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![Page 1: Refining and Redefining Emergency Flows Dr Veronica Devlin Programme Lead Service Improvement and Clinical Governance Emergency Care.](https://reader036.fdocuments.net/reader036/viewer/2022062407/56649cfa5503460f949cbbef/html5/thumbnails/1.jpg)
Refining and Redefining Emergency Flows
Dr Veronica DevlinProgramme Lead
Service Improvement and Clinical Governance
Emergency Care
![Page 2: Refining and Redefining Emergency Flows Dr Veronica Devlin Programme Lead Service Improvement and Clinical Governance Emergency Care.](https://reader036.fdocuments.net/reader036/viewer/2022062407/56649cfa5503460f949cbbef/html5/thumbnails/2.jpg)
Defining flows
• Resus <5%• Majors 40-45%• Minors 55-60%
• Admitted, by specialty
• Assessment majors• Minors• Planned returns• Ward work
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A&E52,398
Minors 32,388 61.8%
Medical 8,620 16.5%
Acute ass. 7,713 14.7%
GP follow up
# 7,912
15.1%
Avg. 113 min
Patient Numbers Accident & Emergency March-May 2009 (3months)
NHSL Overall
No Follow Up
# 28,302
54.0%
Avg. 107 min
# 5,190
9.9%
Avg. 137 min
AdmissionDeaths 82 0.2%
Other*
Emergency Receiving
Unit
# 7,973
15.2%
Avg. 144 min
# 3,021
5.8%
Avg. 81 min
*e.g. Other Hospitals, Primary Care Emergency Centre
Surgical 3,595 6.9%
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Theory…..
![Page 5: Refining and Redefining Emergency Flows Dr Veronica Devlin Programme Lead Service Improvement and Clinical Governance Emergency Care.](https://reader036.fdocuments.net/reader036/viewer/2022062407/56649cfa5503460f949cbbef/html5/thumbnails/5.jpg)
Practice….
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• History of specialty• 3 ED’s• Fewer middle
grades• Recruitment issues• Retention issues• Casemix challenge• Access block• Audit Scotland• Quality standards• Delivery
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Theory….
![Page 8: Refining and Redefining Emergency Flows Dr Veronica Devlin Programme Lead Service Improvement and Clinical Governance Emergency Care.](https://reader036.fdocuments.net/reader036/viewer/2022062407/56649cfa5503460f949cbbef/html5/thumbnails/8.jpg)
Practice…
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Lean in emergency flow
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Lean principles
• Specify value• Map the value stream (patient flow)• Implement flow• Establish pull where you can’t flow• Work to perfection
• Voice of the customer
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Lean tools
• Standard work • Standard operating procedures• Managing variation• Metrics• Dashboards
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In God we trust
all others must bring data
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![Page 14: Refining and Redefining Emergency Flows Dr Veronica Devlin Programme Lead Service Improvement and Clinical Governance Emergency Care.](https://reader036.fdocuments.net/reader036/viewer/2022062407/56649cfa5503460f949cbbef/html5/thumbnails/14.jpg)
Deming
• You can’t manage on visible figures alone
• Figures on the most important areas of management may be unknown or unknowable, and successful managers must nevertheless manage those areas.
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Vital Signs - measurement
• ED • TTFA• DNW’S• Unplanned returns• Planned returns• Delays to care
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Vital Signs - measurement• Admission/
discharge balance• Discharges before
noon• Diversions• 8 and 12 hour
delays to care• Boarders• Additional beds• Delayed discharges
• Length of stay on Medical Receiving Unit
• Total hospital length of stay
• Diversions• Cancelled electives
due to lack of capacity
• Surge capacity• Use of off site beds
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Monklands
• Minors flow• Majors pitstop• ACE• GP assessment bay
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minors
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Minors flow Monklands
• Maintaining operation• Timing of stream operation• Staffing• Operational set up• Monitoring• Follow up arrangements
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Patients had to go outside after registration
reception
store
xray
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Patients’ journey contained within the department – and no compromise in Waiting Room space
receptionstore
xray
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Majors Pitstop
• Proof of concept• Dedicated approach for assessment
of majors• Negotiated diagnostics• Senior decision-making• Average tat 102 minutes during
trystorm
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Majors pitstop
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GP assessment bay
• Complete team based assessment• Meds rec• Admission avoidance• Decide to admit vs admit to decide
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Implement ASSESSMENT BAY and ACE
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Hairmyres STATUS CHANGE
• Medical Assessment bay• Minors flow• CPAU pathway• Stroke pathway
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AMRU Dashboard Key Performance Indicators
LENGTH OF STAY
am/pm Ward Round
Start Times
Ward Pull
Parent Specialty Mix
Porter Response Times
MAB Performance
Surge Beds
Patient moves
Before noon
Admissions vs.
Discharges &
Transfers
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Medical Assessment Bay (MAB)
Consistent staffing, bed availabilityAmbulance Service/ERC Criteria for access.
JULY MAB ADMISSIONS VS D/C
0
10
20
30
40
50
60
70
80
90
ADMIT DISCHARGE
Change Detail Sustainability
Key Performance Indicators
4 Trolley bay in AMRU for the review of GP referred medical patients between 9am and 7pm weekdays)
25% of patients
Discharged from MAB
MAB Activity
0
2
4
6
8
10
12
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Medical Assessment Bay (MAB)
Consistent staffing, bed availability? Senior Decision Maker availability in MAB
Change Detail Sustainability
Key Performance Indicators
4 Trolley bay in AMRU for the review of GP referred medical patients between 9am and 7pm (weekdays)
Average Total Journey Time July 2010
0 50 100 150 200 250
A&E (Medical Flow)
MAB
mins
Ave TTFA - July 2010
0 10 20 30 40 50 60 70 80
A&E (Medical Flow)
MAB
mins
% Patients Admitted to Bed in <2hrs
Pre-Kaizen
Improvement
Remainder
% Patients Admitted after 210 mins
Pre-Kaizen
Remainder
% Patients Admitted after 210 mins
Post-Kaizen
Remainder
MAB journey time
37 mins
less than A&E
MAB TTFA
30 mins
less than A&E
Was 9%
Now 18% admitted
in <2hrs
From 48% to 33%
Admitted between
210 & 240 mins
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Daily Dashboard
Change Detail Sustainability
• Visual management• Target driven• Updated and
reviewed daily• Also for surgical
and medical flow• Monitors individual
ward performance
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Positives
Excellent clinical engagementData drivenPerceive the service from customer
viewpoint
But….
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Reshaping Emergency Medicine
• Clinical Director• Consultant appointments• Review of skillmix• Standard operating procedures• Quality Standards• Safety Brief• Roles and Responsibilities redefined
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Consolidate core service
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Non core ED work
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