1. Emergency Access Information Network - May 2009 ‘Why do people attend’ NHS Forth Valley A&E and what do we need to do to better manage demand’ Kathleen McCormac Redesign Programme Manager

2. Objectives Describe a range of approaches – Exploratory Survey completed in 2007 Case note review completed in 2008 Current state analysis of ‘Front Door Demand’ 2009 Summarise our Conclusions and illustrate our approach to managing demand

3. Exploratory Survey completed November 2007 Aim – study the referral patterns of emergency patients attending SRI Sample – people over 16 years presenting during one week (excluded those people presenting with a minor injury/illness) Methodology – Trained nurses in A&E and Assessment Unit completed questionnaires for each person

4. Exploratory Survey completed November 2007 Results – 438 questionnaires completed (37% of all attendances and 93% of all admissions) Main findings related to mode of transport and time of attendance by referral source, e.g. 54% of patients arrived by ambulance (70% of NHS24 referrals, 50% of self referrals, 33% of GP referrals) 70% of GP referrals arrive before 17:00 hours Main findings also related to appropriateness of presentation e.g. For 59 patients their presentation and/or admission could have been prevented (34 patients could have been managed differently today) For 29 patients the referral process could have been improved

5. Case Note Audit 2008 Public Health Consultant reviewed the case notes of all emergency admissions on one day (78 case notes reviewed) Main findings Majority of patients had a very short Length of Stay (<1 day) Patients discharged at first consultant ward round Multiple investigations with apparent dependence on tests despite clear signs for discharge Evidence of multiple ‘clerk ins’ Admissions with no record of why and no clear care plan Little evidence of interventions other than nursing and bed for the night No discharge plans Little senior input prior to consultant ward round Conclusion – admission is the simplest/easiest option

6. Current State Analysis of ‘Front Door’ Demand

7. 7 NHSFV Front Door Services – Current State Outbrief v1 A consolidated front door therefore shows the need to manage significant variations in demand

8. 8 NHSFV Front Door Services – Current State Outbrief v1 A&E Minors indicates 4 main variations in demand (and hence Takt times) throughout the day Significant increase in attendance from the overnight profile

9. 9 NHSFV Front Door Services – Current State Outbrief v1 Whilst the combined doctor and ENP resource for Minors (S3) is an issue throughout the day The problem is not isolated to Resus and Majors, and is more prolonged within Minors

10. Conclusion Need to DESIGN model for Acute and Urgent Care across the whole system

11. Call Handling/Referring Services Scottish Ambulance Service Acute and Urgent Care Whole System - Vision Acute and Urgent Care Whole System - Vision Public Information, Education and Self Care Advice SASNHS24GP Practices Emergency VehiclesCommunity Paramedics Urgent Care Minor Injury / minor illness Day medicine/Rapid access to Specialist assessment and investigations Acute Hospital Emergency Care Accident and Emergency Major Injury and/or illness Minor Injury Short Stay Assessment Unit Acute Illness Inpatient Beds Specialist beds Ambulatory /Day Medicine Rapid access to specialist assessement and investigations Community Healthcare & Social Care Community Hospitals Local units Community Services Complex care Specialist outreach Supported discharge Outreach Rehabilitation Community Nursing Palliative Care 1 2 3 4 5 6 GP services Medicine Manageement Advanced Care Planning Direct Access Diagnostics Social Care Social Care Package Home Care Rapid Response