Six Hour Rules
Dr Peter Jones
Outline
‘Six Hour’ Rules?
The Shorter Stays in ED Target
Dr Peter Jones FACEM MSc (oxon)
Emergency Medicine Specialist
Objectives
Understand background to the Target
How it relates to Quality
Outline the UK experience
Where ADHB is at
Introduce target research
Vent your spleen?
SSED Target - What is it?
MOH suite of targets (http://www.moh.govt.nz/moh.nsf/indexmh/healthtargets-targets)
SSED
Elective Surgery (↑4000 per year)
Radiation Therapy (<4/52)
Immunisation (90% 2011, 95% 2012)
Smoking (90% admitted pts 2011, 95% 2012)
CVD risk assessment especially diabetes (↑%)
SSED
95% Patients leave ED <6hrs after arrival
From July 2009
Why SSED?
http://www.moh.govt.nz/moh.nsf/indexmh/healthtargets-targets-emergencydepartments
ED length of stay is an important measure of the quality of acute care in our public hospitals, because:
EDs are designed to provide urgent (acute) health care; the timeliness of treatment delivery (and any time spent waiting) is by definition important for patients
long stays linked to overcrowding of the ED
long stays and overcrowding = negative clinical outcomes / longer inpatient lengths of stay
overcrowding = compromised standards of privacy and dignity
To Stop ED Overcrowding
Quality Dimensions NZ
SSED Origins
NHS ‘Four Hour Rule’
Officially
2001 Time to clinician important (NHS Plan)
Sign on was unreliable (no IT / doctors will cheat)
Associated with time to discharge
Enforce time to discharge will force sign on time down
Reality
Abysmal care in ‘A&E’
Grossly understaffed / poor training
Patients neglected / die in corridors
The NHS: What Happened?
Quantitative Outcomes
6 cohort studies
Spending Increase £820,000,000
Admissions Increase 35% (whole NHS)
Investigations ? No Change ?Increase 13%
Mortality No Change
Did Not Wait No Change
Effect on Surgical Wait Lists None
Productivity Depends how measured
% #NoF Analgesia <1hour No Change med 37-40% (0-80)
Time to See Treating Clinician ? No Change ?↓19min
ED Returns ↓0.1% per month
Admissions ↓0.31% per month
% Children Analgesia <1hour Improved med 57->78% (20-100)
Qualitative
3 Studies
1 Published, 2 Grey literature
9 Nurses in one hospital
81% of ‘A and E’ Consultants (BMA survey)
90 Patients / Cares of Patients with complex healthcare needs (Healthcare Commission)
Variable Quality
Themes
Concept good
Concerns over attention to target rather than clinical care
Qualitative Outcomes
“The four-hour target has been a huge benefit to us. We feel our service has improved.”
“approach of the Trust meant that the care of patients had become secondary to achieving targets and minimizing breaches”
“Senior doctors were criticised for spending time in resuscitation area.”
The NHS: Propaganda
“long waits are an enduring problem around the world…By contrast, however, the approach of the NHS in England was hailed as an exemplary success…
the timeliness of care in English EDs is becoming the envy of the world”
Alberti G. Transforming Emergency Care in England: Department of Health; 26 October 2004. 263639.
Does reducing time to leave ED reduce time to see a clinician?
Was The Target Really Met?
BMA Survey of A & E Waiting Times 2005
50% of departments reported that they met the target
26% confirmed that the figures submitted were accurate
Healthcare Commission Report 2008
Target achievement: Trust level 97.6% individual hospitals 79%
Patients reporting < 4 hr: 67% in 2004 and 73% in 2007
Mid-Staffordshire Trust Investigation 2009
Inconsistencies in what was reported to DH and the truth
Sheffield (highly performing Trust, low mortality)
Trust documents state target met 98% 2005
Submitted Study
failed to meet the target: 83% in 2003, 88% in 2005
Was There ‘Manipulation’?
