Evaluating a new Approach for Improving Care in an Accident and Emergency

Department The NU-Care project

The 2004 Healthcare Conference

25-27 April 2004, Scarman House, University of Warwick

NU-Care project

Significance of the NU-Care Project Method of approach Evaluation results Wider implications

Government Policy

Make the NHS better for everyone Improve in out-of- hours access to urgent care improve in A&E completion times

Overall verdict

Response times improved Patient satisfaction Staff endorsement partially met Cost neutrality Clinical assessment system

Basic structure of an A&E department

discharge discharge

admission

referral

death

arrival registration triage cliniciantests &treatments

elapsed time

Overall verdict

Response times improved Patient satisfaction Staff endorsement partially met Cost neutrality

Overall verdict

Response times improved Patient satisfaction Staff endorsement partially met Cost neutrality

Overall verdict

Response times improved Patient satisfaction Staff endorsement partially met Cost neutrality

Key results

Response times Cut by half Higher throughput Fall in absconder rate Overcrowding eliminated

Throughput and response times

80

90

100

110

120

130

140

150

160

170

180

2.00 2.50 3.00 3.50 4.00 4.50 5.00 5.50 6.00

average completion time

da

ily t

hro

ug

hp

ut

(pa

tien

ts

dis

ch

arg

ed

ho

me

)

March 2002

March 2003

Absconders

80

90

100

110

120

130

140

150

160

170

180

2.00 2.50 3.00 3.50 4.00 4.50 5.00 5.50 6.00

average completion time

da

ily t

hro

ug

hp

ut

(pa

tien

ts

dis

ch

arg

ed

ho

me

) March 2002March 2003

Ready reckoner

02:00

02:30

03:00

03:30

04:00

04:30

05:00

05:30

06:00

00:00 01:00 02:00 03:00 04:00 05:00 06:00 07:00 08:00 09:00 10:00 11:00 12:00 13:00 14:00

time (hours:minutes)

aver

age

com

ple

tio

n t

ime

(ho

urs

:min

ute

s)

10% 50% 70% 75% 80% 85%90%

March 2003

March 2002

National target

Performance on matched days 2002/03

01:00

02:00

03:00

04:00

05:00

06:00

07:00

08:00

09:00

S S M T W T F S S M T W T F S S M T W T F S S M T W T F S S

day of the week

av

era

ge

co

mp

leti

on

tim

e (

ho

urs

:min

ute

s)

March 1st- March 30th 2003

March 2nd-March 31st 2002

Patients’ comments on waits (before)

Terrible. Three hours waiting with a baby of one year old is beyond belief.If you had more doctors we wouldn’t have to wait so long to be seen. First was 4 hours after arriving. Two hours later the medical team came…..We pay a lot of National Insurance.

Patients’ comments on waits (after)

Waiting times much better…… very nice doctorsService was very good and prompt. The ambulance was quick. All services were very good.I am happy to see a huge change in timing as I was seen sooner.

Bottlenecks

Key issues -1 Triage

“Very dissatisfied -14 month child with head injury. Waited 2 hours to see triage nurse”.

Triage comparison

0:00

0:15

0:30

0:45

1:00

1:15

1:30

8-9

9-10

10

-11

11

-12

12

-13

13

-14

14

-15

15

-16

16

-17

17

-18

18

-19

19

-20

20

-21

21

-22

22

-23

23

-24

time of day

av

era

ge

wa

it (

ho

urs

:min

ute

s)

baseline

after 6 months

Managing Triage

0

1

2

3

4

5

6

7

8

9

10

0 10 20 30 40 50 60 70 80 90 100 110 120

expected waiting time (minutes)

pat

ien

ts w

aiti

ng 1234

Bottlenecks

Key issues -1 Triage

“What’s the point of the triage nurse when after waiting an hour the sisters ask exactly the same questions then say exactly the same things. It seems like needless red tape”.

Streaming

Key issues -1 Triage

Average timefrom arrival to

triage (A)

Average timefrom triage toclinician (B)

Average timefrom arrival toclinician (A+B)

Total time indepartment

No NU-Care & no streamingA&E 00:39 01:21 02:00 03:32NU-Care n.a. n.a. n.a. n.a.

NU-Care with no streamingA&E 00:34 01:27 02:01 03:15NU-Care 00:44 00:43 01:27 01:44

NU-Care with initial streamingA&E 00:20 00:41 01:01 01:46NU-Care n.a. n.a. 00:22 00:44

Bottlenecks

Key issue -2 Waiting for a clinician

“If you had more doctors we wouldn’t have to wait so long to be seen. First was 4 hours after arriving. Two hours later the medical team came, and almost two hours later seen by ENT”.

