HB Top 10: achieving high in A&E services

With news that the majority of NHS A&E departments are failing to meet four hour waiting time targets and research showing significant variation across trusts, Health Business takes a closer look at those departments which are performing best

In January this year, the National Audit Office (NAO) cautioned that emergency hospital staff were finding it increasingly difficult to cope amid unprecedented, rising demand, the recruitment crisis and wider NHS pressures. The NAO review examined ambulance performances in England and outlined that the majority of ambulance services were not meeting the eight‑minute target. It also highlighted that while the rise in demand had risen by 30 per cent over four years, the correlating rise in budget has only been 16 per cent over the same period.

In addition to this, the Royal College of Paramedics (RCP) warned in April that the number of times hospital A&E units in England had to close their doors to ambulances almost doubled in the 2016-17 winter , when compared with the previous three.

Citing research from the Nuffield Trust, Winter Insight 3: The Ambulance Service indicated that in the last five years, the number of category A calls (the most serious) resulting in an ambulance arriving at the scene of an incident has increased by 7.4 per cent year on year (from 2.5 million in 2011/12 to 3.3 million in 2015/16) – whereas over the same period there has been an average annual increase of 2.1 per cent in the number of emergency admissions to hospital, and a 1.6 per cent average annual increase in the number of attendances at A&E.

The report revealed that the three main urgent response time targets have been met in only six out of the last 49 months, and none have been met since May 2015. The most recent figures published, covering January this year, show that just 67 per cent of ‘Red 1’ calls for ambulances (which include those for cardiac arrest patients who are not breathing and do not have a pulse), and only 58 per cent of Red 2 calls (which are serious, but less immediately time-critical), received a response within eight minutes – significantly off the target of 75 per cent.

The HB Top 10 A&E list has been compiled through analysis of released NHS England data covering A&E performance for the first quarter of 2017. Trusts with a major A&E department were ranked based on their ability to meet the four hour target standard, examination of innovative A&E-specific schemes and Care Quality Commission (CQC) rankings. Among the number of trusts failing to meet targets, these organisations have exceeded expectations and performed admirably, despite the rising pressures that hinder their performance levels.

1 - Luton and Dunstable University Hospital NHS Foundation Trust

98.5 per cent of 24,882
CQC: good/outstanding June 2016

Ranked top of the list, (and officially top performer in the country) Luton and Dunstable University Hospital NHS Foundation Trust saw 98.5 per cent of the 24,882 patients which visited it‘s A&E in the first quarter of 2017 within the four‑hour time period.

According to the trust’s latest CQC report: “Visionary leadership from the board to all areas of Emergency Department (ED) resulted in the ownership of the emergency pathway throughout the hospital. The leadership team in ED over the past five years had transformed the service from one of the worst performing ED’s in the country, to one of best performing nationally. This significant improvement in performance, despite a continuing rise in year on year attendances, had been recognised at a national level by senior NHS and government leaders.

“During 2015/16, more than 98 per cent of patients attending the ED completed their care within four hours, against a national target of 95 per cent. This has been achieved at a time when the hospital has experienced its highest number of attendances ever, with the ED now seeing more than 300 people a day.”

Mr David Kirby, operational medical director, at Luton and Dunstable also confirmed that the trust has secured planning permission for a helipad as part of its emergency service offering, commenting that it was ‘another step towards the site’s redevelopment’ that will see ‘critically unwell patients receiving the life‑saving treatment they need, faster’.

2 - Sheffield Children’s NHS Foundation Trust

97.1 per cent of 14,331
CQC: good/good, October 2016

In second place, Sheffield Children’s NHS Foundation Trust saw an impressive 97.1 per cent of A&E visitors within the target four hour time. Furthermore, the trust’s latest CQC report praised: “The care and commitment provided in the A&E department was found to be excellent and the trust had consistently met the A&E four hour target for the previous 12 months.”

It also extolled the department’s drive ‘to deliver care closer to home and reduce unnecessary admissions’. In an interview with the Nursing Times, Sally Shearer, director of nursing and quality at the trust, spoke about how the trust has worked with the University of Sheffield to develop an advanced nurse practitioner course, aimed at supporting A&E and other areas.

The hospital carried out a modelling exercise to look at patterns in A&E attendance and patient flow in Sheffield Children’s Hospital’s A&E. The exercise informed the trust with an understanding of how many children and young people come through the door, where they are coming from, what conditions they are presenting with, their age group and other necessary details. The advanced practitioner roles enable specialist individuals to work in ED, granting a range of skills in the department ‘so when a child comes through the door they can be directed to the person best suited to help them’.

