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

2. 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)

4. 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

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

6. 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

7. 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: % average, 21% poor
Success of handover : 16% felt 80% handovers successful
<10% felt 90% successful

8. 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

9. 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

10. 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

11. Changing profile of patients changing needs
65% admissions > 65
Pts > 65 occupy 70% of bed days
> % 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

12. 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

13. 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

14. 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
( )
AMI
68932
13.5%
6803
14.4%
2650
0.002
1.08
AKI & other Renal
Failure
14134
25.6%
2924
33.3%
909
1.45
Aylin P et al (2010) Qual Saf Health Care; 19:

15. 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

16. 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

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

18. 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

19. 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

20. 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

21. RCP initiatives : consultant delivered care/ organisation of care
Acute Care toolkit 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

23. 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 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

24. 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

25. 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 +?)

26. 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
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

27. 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 ]

28. 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

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

31. 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

32. 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?

33. 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

34. 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

35. 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

36. RCP - Future Hospital Commission www. rcplondon. ac
RCP - Future Hospital Commission 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