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					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 Coronary
                                        Syndrome
                                        Pacemaker

                                        Urgent coronary surgery

                                        Implantable Cardioverter
                                        Defibrillator
                                        Valve surgery

                                        Pacemaker with wire

                                        Transplant assessment

                                        Pericardial effusion

                                        Other


The majority of patients waiting for transfer were waiting with acute
                     coronary syndrome (73%)
                     Number of patients reported awaiting transfer
                       at each hospital Manchester Dec 2003
                     60
Number of patients




                          48
                     50

                     40        35   34
                     30                  24   24   22
                     20                                 17
                                                             14   12
                     10                                                6   6   6   5   5

                      0
                          A    B    C    D    E    F    G    H     I   J   K   L   M   N

                                                   Hospitals
       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 organisation
                      Inter-hospital Transfers
                               Audit
                      Topline Average Waits
Admitted
                Angiogram       Referred        Transferred    Procedure
To DGH


           5.9 Days       1.6 Days         7.5 Days     1.5 Days



                         15 Days


                              16.5 Days
                      Difference between PCI and
 PCI                        Cardiac Surgery

                                                            16 Days
                                              14.8 Days
            5.9 Days     1.3 Days       7.6 Days      1.2 Days


Admitted
                 Angiogram       Referred     Transferred   Procedure
To DGH


           5.2 Days       2.4 Days      11.1 Days     3.5 Days
                                              18.7 Days
                                                            22.2 Days

 CARDIAC SURGERY
       Intervention on site or transfer
INTERVENTION ON SITE
                           8.3 Days

           3 Days      1.5 Days         3.8 Days     2.2 Days


Admitted
               Angiogram         Referred   Transferred    Procedure
To DGH


       6.3 Days       1.7 Days          8.0 Days     1.1 Days


                           16 Days

TRANSFERRED FOR INTERVENTION
Average waiting time between
admission and angio:
DGH with a Catheter Lab   5.5 Days
DGH without a lab         8.2 Days


   40.1% of the DGHs submitting
  data had a Cath Lab of some sort
 Wait after transfer to procedure
       16
       14
       12
       10
Number
        8
                                                  CABG
        6
       4
                                                  PCI
       2
       0
            0   1     2   3   4   5   6   7   8
                    Average wait (days)
  Geographical Differences In Average Waits (Days)

The North
                                                        The Midlands and Anglia
Average wait from admission to PCI :             12.8
Average wait from admission to cardiac surgery: 16.3    Average wait from admission to PCI :             12.6
Average wait from admission to procedure (all) : 12.9   Average wait from admission to cardiac surgery : 23.0
                                                        Average wait from admission to procedure (all): 14.5




                                                         The South East & London

The South and West                                       Average wait from admission to PCI :            15.5
                                                         Average wait from admission to cardiac surgery:19.9
Average wait from admission to PCI:             23.5     Average wait from admission to procedure (all): 17.0
Average wait from admission to cardiac surgery:25.4
Average wait from admission to procedure (all): 20.9
                 Number of centres submitting data


            The North                      The Midlands and Anglia

Number of Interventional Cardiology    Number of Interventional Cardiology
    Sites submitting data : 17            Sites submitting data : 10




                                                 The South East & London

                                         Number of Interventional Cardiology Sites
                                                   submitting data : 10
        The South and West

Number of Interventional Cardiology
    Sites submitting data : 6
                        Average Wait In Days Per Patient By Trust For Angio +/- Proceed
                            Admission to Ref erral      Ref erral to Transf er       Transf er to Procedure
              66
              0
             1 9
              95
              40
              76
              3
             1 6
              60
              49
                6
              4
             1 0
              2
             1 6
              73
              27
              28
              35
              93
              23
              43
              56
              2
             1 2
                9
              21
              31
              1 0
              1 3
              47
              2
             1 3
              87
              61
              1
             18
              59
              42
              62
                3
              25
                7
              30
              96
               17
              34
              3
             1 0
              97
              22
              44
              2
             1 9
              3
             1 4
               11
              26
              1 8
              4
             1 2
              50
              0
             1 7
              3
             1 7
              1 2
              1
             16
              82
              1 4
              57
                8
              2
             1 4
                4
              1
             10
Trust Code




