CHALLENGES FOR ACUTE SURGERY Elective Acute

Improving Elective Practice Improving Acute Practice Generic Models of Care Improving Elective Practice Pre-admission Assessment Day Surgery Day of Surgery admissions Discharge planning 2010 Improving Acute Practice Separate stream Early access to Senior Decision Makers Acute Surgical Assessment Units 2013 Common goals Peri-operative Governance TPOT Designated beds and theatres 10/02/2016

NCP / HIU / HIPE / OpenApp -> NQAIS Surgery Discharges between 2010 and 2014 (including Acute and Elective admissions for surgery or surgical care) National figures Acute & Elective discharges from Model 4, 3 & 2 hospitals excluding Maternity, hospice and rehabilitation type hospitals 10/02/2016 NCP / HIU / HIPE / OpenApp -> NQAIS 3

CANCEL PLANNED ADMISSIONS WAITING LISTS TROLLIES ↑ CANCEL PLANNED ADMISSIONS 10/02/2016

10/02/2016

Hospital overload EXCESS UNPLANNED CARE DELAYED DISCHARGES Poor, untimely planning Inadequate Fair Deal Inadequate Community Care Increasing Numbers Increasing Age, Chronic Diseases & Complexity Inadequate or unused 1⁰ Care Inadequate access to diagnostics Inadequate Resource Beds Diagnostics Theatres Workforce Inefficient Flow Process Performance Integration IN HOUSE CONSTRAINTS PLANNED CARE 10/02/2016

National HIPE discharges in 2014 AvLOS = 5.16 days 10/02/2016

Hospital referral / Transfer GP referral to A*AU – under criteria guidance AMAU/ASAU Senior Decision maker Hospital referral / Transfer SSU GP AEC Senior Decision maker AEC Treat/ Follow up/Discharge ? Discharge path/GP TRIAGE SELF ED CDU/RATU Minor Injuries RESUS AMBULANCE Triage is not necessary if there is enough staff to meet individual needs. It is necessary when this is not the case and patients require care pathways. Each pathway requiring different skills, having different demands and working a different speeds. Two important roles – to define severity of illness and direct patients to appropriate care setting. Structures are dependant on the size of hospital. Inpatient Ward (observer / recover) Inpatient Senior Decision maker Out Patients Theatre ACUTE FLOOR - PATHWAYS TO ADMISSION AVOIDANCE OR EARLY DISCHARGE

Rapid transfer from Triage or direct referral from Primary Care ASAU advantages Rapid transfer from Triage or direct referral from Primary Care Surgical cases are in one area. ‘Safari’ ward rounds avoided. Quick prioritisation by experienced, focussed staff. Maximises ambulatory emergency care; nurse-led early discharges . Early imaging and diagnostics Supports E D waiting time targets. More rapid direct access to theatre Shorter AvLOS & more positive patient experience.. Early Senior Decision Maker (Consultant) assessment. Model 3 but ? Model 4 10/02/2016

Managing Inpatient Flow and Performance Maximise ambulatory care Sept ’14 – Aug’ 15 Flow management Complex support needs – hospital and community based 10/02/2016

Managing Inpatient Flow and Performance Patient information Hubs Rounding discipline Ward Cohorting Discharge by 11 Pre-admission assessment DOSA Cancelations Theatre management Weekend working Whole system patient flow hubs/Demand and Capacity Management Ward rounding discipline, Ward Cohorting, Discharge by 11 Pre-admission assessment, DOSA, Theatre management Weekend working 10/02/2016

GENERAL PRACTICE EMERGENCY MEDICINE OLDER PERSONS COMMUNITY CARE SURGERY Model of Care Model of Care Model of Care Model of Care INTEGRATED CARE (COMMUNICATION and UNDERSTANDING) THAT SPANS ORGANISATIONAL BOUNDARIES Ultimately focused on the patient 10/02/2016