Hospital solutions for crowding Dr Ian Higginson MSc FCEM Emergency Physician ianhigginson@nhs.net

No magic wand

Objective To reduce crowding in the ED

Cycle of change

Strategy Optimise what you do control Influence what you don’t

Tactics Developing your sources of power Managing Mordor Building a case for change Creating expectations of others Knowing what you expect from them

The single most important ingredient in the ED response is leadership

Emergency Departments Why is it not OK for an OT to be rushed / crowded, but it is OK for an ED

The ED brand Emergency Medicine in the UK is subject to an outdated value proposition This underpins the current crisis in Emergency Departments The national ED brand

So what? People perceive things Perception drives expectations Expectations drive perception of quality Perceived quality drives perceived value Get the ED brand right and you become valued. If you are valued you are worthy of investment, and you become part of the solution rather than being part of the problem

Emergency Departments Why is it not OK for an OT to be rushed / crowded, but it is OK for an ED

Manage Mordor Hospital managers naturally look to the easiest thing to blame, in order to avoid fixing the things that really need fixing Get the attention where it should be: on the other parts of the system

It’s still about branding Get your local ED brand sorted

Culture (and projection) Internal Relentlessly positive (avoid being the victim) Realistic and honest Be intolerant of poor quality of care Don’t chase targets at the expense of patient care External Frame the problem Crowding isn’t OK: crowding is EVIL It’s a system problem

Keep your side of the street clean Clear leadership, coherent team, consistent approach and message Command and control, flow coordinators Match capacity to demand, sustainably Coherent workforce plan Get “minors” sorted Implement best practice Clinical Process

‘Men chose to believe what they want’ Myths to challenge 1. Just a busy day, no clinical significance 2. All ED’s problem, nothing to do with the back door 3. All about ‘inappropriate attenders’ 40% versus 10-15% 4. All about ‘frequent attenders’ ‘Men chose to believe what they want’ Julius Caesar 43 AD

Building a case for change

The power of narrative …. Me to CEO: It’s really bad and it‘s getting worse CEO: It’s always bad. How bad is it? Me: Dunno. More really bad than the last time I told you it was really bad CEO: La la la la la la I can’t hear you Don’t allow it to be normalised Also need to be able to measure it

The power of data ….

We know crowding when we see it

Occupancy and 4 hour performance The 4 hour standard is actually a measure of ED crowding

Direct measurement of crowding You can measure crowding using some simple indicators: this one is useful because it represents the time when there wasn’t a single flat surface available in the ED.

Breach analysis

Decent breach data can show where the problems are

Targets + Francis + CQC (or Welsh equivalent) = pressure3 Use the levers …. Targets + Francis + CQC (or Welsh equivalent) = pressure3 And then turn the pressure up Learn what drives people, if you need to pull levers to influence change

Safety Narrative Incident reports Complaints and compliments Governance meetings Risk register

Inform and educate Opportunities for advocacy Invite key people into your ED Comms to hospital colleagues Structured meetings Get access to the board Commissioning environment Get crowding on their performance framework

There’s a delicate balance between pursuing the crowding agenda, and irritating off those we need to influence Get your comms right

Expectations of others Providing we can meet the expectations of others, of us, it’s OK to have expectations of them too

“Get a grip” Board level engagement Senior team focusing on the issue Effective bed management

Recipe for success? Ambulatory care Frailty? SAFER bundle Internal Professional Standards Diagnostics Internal referrals Reduce variation: weekends, bank holidays and evenings Effective discharge / links with the “community”

SAFER bundle S - Senior Review, all patients will have a Consultant Review before midday A - all patients will have a planned discharge date (that patients are made aware of) F - flow of patients will commence at the earlier opportunity (by 10am) from assessment units to inpatient wards. Wards are expected to ‘pull’ the correct patient to their ward before 10am E – early discharge, 25% of our patients will be discharged from base inpatient wards before midday. TTO’s (medication to take home) for planned discharges should be prescribed and with pharmacy by 3pm the day prior to discharge R – review, a weekly systematic review of ‘stranded’ patients with extended lengths of stay ( > 10 days) to identify the issues and actions required to facilitate discharge. This will be led by senior leaders within the Trust

Pay attention to the interfaces

Remember “line balance”

Effective escalation Triggers Responses Full capacity protocol Hospital Community Full capacity protocol

“How bad does it have to be before you will consider boarding?” Boyle’s Law: “How bad does it have to be before you will consider boarding?”

Always end on a postive note …

System hits the buffers

OMG Last year we admitted 1500 more patients (elderly) Average length of stay for all patients 8.7 days If all else stays the same: we need to add another ward a year Crowding will get worse

Strategy Get your own house in order, and your department on the front foot Create a strong local brand and service concept (re) Frame the problem, don’t allow crowding to be OK Influence the system change needed Don’t underestimate how tough this is going to get