clear pathway for Gynaecology patients

28

Current Model of Care Causeway Hospital A & E

Mental Health The mental health provision can be improved as there is limited service provision out of hours is limited and the patients are kept in A&E

beds with no mental health medics on site The service is lead by Community psychiatric nurses who are available 9-5pm in A&E.

Flow Management/Coordinator: This post does exist but it is not working optimally. It is felt this role would significantly improve the management of patient flow and

managing breaches within the department and allocating resource where required.

Outlying to Surgical beds Recently Surgery stopped taking outliers in last 2 months after removed surgery from Mid Ulster and only permits if an Estimated

Discharge Date (EDD) and a discharge letter are provided The A&E could benefit from creation of surgical assessment room for transfers

Information/Monitoring of targets A manual system is used for bed management information There are delays in accessing both assessment beds and specialty beds Twice daily emails regarding bed availability are sent across the Trust There are online printed manual for all conditions but no tick box pathway protocols A discharge date is set on admission (where possible). Performance against 4 hours are close to 90% The trust has set a 1 hour limit for the surgical specialties to respond within No reported delays in waiting for a surgical opinion (orthopaedics, paediatrician, gynaecology) obstructs the flow Operational policies are perceived as success There are however inappropriate nursing home admissions including end of life care.


The diagnostic routine is functioning well

with few delays

Access to mental health acute provision

an issue

The role of the flow coordinator should be

expanded to better manage breaches

.

29

The Current Model of Care Causeway Hospital MAU

The Model There are 6 admissions to the MAU per day. This is 56 % of all medical admissions (34% go to CCMU and 10 % to Specialty Beds) All patients come through A&E There is no High dependency unit, Short stay ward or Clinical decision unit The Length of stay should be up to 48 hours.

Staffing 1 wte Physician cover MAU according to a physician of the week model There are 4 band 7 nurses The physicians rota arrangement is 1 in 6 week but there is no acute physician. Specialists present at ward rounds:

– Geriatrics present weekends only

– All other specialities are present daily. (Stroke, Diabetes nurses, cardiac, respiratory, early discharge team.) The discharge pattern is even though the week with but low during weekends. Social worker is available but no dedicated Physiotherapist The community and step down beds doesn’t receive patients during weekends.

Systems & Processes Two daily rounds: morning and afternoon, coronary care unit is included in the round. Physicians for all areas except geriatrics participates on the ward rounds (Physician, Physiotherapist, Pharmacist, Social worker ) There is a daily ward meeting with the board team. SOLVER System is used to get input from as many specialists as possible. This process is still in progress. If the patient is likely to be discharged within 72 hours they will be retained and managed on the MAU. There is a treatment plan pro forma in use in the MAU The estimated date of discharge is set in MAU, multi disciplinary team meetings are held morning and evening. There are no ICPs in use for treatment guidelines. The lack of isolation wards effects the patient flow There is a need for more speciality physicians in the intensive care unit so that all patients are seen by professional staff


All patients go from A&E to MAU on

average 6 per day.

30

Current Emergency Flows Causeway Hospital


A & E

GP & Self Referred Walk-ins,Blue light emergencies Acute Medical Patients triaged In A&E those requiring assessment to MAU

Not admitted

Triage & Assessment

Resus , Majors, Minors

Treatment >4 Hours

Children's A&E

Triaged Medical Patients Transfer

to AMU

Paediatric

Admission Wards

MAU 12 Beds

48 Hrs Target LOS Not admitted

Medical Specialty Wards

RATS Team

Hospital Diversion Team


A summary of the current emergency flows at Causeway

Hospital is shown in the diagram opposite

31

Causeway Hospital – Issues Emerging from the Review

Front Door High level of Urgent Care cases presenting at A&E in 08/09Triage 4/5 = 24,000 represents 60% of total a daily average of 65-70 patients

per day Use of the Manchester triage system ensures standardised mechanism for triage to reduce clinical variation practices. The self referred & GP referred medical patients are being managed through A&E which is not UK best practice. Self referred patients being managed through A&E

Admissions There are 3859 non-elective admissions for all medical specialties, excluding Stroke and Myocardial Infarction (MI) there are 3571; of

these 56% go to MAU 10 % of the MAU admissions are discharged within 24 hours 473 admissions in A&E were ante natal not related to delivery or an event of which 53 were discharged same day (11%).

