Harrogate and District NHS Foundation Trust Emergency Care Winter Challenge Dr Matt Shepherd & Mike Forster

BRACE YOURSELF!

4 Hour target – A measure of system performance The target is a measure of the % of patients who are either treated and discharged or admitted from the ED within four hours. Delivery requires the whole system to work effectively to support rapid assessment and treatment of patients in ED and availability of bed capacity for those that require admission. Clinical evidence shows that extended waits in ED results in: Poorer outcomes longer stays in hospital worse morbidity and mortality Delivery of the target results in additional (PSF) income for Trusts. Nationally 4 hours is used to assess how well a system is coping. This is especially true in Winter due to media and political interest.

What’s different about winter to any other time of the year? Sustained cold spell: Higher incidences of heart attacks, strokes, influenza like illnesses and respiratory conditions Vulnerable people, particularly those with long term, chronic conditions are particularly susceptible. Higher conversion of ED attendances to admission and more complex discharge arrangements due to acuity of patients. Norovirus is most prevalent over the months of October to March resulting in bed closures Impact of Christmas and New Year bank holiday periods results in lower discharge rates due to lack of available alternatives Increased demand for primary care services Pressures during winter greater for those patients requiring admission due to above so focus is on supporting flow through the hospital and into the community.

HDFT Trend Harrogate ED and the hospital continues to receive more acutely ill or injured patients each year. Higher acuity leads to more admissions Can result in increase waits for admission in ED

Winter Pressures

TARGETS ED performance target for 90% Jan /Feb and 95% for March. Delayed Transfers of Care (DTOC) – 3.5% Long stay patients – 53 (26% reduction) Waiting lists at March 2017 Zero 52 week waits

HDFT Approach

4 hour target - Not just for Christmas! Stop avoidable attendance to ED Streaming to collocated GPOOH service 111 Clinical Advisors and direct access slots / GP Extended Access Improving awareness of alternatives Have alternatives for those that do attend Joint Assessment Unit adjacent to ED Minimise avoidable delays See and Treat / Protecting Minor Streams in ED SAFER - reduction in “non productive” days in hospital Enhanced Supportive Discharge Service Multi Agency Discharge Hub Improved capacity in out of hospital rehab / reablement beds Patients awaiting decisions on long term care transferred for assessment outside hospital Good infection control processes to minimise spread of infection and loss of beds Some of these are part of our Winter Plan but will start in December and support our resilience all year round

Other actions over winter System Winter Plan Operational Pressures and Escalation Levels – OPEL Weekly teleconference with WY&H and NHSE Bed Escalation Plan Flu - Target 100% of front line clinical staff Communication Plan / Choose well Every Hour Matters

NHSE and PHE Winter Communications Plan National Communication Plan NHSE and PHE Winter Communications Plan

Every Hour Matters - Approach to managing bank holidays Mon Tues Weds Thurs Fri Sat Sun 17.12.18 18.12.18 19.12.18 20.12.18 21.12.18 22.12.18 23.12.18 24.12.18 25.12.18 26.12.18 27.12.18 28.12.18 29.12.18 30.12.18 31.12.18 1.1.19 2.1.19 3.1.19 4.1.19 5.1.19 6.1.19 7.1.19 8.1.19 9.1.19 10.1.19 11.1.19 Maximising Discharge - Lowering Bed Occupancy to 75% Weekend service Acute Focus Weekend cover Bank Holiday BH Every Hour Matters - Acute Focus and Recovery Over weekends and bank holidays discharges reduce due to lack of 7 day services (external and some internal) Requires a distinct plan to recover: Every Hour Matters Free up dairies and job plans to focus on acute work / minimise elective work to outpatients and day cases Clear diagnostic / assessment backlogs Senior decision makers on the wards / clear plans well communicated Plan to be at highest level of escalation / Multi System Command and Control

Every Hour Matters - Approach to managing bank holidays Recovered target by 5th Jan 18 Reduced bed occupancy back to below 100% by 8th Jan 18 Outliers reduced by 34 in 5 days

Any questions?