              1
             19
              3
             1 5
              63
              91
                2
               1
              15
              77
              3
             1 3
               15
              2
             1 5
              84
              64
              0
             1 0
              0
             1 3
              2
             1 7
              92
              54
              48
              3
             1 8
              52
              2
             1 0
              3
             1 1
              45
              0
             1 6
               71
                1
              1
             13
              83
               1
              17
              0
             1 5
              98
              75
              39
              37
              90
              85
              88
              36
              2
             1 8
              58
              38
              3
             1 2
               1
              11
              80
              2
             1 1
              1 9
              1 6
              74
               51
              0
             1 4
              78
              1
             14
              0
             1 8
              81
              89
              0
             1 2
              53
              72
              3
             1 9
              20
              29
              79
              67
                5
              55
              33
              4
             1 1
              0
             1 1
              94
              70

                    0   5                      10                    15                     20                25   30
                                                     Ave r age Wait (Days ) Pe r Patie nt
                                       Average Wait In Days Per Patient By Trust For CABG

                            Admission to Ref erral   Ref erral to Transf er     Transf er to Procedure

              22
              68
              37
              23
              2
             1 8
              0
             1 7
              44
              42
              1 0
              94
                6
              1
             10
              1 8
              2
             1 9
               51
               17
              2
             1 2
               11
              3
             1 5
              0
             1 8
              56
              92
              96
              2
             1 1
              76
                7
              77
              3
             1 1
              3
             1 4
              82
              60
              49
               1
              11
              3
             1 3
              3
             1 8
                5
              43
               71
              2
             1 3
              3
             1 2
              1 4
              65
              1
             12
              78
               1
              17
              86
              45
Trust Code




              85
              66
              3
             1 0
              98
              63
              35
                1
              1 9
              0
             1 0
              61
              50
              81
               1
              15
              46
              39
              38
              72
              3
             1 6
               15
              2
             1 5
              1
             19
              75
                8
              54
              97
              83
              30
              0
             1 1
              24
              99
              67
              1
             16
              29
              2
             1 6
              2
             1 4
              91
              0
             1 3
              55
              3
             1 9
              0
             1 4
              69
              33
              89
              4
             1 1
              84
              58
              0
             1 9
              87
              74
              70
              20
                2

                    0   5      10             15       20              25         30            35       40   45   50
                                                     Ave r age Days Wait Pe r Patie nt
                           Average Wait In Days Per Patient By Trust For Definite PCI

                       Admission to Ref erral         Ref erral to Transf er           Transf er to Procedure


             86

             35

             34

             113

             43

             92

             133

             15

              8

             112

             121

             83

             18
Trust Code




             17

             91

             56

             65

             53

             20

             89

             136

             85

             24

             14

             98

             55

             33

                   0   5               10              15                 20                25                  30   35
                                                Ave r age Wait (Days ) Pe r Patie nt
        Ave ra ge W a it In Da ys Pe r Pa tie nt By SHA And Trust For Angio +/- Proce e d
                    A dmission to Ref erral   Ref erral to Transf er    Transf er to Procedure
        109
         76
         73
          17
         44
AVON    1
         92
          01
           6
        140
        107
BEDS    127
          1
         77
           8
        105
        128
BIRM    104
           5
           7
         97
          1
        1 9
            1
         90
         88
CHES    1
          1
         1 1
         39
         70
           9
        129
CUMB     45
         66
          10
         59
DORS    106
         94
         82
           2
DURH    1
         48
         26
          13
 ESS     37
         60
         26
HAMP     85
           3
         34
           8
KENT     36
         49
         28
LEIC      1
        1 6
          1
        1 5
          51
LINC    1
         78
         36
         93
         56
        130
MANC     75
          1
        1 4
          81
         47
        123
 NCL    1
        1
         00
         03
         23
        122
         42
 NEL      1
        1 0
        125
         27
         43
          1
        1 8
         25
         30
NORF     22
         57
        108
         55
         95
        142
 NWL     20
         67
          61
         62
         96
 SEL    133
          19
         29
          71
         38
SHROP   1 41
          1 1
          14
          91
          1
        1 3
SURR    1
        1
         32
          21
         74
         72
         35
          31
 SWL      1
         89
         50
           2


SWPEN   1
         58
         24
           4
SYORK    64
         79
         40
          21
THAME   134
         54
         87
        137
         63
TRENT   1
         80
         02
         53
          15
        138
         52
TYNE     83
         98
         84
          1
        1 7
WMIDS   1
          1
         35
           6
        120
        1 31
         39
WYORK    33

                0               5             10                15                 20            25   30
                                               Ave r age Wait (Days ) Pe r Patie nt
                         Ave ra ge W a it In Da ys Pe r Pa tie nt By SHA And Trust For CABG
                    A dmission to Ref erral        Ref erral to Transf er      Transf er to Procedure

