Hospitals on the edge Crisis in acute medical services Dr Mark Temple Consultant Physician & Nephrologist Acute care fellow Royal College of Physicians

Overview: crisis in acute medical services The treatment Symptoms Hospitals on the edge Changing pts changing needs Out of hours care breakdown Weekend mortality Imbalance of care community / 2o care The case for consultant delivered care Acute care toolkits – organisation of care & consultant working What type of consultant? generalists vs specialist 7 day working Hospitals on the edge – priority areas (summary)

Crisis : Hospitals on the edge September 2012 Clinical demand 37% admissions (10yr) 33% acute beds (25yr) Casemix/organisation Age, co-morbidity & expectation complex care available to all Changes to out of hours care. Over-reliance on secondary care OOH Workforce crisis pressure consultants 70% (3yr) 27% SpRs unmanageable workload Recruitment EM, elderly care, GIM training Pressure : Nurse, AHP staffing

Increased Emergency Admissions HEFT 07-09 Emergency Admissions (>0 days) Sept 07 – Dec 07 Sept 08 – Dec 08 Sept 09 – Dec 09

RCP Health Bill survey All members & fellows - March 2012 Top 5 Concerns – wider health agenda Lack continuity of care Efficiency savings/funding Clinical staff shortages Health reforms Education training & research

RCP: Members & Fellows survey Recommend their hospital to family member? 1:10 NO, 1:4 not sure Hospital’s ability to deliver high quality care 24/7? 34% average, 10% poor Continuity or care the norm? 43% average, 25% poor Stable teams care & teaching? 40% average, 21% poor Discharge with realistic allocation responsibility for further actions: 38% average, 21% poor Success of handover : 16% felt 80% handovers successful <10% felt 90% successful

Hospitals on the edge RCP September 2012 Fractured care Lack of continuity of care major concern March 12 Multiple ward moves, handover, LOS Outcomes: mortality w/e (10%) NCEPOD – high quality care = consultant care (time to intervene DNAR) Francis report (ii) - Mid Staffs – systematic failure of good care Inadequate staffing / patient centred care NHS financial climate

Medical workforce Emergency Medicine 1:10 posts vacant 1:5 SpR posts vacant 1:8 trainees change to another specialty in first 3yrs Elderly care 50% posts last 12/12 unfilled and of these 2/3 no applicants GIM - unpopular undervalued 54% SpR dual accredit Of these only 42% wish practice GIM as cons SpR “unmanagable workload” o/c Rota gaps SpR 10-15% NE England

Elephants in the room Social care funding & occupancy of acute medical beds. 7/7 admission 5/7 discharge NHS 7 day working = secondary care Failure to develop alternatives to hospital admission

Changing profile of patients changing needs 65% admissions > 65 Pts > 65 occupy 70% of bed days > 85 - 25% bed days Last decade : 65% increase admissions age >75 [31% age 18-59] Mean LOS Age > 85 LOS 11 days Age < 65 LOS 3 days 25% of all in-patients have dementia

Out of hours care breakdown Secondary care is the health service OOH Factors influencing decision to admit: Lack of alternatives to admission - accessible 7/7 Less experienced staff (OOH) admit “senior review mane” “Momentum to admit” NH resident OOH carer expectation Baseline clinical status uncertain “less responsive”, “not eating”, “off legs” Minor illness/major social support issues -admit “safe” option & perceived as only way to assess adequately

Weekend mortality for emergency admissions Aylin P et al (2010) Qual Saf Health Care; 19: 213-217 2005/6 emergency admissions England (4.3M) In hospital deaths (medical, surgical, cancer) 215,054 deaths crude mortality 5% Odds death admit at w/e compared with during the week -adjusted age sex comorbidity socio-economic status & diagnosis

Weekend mortality increased - all admissions + 8/32 diagnostic groups with highest deaths Number of admissions Weekday Death % (no.) Weekend p OR (95% CI) All Emergency Admissions 4, 317,866 4.9% 162, 639 5.2% 52,415 <0.001 1.10 (1.08 - 1.11) AMI 68932 13.5% 6803 14.4% 2650 0.002 1.08 1.03 - 1.14 AKI & other Renal Failure 14134 25.6% 2924 33.3% 909 1.45 1.32 -1.60 Aylin P et al (2010) Qual Saf Health Care; 19: 213-217

