THE trust behind Queen Alexandra Hospital said it is making changes in its A&E department after it came under criticism from leading doctors.
Portsmouth Hospitals NHS Trust has taken on Rick Strang as deputy chief operating officer in emergency care to improve the flow of patients coming into the A&E department, and patients leaving QA to make sure there are enough beds.
The hospital’s emergency department is one of four areas commissioners said they are concerned about performance and putting patient safety at risk.
As reported, three separate letters were sent to Ursula Ward, chief executive of PHT.
The letters were sent by the leads of the Portsmouth, Fareham and Gosport, and South Eastern Hampshire Clinical Commissioning Groups (CCGs) last month.
But the green shoots of recovery are starting to show, since Mr Strang put new ideas in place in October.
This includes increasing the number of beds available in the hospital, holding more daily meetings to identify which patients can be discharged, extending care given by the medical assessment unit and introducing a phone line that GPs can call to get a second opinion before sending a patient to A&E.
And the figures show that immediately after the changes were put in place, there was an improvement in waiting times in the emergency department.
NHS England statistics, above, show the week ending October 13, 96 per cent of patients were seen within four hours – above the national average that week of 93.8 per cent.
Mr Strang said: ‘When I started, I knew what state we were in – we were one of the bottom five performing emergency departments in the country.’
‘So we all knew what we were up against.’
But since Mr Strang started, he has been working tirelessly to ensure patients are being treated promptly, and where appropriate.
‘There are things we have put in place that have already helped,’ he said.
‘It’s pulled us into the top third best-performing trusts compared to others of a similar size to us.’
And the work has been welcomed by Councillor Will Purvis, who is a member of the hospital trust’s board of governors.
He said: ‘We are aware of the pressures on A&E, and the work taking place to help ease the pressure. We saw the changes had made things better, but winter pressure has caused a spike again. ‘The staff do an amazing job considering the pressures they are under and the difficult circumstances during winter.’
The trust works on a six-week average and work out how many patients are likely to come through the door each day.
Throughout the day these figures are monitored, and ward managers go out and try to find spaces.
Mr Strang said: ‘Teams go out into the wards and see who can be discharged, and that creates space.
‘If there are no spaces in the hospital, then the patients have to stay in the emergency department, and that’s when you start to get the queues.
‘Throughout the year, we have about 275 people come through the emergency department a week, and we are pushed.
‘During winter, that increases to about 310, and makes it even more difficult.
‘We felt winter hit us at the start of December.
‘Usually there are about 65 patients a day, but in the winter it goes up to 80-plus patients, and a quarter of them will be those with respiratory or cardiac problems.’
Mr Strang believes one of the biggest things that will help meet targets, is addressing patient flow within the entire hospital.
‘The ED is not separate from the rest of the hospital, and it all needs to work together,’ he said.
‘Patients that go into resuscitation or the major beds will get seen too, as their problems are life-threatening.
‘About 55 per cent of the cases that come in are for minors, and it’s usually these patients that can face long waits.
‘We have to keep the flow going all the time. If we’ve got someone that needs to come in and be admitted, then we also need to make sure people are being discharged quickly as well.
‘It’s not as simple as adding more beds. The first reason is because we don’t have enough space, and the second reason is that would only work for a short-term.
‘Even if you control the tap, which is the flow of people coming in, you still need to make sure the sink is unblocked, ie the number of people being discharged.
‘It’s not about how big your ED is, but how quickly you can move people along so beds become available.’
Last month, Portsmouth patient watchdog group Healthwatch visited the department.
Manager Steven Taylor said: ‘The pressures on the emergency department are not just about the demand – it’s also about other parts of the hospital working to support admissions.
‘And most importantly discharge arrangements which mean more patients can’t come in because they are full.
‘The four-hour wait time is a really good tool to use, but it’s more than just a measure of when patients are seen, it’s about a lot more and it shouldn’t be the only thing we look for.
‘Pressure on the department, especially at peaks times, means they can’t cope.’
He added: ‘There needs to be more coordination between GPs and the out-of-hours services to take some of the demand off.’
Improving – but still a war left to tackle
THE trust knows it can’t celebrate too soon, as commissioners are worried about the sustainability of improvements.
The government has set a guideline time of four hours, where a patient entering an emergency department is either admitted, transferred or discharged.