3 - Birmingham Women’s and Children NHS Foundation Trust

96.1 per cent of 15,448
CQC: outstanding/ good, February 2017

Following up in third place, Birmingham Women’s and Children NHS Foundation Trust achieved a noteworthy 96.1 per cent of A&E visits seen within four hours. Over 270,600 patients visit the hospital each year, including over 53,000 ED patients, 175,000 outpatients and approximately 44,000 inpatient admissions.

According to the trust’s latest CQC report, inspectors noted how kind, caring and compassionate staff were towards children, young people, and their families. It also applauded the hospital’s use of an admission avoidance board, which updated attendees about alternative support available to them in the community which could mean they were seen quicker elsewhere.

The trust also piloted a service with the aim to reduce readmissions to the hospital, by having health visitors conduct follow-up calls to patients who had been discharged from ED.

4 - Alder Hey Children’s NHS Foundation Trust

96.7 per cent of 14,714
CQC: good/good, December 2015

Alder Hey Children’s NHS Foundation Trust has the biggest and busiest ED in Europe, seeing around 60,000 children and young people each year. In 2015, the casualty unit was rebuilt at a cost of £237 million. The new hospital building contains 270 beds and 16 operating theatres across five storeys. The A&E department is staffed by 11 nurses and between six and 10 doctors at any given time. During its first 24 hours of operation, the trust took in took in 159 patients – including three major trauma patients.

The design of the new A&E means each child now has their own room with a plasma screen, providing access to Alder Hey TV. There is also a multi-sensory room for children with autism. Other features of the new hospital include an indoor treehouse, outside play decks for the six wards, and a relaxation garden. Patient waiting areas also have interactive screens for patients and families to use.

5 - Gateshead Health NHS Foundation Trust

95 per cent of 21, 434
CQC: good/good

The design of the Emergency Care Centre at Gateshead Health NHS Foundation Trust was recognised by NHS England as a best practice model providing a single point of access for emergency care.

As part of the North East Urgent Care Network, the trust was involved in the northern regional whole-system transformation vanguard for urgent care. The planned outcomes were to create and implement one urgent and emergency care model providing consistent care, wherever patients presented with no difference in the clinical outcomes delivered.

The £32 million newly built A&E facility, which opened in August, won the Infrastructure accolade at the 2015 Royal Institution of Chartered Surveyors’ (RICS) Awards Grand Final for ‘heralding a new era in medical design’. The facility combines the traditional A&E, walk-in centre, medical and surgical assessment and urgent children’s services all under one roof. This means trauma patients do not need to be moved around a large hospital site for the various tests by different departments, as they can all be carried out in a single, dedicated unit.

The panel extolled: “It brings together all the medical facilities required to treat patients during an emergency into a single bright modern building that is also welcoming. All of this, coupled with the latest wireless technologies, which streamline patient flow, make it an outstanding winner by far which will greatly benefit the Gateshead community and surrounding areas for generations to come.”

6 - South Warwickshire NHS Foundation Trust

95.3 per cent of 15,172
CQC: requires improvement/ A&E ‘good’ at Warwick hospital, March 2017

In its CQC report, South Warwickshire NHS Foundation Trust was noted for ED specific areas of outstanding practice, including its use of reminiscence therapy for patients with learning disabilities, dementia and mental health conditions. The ED staff also worked with external agencies to provide services, including substance misuse liaison specialist support for patients and consistently exceeded standards in terms of the amount of time people spent in the department waiting for treatment. The amount of people waiting four to twelve hours from the decision to admit until being admitted was consistently lower than the national average, with no patients waiting over 12 hours for admission between September 2014 and August 2015. This meant that patients could access services in a timely way.

Responding to the praise, Glen Burley, chief executive, said: “We employ some of the best clinicians in the country and are extremely proud of the services that we deliver across Warwickshire and of our teams that provide them. After reviewing the CQC report from our inspection in March it highlights a number of very positive findings, rating us ‘good’ or ‘outstanding’ in 46 out of 59 categories.

“The report confirms that we have been recognised nationally in many areas, in particular our work within A&E and urgent care to improve patient flow where we are now providing support and advice to other organisations to help them improve safety. The CQC has reported that our culture is positive and open with excellent staff survey results and patient feedback. There were only three recommendations that the CQC highlighted as important and these have all been addressed. We have requested a re-inspection at the earliest convenience with a different inspection team.”

7 - Western Sussex Hospitals NHS Foundation Trust

93.6 per cent of 31,6444
CQC: outstanding/outstanding, April 2016

Western Sussex Hospitals NHS Foundation Trust achieved a noteworthy overall rating of outstanding and an outstanding rank for emergency services for its A&E departments at St Richard’s Hospital and Worthing Hospital. Last year (April 2016), A&Es in Worthing and Chichester were ranked fourth in the country in terms of A&E performance, seeing 96 per cent of people within four hours.

