Q Exchange
A&E Redesign – go with the tide, not against it.
- Proposal
- 2023
What is the challenge your project is going to address and how does it connect to the theme of 'How can improvement be used to reduce delays accessing health and care services'?
Many patients use A&E services due to systemic failures in the access and flow of patient care across the NHS system. For years the NHS has looked to divert the tide of patients choice without success. We are attempting to imagine a new quality improvement driven approach that will better allow us to safely filter the needs of the patients who present to A&E. Instead of diverting them away, instead develop new pathways, assessments and services to meet the changing needs of our patient populations. Working with the tide of patient choice, rather than attempting to divert patients away, which will ultimately delay patient care. Instead we will focus on maintaining patient safety for our sickest patients, while supporting the need for 24/7 non-urgent patient services needed. This programme will trial multiple options to support patients via the CQC FIRST model to help patients access the appropriate healthcare services they need.
What does your project aim to achieve?
Measurable and demonstrable improvement to A&E pathways and new ways of working that will aim to deliver the patient care services needed by those patients presenting to A&E. This will involve patient and clinician risk stratification, with filtration of care needs meaning a different approach to pathway design. Where successful, all improvements and pathways developed will be appropriate for all NHS A&E settings and will be easy to follow and duplicate. Both PDSA cycles of improvement and a LEAN mapping approach will be followed, meaning clear patient journey pathways will be developed. This approach will help with the overall synergy between NHS settings, including specialty outpatient and GP settings, meaning overall clearer pathways to patient care for all, patients and clinicians within the NHS. Patients can therefore access services more quickly and effectively, whilst clinicians reduce the number of repeated attendances, prior to the most appropriate clinical referrals being made.
How will the project be delivered?
A single A&E within the Trust will act as the QI lead to refine our pathway understanding, develop our understanding of patient needs and reframe the questions being asked of patients presenting to A&E. Shifting from ‘why are you here?’ to ‘how can we help you?’ model, we will seek to more effectively stream the needs of our patient populations. Rather than patients being triaged into pre-existing models of patient care within A&E, we will seek to redesign A&E pathways to meet their needs. Meaning we will keep our focus on the sickest patients, whilst preventing others from sitting for hours to hear we cannot help them and that they need to access the help via another route. We will also aim to more effectively support our clinical colleagues marry up patients needs to services, rather than a default ‘attend A&E’ approach, driven by a lack of external pathway transparency.
How is your project going to share learning?
All final pathways and the patient needs will be published at the end, meaning a buffet of A&E pathways that can be easily replicated and personalised for other A&E settings will be available. Minimal work would need to be done to make bespoke A&E pathways for other clinical settings and it would act as a framework for patient pathway information sharing and redesign across the emergency medicine network. The main issue with the focus of ‘prevent’ has stymied the improvement focus on fulfilling patient care needs, therefore filling an important gap in patient flow support. A lot of work is unofficially done already by A&E clinicians to marry patient need and service provision. This approach embraces this key patient/system need, making it the core of the improve work. Focusing in on improving overall patient access to the care they need, rather than a ‘protect against the tide’ of patient influx.
How you can contribute
- We would like you to share your ideas for safely triaging and streamlining the care in A&E, so we can look to refine and test them, on top of our existing plans.
- Help us develop GP outreach to help support transparent pathways for patients, we are particularly looking for GP colleagues to suggest their most pressing needs.
- Help us keep people at home, without the need to travel to A&E for our skills and knowledge, particularly looking for support from social care colleagues and nursing home staff. To understand how we can safely share the risk of making the right decisions for our patients, together.
Plan timeline
| 26 Mar 2023 | ABOVE DATES NOT CORRECT DUE TO ENTRY ISSUES ON SYSTEM |
|---|---|
| 26 Mar 2023 | Collaborative triage pathway mapping |
| 26 Mar 2023 | Completed data analysis |
| 26 Mar 2023 | Consultant QI Meeting and discussions |
| 26 Mar 2023 | Data analysis |
| 26 Mar 2023 | External stakeholder engagement and review |
| 26 Mar 2023 | Full A&E team meeting |
| 26 Mar 2023 | Pathway completion and publication for wider information sharing |
| 26 Mar 2023 | Suggested pathways PDSA cycled for improvement |
Comments
Amy Dennis 23 Mar 2023
I like this idea, especially asking patients what they need, what help they require. I also think pathway work is the way forward across all parts of the system so it will be interesting to see what you discover. I would also be interested in whether other professions, such as physiotherapy could provide alternative triage options in this setting?
Samantha Mills 24 Mar 2023
Hello Amy, thank you so much for your supportive comments and important builds on this work. We are fortunate to be able to access physiotherapy and occupational therapy support in our A&E but I do not think all our rotating medical teams are fully aware of the great work they can do. Including things like chest physio, which has saved more than one of my patients from becoming seriously unwell. It is currently limited to certain in hours offerings and there are not many streaming pathway options associated with this, so we cannot necessary access an emergency/hot clinic offering for maybe the next day say. I think this is a great suggestion that we will be moving forward with that suggestion as part of this work. Thank you so much, please do share anything else you can think of! Samantha :)
Paul Sullivan 19 Mar 2023
This is great. From the patients' viewpoint, they have paid their taxes, and have paid for care, and you could say we have an obligation to meet their perceived needs; diversion back to a system that has failed them, or they expect to fail them, seem wrong. There are many schemes that provide alternatives to mainstream ED, but these are generally branded as ways to help the health service - designing a service with the stated aim to help patients will nudge professionals to look mat care delivery in a more patient centred way.
