UNDERSTANDINGED ATTENDANCESIN LANARKSHIRE

Dr Veronica Devlin Lean Leader NHS Lanarkshire

Prof Graham WattDepartment of General PracticeGlasgow University

population 556,000 3 ED’s 194,000 new attendances in2008/09 10% of ED attendances are GP

referrals Population over 65 close to Scottish

average

Bed complement

•Monklands Hospital -478 inpatient beds

•Hairmyres Hospital-353 inpatient beds

•Wishaw Hospital -633 inpatient beds

A Day in the Life of Monklands

CONTEXT

Mostly urban Set in centre of Airdrie High deprivation High number of single handed GP’s Average 66,500 new attendances per

year

Methodology

ED records pulled for 24 hours – Tuesday

Examined by EA Programme Manager and LTC manager or Charge Nurse from ED

Categorised into broad groupings

Attendance Profile

165 new attendances

Admissions 12 surgical 2 diverted from Wishaw 5 ortho including 2#NOF 33 medical 1 psychiatry 1 ITU 1 Unknown disposition

Medical

9 chest pain 8 chest infection or

SOB 2 alcohol intoxication 1 accidental o/d 1 respiratory failure 1 intentional o/d 1 seizure 1 alcohol withdrawal 1 asthma

1 rash 1 palliative care 1 collapse 1 haematemesis 1 headache 1 pneumonia 1 off legs 1 respiratory failure 1 unclear!

“Primary Care” Appropriate

55 Primary Care appropriate 3 referred by NHS 24 1 by police 1 by GP receptionist- 4/12 old foot inj 1 by GP - reflux 1 by ED for detox team 4 dialled 999 10 children, 5 of those in working

hours

Long Term Conditions

9 with at least 1 LTC 2 known to be on SPARRA register

1 with leg pain self referred, 999, known OA 10.00, discharged

4 admitted with exac COPD 1 admitted with accidental OD 1 incidental head injury 1 ? CVA in patient with COPD and IHD 1 with known IHD admitted with chest pain

Alcohol and Drugs

18 presentations where alcohol was involved – >10% of presentations

6 presentations where drug use mentioned

1 heroin o/d signed IRD

Nursing Home

23 nursing homes in catchment Average 2 admissions from NH per

day 1 documented care home admission

GP OOH

10 patients diverted to GP OOH at triage

2 were 999 self referrals

1 abdo pain 1 chest pain 2 earaches 1 sick baby 2x20 year olds short

of breath 2 back pains 1 unwell 43 year old

GP APPROPRIATE TIME OF ARRIVAL

GP APPROPRIATE ARRIVALS MONKLANDS

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TIME OF REGISTRATION

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GP APPROPRIATE ARRIVALS

Also of note…

1 cardiac arrest who died 1 multiple trauma who breached 1 standby for respiratory failure who

was admitted

18 alcohol related attendances 5 drug related attendances

Prospective Audit of “Elsewhere appropriate attendances”at the ED

Prospective clinician collected subjective data for month of June

Acute injuries excluded – musculoskeletal pain non-trauma included

Hairmyres 32 useable audit forms Monklands 90 Wishaw 121

Condition Age and gender distribution Time of registration Referral Source Symptom Duration Outcome

Monklands by Conditionn=90

mus

culo

skel

etal

UT

I

FE

VE

R

CY

ST

S

SK

IN

ST

ING

S gi

psyc

h

resp

ent

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al

eyes

mis

cella

neou

s

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Monklands by condition

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Monklands Gender Split

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Monklands Gender Split

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Monklands Age SpreadMonklands age spread

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under 5 age 5-15 16-25 25-45 45-65 65-80 over 80

Series1

Monklands Attendance Spread

Monklands attendance spread

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Monklands Referral SourceMonklands referral source

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GP self GP receptionist NHS 24

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Monklands Duration of Symptoms

Monklands duration of symptoms

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<24 hours 24-48hrs 48-72 hours 3-7days > 1 week

Series1

Monklands Outcome

Monklands outcome

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substance misuseteam ref

advised GP d/c with advice referred to GPOOH

treatment unknown xray

Series1

NHS Lanarkshire overview

One of the highest 999 ambulance call to ED attendance conversion rates in Scotland

