How to streamline inter-hospital transfers
Dr Richard Levy
Wythenshawe Hospital, Manchester
CHD Collaborative
National Clinical Lead
“Real life” technical considerations ?
What is the evidence?
REASON FOR TRANSFER
Acute CoronarySyndrome Pacemaker
Urgent coronary surgery
Implantable CardioverterDefibrillatorValve surgery
Pacemaker with wire
Transplant assessment
Pericardial effusion
Other
The majority of patients waiting for transfer were waiting with acute coronary syndrome (73%)
48
35 34
24 24 2217
14 126 6 6 5 5
0
10
20
30
40
50
60
A B C D E F G H I J K L M N
Number of patients reported awaiting transfer at each hospital Manchester Dec 2003
Hospitals
Num
ber
of p
atie
nts
Inter-hospital transfer for revascularisation
At a CHD Collaborative Angina Workshop in September 2003 this was identified as national problem # 1
Organise a national survey and audit of current practice in patients with ACS
ACS Transfer
• Study from Manchester Royal Infirmary from May to October 2003 recorded 212 patients in 16 DGHs occupying 1755 bed days waiting for transfer
(N Curzen, Lancet letter 2004)
Inter-hospital transfers for revascularisation
“ view from-----
----- the DGH”
Inter-hospital transfers; view from the DGH
• We do all the right things• We triage the patients, identify the high risk
patients (Troponin testing etc)• We select the correct patients for angiography+/-
revascularisation and refer to the Centre• And then we wait• ----- and wait
----- and wait
Inter-hospital transfers for revascularisation
“view from
the Ambulance Service”
Inter-hospital transfers;
view from the Ambulance service
• We have to match the type of vehicle, equipment and crew to needs
• This can have an adverse impact on category A calls
• The patient is never ready when we arrive• And then we wait• ----- and wait ----- and wait
Inter-hospital transfers for revascularisation
“view from-----
----- the Centre”
Inter-hospital transfers; view from the Centre
• We must first meet our targets for elective revascularisation [PCI & CABG]
• This will dictate our “star rating” and application for Foundation status
• We have a “white board” for listing patients for transfer for non-elective revascularisation
• This is always full
Inter-hospital transfers; view from the Centre
• We do our best to deliver non-elective revascularisation --- and in time we do deliver
• After revascularisation we may need to transfer patients back to the DGH
• The DGH is always full• And then we wait• ---- and wait
---- and wait
Inter-hospital transfers for revascularisation
• This is a major challenge for Cardiology
• Unrecorded waiting list
• Surge in referrals due to advances in clinical practice
• No indicator for non-elective revascularisation
CHD-C Survey and Audit
• National survey to scope the problem of interhospital transfer for the treatment of ACS
• Review of Central Returns (RoCR) insisted on voluntary contribution
• Collect baseline data about referring DGHs, transfer process and interventional/surgical centres across England
• Identify process redesign work already introduced and share best practice
CHD-C Survey and Audit
• Collect data about waiting times for transfer from DGH to referral centre for angiography and revascularisation in England over 4 weeks in March 2004
• These data provide a snapshot of our capacity to provide non-elective revascularisation
• Expose any limitations in the system
Sometimes Wythenshawe seems very far away……
ACS transfer
• Data suggest that at-risk patients with ACS benefit from early invasive assessment within 72hrs and this is recommended in local, national and international guidelines
A National Study of Transfer of Cardiac Patients
March 2004
Submitted Forms
• We tried to reach all the trusts in England
• 141/148 Trusts submitted forms
Team organisationTeam organisation
Admitted To DGH
Angiogram Referred Transferred Procedure
