How to streamline inter-hospital transfers

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How to streamline inter-hospital transfers

• Dr Richard Levy
• Wythenshawe Hospital, Manchester
• CHD Collaborative
• National Clinical Lead

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Real life technical considerations ?
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What is the evidence?
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The majority of patients waiting for transfer
were waiting with acute coronary syndrome (73)
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Number of patients reported awaiting transfer at
each hospital Manchester Dec 2003
Number of patients
Hospitals
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Inter-hospital transfer for revascularisation

• At a CHD Collaborative Angina Workshop in
  September 2003 this was identified as national
  problem 1
• Organise a national survey and audit of
  current practice in patients with ACS

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ACS Transfer

• Study from Manchester Royal Infirmary from May to
  October 2003 recorded 212 patients in 16 DGHs
  occupying 1755 bed days waiting for transfer
• (N Curzen, Lancet letter 2004)

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Inter-hospital transfers for revascularisation

• view from-----
• ----- the
  DGH

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Inter-hospital transfers view from the DGH

• We do all the right things
• We triage the patients, identify the high risk
  patients (Troponin testing etc)
• We select the correct patients for
  angiography/-revascularisation and refer to the
  Centre
• And then we wait
• ----- and wait
• ----- and wait

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Inter-hospital transfers for revascularisation

• view from
• the
  Ambulance Service

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Inter-hospital transfers view from the
Ambulance service

• We have to match the type of vehicle, equipment
  and crew to needs
• This can have an adverse impact on category A
  calls
• The patient is never ready when we arrive
• And then we wait
• ----- and wait
• ----- and wait

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Inter-hospital transfers for revascularisation

• view from-----
• ----- the
  Centre

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Inter-hospital transfers view from the Centre

• We must first meet our targets for elective
  revascularisation PCI CABG
• This will dictate our star rating and
  application for Foundation status
• We have a white board for listing patients for
  transfer for non-elective revascularisation
• This is always full

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Inter-hospital transfers view from the Centre

• We do our best to deliver non-elective
  revascularisation --- and in time we do deliver
• After revascularisation we may need to transfer
  patients back to the DGH
• The DGH is always full
• And then we wait
• ---- and wait
• ---- and wait

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Inter-hospital transfers for revascularisation

• This is a major challenge for Cardiology
• Unrecorded waiting list
• Surge in referrals due to advances in clinical
  practice
• No indicator for non-elective revascularisation

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CHD-C Survey and Audit

• National survey to scope the problem of
  interhospital transfer for the treatment of ACS
• Review of Central Returns (RoCR) insisted on
  voluntary contribution
• Collect baseline data about referring DGHs,
  transfer process and interventional/surgical
  centres across England
• Identify process redesign work already introduced
  and share best practice

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CHD-C Survey and Audit

• Collect data about waiting times for transfer
  from DGH to referral centre for angiography and
  revascularisation in England over 4 weeks in
  March 2004
• These data provide a snapshot of our capacity to
  provide non-elective revascularisation
• Expose any limitations in the system

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Sometimes Wythenshawe seems very far away
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ACS transfer

• Data suggest that at-risk patients with ACS
  benefit from early invasive assessment within
  72hrs and this is recommended in local, national
  and international guidelines

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A National Study of Transfer of Cardiac Patients