Locker 2005/06: UK ‘A & E’ Departments
Now the NHS has pulled back
- CEM Indicators 2011
1 Ambulatory care
2 Unplanned re-attendance rate
3 Total time in ‘A&E’
4 Left without being seen (LWBS) rate
5 Service experience
6 Time to initial assessment
7 Time to treatment
8 Consultant sign-off
Why Us?
-2008: Larger hospitals in crisis
-Opportunity knocked…
“We have been complaining (loudly) about the access block and delays in care that bedevil our service for a long time. This is the one-off opportunity to fix some of the worst inefficiencies and allow us to concentrate on our core business - looking after emergency patients.” TP 19/6/09
- Incoming health minister successfully lobbied
“…will significantly improve the level of service …the target will come into effect from 1st July 2009” Rt. Hon. Tony Ryall May 2009
Why 6 Hours?
-It’s longer than 4 hours
What About the NHS failures?
-We’re all about quality
-We won’t cheat
So What’s Happened?
- Until 2010 very little apparent improvement
- No clinical quality data
The Pressure is ON!
ADHB 76% in Dec 2010, 18th out of 21
More Resources
ED Staff
ED Short Stay Ward
More Inpatient Beds
Process Changes
Discharge Planning
‘House Rules’
ADHB March 2011 88% (13th of 20): Now at 93%!
Difference = whole hospital approach / MOH pressure
Hospital occupancy lower
Quality Improvement?
ADHB recognised that after years of financially based decision making, the focus needed to change to Quality Improvement focused on the customer (ultimately the patient).
Hired external consultants
Adopted the Lean Six Sigma approach which was developed in the manufacturing industry and now used world-wide not only in manufacturing but also service industries.
By using the same approach, ADHB-wide personnel use the same language and understand each others work.
ADHB entry level training is at “Green Belt” level with the aim to teach the methodology and tools under the guidance of a “Black Belt” and produce a project.
Lean Six Sigma – What??
Six Sigma…
- Emphasizes need to recognize opportunities and eliminate defects
- Recognizes that variation hinders ability to reliably deliver high-quality services
- Requires data-driven decisions and incorporates a comprehensive set of standard tools for effective problem solving
- Provides a highly prescriptive cultural infrastructure effective in obtaining sustainable results (continuous improvement through an empowered workforce)
Lean…
Focuses on maximizing process velocity
Provides tools for analyzing process flow and delay times at each activity in process
Removes non-value added steps in process
Provides a means for quantifying and eliminating the cost of complexity
ADHB All ED Presentations
ADHB All ED Presentations
ADHB ED Discharges
ADHB ED Referrals
Lisa Middelberg
“Improving time of surgical sign on to <30min”
Project Name: Emergency Medicine (EM) Referrals Project
Project Goal: The right patient with the right investigations is referred under 3hrs, 90% of the time
What’s Really Happening?
Primary Outcomes (Nationwide)
ED LOS
Hospital LOS
Re-attendance rates within 48 hours of discharge
Access Block / Overcrowding
Age / Ethnicity / Deprivation
Co-morbidity
What’s Really Happening?
Secondary Outcomes
Mortality
Time to reperfusion for myocardial infarction
Time to analgesia in ED
Time to theatre for fractured neck of femur
Time to appendectomy for acute appendicitis
Time to antibiotics for severe infections
Time to treatment in acute asthma
Proportion of patients who leave without being seen
‘Gaming’ the target
What’s Really Happening?
System-wide Stakeholder Meeting Dec 2010
Further Outcomes
-CT in Head Injury
-Quality of Communication
-Appropriateness rather than just timeliness of care
What’s Really Happening?
Qualitative Arms Underway
DHB Implementation of target (interviews staff)
Survey of resources used
Quantitative Arm Ready to Go
Liaising with DHB IT teams / NZHIS
Piloting data collection forms
Finalising sample sizes for clinical outcomes
Will SSED Affect Trauma Care?
Front end
unlikely to be harmful
pressure to admit
Back end
pressure to discharge
Opportunities
lobby for more resource
clinician led quality improvement
collaborative research?
ADHB
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Ministry of Health