10% higher odds death admitted w/e 3369 “excess” deaths – 3201 all road deaths 2006 “excess mortality may reflect differences in standards of care” Pts should expect same standard of care irrespective of day of week admitted Recommendation - Hospitals revise: patterns of care Level of service provision at w/e

Mortality: patients admitted on a weekday vs weekend – preliminary data 2012 Diagnostic group Weekday weekend Acute and unspec. Renal failure 19.5% 25.1% Aneurysms: Aorta, peripheral, visceral 27 36.5 Carcinoma of bronchus 28.4 34.2 Carcinoma of pancreas 25.1 34.4 Secondary malignancies 16.3 20.9 Congestive cardiac failure 14.6 16.5 Pneumonia 19.9 Acute cerebrovascular disease 19.2 22.2 Dr Foster

Rate of diagnostic procedure on the day of admission Dr Foster 2012 Rate of diagnostic procedure on the day of admission Dr Foster 2012. Expressed: % admissions including the diagnostic procedure Diagnostic Procedure Weekday Weekend CT 54% 52% MRI 19% 11% Upper GI endoscopy 13% 8% Dr Foster

Benefits of consultant delivered care Benefits of consultant delivered care. Academy Royal Medical Colleges 2012 Rapid, appropriate decision making (endorse DNACPR where CPR futile) Improved outcomes More efficient use of resources GP access to fully trained Dr Pt expectation of access to appropriately skilled clinician & info Benefits to training junior doctors

Benefits of consultant delivered care Academy Royal Medical Colleges Increased mortality & morbidity associated with delay in consultant involvement – range of fields (acute medicine) Increased mortality at w/es attributed to reduced consultant input in care Studies designed to improve pt care incorporating earlier consultant involvement – improved outcomes

Consultant presence RCP Position statement 11/2010 Hospitals undertaking the admission of acutely ill medical patients should have a consultant physician on site for at least 12 hours per day, seven days a week, at times relating to peak admission periods. The consultant should have no other duties scheduled during this period. Currently - average hospital consultant cover gap: Weekday 4.4 hrs - requires 35% increase cons hrs Weekend 7.3 hrs - 60% increase consultant hours

RCP initiatives : consultant delivered care/ organisation of care Acute Care toolkit 2 - 2011 Evaluation consultant working 2011 Acute Care toolkit 4 – Oct 2012 Toolkit 2 – High Quality Acute Care NEWS – July 2012 Toolkit 6:The medical patient at risk Effective Ward Round – Oct 2011 Early cons. Review 7/7 – Toolkits 2,4 Future Hospital Commission Consultant care: AMU Consultant care : wards Deteriorating patient detection / escalation Clinical decision making include CPR decisions

ACT 2: High quality care for acutely ill patients 1: AMU Consultant on site 12 hours day without conflicting duties At least 2 consultant WRs during 12 hrs In period AMU staffed by consultant all newly admitted patients should be seen within 6-8 hrs. Patients admitted overnight seen within 12-14 hrs The staffing, resources and specialist support services involved in the care of medical emergencies should be organised on the basis of 7 day working

AMU: Support for patterns consultant working: RCP survey Feb-April 2010: Association pattern of cons cover acute medical admissions & patient outcomes : Admitting cons > 4hrs/day, 7 days a week lower 28/7 re-admissions rate Consultant on call no other fixed commitments lower adjusted case fatality rate Consultants conducting >2 WRs / day on AMU lower adjusted mortality pts LOS > 7days Consultant on call works blocks of >1 day, < 7days lower overall week-end mortality Clin Med 2011 (11) 1: 17-19

ACT 2: High quality care for acutely ill patients Improving care - Medical and surgical wards Particular risk: Transfer out of AMU within 48 hrs – evolving acute illness Move to a different landscape! From AMU : enhanced staffing (cons) organisation of care To wards: Unfamiliar with pt/acute care Uncertainties about diagnosis & management Quality monitoring /response pt deterioration? Patient transfer Friday pm (next cons round 72 hours +?)

