The Medical Director for the Emergency Care Improvement Programme looks at a new approach to helping hospitals cope with peak winter pressures:
We often keep patients in hospital for too long.
We make them wait for all sorts of things such as, tests, reviews, medication, social care packages, discharge papers, and so on. This waiting is not passive, it can be harmful.
But it doesn’t have to be like this.
The Emergency Care Improvement Programme (ECIP) was established to help address the challenges patients and urgent and emergency care systems face, especially through the winter months. ECIP is a clinically led programme designed to offer intensive practical help to 28 urgent and emergency care systems under the most pressure.
There is evidence from the first week of January last year that there were increased blockages in patient flow and disrupted performance across the system for a significant time after. For example, in 2014-15, there was a spike in the number of patients waiting over four hours from decision to admit to admission – so-called “trolley waits” – in the days immediately after the festive period.
Further evidence shows a partial but significant cause is the in-hospital reduction in discharge decision-makers time over the holidays, most notably of consultant reviews.
It is for this reason we have created the Safer Start campaign, specifically to support systems to improve patient flow from January onwards.
Safer Start will deliver a unified whole system approach in two parts; firstly, systems agree to have appropriate levels of senior medical, nursing, diagnostic, social care and therapy cover from 25 December through to the second week of January; and secondly each system runs an accelerated discharge or breaking the cycle type event in order to safely discharge patients no longer requiring an acute level of care. More details can be found on the ECIP website.
An example of this approach was implemented in Colchester where the System Resilience Group were challenged to tackle the blockages to patient flow head on. The challenge was accepted.
#Safer343, as it has become known, established three exemplary wards for three weeks implementing the SAFER patient flow bundle, a simple set of rules (like a clinical care bundle) any system can implement.
They started by taking an in depth look at what was happening on the wards of Colchester General Hospital. Multi-disciplinary teams from across the local system, supported by ECIP, walked the wards looking for medically fit patients who could be appropriately discharged.
The teams challenged rules around unnecessary paperwork and the clinical need for some tests, supported staff to go and get the results of tests rather than waiting for them, and together they got a significant number of people safely out of hospital that day, with the appropriate support from social care. This freed up the flow of patients through the system and led to an empty ambulance bay for the first time in memory and free beds in the emergency department.
Dr Menon, a consultant at Colchester General Hospital, told us: “Our medically fit patient number has come down to around six at present. This has meant we were able to pull more patients into the ward from EAU and in many instances treat and discharge them fairly quickly. This has meant that our length of stay has come down and flow is much better.”
The ECIP team has been in to all 28 systems to undertake a diagnostic review. We have seen dedicated hardworking staff often frustrated by ill-fitting processes, bureaucracy and unnecessary complexity. What ECIP has proven is that staff can be empowered, antibiotic IVs can be given in the community, occupational therapists and physios can be freed up to be more effective, and that a ‘home first’ policy should be the goal of every system.
Senior clinicians need to feel comfortable owning the risks that allow patients to be discharged early. They can lead by example on ward rounds and set precedents that mean their junior doctors complete discharge summaries before lunch so nurses don’t have to spend valuable time chasing them. This comfort comes from strong, continuous and effective leadership, leaders who will commit to improvements and see them through, despite the bumps in the road.
Increased patient flow saves lives and too often unnecessary complexities, unhelpful processes and lack of ownership of risk silts up the system. But the systems within the ECIP programme, supported by the experts within ECIP, have shown it is possible to overcome those blockages.
ECIP are preparing a number of quick guides and other helpful material on our website which I would encourage systems to look at. We also run a number of events and webinars which will also be useful.
Perhaps this Christmas your present to your patients and service users, if you aren’t already planning it, might be to implement one or more of these improvements.