This document discusses optimizing patient flow through emergency care by segmenting patients into categories based on length of stay and clinical needs. It advocates using expected date of discharge and clinical criteria for discharge as goals to coordinate care and discharge planning. Key steps include allocating patients early to specialty teams, standardizing care pathways, minimizing handovers, and conducting daily board rounds to focus on constraints and moving patients smoothly through their care. The overall aim is to get patients home safely and faster while improving outcomes.

1. 'Understanding the admitted flow streams and how to optimise patient journeys’ Dr Ian Sturgess Director, IMP Healthcare Consultancy Ltd

2. What are we trying to achieve? Getting patients better faster and safer
Safety
Reliability
Flow
Ideal Care
Improving outcomes
•No avoidable deaths
•No harm
•No unnecessary pain
•No waste
•No delays
•No feelings of helplessness
•No inequality
•Getting everyone on the ‘same page’
•NOT - ‘Hitting the target but missing point’

3. The Patient’s Perspective in Admitted Emergency care
I expect what to know and know what to expect from day 0:
•
What is wrong with me?
= Competent assessment
•
What is going to happen today and tomorrow?
= End to end case management plan
•
What needs to be achieved to get me home?
= Clinical criteria for discharge
•
When is this going to happen?
= Expected date of discharge
‘No decisions about me without me’

4. Occupied Beds = Work in Progress or Inventory Patients Waiting for the next useful thing to happen
Do you use average LOS to ‘measure’ improvement?

5. What is the Goal for Admitted Emergency care?
To maximise PbR Tariff ? - No To treat patients safely? - Yes but what else? To get patients back home having achieved an improvement in their acute condition without causing any harm? - Yes but a bit long Deliver EDD and CCD? - Yes – the ‘Goal’

6. Short Stay Unit
Home
Social care
D+T - OPA
IC
Specialist units
MAU - Decision to admit
Churn
Handover
Handover
Handover
Handover
Traditional Model for Acute Care
GP referrals
A+E Referrals
Handover

7. Expected Date of Discharge (EDD) and Clinical Criteria for Discharge (CCD)
•
Use EDD and CCD to support Care Coordination = the Goal.
–
When setting an EDD do not build in the delays that exist within the system (clinical length of stay only)
–
Set the clinical (incl functional) criteria for discharge
–
EDD can be changed for (real) clinical reasons only
–
EDD + CCD are the (case management) goal
•
Communicate Plan, EDD and Criteria for discharge
–
Creating the expectation
•
Clinical Team
•
Patient and family
–
Identify the constraints to delivery of the EDD and CCD
•
Focus on the key one (TOC) of each of:
•
Internal
•
External

8. Pareto Analysis
20%
20
80
60% of demand
19%
1% of demand: Red stream: Rare Strangers
Sick Specialty
25% OBD
0
100%
Cumulative Demand
LOS
Sick General/frail 55% OBD
Short Stay 10% OBD
Complex

9. Managing the Streams
–
Short stay Sick specialty Sick Frail Complex
–
Allocate early to teams skilled in that stream
0
50
100
150
200
250
1
3
5
7
9
11
13
15
17
19
21
23
25
27
29
31
33
35
37
39
41
43
45
47
49
51
53
55
57
59
Length of stay (days)
Number of patients
Clarity of specialty criteria
Specialty case management plan at
Handover – no delays
Green bed days vs red bed days
Short stay – manage to the hour Maximise ambulatory care
Complex needs – how much is decompensation? Detect early and design simple rules for discharge
Minimise handover
Decompensation risk
Early assertive management
Green bed days vs red bed days

10. Segmentation by LOS – 1 – Short Stay
Short Stay – Requires decision makers
•
Locus of control = Internal:
•
65-70% of Medical take with LOS < 3 days
•
Big impact on within day and day to day variation in demand – hourly drum beat
•
Needs - Generalist skills + standardisation (decision making and case management)
•
Common Constraints
•
Senior decision making and diagnostics available 8 a.m. to 10 p.m.

11. Segmentation by LOS – 2 – Sick Specialty
Sick Specialty: Need specialist skills
•
Locus of control = Internal:
•
Needs - Specialty specific standardisation
•
Variation in diagnoses and treatment – specialty specific – pull from point of access
•
Common Constraints
•
Specialist decision maker availability – attending model
•
Specialist diagnostic/intervention

12. Segmentation by LOS – 3 – Sick Frail + general
Sick frail/general
•
Require planners and decision makers
•
Loci of control = Internal and External:
•
Frequently frail older people
•
Needs - Identify early (at admission), CGA on admission and assertive case management
•
Main constraints
–
Early de-compensation – minimise handovers/moves
–
‘Over working’ through multiple in-hospital assessments
–
Frequently externalised to Social Services Delays

13. Integrated Flow – Frailty – Stranded Patient

14. Daily Board Rounds
Key principle - focus on the processes and outcome not structure
1. Nursing and Medical Director:
–
Set the principle – ‘drum beat and constraints’
2. Clinical Director
–
Describe and standardise the process - inclusivity
–
Consider ‘Attending Model’ – but focus on behaviours
–
Ensure peer review – with supportive challenge
3. Ward senior clinicians
–
Consultants, Ward Manager and AHP leads
–
Deliver the process – create ‘safe competition’ between wards
–
Identify the constraints
4.
Trust Exec and Non Execs
–
Walk the floor – go and watch daily board rounds!
–
Embed within safety walk rounds
5.
Management of ‘disruptive behaviours’
–
Make it a ‘red rule’
–
Are you prepared to have those difficult conversations?

15. What are we trying to achieve? Getting patients better faster and safer
Safety
Reliability
Flow
Ideal Care
Improving outcomes
•No avoidable deaths
•No harm
•No unnecessary pain
•No waste
•No delays
•No feelings of helplessness
•No inequality
•Getting everyone on the ‘same page’
•NOT - ‘Hitting the target but missing point’