Length of Stay Average Length of stay (ALOS) in MAU is 2.0 days compared to the UK average of 0.8 days

Suggestions to improve flow: Active streaming and management of minors by emergency nurse practitioners in a separate area All GP referred cases should go direct to MAU All strokes following assessment and confirmed stroke should go to Hyper Acute Stoke Unit. All Myocardial Infarctions following confirmed diagnosis should go to CCMU A care of the elderly service at the front door to manage patients through Care of Elderly assessment beds in the community and

establishment of an older people rapid access clinics.


The key object of the review is to assess

the efficiency of triage and streaming of

patients in the A&E.

.

32

4 Opportunities for Improvement using UK Best Practice

33

Proposed Model of Care


MIU Treatment

CAU

Triaged Self referred Cases to MAU for assessment prior to admission/ discharge

A & E

• Self Referred Walk-ins, & Blue light emergencies direct to A&E • Acute Medical Self Referred Patients triaged In A&E those requiring assessment to CAU

Not admitted

Treated within CAU 24 hours

Admitted to Specialty Ward with a treatment plan/ EDD

Discharged from specialty beds

Triage

See & Treat, Minors

Further Assessment

Observation Beds

Children's A&E

Triaged SR Medical Patients Rapid Transfer

to CAU

Ambulatory Treatment

Collaborative Care Teams

Direct

CAU

• All GP referred medical & surgical patients direct to MAU• Patient s admitted to A&E where treatment is >4 hours transfer toCAU

Short Stay Unit

Opportunities for Improvement

CAU is a Combined Assessment Unit for

both medical and surgical assessments

All GP referrals direct to CAU

34

Moving Forward

Using What We Know About Best Practice in the Design and Management of A&E

The Vision for the Emergency Department Appropriate practitioner, right skills and expertise Rapid access to diagnosis, assessment and treatment Paediatrics and Adults 98% compliance on the 4 hour target Patient experience is good Clinical outcomes are optimum Readmission rate is low

The Model Reduce the number of attendances in the medium/ long term Utilise and create alternatives to admission Increase ambulatory emergency care

The Flows Segmentation and management of defined flows Staffing of the flows Process and systems Protocols and guidelines

Resources Understanding peaks and troughs Matching staffing resources with demand Appropriate skills and expertise Admission rights – responsive specialty input Availability of beds

The new model of care should reduce

attendances through effective use of

alternatives, match resources when most

needed and ultimately improve patient experience and

outcomes.


35

Key Issues to consider

The following strategy is suggested to optimise the flow: GP Referred acute medical patients are directed to the MAU

for assessment – the role of emergency medicine

Self referred cases continue to be directed though A&E for initial assessment and work up within four hour period

DH Guidance supports 24 maximum LOS for effective assessment function

UK ALOS for MAU is 0.8 days

The Royal College of Physicians of England’s clear objective is rapid access to speciality based care

The stroke pathway – guidance from A&E to a Hyper Acute Stoke Unit.

Management of MI – Guidance supports from A&E to Coronary care unit primary PCI

Definitive list of ACS pathways which will be provided to model the trolleys/couches etc this will reduce bed days and inpatient beds.

Best Practice Issues to be considered

Key Issues to be Address in the Proposed Model of Care

Direct the GP referred admissions to MAU this would potential take around 19 admission from Antrim and 13 from Causeway per day from A&E to MAU

Segment the flows in A&E

Care of the Elderly consultant input at the front door with options to transfer to assessment beds, intermediate care beds, step down care

Consider how best to manage the Minor Flow – which constitutes 48% (Antrim) and around 60% (Causeway) of the overall attendances at A&E – looking at the best practice management of minor injury and minor illness

Development of ambulatory emergency care – potential for significant reduction in inpatient beds

Development of Gynaecology Direct Referral system and Early Pregnancy Assessment Unit

Creating alternatives to admission.