• March 2004

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Submitted Forms

• We tried to reach all the trusts in England
• 141/148 Trusts submitted forms

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Team organisation
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Inter-hospital Transfers Audit Topline Average
Waits
Admitted To DGH
Angiogram
Referred
Transferred
Procedure
5.9 Days
1.6 Days
7.5 Days
1.5 Days
15 Days
16.5 Days
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Difference between PCI and Cardiac Surgery
PCI
16 Days
14.8 Days
5.9 Days
1.3 Days
7.6 Days
1.2 Days
Admitted To DGH
Referred
Procedure
Angiogram
Transferred
5.2 Days
2.4 Days
11.1 Days
3.5 Days
18.7 Days
22.2 Days
CARDIAC SURGERY
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Intervention on site or transfer
INTERVENTION ON SITE
8.3 Days
3 Days
1.5 Days
3.8 Days
2.2 Days
Admitted To DGH
Angiogram
Transferred
Procedure
Referred
6.3 Days
1.7 Days
8.0 Days
1.1 Days
16 Days
TRANSFERRED FOR INTERVENTION
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Average waiting time between admission and angio
DGH with a Catheter Lab 5.5 Days DGH without a
lab 8.2 Days
40.1 of the DGHs submitting data had a Cath Lab
of some sort
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Wait after transfer to procedure
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Geographical Differences In Average Waits (Days)
The North Average wait from admission to PCI
12.8 Average wait from admission
to cardiac surgery 16.3 Average wait from
admission to procedure (all) 12.9
The Midlands and Anglia Average wait from
admission to PCI 12.6 Average
wait from admission to cardiac surgery
23.0 Average wait from admission to procedure
(all) 14.5
The South East London Average wait from
admission to PCI 15.5 Average
wait from admission to cardiac surgery19.9 Averag
e wait from admission to procedure (all) 17.0
The South and West Average wait from admission
to PCI 23.5 Average wait from
admission to cardiac surgery25.4 Average wait
from admission to procedure (all) 20.9
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Number of centres submitting data
The Midlands and Anglia Number of
Interventional Cardiology Sites submitting data
10
The North Number of Interventional Cardiology
Sites submitting data 17
The South East London Number of Interventional
Cardiology Sites submitting data 10
The South and West Number of Interventional
Cardiology Sites submitting data 6
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AVON
BEDS
BIRM
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CUMB
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DURH
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HAMP
KENT
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NCL
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NORF
NWL
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SHROP
SURR
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SWPEN
SYORK
THAME
TRENT
TYNE
WMIDS
WYORK
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AVON
BEDS
BIRM
CHES
CUMB
DORS
DURH
ESS
HAMP
KENT
LEIC
LINC
MANC
NCL
NEL
NORF
NWL
SEL
SHROP
SURR
SWL
SWPEN
SYORK
THAME
TRENT
TYNE
WMIDS
WYORK
40
AVON
BIRM
ESS
HAMP
KENT
LINC
MANC
NORF
NWL
SEL
SURR
SWL
THAME
TRENT
TYNE
WMIDS
WYORK
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Tertiary Centres Names and codes
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Inter-hospital Transfers Audit Average Admission
to Procedure Waits by Trust 1 March to 28
March 2004
Referred
Admitted To DGH
Transferred
Procedure
Angiography /- PCI (with and without
angiography)
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Inter-hospital Transfers Audit Average Admission
to Referral Waits by Trust 1 March to 28
March 2004
Referred
Admitted To DGH
Transferred
Procedure
Angiography /- PCI (with and without
angiography)
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Inter-hospital Transfers Audit Average Referral
to Transfer Waits by Trust 1 March to 28 March
2004
Referred
Admitted To DGH
Transferred
Procedure
Angiography /- PCI (with and without
angiography)
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Inter-hospital Transfers Audit Average Transfer
to Procedure Waits by Trust 1 March to 28
March 2004
Referred
Admitted To DGH
Transferred
Procedure
Angiography /- PCI (with and without
angiography)
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Inter-hospital Transfers Audit Average Admission
to Procedure Waits by Trust 1 March to 28
March 2004
Referred
Admitted To DGH
Transferred
Procedure
CABG
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Inter-hospital Transfers Audit Average Admission
to Referral Waits by Trust 1 March to 28
March 2004
Referred
Admitted To DGH
Transferred
Procedure
CABG
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Inter-hospital Transfers Audit Average Referral
to Transfer Waits by Trust 1 March to 28 March
2004
Referred
Admitted To DGH
Transferred
Procedure
CABG
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Inter-hospital Transfers Audit Average Transfer
to Procedure Waits by Trust 1 March to 28
March 2004
Referred
Admitted To DGH
Transferred
Procedure
CABG
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Inter-hospital Transfers Audit Average Admission
to Procedure Waits by Trust 1 March to 28
March 2004
Referred
Admitted To DGH
Transferred
Procedure
Definite PCI
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Inter-hospital Transfers Audit Average Admission
to Referral Waits by Trust 1 March to 28
March 2004
Referred
Admitted To DGH
Transferred
Procedure
Definite PCI
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Inter-hospital Transfers Audit Average Referral
to Transfer Waits by Trust 1 March to 28 March
2004
Referred
Admitted To DGH
Transferred
Procedure
Definite PCI
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Inter-hospital Transfers Audit Average Transfer
to Procedure Waits by Trust 1 March to 28
March 2004
Referred
Admitted To DGH
Transferred
Procedure
Definite PCI
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Names of tertiary centres and codes
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Interventional Centres Overall All procedures
Transferred
Procedure
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Interventional Centres Angiography /- proceed
Transferred
Procedure
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Interventional Centres CABG
Transferred
Procedure
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Interventional Centres Definite PCI
Transferred
Procedure
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Summary
Average days wait in DGH 15.3 Days Patients
admitted to a DGH during 4 week audit
period 2196 Occupied Bed Days for ACS
pts 13295 over 4 weeks based on 3 days
for Possible proceed and 7 days for CABG
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Clear unambiguous guidelines
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Interhospital Transfers

• Redesign work

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What are we doing to address this?

• Competencies for transfer
• Treat and return
• Transfer service
• Working together across the network
• Shared care of patients
• Electronic communication
• Jointly developed pathways / processes
  
• Coordinator role
• Optimise the patient - fit for procedure
• Dedicated beds

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Coordinator role

• Middlesborough James Cook Hospital appointed
  Cardiology Pathways Coordinator Reduced DGH
  average wait from 12 6 days
• Co-ordinates transfers with 11 referring DGHs
  single point of contact
• Arranges booking and scheduling of lists
• Ensures consistent data management
• Leads weekly meetings to review list based on
  clinical priorities

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Streamlining the Process

• Walsall Hospitals NHS Trust
• Reduced average times from decision to proceed
  through to discharge following PCI from 19 to 5
  days
• Faxed referral proforma
• Tracking document across organisations from
  referral to rehabilitation
• Educational sessions for all staff on process
• Patient information leaflet at DGH patient
  better informed before transfer.

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Working across boundaries

• 11 referring hospitals in North East London and
  Essex with Barts and the London NHS Trust
• Complete review of transfer process
• Pre-schedule slots for DGHs according to demand
• Prebook ambulance slots with private ambulance
  provider
• Plans to use NHS paramedic service to eliminate
  the need for nurse escort

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A redesigned service

• West Yorkshire 13 DGHs and Leeds general
  Infirmary
• Previously median wait of 8.2 days to approx 2.5
  days for PCI since 2001
• Cardiac Cath lab scheduler post
• Ring fenced beds DGHs and Centre
• Common waiting list
• Demand and capacity work which led to case
  specific sessions, equalising the working day for
  all staff
• Nurse led intervention beds

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I believe that public servants are working flat
out but in a system that shrieks out for
fundamental changeIf we dont get the systems
and structures right we will never get to the
roots of the problem, only prune its visible
branches.The key to reform is redesigning the
system round the user.

• Tony Blair
• Prime Minister
• October 2002

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2005

• Agree a national standard for inter-hospital
  transfers eg 72hrs
• Repeat study planned for September 2005

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The power of free speech!!
British intellectual sophistication!!
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