                  109
                  1 01
          AVON     92
                   76
                   44
                   1 7
                  107
          BEDS    128
                     6

                  104
                   99
          BIRM     77
                   1 8
                     5
                  139
                  191
          CHES      1
                   11
                   97
                   70
                     7
                     1
                  129
          CUMB     45
                   94
                   66
          DORS     1 0
                   82
          DURH    126
                     2

                   86
           ESS     37
                   85
                   60
          HAMP     46
                     8
   KENT           161
          LEIC     49
                  151
                   78
          LINC     51
                   24
                  136
                  130
                   81
          MANC     75
                   56
                  123
                  103
           NCL    100
                   69
                  125
                  122
                  101
           NEL     42
                   23
                  108
                   55
          NORF     43
                   30
                   22
                   67
           NWL    1
                   20
                   33
                   96
                   61
           SEL     29
                   1 9
                  1 41
                   71
          SHROP    38
                  132
                  1 21
                   91
                   74
          SURR     72
                   1 4
                    11
                   89
           SWL     35
                   68
                   58
          SWPEN    50
                  124
SYORK             134
                   65
          THAME    54
                   87
          TRENT   1
                   63
                   38
                   98
                   83
          TYNE     1 5
                  171
                  121
          WMIDS    84
                  135
                  1 31
          WYORK    39
                   33

                         0        5           10       15           20       25         30          35   40   45   50
                                                             Ave r age Wait (Days ) Pe r Patie nt
                  Ave rage Wa it In Da ys Pe r Pa tie nt By SHA And Trust For De finite PCI
                  A dmission to Ref erral   Ref erral to Transf er     Transf er to Procedure


        92

AVON    17

        18
BIRM
        86
 ESS
        85
HAMP
        34

KENT     8

        24
LINC
        136
MANC
        56

        55
NORF
        43


 NWL    20

        133
 SEL
        121

        113
SURR
        91

        14

        89
 SWL
        35

        65
THAME
        53
TRENT
        98

TYNE    83

        15

        112
WMIDS
        33
WYORK
              0              5              10                 15              20               25   30   35
                                                      Ave r age Wait (Days ) Pe r Patie nt
                    Average Wait In Days Per Patient By SHA For Angio +/- Proceed
                   Admission To Ref erral        Ref erral To Transf er     Transf er to Procedure

       AVON
       BEDS
       BIRM
       CHES
       CUMB
       DORS
       DURH
        ESS
       HAMP
       KENT
        LEIC
        LINC
       MANC
        NCL
SHA




        NEL
       NORF
        NWL
        SEL
      SHROP
       SURR
        SWL

      SWPEN
      SYORK
      THAME
      TRENT
       TYNE
      WMIDS
      WYORK

               0                5           10                   15          20               25     30
                                            Ave rage Wait (Days ) Pe r Patie nt
                         Average Wait In Days Per Patient By SHA For CABG
                   Admission To Ref erral        Ref erral To Transf er    Transf er to Procedure

       AVON
       BEDS
       BIRM
       CHES
       CUMB
       DORS
       DURH
        ESS
       HAMP
       KENT
        LEIC
        LINC
       MANC
        NCL
SHA




        NEL
       NORF
        NWL
        SEL
      SHROP
       SURR
        SWL
      SWPEN
      SYORK
      THAME
      TRENT
       TYNE
      WMIDS
      WYORK

               0     5          10          15           20           25       30          35       40   45
                                            Ave rage Wait (Days ) Pe r Patie nt
                          Ave ra ge Wa it In Da ys Pe r Pa tie nt By SHA For De finite PCI
                    A dmission To Ref erral        Ref erral To Transf er        Transf er to Procedure

       A V ON


        BIRM


         ESS


       HA MP


        KENT


        LINC


       MA NC


         NCL
SHA




       NORF


        NWL


         SEL


       SURR


        SWL


      THA ME


       TY NE


      WMIDS


      WY ORK


                0              5              10            15              20            25              30   35
                                                   Ave r age Wait (Days ) Pe r Patie nt
            Inter-hospital Transfers Audit
           Average Admission to Procedure
                   Waits by Trust –
             1 March to 28 March 2004

Admitted          Referred     Transferred   Procedure
 To DGH




                Angiography +/- PCI
           (with and without angiography)
           Inter-hospital Transfers Audit
           Average Admission to Referral
                  Waits by Trust –
            1 March to 28 March 2004

Admitted          Referred     Transferred   Procedure
 To DGH




                Angiography +/- PCI
           (with and without angiography)
          Inter-hospital Transfers Audit
   Average Referral to Transfer Waits by Trust –
           1 March to 28 March 2004


