Transforming Emergency Care – From dream to reality by @angela_oneill1

Not a dream, a widely shared vision

Many years ago as a young enthusiastic Charge Nurse, responsible for the then Medical Receiving Unit at Crosshouse hospital, I had a dream – a dream that would shape my career for the next 15 to 20 years.  Working within the confines of a small unit, with its many physical limitations and a model of care based on ‘admitting’ patients to ‘decide’ if they actually needed to be admitted to an acute hospital was not the way forward. It clearly needed to change and the dream of providing person centred care in a unit which facilitated a new vision of unscheduled care based on models of acute assessment supported by evidence based pathways and early senior decision making had to become a reality.

Not a dream but a widely shared vision…………

I was not alone  – I quickly learned that the belief that we could strive for ‘a safer, more effective  model of care  which puts the patient at the centre of their journey’  – was not really a dream but a vision that  was shared widely across  many professional teams, leaders, clinicians, managers and disciplines who recognised the need for change.

The drivers for change:

The increasing demand for Unscheduled Care continues to outstrip projected demographic change, placing increased pressure on the front door services at both Ayr and Crosshouse Hospital.  The main drivers include the fact that:

• Existing acute services are already under pressure from high volumes of patients admitted into acute care through the Emergency Departments.
• The elderly population continues to grow with the over 65 age group in Ayrshire expected to make up 29.7% of the population by 2035. More worryingly it is anticipated that 68% of the over 75 age group will be living alone.
• There are a number of structural issues that need to be addressed
• The existing configuration of front door facilities, as shown,  significantly compromises the ability to deliver effective high quality care in a manner which makes best use of the available resources
• There requires to be a winning of hearts and minds which means that emergency admission to hospital is not the default position

Despite the efforts of all concerned it is evident that the existing model of acute care is experiencing some difficulty coping with the demands placed on it by the current population. The changes in the structure of that population, combined with the likely future health profile, are likely to result in an ever increasing demand for healthcare. It is therefore unlikely that, in its current form, the model of emergency healthcare provision in Ayrshire and Arran could continue to effectively meet the needs of the local population over the next 10 – 15 years.

The coming together of like minds in the form of the Emergency Care Quality Improvement Programme has provided the foundations for planning, testing and ultimately improving the provision of emergency care across Ayrshire.  Clinicians from all specialties have been able to influence and shape the work of the ‘Building for Better Care’ programme keeping the vision on building fit for purpose facilities which will support the new safer and more person centred model of care.

The Journey of change

Don Berwick  – Institute of Health Care Improvement captured the challenges facing us and provided us with some guiding principles as we embraced what can be a difficult path to change.

Coming off the beaten track

The necessity to come off the beaten track was clearly obvious to all – creativity  was required but the  roots needed to remain  in the desire to promote the provision of high quality care –  not a hard decision to make  but one that needed to ensure understanding and ownership to  take both our staff and our public with us.

Winning hearts and minds – the stepping stones to change…………………..

How do we get from here to there?

The answers lies in small steps of change which staff and the public can relate to and be part of. A sense of ownership and a belief that we hold the power to change in our hands will ultimately shape the new model of care.

A number of projects designed to ensure that our systems and processes are efficient as possible and do truly support our clinicians to deliver the best possible care to the population of Ayrshire are currently being tested across the whole journey of care.

Improving the flow of patients admitted from primary care in and out of hours is crucial to the success of the new model of care.  Admission to acute hospital needs to be viewed as an interruption to daily life and should only be the answer when absolutely necessary and when all alternative options  now available much closer to the persons home have been considered. The challenge lies in increasing awareness and understanding of these alternatives so that informed options and person centred choices can be made. This will of course only be possible with increased public confidence and a change in the hearts and minds of the public who have grown up with the traditional belief that hospital is the safest and often the only place to be when you are sick.  This is no longer the case with many advanced home care options now available.

The frail elderly pathway being tested at University Hospital Crosshouse is one excellent example of collaborative working designed to improve immediate specialist assessment for those over the age of 65 including review by a dedicated geriatrician within the Emergency Department. This pathway has been instrumental in supporting alternative options for care, often supporting frail elderly patients to return to their own homes with the support required put in place.

Exciting times for Emergency Care in Ayrshire……..

The stepping stones of change are now testing the new model of care and will ultimately provide the model which will be supported by the creation of the new purpose built Emergency Department at University Hospital Ayr and the new Combined Assessment Units on both sites.

There are many examples of innovation, too many to mention,  ranging from the many benefits of now having Acute Medicine Physicians who have worked with the multi-disciplinary teams to establish the new GP assessment units to the expansion of clinical pathways and  the creation of the Clinical Decisions  Unit on the Ayr site.

Development of supporting systems such as the electronic whiteboards and ward standardisation are equally important and all form part of the journey of improvement.

Crucially the views of patients and carers on what really matters to them are being sought along the way and it is this essential feedback that will ultimately shape the final vision.

At the last meeting of the Building for Better Care team we talked about putting the first brick in the ground  – it’s that close – we can almost touch it. Roll on the completion of the new builds and I along with many others can’t wait for that vision to truly become a tried and tested reality…

This week’s blogger was @angela_oneill1 (Angela O’Neill), Associate Nurse Director, Acute Service, NHS Ayrshire & Arran