Key IssuesThe key features and issues of the

proposed model of care include

Segmented flows

GP referrals directed to MAU

Maximum stay in MAU of 0.8 day

Use of pathways

Creating alternatives to admission


36

Management of the A&E Flows

Directing GP Referred Acute Medical Patients to MAU Relocate GP referred medical patients currently presenting at A&E to MAU This will free up capacity in the A&E Reduces overall wait time for assessment Reflects UK best practice Takes 19 admission from Antrim and 13 from Causeway from A&E to MAU for assessment & work-up Reduces duplication of function Emphasis on rapid assessment Creates a similar cohort of patients being managed by one team

Use of specific flows for the following patient groups Paediatrics: young patients are treated separately both for safety and efficiency reasons Minors: Estimate 50% of Trusts in the UK have some form of primary care service working with the emergency department.

Approximately 30% have been classified as “primary care” cases. There are three operational models for a GP managed minors flows:1. A GP service located alongside or next to the emergency department. 2. GPs working at the front of the department screening attendees and either treating or diverting to other places – effectively acting as a

filter.3. GP services fully integrated into a joint operation covering the whole range of primary care and emergency services. We came across

a small number of systems that offer a full primary care service to appropriate patients Ambulatory Care Service: predestined HRGs are treated in ambulatory care and kept separated from the A&E Majors: patients goes timely though A&E to appropriate bed (if admitted). Separate flow (not though A&E) for

– Cardiology– Chemotherapy– Complex Elderly– Maternity

Resuscitation: Separate area for resuscitation

Key feature of the model of care is

effective streaming consisting of all GP

referred acute medical patients

direct to MAU and clear flows for

remaining categories including minor

attendances goes to a form of primary care


37

Options for the Management of the Care of Elderly

Care of the Elderly

Options for the management of elderly patients

Use of care of elderly – geriatrician led rapid access clinics

Refer to care of the elderly assessment beds

Use of intermediate care coordinators in- reaching to A&E / MAU

Refer to intermediate care beds

Refer to palliative care , end of life care

Refer for social work assessment

Collaborative care team / home care package

Care of the Elderly improvements to the

model of care are fundamental given the

aging profile and significant pressure

this specialty has on the unscheduled care


38

Ambulatory Emergency Care

Analysis of the current inpatient data has been carried out to understand the impact of fully developing ambulatory care sensitive (ACS) pathways.

This includes reviewing the 2008/09 admitted patient data and comparison of the proportion of patients with no overnight stay against the recommended proportion from the Institute for Innovation & Improvement Directory of Emergency Care for Adult..

Full details are in Appendix 11 & 12 for the top 10 conditions however the summary results are shown below which provides analysis of the spells and beds days associated with ACS conditions and indicate the potential bed savings at both the maximum and minimum % from the report.

The key findings from this indicate: Overall 15% of ACS conditions are currently discharged with no overnight stay Between 7 and 14 beds spaces are required in Antrim and 5 to 10 beds spaces are required at Causeway for ACS conditions assuming 12 hour and 60% occupancy

rate. Impact is between 27 and 55 bed reduction

Site Total Spells

Total bed days

Indicative beds

Total % discharged

in day

Beds saved -

max

Beds saved – min

Antrim 4,659 3,252 61 17% (34) (17)

Causeway 2,843 12,710 35 12% (21) (10)

Total 7,502 15,962 96 15% (55) (27)

Ambulatory care improvements are

recommended by a number of

organisations


39

The Scope for Improvement – Development of Early Pregnancy Assessment Unit & Gynaecology Direct Referral system

At Antrim, currently all early pregnancy patients and gynaecology emergencies are directed through the A&E. At Causeway there is an Early Pregnancy Assessment Unit (EPAU)

In 2008/09 there were 532 spells of antenatal admissions in Antrim not related to a delivery presenting through A&E utilising 1283 occupied bed days only 12% were discharged within 24 hours of admission.