Inter-hospital Transfers Audit
Topline Average Waits
5.9 Days 1.6 Days 7.5 Days 1.5 Days
16.5 Days
15 Days
Admitted To DGH Angiogram Referred Transferred Procedure
Difference between PCI and Cardiac Surgery
5.2 Days 2.4 Days 11.1 Days 3.5 Days
PCI
CARDIAC SURGERY
5.9 Days 1.3 Days 7.6 Days 1.2 Days14.8 Days
18.7 Days
16 Days
22.2 Days
Admitted To DGH
Angiogram Referred Transferred Procedure
Intervention on site or transfer
6.3 Days 1.7 Days 8.0 Days 1.1 Days
INTERVENTION ON SITE
TRANSFERRED FOR INTERVENTION
3 Days 1.5 Days 3.8 Days 2.2 Days
8.3 Days
16 Days
DGH with a Catheter Lab 5.5 DaysDGH without a lab 8.2 Days
40.1% of the DGHs submitting data had a Cath Lab of some sort
Average waiting time betweenadmission and angio:
Wait after transfer to procedure
0
2
4
6
8
10
12
14
16
Number
0 1 2 3 4 5 6 7 8
Average wait (days)
CABGPCI
The North
Average wait from admission to PCI : 12.8Average wait from admission to cardiac surgery: 16.3Average wait from admission to procedure (all) : 12.9
The South and West
Average wait from admission to PCI: 23.5Average wait from admission to cardiac surgery:25.4Average wait from admission to procedure (all): 20.9
The Midlands and Anglia
Average wait from admission to PCI : 12.6Average wait from admission to cardiac surgery : 23.0Average wait from admission to procedure (all): 14.5
The South East & London
Average wait from admission to PCI : 15.5Average wait from admission to cardiac surgery:19.9Average wait from admission to procedure (all): 17.0
Geographical Differences In Average Waits (Days)
The North
Number of Interventional Cardiology Sites submitting data : 17
The South and West
Number of Interventional Cardiology Sites submitting data : 6
The Midlands and Anglia
Number of Interventional Cardiology Sites submitting data : 10
The South East & London
Number of Interventional Cardiology Sites submitting data : 10
Number of centres submitting data
Average Wait In Days Per Patient By Trust For Angio +/- Proceed
0 5 10 15 20 25 30
709410114133555
67792920
1397253
1028981
10811478
10451741619
12180111
1323858
128368885903739759810511783113
171
1064513112052
138485492127103100648412515
133771152
9163135119110
4124
857148211612
13710750
142182611
134129442297
1303417
9630
7253
6242591186187
12347131031219
1225643239335282773
126140
64960
136764095
10966
Tru
st C
od
e
Average Wait (Days) Per Patient
Admission to Referral Referral to Transfer Transfer to Procedure
Average Wait In Days Per Patient By Trust For CABG
0 5 10 15 20 25 30 35 40 45 50
220707487
1095884141893369
10413955
10391
12412629116679924101308397548
7511912515
13672383946115815061
100191
356398
13066854586117781126514
132123
7143
5138133111496082
134131777
76121969256
108135
11122
1751
12918
1106
9410424410712823376822
Tru
st C
od
e
Average Days Wait Per Patient
Admission to Referral Referral to Transfer Transfer to Procedure
Average Wait In Days Per Patient By Trust For Definite PCI
0 5 10 15 20 25 30 35
33
55
98
14
24
85
136
89
20
53
65
56
91
17
18
83
121
112
8
15
133
92
43
113
34
35
86
Tru
st C
od
e
Average Wait (Days) Per Patient
Admission to Referral Referral to Transfer Transfer to Procedure
Average Wait In Days Per Patient By SHA And Trust For Angio +/- Proceed
0 5 10 15 20 25 30
333913112013516
11784988352
1381553
1028063
1378754
134214079644
1245850891231357274121132113911411
14138712919
1339662616720
1429555
108572230251184327
12511042
12223
1031001234781
11475
1305693
1367851
1151162849368
343
8526603713
126482
8294
10659106645
1299
701391118890
11199775
1041281057718
127107140
61019244177376
109
Average Wait (Days) Per Patient
Admission to Referral Referral to Transfer Transfer to Procedure
AVON
BEDS
BIRM
CHES
CUMB
DORSDURH
ESS
HAMP
KENTLEICLINC
MANC
NCL
NEL
NORF
NWL
SEL
SHROP
SURR
SWLSWPENSYORK
THAME
TRENT
TYNE
WMIDS
WYORK
Average Wait In Days Per Patient By SHA And Trust For CABG
0 5 10 15 20 25 30 35 40 45 50
333913113584112117158398
