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

NU-Care project § § Significance of the NU-Care Project Method of approach Evaluation results NU-Care project § § Significance of the NU-Care Project Method of approach Evaluation results Wider implications

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

Overall verdict § § § Response times improved Patient satisfaction Staff endorsement partially met Overall verdict § § § Response times improved Patient satisfaction Staff endorsement partially met Cost neutrality Clinical assessment system

Basic structure of an A&E department Basic structure of an A&E department

Overall verdict § § Response times improved Patient satisfaction Staff endorsement partially met Cost Overall verdict § § Response times improved Patient satisfaction Staff endorsement partially met Cost neutrality

Overall verdict § § Response times improved Patient satisfaction Staff endorsement partially met Cost Overall verdict § § Response times improved Patient satisfaction Staff endorsement partially met Cost neutrality

Overall verdict § § Response times improved Patient satisfaction Staff endorsement partially met Cost Overall verdict § § Response times improved Patient satisfaction Staff endorsement partially met Cost neutrality

Key results Response times § Cut by half § Higher throughput § Fall in Key results Response times § Cut by half § Higher throughput § Fall in absconder rate § Overcrowding eliminated

Throughput and response times 180 170 March 2003 150 discharged home) daily throughput (patients Throughput and response times 180 170 March 2003 150 discharged home) daily throughput (patients 160 140 130 120 110 100 March 2002 90 80 2. 00 2. 50 3. 00 3. 50 4. 00 average completion time 4. 50 5. 00 5. 50 6. 00

Absconders 180 170 March 2003 March 2002 150 discharged home) daily throughput (patients 160 Absconders 180 170 March 2003 March 2002 150 discharged home) daily throughput (patients 160 140 130 120 110 100 90 80 2. 00 2. 50 3. 00 3. 50 4. 00 average completion time 4. 50 5. 00 5. 50 6. 00

Ready reckoner Ready reckoner

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

Patients’ comments on waits (before) ·Terrible. Three hours waiting with a baby of one 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.

Patients’ comments on waits (after) ·Waiting times much better…… very nice doctors ·Service was 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.

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

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

Managing Triage Managing Triage

Bottlenecks Key issues -1 § Triage “What’s the point of the triage nurse when 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”.

Streaming Key issues -1 § Triage Streaming Key issues -1 § Triage

Bottlenecks Key issue -2 § Waiting for a clinician “If you had more doctors 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”.

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

Staff on duty 30 25 staffing level 20 15 10 six-month stage A 5 Staff on duty 30 25 staffing level 20 15 10 six-month stage A 5 A B baseline 0 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

People in the system People in the system

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

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

Admissions to wards Key issue -4 § Admissions to wards “Whilst everyone who dealt 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”.

Ward admissions Ward admissions

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

Summary at 6 month stage - patients discharge home Summary at 6 month stage - patients discharge home

Staff endorsement Staff views § A majority said that NU-Care had addressed or partly 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

Economic evaluation Cost neutrality § Ongoing costs of £ 650 k a year § Economic evaluation Cost neutrality § Ongoing costs of £ 650 k a year § Time savings to patients of £ 1. 4 m 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

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

Overall satisfaction (after) ·Patient’s son is very impressed with the whole service. …. . 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!

Queuing model Queuing model

Scientific legacy § How to measure activity in A&E departments § Combining wide range 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

Outstanding issues § § § Sustainability Further efficiencies Model of service Better use of Outstanding issues § § § Sustainability Further efficiencies Model of service Better use of information Computer decision support systems

Overall verdict § § Response times improved Patient satisfaction Staff endorsement partially met Cost Overall verdict § § Response times improved Patient satisfaction Staff endorsement partially met Cost neutrality § Clinical assessment system