Samantha Mills 24 Mar 2023
Hello Paul, thank you this was a joy to read. Exactly our aims, really well articulated thank you. We really hope we will get the honest engagement with our patients, unfortunately the previous approach of system support over patient options has damaged the trust, with many patients feeling the need to lie about what has happened to them or what they need, in order to get help from us. Although I am absolutely certain the previous system support was never intending to do this and had the same aim as us, to support patient safety, things went a bit wrong. So now what we are left with is a disjoined care system that frustrates all involved. Fingers crossed for the support to get this off the ground and see what we and our patients can come up with. Many thanks for your kind words and support, any further ideas or suggestions are very welcome, we love the hive mind approach. Oh and I may be stealing your descriptions above, with pride and appropriate credit of course, Samantha :)
Joy Furnival 18 Mar 2023
I like your ideas here and how you are using theory, method and best practice from the regulator to test out your changes safely. I’m curious to find out what you learn on the way. I’m curious if you might be able to connect with your local ambulance service to collaborate on improving your triage process with you and also support ambulance service improvement in ED at the same time.
Samantha Mills 24 Mar 2023
Hello Joy, great minds think alike, Jaqualine has also mentioned this, thank you so much for the build on our offering. We are fortunate to interact with two ambulance Trusts and we certainly would be looking to engage with them as part of this work. Including to offer additional support for out of A&E advice, similar to the GP and 111 support offerings. Ideally the handover process will also be streamlined within the current plans to look at the triage and streaming options. So that the patients get the best options for care for them from the very beginning. Thank you for your really supportive comments, it is much appreciated, I am passionate about making the patient journey in A&E as useful for them as possible and very much hope we get the support to share the learning with you. We would love to hear anymore of your ideas! Many thanks Samantha :)
Pi Shetshotisak 14 Mar 2023
I'm not sure about other hospitals but in my city, patients in AE don't even receive triage of any kind.
This is quite strange in the eyes of a foreigner like me because in Thailand (which is a developing country) this kind of triage system is very well established even for the small hospitals in the rural area.
Other thing is that the way AE room are designed here is not very efficient. It has wall to separate each patients (may be due to privacy issues) but it means that it limits the number of beds which could fit in AE room while in principle, AE room should be able to host a lot of beds for mass casualties. In Thailand AE room are designed based on this measure so every bed are separated just by the curtains and lastly, privacy is not a really important issue because in the situation when you need to go to AE, privacy is not going to save your life but doctors do.
Samantha Mills 24 Mar 2023
Hello Pi, thank you so much for your really detailed response. I was fortunate to do a little on the ground work in Thailand last year (although as emergency help rather than in a official position), it is a beautiful country. I think your comments really helped me understand that one of the things we really need to do is communicate more with patients on how A&Es work. We do have triage systems in the UK and one of the most common is the Manchester triage model, which looks to priorities seeing and caring for patients based on the most sick being seen first. With the 'stable' patients being allowed to wait in preference of those who need our hep first. The need for this work is that the number of patients are now more complicated and overwhelm the ways we use to triage patients. Its a bit like not being able to see the 'wood for the trees' with even really sick patients potentially getting lost in the sheer volume of patients we are seeing.
As a short aside I should say the 'tide' of patients is alluding to a 12th century story my Dad told me about when growing up. He used to say when things were beyond our control/influence, it was like 'shouting at the tide'. King Canute (an old king) showed his subjects that he had no power compared to nature, to demonstrate it, he went and shouted for the incoming tide to stop. Which obviously did not work. So hoping that patients will choose another option in the NHS system is feeling more and more like that.
I really appreciate your comments about how the A&E is structured physically and we are looking at how we can support patients with this. Most A&Es have a minor injuries area (broken limbs etc), an area where we care for more seriously unwell patients called majors. Along with an area for emergency resuscitation, which would be your mass casualties etc and can offer the highest level of patient support. We are also fortunate to have a rapid assessment area for initial see and treat of patients coming in by ambulance or who present very unwell. This helps rapidly see them and make some decisions to help improve their conditions. However all areas are separated physically and people might not understand we have different areas for different needs. So thank you, maybe understanding the whole picture will help the patients give us the right information for their needs.
The reasons we have physical separation in many of our areas in our A&E is to prevent infections spreading and also to allow privacy. Although more physical space is always a wish, the major thing we want to concentrate on with this work is to look to identify the types of help patients need and if there are different ways we can work to support them and us, while still prioritising safety.
We would love to hear anything else you have to share with us on this work, it has really helped with seeing things from a different perspective and highlighted the need for communication with this work even more for me personally. Thank you so much, Samantha :)
Jaqualine Lindridge 8 Mar 2023
Great idea, I can see this being a very helpful contribution to knowledge in this area. I wonder if you intend to engage with your local ambulance trust on this? There may be opportunities to intervene differently with both those conveyed and those advised to attend following a telephone consultation.
Samantha Mills 24 Mar 2023
Hello Jaqualine, thank you so much for the build on our offering. We are fortunate to interact with two ambulance Trusts and we certainly would be looking to engage with them as part of this work. Including to offer additional support for out of A&E advice, similar to the GP and 111 support offerings. Ideally the handover process will also be streamlined within the current plans to look at the triage and streaming options. So that the patients get the best options for care for them from the very beginning. Apologies for a delayed response, I took my research methodologies a little too seriously and trialled being a patient in my own A&E with a slightly broken leg. Thank you for your input and we would love to hear anymore of your ideas! Many thanks Samantha :)
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