1. Sustainable working in crowding Sharing the responsibility Adrian Boyle Chair of the Quality Emergency Care Committee

2. The Crowding Paradox Emergency Department Crowding hurts those in the Emergency Department most The causes and most effective solutions are usually outside the Emergency Department

3. Diagnosing your ED: Gestalt is not enough 120 mph 180 o tilt 270 o rotatory spin 75 kg man 110 kg motorbike Granular tarmac 6mm leathers S**t

4. Diagnostic Tools: Options Occupancy Four Hour Target Performance Ambulance Offload ED Arrival versus Inpatient Discharge ‘Ready to Leave’ Button ICMED NEDOCS

5. ICMED and NEDOCS ICMED 1.Ambulance Offload 2.5 minutes to triage 3.Left Before Being Seen >5% 4.Occupancy > 100% 5.90% stay > 4 hours 6.Delay to resus patient > 30 minutes 7.<90% have left 2 hours after admission 8.>10% boarders in the ED NEDOCS 1.Waiting time from Triage to bed 2.Number of ventilators in use in the ED 3.Occupancy 4.Longest boarding time 5.Total number of boarding patients 6.Total number of hospital beds

6. NEDOCS NEDOCS=-20+85.8(L ED /bED) + 600(L admit) / b h ) + 5.64 W ED + 0.93 W admit + 13.4L rp Generates a score, usually divided into 6

9. Crowding and Exit Block Exit Block Crowding

10. Capacity and Co-ordination Enough beds at the right time Right sort of bed – Single sex compliance – Monitored – Side room

11. Myths You Need to Challenge 1. Just a busy day, no clinical significance 2. All EDs problem, nothing to do with the back door 3. All about ‘inappropriate attenders’ 40% versus 11% 4. All about ‘frequent attenders’ ‘Men chose to believe what they want’ Julius Caesar 43 AD

12. Input: Ambulance Diversion: LAS Major Urban Centres served by multiple EDs Spread the patient load across multiple EDs Returns ambulances to service quicker Uncertain impact on length of stay, duplication of investigations etc

13. Input: GPs Do not help with exit block Useful for minor illness Need to agree ground rules – Ambulance arrivals – Eyes – Minor injuries

14. Output Solutions Need Board level support Need Operational support Emphasise Emergency Care System Solutions

15. Gathering Support 4 Hour Access Standard

16. Questions to ask your Director of Operations / Chief Operating Officer ‘Is there is a discharge lounge? Who uses it? When is open? Have you ever audited which wards use it?’ ‘How many people are waiting for social care beds?’ ‘What time do beds become available on inpatient wards?’ ‘Can people bypass the ED 24/7 for obvious presentations e.g. Bleeding in Early Pregnancy?’

17. Questions to ask your Director of Operations / Chief Operating Officer How many people do we discharge at the weekend? How many inpatients are waiting for investigations? How many inpatients are waiting for repatriation? Why is the ED full at 8pm but empty at 8am?

18. How bad does it have to be before you will consider boarding? Questions to ask your Director of Operations / Chief Operating Officer

19. Output: Boarding in Hallways of Destination Wards Pros Right person to right ward Stimulates wards to improve discharge processes Spreads the risk across the whole hospital, rather than concentrating and multiplying risk in the ED Small decompressions have big benefits for the ED Supported by limited evidence

20. Limited Evidence Base

22. Boarding in Hallways of Destination Wards Cons Wards have to have sufficient staffing Wards have to have sufficient space Should not be just shifting the problem upstream Potentially toxic

24. Persuading Boards: Boarding In the ED Doris, 85, with a fractured neck of femur Carla, 18, with appendicitis Janet, 92, with multiple falls On the ward Rita, 85, waiting for a nursing home bed Jimmy, 28, with osteomyelitis and daily IVs (Usually sits outside the ED smoking) John, 91, waiting for transport

25. Persuading Boards: Boarding

27. Reverse Boarding New patient goes to their destination ward Bed bound patient goes to the day room to await discharge Too complicated for bed managers to co- ordinate Lacks the incentive component of boarding

28. Full Capacity Protocols Locally agreed triggers Proportionate response Enforcement Incident Fatigue An exceptional response should be exceptional

31. Internal Professional Standards Heavily promoted by ECIST Requires constant enforcement – ‘So what happens if I don’t see this patient in 60 minutes?’ RCS recommends that a surgeon attends within 30 minutes of a call. RCPsych recommends that a clinician assesses within 1 hour

34. Any questions? Adrian.boyle@addenbrookes.nhs.uk