The CQC report commended: “The trust had programmes of work to improve patient flow through the hospital. The hospital met the national target of seeing, treating, admitting or discharging 95 per cent of patients within four hours, ending the year in the top 20 trusts in the country.”

Chairman Mike Viggers said: “Achieving 96 per cent against a back drop of ever‑increasing demand for our emergency services is truly impressive and credit must be given to all the trust’s staff in every department who work so hard to prioritise high-quality care for patients.”

Marianne Griffiths, chief executive, said: “Our staff have worked incredibly hard to achieve this hugely impressive result, this year helping more patients than ever before. Across the country, 2015/16 has been probably the worst ever year for A&E performance with the national average falling below 85 per cent, so we are immensely proud of the exceptional standards we continue to provide to the people we serve.

8 - Ipswich Hospital NHS Trust

89.2 per cent of 20,587
CQC: good/outstanding, April 2015

Rated good overall and outstanding for its provision of urgent and emergency services, the CQC recognised an ‘open culture for quality improvement’ at Ipswich Hospital NHS Trust. The Emergency Therapy Team (ETT) at the trust has extended it service from 8am to 8pm for 365 days-a-year to prevent unnecessary hospital admissions while helping to successfully discharge those who have received care and are clinically fit to go home.

The ETT team is one of only a handful nationally to offer extended hours, and has recruited additional staff to help provide the service. Team members will assess patients promptly after they arrive at hospital and provide any therapy they may need or arrange specialist equipment, such as walking aids, to allow them to return home as soon as they are clinically fit, in turn avoiding an admission to the wards. If a patient does need ongoing hospital care, the team will make sure they go to the right ward to best meet their needs.

The expansion comes after figures show the therapy team completed 7,213 patient assessments between October 2015 and September 2016. Of these: an admission was avoided in 79 per cent of cases referred to the team from ED, the fracture clinic and Brantham Assessment Unit; 93 per cent of FAB patients seen by the team avoided an admission; and 19 per cent of patients seen by the team in the EAU were assessed and discharged the same day.

Hannah Lord-Vince, team lead, said earlier this year: “The ETT has been a great success since its launch in 2010, and is helping patients to return home more quickly every single week. We are delighted that we will become one of the first hospitals in the country to offer extended hours when the service expands on 1 April, which means we will be able to help even more people to avoid a hospital admission.”

9 - South Tees Hospitals NHS Foundation Trust

94.1 per cent of 29,116
CQC: good/good, October 2016

The A&E department at The James Cook University Hospital, part of South Tees Hospitals NHS Foundation Trust, has around 2,000 patients a week coming through its doors. The trust has recently launched a new ‘navigational’ model which will direct patients away from A&E in a bid to focus resources on those in need of urgent care. The model aims to change the way people access emergency care so that the ED can focus on those patients with life threatening illnesses or injuries who really need their help and expertise – which is what the ED is really for.

Keir Rumins, Emergency Department Matron, said: “Patients often come to the ED because they don’t know the best place to go for treatment, or they may feel their symptoms can only be treated at hospital.”

Dr Janet Walker, chair of South Tees Clinical Commissioning Group, which supports the scheme, said: “During our public urgent care consultation around the changes to urgent care services, it was a common response that A&E should be used by the sickest patients and that those with minor conditions should be treated elsewhere. The navigation model allows senior nurses to identify those patients with minor ailments that can be directed to primary care to have their needs met. Patients will be educated about which service best meets their needs, and how best to access help in the future.”

10 - Northumbria Healthcare NHS Foundation Trust

92.3 per cent of 23,480
CQC: outstanding/good, May 2016

Last Summer, Northumbria Healthcare NHS Foundation Trust published a ‘One Year On’ update on the improvements achieved thanks to its new model of emergency care. The Northumbria Specialist Emergency Care Hospital is now the largest receiving ED in the north east and the centralisation of care has resulted in a 15 per cent overall increase in urgent and emergency care activity, with over 150,000 attendances across both the Northumbria hospital and at 24/7 Urgent Care Centres in Hexham, North Tyneside and Wansbeck hospitals. The move has also contributed to a 14 per cent reduction in emergency admissions to hospital with almost 7,500 less people being admitted, resulting in a £6 million saving for the local health economy.

The news came at the same time as the CQC 2015 Survey, released in June 2016, which found patients had rated Northumberland and North Tyneside as among the best in the country.

Annie Laverty, director of patient experience at Northumbria Healthcare NHS Foundation Trust, said: “These national results are truly excellent and further demonstrates that here at Northumbria our patients experience compassionate care delivered by dedicated, caring staff in first-class environments. While we have consistently performed well in national surveys, the changes we have made to transform emergency care last year have had a huge positive impact on patient experience and led to significant improvements in our results.”

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