1. Hospital solutions for crowding
Dr Ian Higginson MSc FCEM Emergency Physician

2. No magic wand

5. Objective
To reduce crowding in the ED

6. Cycle of change

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

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

9. The single most important ingredient in the ED response is leadership

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

14. 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Emergency Medicine in the UK is subject to an outdated value proposition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

15. 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

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

17. 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

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

19. 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

20. 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

22. ‘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

23. Building a case for change

24. 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

25. The power of data ….

28. We know crowding when we see it

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

30. 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.

31. Breach analysis

32. Decent breach data can show where the problems are

34. 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

35. Safety Narrative Incident reports Complaints and compliments
Governance meetings
Risk register

36. 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

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

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

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

42. 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”

43. 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

44. Pay attention to the interfaces

45. Remember “line balance”

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

47. “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?”

48. Always end on a postive note …

49. System hits the buffers

51. 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

52. 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