Admitted          Referred     Transferred   Procedure
 To DGH




                Angiography +/- PCI
           (with and without angiography)
            Inter-hospital Transfers Audit
            Average Transfer to Procedure
                   Waits by Trust –
             1 March to 28 March 2004

Admitted          Referred     Transferred   Procedure
 To DGH




                Angiography +/- PCI
           (with and without angiography)
            Inter-hospital Transfers Audit
           Average Admission to Procedure
                   Waits by Trust –
             1 March to 28 March 2004

Admitted          Referred     Transferred   Procedure
 To DGH




                        CABG
           Inter-hospital Transfers Audit
           Average Admission to Referral
                  Waits by Trust –
            1 March to 28 March 2004

Admitted         Referred     Transferred   Procedure
 To DGH




                       CABG
          Inter-hospital Transfers Audit
   Average Referral to Transfer Waits by Trust –
           1 March to 28 March 2004


Admitted        Referred     Transferred   Procedure
 To DGH




                      CABG
           Inter-hospital Transfers Audit
           Average Transfer to Procedure
                  Waits by Trust –
            1 March to 28 March 2004

Admitted         Referred     Transferred   Procedure
 To DGH




                       CABG
            Inter-hospital Transfers Audit
           Average Admission to Procedure
                   Waits by Trust –
             1 March to 28 March 2004

Admitted          Referred     Transferred   Procedure
 To DGH




                   Definite PCI
           Inter-hospital Transfers Audit
           Average Admission to Referral
                  Waits by Trust –
            1 March to 28 March 2004

Admitted         Referred     Transferred   Procedure
 To DGH




                  Definite PCI
          Inter-hospital Transfers Audit
   Average Referral to Transfer Waits by Trust –
           1 March to 28 March 2004


Admitted        Referred     Transferred   Procedure
 To DGH




                 Definite PCI
           Inter-hospital Transfers Audit
           Average Transfer to Procedure
                  Waits by Trust –
            1 March to 28 March 2004

Admitted         Referred     Transferred   Procedure
 To DGH




                   Definite PCI
               Interhospital Transfers - Tertiary Centre - Average days             Interventional
                wait from transfer to procedure - All procedures - April
                                          2004                                         Centres
                                                                                      Overall – All
              82
              85
              54
                                                                                      procedures
             104
              99
              81
             125
             136                                                               Transferred    Procedure
             117
             116
              53
             132
Trust Code




              89
              29
             139
              67
              20
              69
              98
              79
             103
              24
              58
             101
              55
              19
              33
              17
              94

                   0      1         2         3            4       5       6
                                     Average wait (days)
               Interhospital Transfers - Tertiary Centre - Average days
                 wait from transfer to procedure - Angio +/- proceed -
                                                                                                     Interventional
                                       April 2004
                   (Note Trusts 99,69 and 24 - no data provided/no procedures undertaken)
                                                                                                        Centres
              99                                                                                   Angiography +/-
              69
              24                                                                                      proceed
             104
              85
              82
              54
             136
             116
              89
             125
              53                                                                                Transferred   Procedure
Trust Code




              81
             139
              20
              98
              29
             132
             117
              79
             103
              58
              67
              19
              55
              33
              17
             101
              94

                   0              1               2               3              4          5
                                              Average wait (days)
               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)
                                                                                                         Interventional
                                                                                                            Centres
              24
              53
              79                                                                                                  CABG
              19
              17
              94
              82
              81
             132                                                                                    Transferred      Procedure
             117
              85
             125
Trust Code




              54
             101
              99
              67
             116
              29
             103
              55
             136
             139
             104
              69
              33
              89
              58
              20
              98

                   0                     5                   10                  15            20
                                                 Average wait (days)
               Interhospital Transfers - Tertiary Centre - Average days
                 wait from transfer to procedure - Definite PCI - April                                   Interventional
                                          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)
                                                                                                             Centres
              79                                                                                            Definite PCI
              19
              94
              82
              81
             117
             125
              54
             101
              99
              67
             116
Trust Code




              29                                                                                    Transferred    Procedure
             103
             136
             139
             104
              69
              58
              53
              20
              89
              85
             132
              24
              17
              98
              55
              33

                   0         0.5            1           1.5            2            2.5         3
                                             Average wait (days)
             Summary
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        13295
over 4 weeks based on 3 days for
Possible proceed and 7 days for CABG
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 Trust
Reduced 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
The power
of free
speech!!



British
intellectual
sophistication!!

				
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