13863875465
13412450586835891114727491
1211323871
14119296196
133206722304355
108234211012212569
100103123567581
13013624517811549116
84660853786
1262
8210669445
12917
7097111119139
5187799
104128
610717447692101109
Average Wait (Days) Per Patient
Admission to Referral Referral to Transfer Transfer to Procedure
AVON
BEDS
BIRM
CHES
CUMB
DORSDURH
ESS
HAMPKENT
LEIC
LINC
MANC
NCL
NEL
NORF
NWL
SEL
SHROP
SURR
SWLSWPEN
SYORKTHAMETRENT
TYNE
WMIDS
WYORK
Average Wait In Days Per Patient By SHA And Trust For Definite PCI
0 5 10 15 20 25 30 35
33
112
15
83
98
53
65
35
89
14
91
113
121
133
20
43
55
56
136
24
8
34
85
86
18
17
92
Average Wait (Days) Per Patient
Admission to Referral Referral to Transfer Transfer to Procedure
AVON
BIRM
ESS
HAMP
KENT
LINC
MANC
NORF
NWL
SEL
SURR
SWL
THAME
TRENT
TYNE
WMIDS
WYORK
Average Wait In Days Per Patient By SHA For Angio +/- Proceed
0 5 10 15 20 25 30
WYORK
WMIDS
TYNE
TRENT
THAME
SYORK
SWPEN
SWL
SURR
SHROP
SEL
NWL
NORF
NEL
NCL
MANC
LINC
LEIC
KENT
HAMP
ESS
DURH
DORS
CUMB
CHES
BIRM
BEDS
AVONS
HA
Average Wait (Days) Per Patient
Admission To Referral Referral To Transfer Transfer to Procedure
Average Wait In Days Per Patient By SHA For CABG
0 5 10 15 20 25 30 35 40 45
WYORK
WMIDS
TYNE
TRENT
THAME
SYORK
SWPEN
SWL
SURR
SHROP
SEL
NWL
NORF
NEL
NCL
MANC
LINC
LEIC
KENT
HAMP
ESS
DURH
DORS
CUMB
CHES
BIRM
BEDS
AVON
SH
A
Average Wait (Days) Per Patient
Admission To Referral Referral To Transfer Transfer to Procedure
Average Wait In Days Per Patient By SHA For Definite PCI
0 5 10 15 20 25 30 35
WYORK
WMIDS
TYNE
THAME
SWL
SURR
SEL
NWL
NORF
NCL
MANC
LINC
KENT
HAMP
ESS
BIRM
AVON
SH
A
Average Wait (Days) Per Patient
Admission To Referral Referral To Transfer Transfer to Procedure
Admitted To DGH
Referred Transferred Procedure
Inter-hospital Transfers AuditAverage Admission to Procedure
Waits by Trust – 1 March to 28 March 2004
Angiography +/- PCI (with and without angiography)
Admitted To DGH
Referred Transferred Procedure
Inter-hospital Transfers AuditAverage Admission to Referral
Waits by Trust – 1 March to 28 March 2004
Angiography +/- PCI (with and without angiography)
Admitted To DGH
Referred Transferred Procedure
Inter-hospital Transfers AuditAverage Referral to Transfer Waits by Trust –
1 March to 28 March 2004
Angiography +/- PCI (with and without angiography)
Admitted To DGH
Referred Transferred Procedure
Inter-hospital Transfers AuditAverage Transfer to Procedure
Waits by Trust – 1 March to 28 March 2004
Angiography +/- PCI (with and without angiography)
Admitted To DGH
Referred Transferred Procedure
Inter-hospital Transfers AuditAverage Admission to Procedure
Waits by Trust – 1 March to 28 March 2004
CABG
Admitted To DGH
Referred Transferred Procedure
Inter-hospital Transfers AuditAverage Admission to Referral
Waits by Trust – 1 March to 28 March 2004
CABG
Admitted To DGH
Referred Transferred Procedure
Inter-hospital Transfers AuditAverage Referral to Transfer Waits by Trust –
1 March to 28 March 2004
CABG
Admitted To DGH
Referred Transferred Procedure
Inter-hospital Transfers AuditAverage Transfer to Procedure
Waits by Trust – 1 March to 28 March 2004
CABG
Admitted To DGH
Referred Transferred Procedure
Inter-hospital Transfers AuditAverage Admission to Procedure
Waits by Trust – 1 March to 28 March 2004
Definite PCI
Admitted To DGH
Referred Transferred Procedure
Inter-hospital Transfers AuditAverage Admission to Referral
Waits by Trust – 1 March to 28 March 2004
Definite PCI
Admitted To DGH
Referred Transferred Procedure
Inter-hospital Transfers AuditAverage Referral to Transfer Waits by Trust –
1 March to 28 March 2004
Definite PCI
Admitted To DGH
Referred Transferred Procedure
Inter-hospital Transfers AuditAverage Transfer to Procedure
Waits by Trust – 1 March to 28 March 2004
Definite PCI
Interhospital Transfers - Tertiary Centre - Average days wait from transfer to procedure - All procedures - April