This HRG is clearly an ambulatory case sensitive (ACS) condition and the estimates based on the clinical evidence are that 30% to 60% of those patients could be managed through an EPAU, reducing the Occupied bed Days (OBDs) by almost 2 inpatient beds, improving the patient experience and reducing the burden on the A&E service by on average 2 cases per day.

Emergency gynaecology / Early Pregnancy Assessment Unit service

A 24 hour consultant-led service for early pregnancy and emergency gynaecology that incorporates a 09.00 – 17.00 appointment service for direct referral from GPs.

Services provide assessment and management of early pregnancy problems, including early pregnancy bleeding up to 12 weeks’ gestation.

Units are part of the gynaecology department

Establishing an Early Pregnancy

Assessment Unit in Antrim to treat direct

Gynaecology referrals

40

Diagnostic Support

Dedicated slots in imaging including Ultra Sound (US) and computerised tomography (CT) where delays are likely to contribute to breaches

Point -of -care -test (POCT) in A&E and MAU Dedicated slots for endoscopy emergencies and “urgents” Use of rapid access clinics Dedicated slots in OP clinics Care of the elderly consultant sessions in the A&E to “pull “ out from the A&E those patients who require assessment by a geriatrician

rather than admission to an acute medical bed. Use of the community hospital beds for , care of the elderly assessment step down and rehabilitation Longer term the development of collaborative care teams (CCT) and better utilisation of the existing Rapid Access Teams to pick patients

up at the front door & take home with support, home care packages.

Improvements to diagnostics


41

Summary and Next Steps

Four key steps in taking forward the

work

The diagram opposite summarises the next steps including: Agreement on the model of care covering

– GP referrals routed straight to MAU

– Streaming of minors to GP service in A&E

– Improvements to Care of the Elderly service

– Roll out of all ambulatory care pathways

– EPAU / GDR established in Antrim

– Improvements to diagnostics Agree the planning assumptions underpinning the above

– Including target performance for the specialty beds Factor in additional capacity required in Antrim as a result of the

reconfiguration of services at Mid Ulster and Whiteabbey

– Including the impact to A&E, MAU and specialty beds Model the changes

– Robust and bespoke bed model to take on board performance improvements, new model of care and reconfigurations across the Trust.

42

5 Appendices1. Antrim A&E Current Flows 422. Antrim Triage Categories 433. Antrim: Disposal from A&E 44 4. Antrim: Performance Against the 4 hour Target? 455. Causeway A&E Current Flows -1 466. Causeway A&E Current Flows 2 477. Causeway A&E Top Ten Presenting Conditions 488. Causeway A&E Top Ten Presenting Conditions – Triage 4&5 499. Causeway: Disposal from A&E 5010. Causeway: Performance against the 4 Hour Target 5111. Antrim – Ambulatory Care Sensitive Conditions 5212. Causeway – Ambulatory Care Sensitive Conditions 53

43

1. Antrim A&E Current Flows

Average A&E Attendances 178 per

day. 95th Percentile in excess of 240 per

day. Average A&E Attendances Monday

203 per day.

Appendices

Average Daily Presentations (+/- 1.96 2 s.d) To Antrim A&E, Each Month During 2008/2009 Compared With Daily Average Over Year (178)

181 190 188 175 172 178 173 174 178162 175 187

0306090

120150180210240270

April May June July Aug Sept Oct Nov Dec Jan Feb Mar

Pres

enta

tions

Average Daily Presentations To Antrim A&E, On Days Of the Week During 2008/2009 Compared With Daily Average Over Year (178)

203

175 176 172 174 169 178

6080

100120140160180200220


Pres

enta

tions

44

2. Antrim Triage Categories Appendices

Triage Antrim TriageTriage 1 Immediate Care (High Dependency)Triage 1 (Paediatrics) Children MajorsTriage 2/3 Adult/Paeds **MAJORS A**