Last week the national average failed to meet the 95 per cent target set by government – however QA was above the benchmark.
The week ending January 19, saw that 96 per cent of the 1,729 people that attended were seen within four hours.
That compares with the national average of 93.1 per cent.
But between promising October figures, published above, and the latest A&E performance reported, QA dipped in November and December.
Rick Strang, deputy chief operating officer in emergency care, said: ‘We have had some difficult weeks, and there’s no way around that.
‘There has been a rise in our over-65s population needing emergency attendance, and that has made it difficult for us.
‘But you have to look at it in perspective.
‘We will have good weeks, and we will have bad weeks.’
The week ending November 17, saw 1,848 people attend, with 90.7 per cent being seen within four hours.
That compares to the national average of 94.1 per cent in the same week.
And the trust plummeted further still, as the week ending December 15, saw only 78.1 per cent of the 1,922 attendances were seen quickly.
The national average that week was 92.1.
‘December marks the end of quarter three for this financial year,’ said Mr Strang.
‘It shows 92 per cent of people were being seen within the four-hour waiting time target.
‘In the last year financial year, at the same time, we were at 86 per cent, so it’s all relative.
‘Where we are now is still not where we want to be.
‘We are much better than we were, but it will still take some time.
‘The changes we have made will take some time to become embedded and working.
‘It’s a difficult time to put changes in – we should really have done it in the summer.
‘But we are pleased with our progress and that has come from a team effort.’
Mr Strang added: ‘In the Portsmouth area there are a lot of people with young families, and a big older population.
‘There are also high levels of depravation, which gives a lot of attendance to A&E.’
Changes have been made in the bid to win the battle against bed-blocking at Queen Alexandra Hospital.
The changes listed below have been implemented by commissioners and the hospital trust, cut the number of people coming in, and to also discharge patients quicker.
The five key ideas are:
URGENT CARE CENTRE
At key times, such as weekends, a GP is placed in the emergency department.
The doctors target people who do not need urgent care.
They can advice them or where is better to get help, such as making an appointment with their own GP or visiting a pharmacy.
AMBULATORY CARE EXPANDED
This is an extension of the work done by the Medical Assessment Unit.
An area has been set up within the department to monitor a patient for things such as fluids or making sure they have the right medication.
By setting up this area, patients get checked and if the progress is fine, avoid being admitted into hospital.
CONSULTANT TRIAGING GP CALLS
GPs can speak to consultants before they send them in to the emergency department.
On average, A&E gets about 50 referrals from GPs a day.
But by ringing up and speaking to a consultant for a second opinion, referrals have been halved.
The service runs from 8am to 8pm.
Additional consultants have been taken on to work in the emergency department, medicine and at the weekends.
EXTRA BEDS MADE AVAILABLE
An extra 50 beds have been opened up in the hospital for the winter, which had been closed, and staff brought in.
The News reminds of task ahead
Rick Strang started his role three months ago.
As reported, Mr Strang was brought in by Portsmouth Hospitals NHS Trust – which runs Queen Alexandra Hospital – to help solve waiting times in A&E.
In October, The News published figures highlighting the ‘unacceptable’ number of patients left waiting more than the government benchmark of being treated within four hours.
Figures from NHS England showed in September last year, on average 85 per cent of those attending the emergency department at the hospital in Cosham were either admitted, transferred or discharged within the government guideline time of four hours.
It meant 15 per cent of people were waiting longer than they should be.
That ﬁgure was six per cent less than QA’s average in September 2012 – and 10 per cent less than the national benchmark.
And as a reminder of the task ahead, Mr Strang has printed out the front page and stuck it on a wall by his desk.
He said: ‘In the first week I started with the trust, that story was the front page, and doesn’t make for good reading.
‘We all know there’s a lot of work to do, but I am confident we will get there.
‘This isn’t just about me, but about the whole team and all the staff working here.
‘The team is dedicated and hardworking, so although it’s a difficult time, we will get better.’
The changes that have been made so far, which have been listed in the panel above, show that within the first few weeks of Mr Strang starting, things started to look better.
In the week ending October 13, 1,904 people attended the emergency department.
And of those, 96 per cent were seen within four hours – beating the benchmark of 95 per cent, and the national average that week was 93.8.