Clinician waits

0:00

0:30

1:00

1:30

2:00

2:30

3:00

3:30

8-9

9-10

10-11

11-12

12-13

13-14

14-15

15-16

16-17

17-18

18-19

19-20

20-21

21-22

22-23

23-24

time of day

aver

age

wai

t (h

ou

rs:m

inu

tes)

baseline

after 6 months

Staff on duty

0

5

10

15

20

25

30

00:00

S

12:00

S

00:00

M

12:00

M

00:00

T

12:00

T

00:00

W

12:00

W

00:00

T

12:00

T

00:00

F

12:00

F

00:00

S

12:00

S

time of day

sta

ffin

g l

ev

el

six-month stage

baselineA AB

People in the system

0

10

20

30

40

50

60

70

80

90

100

00:00M

12:00M

00:00T

12:00T

00:00W

12:00W

00:00T

12:00T

00:00F

12:00F

00:00S

12:00S

00:00S

12:00S

00:00M

12:00M

00:00T

12:00T

time of day

nu

mb

er o

f p

atie

nts

in s

yste

m

weekendsmid-week

Bottlenecks

Key issues -3 Diagnostic tests

“Waited four hours for blood results!”

Test waits

00:00

00:15

00:30

00:45

01:00

01:15

01:30

01:45

02:00

8-9

9-10

10

-11

11

-12

12

-13

13

-14

14

-15

15

-16

16

-17

17

-18

18

-19

19

-20

20

-21

21

-22

22

-23

23

-24

time of day

ave

rag

e d

ura

tion

(ho

urs:

min

ute

s)

baseline

after 6 months

Admissions to wards

Key issue -4 Admissions to wards

“Whilst everyone who dealt with my mother was helpful and efficient it was the sheer time that upset. Arriving at 15:00 we are still waiting for a bed to be allocated at 22:00. We are thirsty and hungry”.

Ward admissions

Destination % of patientstransferred

Averagecompletion timein A&E (hours)

Total time inA&E by

category (days)

% of total timein A&E

West Wing 10.0 5:38 361 10.0Carroll 6.7 5:31 236 6.5

Dickens 3.5 10:21 234 6.4Hardy 3.1 11:28 226 6.2

Fracture clinic 9.7 3:20 208 5.7Gray 3.1 9:29 191 5.3

Jenner 2.5 9:43 155 4.3GP 6.9 3:24 152 4.2

Herrick 2.1 10:59 149 4.1All 100.0 5:38 3625 100.0

March to September 2002

Decision to admit

0

2

4

6

8

10

12

14

time of day

pe

rce

nta

ge

fre

qu

enc

y

Summary at 6 month stage - patients discharge home

discharge

discharge

home

arrival registration triage cliniciantests &treatments

elapsed time

54 mins

43 mins

5 mins

2 mins

33 mins

19 mins

1:56 hours

1:07 hours

baseline

6-monthstage

Staff endorsement

Staff views A majority said that NU-Care had addressed or

partly addressed their concerns The views changed in 6 months from ‘more

nurses’ to ‘more doctors (clinicians)’ Senior clinicians were more critical

Economic evaluation

Cost neutrality Ongoing costs of £650k a year Time savings to patients of £1.4m a year No attributable impact on the wider health economy of

NU-Care Productivity improvements No significant impact on pattern of repeat visits Reduced overcrowding

Overall satisfaction (before)

A nightmare experience of uncertainty.

Very, very, very dissatisfied.

It’s too much like a third world country.

In general service poor. I hope the NHS improves for everyone.

Overall satisfaction (after)

Patient’s son is very impressed with the whole service.…..No complaints whatsoever.

All staff very polite and efficient, I am pleased with the service, many thanks.

Patient’s husband very happy with service. They don’t bother with GP as GP is not very good!

Queuing model

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

time to completion (z hours)

p(z

)

1s

7s

0

1

2

3

4

5

6

7

8

9

10

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

time taken to clear given pecentage (hours)

aver

age

com

ple

tio

n t

ime

(ho

urs

)

10% 50%

90%

75%

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.4

0.45

0.5

0 2 4 6 8 10 12 14 16 18 20

arrivals per hour

pro

bab

ility

> X

pat

ien

ts in

th

e sy

stem

1 hour1.5 hours2 hours2.5 hours3 hours3.5 hours4 hours

A

B

C

Scientific legacy

How to measure activity in A&E departments Combining wide range of research techniques,

quantitative and qualitative Use of modelling techniques especially

queuing theory

Outstanding issues

Sustainability Further efficiencies Model of service Better use of information Computer decision support systems

Overall verdict

Response times improved Patient satisfaction Staff endorsement partially met Cost neutrality Clinical assessment system