Triage 4/5Minors, Primary Care PractitionersPre-Stream, Self Care Advice

45

3. Antrim: Disposal where did they go from A&E? Appendices

Coronary Care Unit, 2%

MAU, 2%

SSW Ambulatory, 1% Intens ive Care Unit, 0.1%

Del ivery Sui te, 0.1%

SSW Bed, 3%

Ward, 4%

Discharged, 87%

Discharged

SSW Bed

MAU

Coronary Care Unit

Ward

SSW Ambulatory

Intens ive Care Unit

Del ivery Sui te

46

4. Antrim: What is the Performance Against the 4 hour Target? Appendices

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10

%

% 0-4 hours

% 4-12 hours

% 12 hours +

47

5. Causeway A&E Current Flows-1

Average A&E Attendances 112 per day but Seasonal Variation

Appendices

Average Daily Presentations To Causeway A&E, Each Month During 2008/2009 Compared with Full Year Daily Average (112)

115127 120 119 122

112103 105 105

96108

116

020

406080

100

120140

April May June July Aug Sept Oct Nov Dec Jan Feb Mar

Prese

ntatio

ns

48

6. Causeway A&E Current Flows-2

Average A&E Attendances 112 per day but Seasonal Variation

Appendices

Average Daily Presentations To Causeway A&E, On Days Of the Week, March to End of August (6 ms) Compared with Daily Average Over Full Year (112)

132129

122

111

117113

123

100

105

110

115

120

125

130

135


Pres

enta

tions

Average Daily Presentations To Causeway A&E, On Days Of the Week, Sept to end of Feb (6ms) Compared with Daily Average Over Year (112)