ACT 2: Pts transferred out of AMU – receive a consultant review within 24 hrs – 7/7 Patients transferred out AMU: Enhanced review - Consultant of team responsible for continuing care “Golden Hour” priority duty in first working hour Template cons physician working 7/7 all wards “Buddy” arrangements : link medical teams to Surgical wards Weekday: reschedule conflicting duties 8.30-10 Weekend: consultand rota for shared bed patch Review all New + acutely ill Facilitates:Reliable cons review critical time acute illness Confirm: Diagnosis, Rx, discharge, ceilings of care, Support ward nurses & covering med staff Review newly transferred & acutely ill

Heartlands Hospital – Consultant duties 7 / 7 AMU: 8am: 2 Consultants review pts All Medical and Surgical Wards: 8.45am (weekday) - 6 Consultant Physicians reviewing patients (new and/or sick) – all will provide ongoing care 9.15am (weekend) – 4 Consultant Physicians reviewing patients [Previously 2 physicians “safari”of pts - no ongoing care responsibility ]

How to change consultant working The Physicians story - Paul Woodmansey (2011) AMU consultant cover 12hrs w/d, 6-8hrs w/e W/E Troubleshooting Consultant visits all med wards : sick & quick d/c Increase early discharge Coincided reduction mortality (all and w/e) Major change working life : introduced with relative ease Consultant proposed tried & accepted Good for pt care “Greatest challenge is cons delivered (not led) service required” “Pace .. in hospital .. pts need daily senior input” Clin Med 2011 (11) 1: 17-19

Acute care toolkit 4: Consultant 12 hour 7 day presence – October 2012

More consultants needed: - support acute take 7/7 What type of consultant? Changing patients & needs The generalist – Back to the future? DeLorean 1981 Renaissance for GIM? GIM physician – once dynamic! Now unpopular – flight to specialty away from acute take < 25 % dual trainees (GIM /specialty) wish to practice GIM Pts now rarely present with a isolated single organ illness

Supporting the consultant led 7 day ward round (1) : the 7 day Hospital Diagnostics Assessment & treatment: Therapists, SW, specialist nurses Nursing culture monitoring progress – proactive use consultant decision making ceilings of care (DNACPR) Escalation enhanced care beds (level 1 – 1.5) Discharge support pathways out (intermediate care, interim beds) Ambulatory care – default alternative to admission?

Supporting the consultant led 7 day ward round (2) : the community RCP – Hospitals on the edge - admissions Move focus from episodic care [crisis] – Kings Fund to: Prevention – post d/c what to do in an emergency Proactive management declining health: advanced care decisions Integrated care (COPD) - manage chronic disease Consistent standards primary care - 7 day Develop alternatives to admission that work 7/7 Discharge pathways working consistently 7/7

Dignity and patient centred care Summary Hospitals on the edge – a time for action 10 priority areas (1-5) Dignity and patient centred care Patient placement acuity of illness, staffing Redesign services / organisation of care Design : maximise continuity, min. ward moves Medical education & training/ right skill mix Right balance generalist / specialist skills More extensive training elderly care skills Re-invigorate GIM

Hospitals on the edge – a time for action Priority areas 6-10 Improve availability of primary care Integrated care 7/7 services 2o care in community Revolutionise: use of information, EPR Embed quality improvement Relevant, timely performance data Renegotiate the new deal Provide national leadership: implement national standards & systems where this is in the interest of patient care

RCP - Future Hospital Commission www. rcplondon. ac RCP - Future Hospital Commission www.rcplondon.ac.uk/futurehospital reports 3/13 Workstreams: Place and process Patients &compassion People Planning & infrastructure Data for improvement Focus: Patient centred care Continuity of care Staffing, skills & organisation of care to match pts needs across community & 2o care [enhanced care beds 1-1.5] 7 day working