SW Strategic Clinical Network for Maternity & Children Reducing Avoidable Unplanned Hospital Admissions Long term Conditions 14 th October 2014 Exeter.

SW Strategic Clinical Network for

Maternity & Children

Reducing Avoidable Unplanned Hospital Admissions

Long term Conditions14th October 2014 Exeter Rugby Club

Matthew Ellis

Associate Clinical Director

SW Strategic Clinical Network for

Maternity & Children

SCN Conference Reducing Avoidable Unplanned Hospital Admissions

Long Term Conditions

November 2014

CYP Priorities Working Groups

• Avoiding Unplanned Admissions

• Long Term Conditions

Themes

Smarter network thinking

• expertise earlier on pathways

Integrated working

• (1° / 2°/ 3°, Health/CYPS)

Making the Unplanned Planned

Parity of Esteem

NHS Outcome Framework areas for improvement

• 2.3 (2) Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s

• 3 a Emergency admissions for acute conditions that should not usually require hospital admission

• 3.2 Emergency admissions for children with LRTI

Scale of CYP patient flow on the ’emergency/urgent care pathway’ around the South West?

How big is the patient flow on the ’emergency/urgent care pathway’ around the South West>120,000 emergency department walkins involve CYP around south west annually> 18,000 GP referrals involve CYP around south west annually

• >120,000 emergency department walkins

• > 18,000 GP referrals for urgent care

• > 25,000 CYP assessed in specialist paediatric assessment units (SPAUs)

Big 6 (account for >50% admissions) +• abdominal pain

• asthma/wheezy child

• bronchiolitis

• feverish illness

• gastroenteritis

• head injury

• + self harm (up by 68% in the last 10 years)

Variation across the Regioneg Zero length of stay admissions

6 Zero days admissions

Provider responses (n=10 of potential 14)Assessment Unit (SSPAU)

• 7 units report this provision

•  variables where/when/who?

Rapid Access Clinic

• 6 units report this provision

• Variables how often?

Complexities of Systems

Taxonomy of Potential Pathways and Referral Routes

GP

Paeds ED

Primary Care

Incl MIU, Community Nurse, CAMHS, Social services, Midwives etc

Family

1

2

3 5

SWAST

Ambulance service

PAU

WARD

7

4

Homee

Home

Home Home

Home

Home

HOT CLINIC

e.g. Next Day Service

8 Home

1s

8a

7c

IP

6i 6c

6a 3c

2h

2c

2p

1p

1e

1g

3h

8h

6h

7h

5h

4h

4c

4e

4p

3p

5c 5u

5a 5e

OP

6o

6 8a

8e

Advice and Guidance8 (of 14) hospitals consulted ‘offer’ this service

• 3 - Consultant, 3 – ST, 1 - SHO,1 - ED,

Only 1 is formally commissioned and routinely records the activity for this service

Commissioned @£100k PA

20% deflection

• Vast majority to ‘home care’

• Minority to ‘hot clinic’

“It’s Good to Talk”: Looking at the effect of a GP Phone Advice Service within a Children’s Emergency Department

Dr Zoe Roberts, Dr Rosie Fish, Dr Jacqueline Seckley, Dr Will Christian

IntroductionThe Children’s Emergency Department has seen a significant increase in yearly attendances, many of which could have been dealt with in the primary care setting. With increasing pressures on acute paediatric services, the Bristol Children’s Emergency department introduced a telephone advice line for primary care providers in April 2012. The aim is for this to be delivered by the ED consultant group in order to try and reduce unnecessary visits and support primary care providers in their clinical practice.

Methods/DesignA one-month pilot study was undertaken in May 2011 to inform the development of the service. Following this a further, more detailed analysis was undertaken in June 2011, looking at all phone referrals to the department. Details documented included:

Following this a survey was distributed to all GPs involved in the pilot study for feedback.

Results: Total of 350 calls in June (average 12 per day)

Outcome of Call (by grade)

• Grade of person taking the call• Time of call• Patient demographics• Referrer• Reason for referral

• Brief history /examination findings including vital signs

• Agreed Plan • Outcome (including advice given

and disposal)

GP Feedback Survey YES NO DON’T KNOW

Did you find speaking to the doctor helpful 87.5% - 12.5%

Was it clear which grade of doctor you spoke to? 62.5% 37.5% -

Did you think it enhanced the patient journey? 75% 12.5% 12.5%

Did you feel happy with the advice given? 87.5% - 12.5%

If no to above, was this because you spoke to a junior? - 66.7% 33.3%

Was it easy to contact the dept and speak to the right person 85.7% 14.3% -

Should we continue to offer this service? 100% - -

Conclusion: In _ out of _ cases, the call resulted in the avoidance of a same day ED attendance. There was no obvious difference in outcome according to grade which may reflect on both the seniority of the trainees taking the call and the availability of consultant advice during the hours of 0800 – 22.30. Because there is a written record of the call, the consultant / senior trainee is often more aware of the acuity presenting to the ED and in some cases this has resulted in escalation of the pre-hospital management. Whilst we are succeeding in the overall aim of reducing emergency department attendances and there appears to be support for this service from GPs, it has also brought its own challenges namely consultants being drawn away from the shop floor during our busiest times and the potential financial loss caused by the reduction in ED attendance tariffs. Therefore in order to ensure its sustainability, we need to ensure adequate consultant availability and consider the potential for financial recompense for this service.

