Haemorrhaging money – How to get a grip
Barbara’s November blog mentioned that we looked at the potential impact of SortED on breaches of the 4 hour target in our ED trial, so I thought I would summarise what the data tell us. You may not be familiar with this type of clinical trial. It was a simulated clinical use trial where SortED and conventional triage were tested side by side. One nurse used SortED and the other the standard Imperial College Healthcare Trust’s ‘triage only’ system.
Since SortED does much more than triage: selecting investigations and treatments, referral to specialists, or transfer to ambulatory services, we compared the time at which these decisions were taken on SortED versus the times similar decisions were taken by ED clinicians after triage. The ICHT records show when investigations and treatments were ordered – so we compared these genuine orders with our simulated ‘orders’.
We had not originally planned to examine breaches, but our funding contract from SBRI healthcare included a free day with their Health Econonmist Jonathan Belsey. The whole team congregated in our Somerset office – a very pleasurable and useful day. I had only ever considered SortED from the patients’ and ED staff’s points of view: safer, more effective, initial assessments for patients, and less stressful software for nurses with less overcrowding. When Jonathan began to calculate how much money we could potentially save NHS trusts it was a real light-bulb moment! We immediately added analysis of breaches.
The tabloids mention ‘fines’ for breaches but that is not strictly accurate – the mechanism is fund witholding and depends on the excess breaches above the current target percent. The clock starts on admission (to either ED or the UCC) and stops when the patient is either admitted, transferred or discharged. Rumours that these targets would be scrapped have not proved true, trusts still lose money from breaches.
What the results tell us:
We were able to evaluate whether patients breached or not on 444 of our 529 patient cohort (some ICHT records were not recovered). Of these patients 140/444 (31.5%) breached the 4 hours in ED. This is well above target, so ICHT would have faced substantial penalties.
All three main timings, the intervals between arrival and end of triage; last investigation ordered; and last treatment ordered, showed a clear relationship with the % breaches. How we demonstrated this was quite simple. We took each type of timing, sorted it, and divided the patients into quartiles. We then looked at the breached versus no breach percent for each quartile.
For the interval between arrival and end of triage:
Q1 (under 5 minutes) had 24.5% breaches. Q4 (over 20 minutes) had 34.2% breaches. The intervening quartiles, Q2 & Q3 had 31.1% and 35.5% breaches respectively.
For the interval until investigation(s) ordered:
Q1 (under 18 minutes) had 26.0% breaches. Q4 (over 76 minutes) had 47.0% breaches. The intervening quartiles, Q2 & Q3 had 36.2% and 29.0% breaches respectively.
For the interval until treatment(s) ordered:
Q1 (under 46 minutes) had 32.0% breaches, Q4 (over 135 minutes) 41.9 % breaches. Intervening quartiles, Q2 & Q3 had 37.3% and 36.0% breaches respectively.
The message is abundantly clear. The longer it takes for a patient to be triaged, have investigations ordered and then treatment ordered, the more likely the patient is to fall in the breached category. The Q1 – Q4 difference in breaches was particularly marked for the time taken to order investigations.
How did SortED do?
Remember this was a simulated clinical-use trial. Our nurses were triaging (i.e. setting acuity), as well as selecting investigations and ‘ordering’ treatments on the tablets. All of these events took place within the Sort procedure which took a median of 1.43 minutes (interquartile range 1.13-2.07). This took place alongside the control ICHT triage.
Since the investigations ordered on SortED were closely related to the actual investigations ordered by ED clinicians (see my October 2017 blogs), we can predict that, had this been an interventional trial rather than an observational one, fewer patients would have breached.
Breaches can be caused by more than simple delay in ordering investigations. Bed block has been in the news so you will know that one. Complex cases with co-morbidities and frail elderly patients can be another. I’ve also written in prevous blogs (Dec 2017) about the diurnal variation in the ability to discharge – particularly for elderly patients living alone. Putting a number on how many breaches SortED’s earlier investigations would have avoided, is difficult.
Barbara and coleagues kindly analysed a small cohort of 75 patients for us to report to the SBRI, along with a report from the Health Economist predicting savings. The consultants estimated that 29/75 (36.1%) were potentially preventable given the earlier investigations. Based on a more conservative 15% reduction in breaches the Economist estimated potential savings of >£150,000 per ED.
Such in-house analyses rightly raise suspicion (‘Well they would say that wouldn’t they!’). I have therefore prepared a fill in questionnaire on each of the 140 breached patients in our first trial, in order to gather independent consultants’ opinion on why each patient breached. I’ve also asked for an estimate of likelihood of prevention of breach given the SortED versus ICTH timings, plus the investigations and treatments ordered on both systems. Now that winter is upon us I won’t be expecting results soon.
I hope Barbara tells the new ED management consultant her idea about deploying float nurses and clinicians armed with SortED tablets in times of surge. The numbers tell me it would work!
Gillie Francis – Nov 2018