1. MANAGING PRESSURES IN AN ACUTE SETTING Grant Archibald Director Emergency Care & Medical Services 10 TH JUNE 2011

2. A Short Introduction to Queuing Theory AndreasWillig July 21, 1999 The subject of queuing theory can be described as follows: consider a service centre and a population of customers, which at some times enter the service centre in order to obtain service. It is often the case that the service centre can only serve a limited number of customers. If a new customer arrives and the service is exhausted, he enters a waiting line and waits until the service facility becomes available. So we can identify three main elements of a service centre: a population of customers, the service facility and the waiting line.

5. Managing Pressures in an Acute Setting Key Parameters NHSGGC - 9 Acute Hospital Sites 465,000 A&E attendences per year 161,000 emergency admissions per year

6. Managing Pressures in an Acute Setting

7. UCC Performance Chart shows a steady build up of performance figures as improvement work begins to take effect in the departments : April 2006 – 81% compliance December 2007 – 98% compliance achieved for the first time 98% achieved in 18 of the following 22 months as improvements are embedded and sustained Numbers of attenders and admissions increasing in A&E across NGSGGC However, it also shows a recent period of decline and then partial recovery – what has changed?

8. Managing Pressures in an Acute Setting System pressure builds through 2010/11 (1): Pressures re Delayed Discharges Patients moving more slowly through the system ASR - Re-design of Services Winter Pressures –Extreme snow fall/freezing icy conditions –Increased number of H1N1/Flu like/Respiratory illnesses

9. Managing Pressures in an Acute Setting System pressure builds through 2010/11 (2): Significant increase in emergency activity and admissions A&E attenders –24th December to 7th January 2011: 5% increase on previous year Emergency Admissions –25th December to 7th January 2011 : 9% increase on previous year –1st to 3rd January : 17% increase on previous year –3 days when emergency admissions exceeded 500 patients –3 days when emergency medical admissions exceeded 300 patients Continued attender and admission pressures through most of January 2011

10. Managing Pressures in an Acute Setting

11. Response to managing key pressures in system (1) Immediate : Implemented Escalation Policy Opened additional capacity Increased Home Visiting by GPs/Primary Care services Longer Term :Understand Changes in Demand profiles Continuing to progress planned improvements in length of stay and bed usage Ongoing management of delayed discharges Reviewing plans to deal with any exceptional peaks in emergency activity EDD Reviewing Outcomes of A&E Patient Audit and Inequalities Audit A Review of all out of hospital measures – HEAT 10 Work Programme

12. Managing Pressures in an Acute Setting Response to managing key pressures in system (2) System wide Improvement Action Plan for Unscheduled Care (ATOS) March 2011 – Flow Mapping Local team engagement to identify patient processes May 2011 – Stakeholder Engagement Event – whole system Presentation of data analysis Identified key priority issues to be addressed 17 th June 2011 – Stakeholder Event to agree future workplan

13. Reasons for breach Beds = 39% Waiting A&E = 16% Waiting Specialist = 12% Support Services = 15% Clinical Exception = 14% Transport = 9% Bloods = 3.6% Diagnostics = 1.3% Radiology = 3.6% Surgical = 3% Ortho = 2.8% Medical = 3% Other = 2% 46% of admissions < 2 days ALoS ALoS in Wards 4.7 days 40% of A&E admissions are Surgical 12% of Surgical admissions breach 8% of Medical admissions breach 27% of Surgical processed in last 30 mins & getting worse 20% of Medical processed in last 30 mins & getting better Issue Tree Capacity vs Demand mismatch (1 st Dr Assessment is 14%) People & Process? Footprint & routings (layout)

14. Managing Pressures in an Acute Setting

15. Key Issues identified at Stakeholder Engagement Event CAPACITY MANAGEMENT Improve accuracy and use of predictive tools Match staffing and services to demand profile Set capacity parameters for all service flows

16. Managing Pressures in an Acute Setting Key Issues identified at Stakeholder Engagement Event WHOLE SYSTEMS APPROACH Joined up performance targets for Acute services, Primary Care, SAS and NHS 24 Re-emphasis on unscheduled care being a whole service target Review arrangements for chronic disease management / repeat admissions to reduce emergency hospitalisation

17. Managing Pressures in an Acute Setting WAY FORWARD Essential to recognise this is not just a product of extreme winter A new paradigm in demand and capacity Using structured analysis and tools to devise specific, hard edged solutions Develop a programme of sustained improvement Achieve a new steady system-wide steady state, which is also capable of managing demand variations