Best Practice Network Standard Advice and guidance

• An 8 to 8 service for GPs to access advice and guidance from local paediatrician

SEE Revised Facing Future Standards: RCPCH in consultation 2014

‘immediate telephone advice for acute problems for all paediatricians for all specialties’

Advice and Guidance

• Use Network to leverage commissioned advice and guidance by paediatricians for primary care across the region in 2015

• Use Network to leverage specialist advice and guidance for paediatricians by specialist paediatricians across the region in 2015

Assess what works-standardise unit metrics

to allow more informed evaluation of initiatives at unit level

• establish the simple core data needed for evaluation of initiatives at local level using unit trend data

• Pilot data collection in individual units to ensure that data collection is feasible in 2014

• Procede to a region wide evaluation study in 2015

NHS 2013

Long Term Conditions 0-16 years Prevalence South West

• Diabetes: 2,000

• Epilepsy: 8,000

• Asthma: 40,000 boys 30,000 girls

• ‘Core’ Disability: 0-16 yrs 56,000

0-25 yrs 90,000

15

2013 commissioned review 1990-2013

16NHS 2013

• 2/3rds of deaths in those with complex needs

• Half of these

ie 1/3 of all deaths in children with neurodevelopmental conditions

Making the unplanned planned –Community Childrens Specialist Nursing

• Diabetes Nurse – HbA1C control

• Practice Nurse – asthma planning

• Epilepsy Nurse – AED compliance

emergency fit control

Epilepsy 12 audit

Category Title Performance indicator

Professionals 1 Paediatrician with expertise in epilepsies

% of children with epilepsy, with input from a consultant paediatrician with expertise in epilepsies by 1 year

2 Epilepsy Specialist Nurse % of children with epilepsy, referred for input by an epilepsy specialist nurse by 1 year

3 Tertiary involvement % of children meeting defined criteria for paediatric neurology referral, with input of tertiary care by 1 year

Assessment & Classification

4 Appropriate first clinical assessment % of all children, with evidence of appropriate first paediatric clinical assessment

5 Seizure classification % of children with epilepsy , with seizure classification by 1 year

6 Syndrome classification % of children with epilepsy, with epilepsy syndrome by 1 year

Investigation 7 ECG % of children with convulsive seizures, with an ECG by 1 year

8 EEG % of children who had an EEG in whom there were no defined contraindications

9 MRI % of children with defined indications for an MRI, who had MRI by 1 year

Management & Outcome

10 Carbamazepine % of children given carbamazepine, in whom there were no defined contraindications

11 Accuracy of diagnosis % of children diagnosed with epilepsy whostill had that diagnosis at 1 year

12 Information & advice % of females over 12 years given anti-epileptic drugs, who had evidence of discussion of pregnancy or contraception

Paediatrician with

expertise in epilepsy

Epilepsy specialist

nurse Paediatric

neurologist

Appropriate first clinical assessment

Seizure classification

Syndrome classification ECG EEG MRI Carbamazepine

Withdral of

diagnosis

Pregnancy or contraception

discussion

Cornwall 66.7 66.7 100 75.9 77.8 44.4 40 82.8 75 100 100 0 Plymouth 100 16.7 0 73.9 83.3 16.7 71.4 100 40 100 Torbay 36.4 45.5 40 72.7 27.3 92 37.5 100 91.7 Exeter 100 0 100 61.4 85.7 14.3 45.5 95.5 57.1 100 100 100 North Devon 44.4 0 50 62.5 88.9 11.1 55.6 81.3 75 100 100 Taunton 75 50 20 65.6 83.3 8.3 18.2 93.8 45.5 85.7 Yeovil 50 0 57.1 50 0 100 90.5 0 100 66.7 Bath 50 0 50 55.6 83.3 100 22.2 100 66.7 100 100 100 Bristol 100 38.9 100 79.7 66.7 44.4 60 93.2 50 100 100 Weston 100 0 100 70 100 25 66.7 90 100 100 100 100 Swindon 83.3 83.3 33.3 98.2 100 50 43.6 93 69.2 66.7 73.2 100 Gloucester 72.2 11.1 50 73.1 94.4 11.1 40.9 92.5 69.2 100 81.8 Key Significantly better than England No difference from England ignificantly worse than England No data available

Epilepsy12 Performance results across the South West Strategic Clinical Network

ConcluSmarter network thinking expertise earlier on pathwaysIntegrated working (1° / 2°/ 3°, Health/CYPS)Making the Unplanned Plannedsions

Smarter network thinking with expertise earlier on pathways

Integrated working

Making the Unplanned Planned

• Thankyou

• Questions?

How can you help achieve these three principles?