2004
0 1 2 3 4 5 6
9417331955
1015824
1037998692067
1392989
13253
116117136125
8199
104548582
Tru
st C
od
e
Average wait (days)
Transferred Procedure
Interventional Centres
Overall – All procedures
Interhospital Transfers - Tertiary Centre - Average days wait from transfer to procedure - Angio +/- proceed -
April 2004(Note Trusts 99,69 and 24 - no data provided/no procedures undertaken)
0 1 2 3 4 5
94101
173355196758
10379
117132
299820
1398153
12589
116136
548285
104246999
Tru
st C
od
e
Average wait (days)
Transferred Procedure
Interventional Centres
Angiography +/- proceed
Interhospital Transfers - Tertiary Centre - Average days wait from transfer to procedure - CABG - April 2004(Note Trusts 24, 53, 79,19,17 and 94 - no data provided/no procedures
undertaken)
0 5 10 15 20
982058893369
104139136
55103
29116
6799
10154
12585
117132
8182941719795324
Tru
st C
od
e
Average wait (days)
Transferred Procedure
Interventional Centres
CABG
Interhospital Transfers - Tertiary Centre - Average days wait from transfer to procedure - Definite PCI - April
2004(Note Trusts 79,19,94,82,81,117,125,54,101,99,67,116,29,103,136,139,104,69 and
58 - no data provided/no procedures undertaken)
0 0.5 1 1.5 2 2.5 3
3355981724
132858920535869
104139136103
29116
6799
10154
125117
8182941979
Tru
st C
od
e
Average wait (days)
Transferred Procedure
Interventional Centres
Definite PCI
Average days wait in DGH 15.3 Days
Patients admitted to a DGH during 4 week audit period 2196
Occupied Bed Days for ACS pts 13295over 4 weeks based on 3 days forPossible proceed and 7 days for CABG
Summary
Clear unambiguous guidelines……
Interhospital Transfers
Redesign work
What are we doing to address this?
• Competencies for transfer• Treat and return• Transfer service• Working together across the network• Shared care of patients • Electronic communication• Jointly developed pathways / processes • Coordinator role• Optimise the patient - fit for procedure• Dedicated beds
Coordinator role
Middlesborough James Cook Hospital appointed Cardiology Pathways Coordinator Reduced DGH average wait from 12 – 6 days
• Co-ordinates transfers with 11 referring DGHs –single point of contact
• Arranges booking and scheduling of lists• Ensures consistent data management• Leads weekly meetings to review list based on
clinical priorities
Streamlining the Process
Walsall Hospitals NHS TrustReduced average times from decision to proceed
through to discharge following PCI from 19 to 5 days
• Faxed referral proforma• Tracking document across organisations from
referral to rehabilitation• Educational sessions for all staff on process• Patient information leaflet at DGH – patient better
informed before transfer.
Working across boundaries
11 referring hospitals in North East London and Essex with Barts and the London NHS Trust
Complete review of transfer process• Pre-schedule slots for DGHs according to demand• Prebook ambulance slots with private ambulance
provider• Plans to use NHS paramedic service to eliminate
the need for nurse escort
A redesigned service
West Yorkshire – 13 DGHs and Leeds general Infirmary
Previously median wait of 8.2 days to approx 2.5 days for PCI since 2001
• Cardiac Cath lab scheduler post• Ring fenced beds – DGHs and Centre• Common waiting list• Demand and capacity work which led to case specific
sessions, equalising the working day for all staff• Nurse led intervention beds
“I believe that public servants are working flat out but in a system that shrieks out for fundamental change…If we don’t get the systems and structures right we will never get to the roots of the problem, only prune its visible branches.
The key to reform is redesigning the system round the user.” Tony Blair
Prime Minister October 2002
2005
• Agree a national standard for inter-hospital transfers eg 72hrs
• Repeat study planned for September 2005
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