The A&E crisis is rarely out of the headlines. While the issues are complex, there are many areas where technology is helping to ease the load. Haidar Samiei, our clinical director and consultant in emergency medicine at Leeds Teaching Hospitals Trust, explains.
Unless you never read the papers or watch TV, you must know that A&E services in England are facing a crisis of unprecedented proportions.
The number of people seeking treatment in A&E across England in the last decade has risen from around 17m in 2005 to over 23m in 2016. That’s equivalent to the work of dozens of departments that haven’t even been built. According to a BBC analysis of NHS England and OECD data, 11% of all patients face a four-hour trolley wait.
At the coal face the change has felt intense and resource hasn’t grown in line with demand. While there is no silver bullet, at EMIS Health we are proud of the many ways in which our technology is helping clinicians to manage demand and work more efficiently.
One: who is visiting A&E and do they need to be there?
If patients are concerned enough to attend A&E, in my opinion they have a legitimate reason to be there. Often they simply cannot get the advice or reassurance they need to make a decision and do not know what other services are available to them. A&E is often the only place with the lights on.
According to statistics for 2015/16, 7.3m people who attended A&E were discharged with “guidance/advice only”; 3.1m were discharged with a “diagnosis that was not classifiable”; and 2.1m received “no treatment”.
Technology can help us to signpost the most appropriate treatment – and often enough this can be given outside hospital. Making patient records available to 111 services (with the patient’s consent) allows call handlers to make more sensible decisions. Similarly, allowing patients to book appointments with GPs at any time of day or night through the Patient Access app often gives them the certainty to know when they are going to be seen.
For many hospitals, having a GP in A&E can make a big difference to managing this demand. By triaging patients at their first contact point – ideally with the support of information from their GP record – a GP can reassure, redirect or treat those who don’t need emergency care. A successful pilot scheme at the Royal Liverpool University Hospital Trust led to thousands of patients being successfully diverted to a more appropriate setting.
In the 2017 Spring Budget, Chancellor of the Exchequer Philip Hammond announced that £100m will go to A&E departments in 2017-18, to help them manage demand ahead of next winter, and get patients to primary care faster.
In the delivery plan for his Five-Year Forward View, NHS England chief executive Simon Steven put flesh on the bones of the Chancellor’s announcement. By October 2017, there is to be an England-wide network of about 150 urgent treatment centres. These will be open for 12 hours every day of the week and be staffed by “GPs, other doctors or experienced nurses”.
This concept is already working in a number of areas already, including an urgent care centre operated by East London NHS Foundation Trust. Concerns remain of course about how this can be staffed nationwide from the current GP workforce.
Work is also underway to improve the way that data can inform work in A&E, and EMIS Health is supporting a project to update the A&E Commissioning Data Set to produce better information. Local commissioners will use this to reconfigure services so that patients are directed to the right care, at the right time, in the right place.
Two: can we do anything to prevent emergency admissions?
Many people do need urgent care in hospital of course – and again there has been an exponential rise in demand. According to NHS Indicators: England, February 2017, there has been a 17% increase in emergency admissions via A&E in the past five years.
According to NHS Digital, patients aged 65 to 69 – so called "baby boomers" – made up the single largest group of patients, with some 1.3 million admissions in 2015-16.
But technology is helping us keep those vulnerable patients fit and healthy in the community. Oxford Terrace and Rawling Road Medical Group used personalised care planning and shared records via EMIS Web to enable its complex care team to care for frail elderly patients at risk of hospital admission.
This preventative approach is becoming much more widespread and it is clear that better, proactive care of the elderly is going to be key to reducing pressure on future emergency services.
Three: can we speed up waiting and treatment times?
It’s no secret that surging A&E attendance has coincided with a decline in the ability of emergency departments to hit four-hour performance targets for discharge, admission or transfer. Over 16% of patients visiting major A&E departments in 2016 waited more than four hours – the worst performance in a decade. (Source: Accident and Emergency Statistics: Demand, Performance and Pressure)
Patients needing hospital admission via A&E face longer waits too. According to NHS England’s A&E Attendances and Emergency Admissions monthly report for December 2016, there were 61,700 four-hour delays from decision to admit to admission, almost double the December 2015 figure of 32,900.
These are complex problems, but technology has a role to play in streamlining workflows and efficiency. Cohorting – the ability to identify and stream patients using technology – has made a real difference. For example, it enables those with stroke symptoms to be referred directly to specialists, bypassing the general A&E doctor. Heart patients go straight to the cardiac cath lab. Medical record sharing and good IT communication supports us in doing that.
Cohorting brings economies of scale; it is faster, better, more efficient. Shared records access lets us do it, and innovations like Share Your Record mean there are few situations where it is not possible.
Technology such as Symphony from EMIS Health can also help A&E departments work in the most efficient way possible, by giving staff real-time data about patients’ acuity, highlighting key conditions such as sepsis, and by integrating A&E data with wider hospital systems.
Four: the thorny issue of ‘bed-blocking’
The extent to which so-called “bed-blocking” has become an issue for A&E is exposed in NHS statistics for delayed transfers of care, which reveal that there were 197,100 delayed days in January 2017. Of those, 35.3% of all delays in January 2017 were attributable to social care, with the main reason “patients awaiting care package in their own home”. The Spectator concluded that “acute hospitals throughout the land are being prevented from performing their vital functions because their beds are filled by almost well people.”
So what is preventing timely discharges? While pressures on social care services are an important factor, there are other issues within the hospital’s control – and technology can help.
Some delays are caused by relatively simple problems such as having discharge drugs ready on time. Others are more complex, such as delays in getting diagnostic results or a lack of therapy services at weekends. The timely communication of accurate and legible discharge summaries is a key performance target for hospitals and eDischarge from EMIS Health is helping achieve it in places like Hinchingbrooke Healthcare NHS Trust.
With the right technology, hospitals can treat patients more quickly while discharging them home safely. A multidisciplinary team is giving safer, more efficient care to vulnerable patients at the Woodland View Hospital in Ayrshire. Using two-way record sharing via EMIS Health, the hospital has reduced the average length of stay by 12 days and cared for 30% more patients in just six months.
Emergency care teams are busier than we ever have been and it’s clear the pressure isn’t going to let up.