117

103 103

98

107103 101

85

9095

100

105

110115

120


Pres

enta

tions

49

7. Causeway A&E Top Ten Presenting Conditions Appendices

29%

10%7%

5%

6%

4%

3%

3%

2%2%

2% 3%

Limb problems

Unwell adult

Abdominal Pain

Wounds

Chest Pain

Head Injury

Eye problems

Shortness of breath

Back Pain

Unwell child

Falls

General Discriminators

50

8. Causeway A&E Top Ten Presenting Conditions – Triage 4&5 Appendices

57%

10%

8%

6%

6%

3%3%2%2%2%

Limb problems

Wounds

Head Injury

Eye problems

General Discriminators

Back Pain

Unwell adult

Local infections and abscesses

Assault

Falls

51

9. Causeway Disposal – Where did they go from A&E? Appendices

68%

16%

8%

5% 3% 0.3%

Discharged

Admitted

Clinic

Blank

Transferred

MH

52

10. Causeway: What is the Performance against the 4 Hour Target? Appendices

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10

% 0-4 hours

% 4-12 hours

% 12 hours +

53

11. Antrim – Ambulatory Care Sensitive ConditionsAppendices

1,394 8,042 22 17% -11 -5

HRG Description

Reported SpellsAmbulatory

Care HRGYear 08/09

OBDSHRG

Episodes Within Spells

Indicative Beds

% Discharged Same Day

ComparisonWith

PracticeGuidelines

Ambulatory Care

(<1 Day) Max

Ambulatory Care

(<1 Day) Min Max MinUnspecified Acute Lower Respiratory Infection 331 3,252 9 2% <Min 60% 30% 5.13- 2.46- Transient Ischaemic Attack >69 Or W Cc 45 368 1 9% <Min 90% 60% 0.82- 0.52- Lobar, Atypical Or Viral Pneumonia W/O Cc 93 847 2 2% <Min 30% 10% 0.65- 0.18- Pleural Effusion W/O Cc 19 252 1 0% <Min 90% 60% 0.62- 0.41- Pulmonary Embolis W/O Cc 25 217 1 4% <Min 90% 60% 0.51- 0.33- Lobar, Atypical Or Viral Pneumonia W Cc 38 568 2 0% <Min 30% 10% 0.47- 0.16- Chest Pain <70 W/O Cc 410 692 2 37% Between 60% 30% 0.44- - Pleural Effusion W Cc 14 146 0 0% <Min 90% 60% 0.36- 0.24- Bronchopneumonia W Cc 15 225 1 7% <Min 60% 30% 0.33- 0.14- Bronchopneumonia W/O Cc 18 203 1 6% <Min 60% 30% 0.30- 0.14- Chest Pain >69 Or W Cc 144 346 1 28% <Min 60% 30% 0.30- 0.01- Pulmonary Embolis W Cc 12 117 0 0% <Min 90% 60% 0.29- 0.19- Deep Vein Thrombosis >69 Or W Cc 24 117 0 8% Between 90% 0% 0.26- - Asthma W/O Cc 63 292 1 5% <Min 30% 10% 0.20- 0.04- Headache Or Migraine <70 W/O Cc 81 167 0 22% <Min 60% 30% 0.17- 0.04- Deep Vein Thrombosis <70 W/O Cc 16 76 0 13% Between 90% 0% 0.16- - Transient Ischaemic Attack <70 W/O Cc 21 45 0 5% <Min 90% 60% 0.11- 0.07- Asthma W Cc 10 77 0 0% <Min 30% 10% 0.06- 0.02- Headache Or Migraine >69 Or W Cc 15 35 0 27% <Min 60% 30% 0.03- 0.00-

Movement in BedsAll spellsBest Practice Guidelines All Spells

54

12. Causeway - Ambulatory Care Sensitive Conditions Appendices

820 3,912 11 14% -6 -2

HRG Description

Reported Spells

Ambulatory Care HRG

Year 08/09

OBDSHRG

Episodes Within Spells

Indicative Beds

% Discharged Same Day

ComparisonWith

PracticeGuidelines

Ambulatory Care(<1 Day) Max

Ambulatory Care

(<1 Day) Min Max MinUnspecified Acute Lower Respiratory Infection 189 1689 5 3% <Min 60% 30% 2.65- 1.27- Transient Ischaemic Attack >69 Or W Cc 22 155 0 0% <Min 90% 60% 0.38- 0.25- Lobar, Atypical Or Viral Pneumonia W/O Cc 72 428 1 0% <Min 30% 10% 0.35- 0.12- Deep Vein Thrombosis >69 Or W Cc 16 137 0 0% Between 90% 0% 0.34- - Lobar, Atypical Or Viral Pneumonia W Cc 33 326 1 0% <Min 30% 10% 0.27- 0.09- Pleural Effusion W/O Cc 13 104 0 0% <Min 90% 60% 0.26- 0.17- Chest Pain >69 Or W Cc 135 224 1 23% <Min 60% 30% 0.23- 0.04- Chest Pain <70 W/O Cc 190 240 1 36% Between 60% 30% 0.16- - Pulmonary Embolis W/O Cc 14 67 0 7% <Min 90% 60% 0.15- 0.10- Headache Or Migraine <70 W/O Cc 41 119 0 15% <Min 60% 30% 0.15- 0.05- Deep Vein Thrombosis <70 W/O Cc 15 57 0 7% Between 90% 0% 0.13- - Bronchopneumonia W Cc 6 72 0 0% <Min 60% 30% 0.12- 0.06- Asthma W/O Cc 38 155 0 5% <Min 30% 10% 0.11- 0.02- Pleural Effusion W Cc 5 30 0 0% <Min 90% 60% 0.07- 0.05- Pulmonary Embolis W Cc 4 26 0 0% <Min 90% 60% 0.06- 0.04- Headache Or Migraine >69 Or W Cc 13 48 0 15% <Min 60% 30% 0.06- 0.02- Transient Ischaemic Attack <70 W/O Cc 7 15 0 14% <Min 90% 60% 0.03- 0.02- Bronchopneumonia W/O Cc 4 16 0 0% <Min 60% 30% 0.03- 0.01-

3 4 0 33% Max 30% 10% - -

Movement in BedsAll spellsBest Practice Guidelines All Spells

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