82% versus 72%

125 999 DNW’S every month

There is a 3 fold variance in GP practice A&E emergency referral rates - from the highest to lowest referring practices - this is consistent over the last 4 years

• Rates have been growing year on year over the last 4 years

• mean rates per 1,000 population - growing as follows

• 264 to 279 to 292 and to 302 in 2008/09

• +6%, +5% and +3% respectively in each year

Standardised emergency admission rates

NHSL is consistently higher than the Scottish average over the last 6 years - although the gap is narrowing in recent years

There is a 200% variance in GP practice emergency admission rates - from the highest to lowest referring practices in 2007/08

There is a 100% variance in GP practice OOH contact (call) rates - from the highest to lowest referring practices in 2007/08

Emergency admissions in context - they account for 75% of all acute admissions and 83% of all acute bed days.

65% of all direct emergency GP referrals to the A&E Department are admitted (49% medical and 16% surgical)

Demand has increased by 9% or circa 16,000 new attendances over the last 3 years.

Table 2 - A&E Attendances - GP Referrals to All Hospitals in Lanarkshire

Annual 2005/06 2006/07 2007/08 2008/09

Attendances 16,118 16,544 16,590 18,262

Yr on Yr Change 426 46 1,672

% 3% 0% 10%

Cumulative Change 426 472 2,144

% 3% 3% 13%

98 GP Practices Cover paper for each Practice Information Pack 1 - A&E attendances Information Pack 2 - Emergency

admissions

REF NO POPNDEPRIVATION

RANKINGUPPER/ LOWER

QUARTILENUMBER OF

GPs

1 na 4 UPPER 1 582 500 1 UPPER

2 na 27 MID 3 913 467 2 UPPER

3 na 3 UPPER 2 1,134 462 3 UPPER

4 na 18 UPPER 1 854 446 4 UPPER

5 na 2 UPPER 1 449 440 5 UPPER

6 na 56 MID 3 1,367 427 6 UPPER

7 na 9 UPPER 4 2,772 426 7 UPPER

8 na 45 MID 5 2,656 423 8 UPPER

9 na 19 UPPER 2 1,563 419 9 UPPER

10 na 20 UPPER 2 1,535 415 10 UPPER

11 na 39 MID 3 1,511 413 11 UPPER

12 na 1 UPPER 5 3,717 409 12 UPPER

13 na 51 MID 8 4,431 405 13 UPPER

14 na 6 UPPER 3 2,715 403 14 UPPER

15 na 44 MID 3 1,872 397 15 UPPER

16 na 5 UPPER 1 823 396 16 UPPER

17 na 28 MID 6 1,523 394 17 UPPER

18 na 7 UPPER 11 7,028 387 18 UPPER

19 na 30 MID 2 804 378 19 UPPER

20 na 59 MID 1 564 372 20 UPPER

21 na 31 MID 3 1,540 371 21 UPPER

22 na 37 MID 1 745 369 22 UPPER

23 na 57 MID 8 3,418 369 23 UPPER

24 na 47 MID 10 2,754 367 24 UPPER

PRACTICE PROFILE SUMMARY

ALL A&E ATTs

CRUDE RATE PER

1,000 POPN

RATES RANKING

RATES UPPER/ LOWER

QUARTILE

NHSL GP PRACTICE

ALL A&E ATTs

REF NO POPNDEPRIVATION

RANKINGUPPER/ LOWER

QUARTILENUMBER OF

GPs

1 na 4 UPPER 1 582 500 1 UPPER 27 23 73 Mid

2 na 27 MID 3 913 467 2 UPPER 60 31 36 Mid

3 na 3 UPPER 2 1,134 462 3 UPPER 57 23 72 Mid

4 na 18 UPPER 1 854 446 4 UPPER 49 26 58 Mid

5 na 2 UPPER 1 449 440 5 UPPER 21 21 84 Lower

6 na 56 MID 3 1,367 427 6 UPPER 108 34 29 Mid

7 na 9 UPPER 4 2,772 426 7 UPPER 317 49 4 Upper

8 na 45 MID 5 2,656 423 8 UPPER 280 45 6 Upper

9 na 19 UPPER 2 1,563 419 9 UPPER 134 36 20 Upper

10 na 20 UPPER 2 1,535 415 10 UPPER 138 37 17 Upper

11 na 39 MID 3 1,511 413 11 UPPER 109 30 39 Mid

12 na 1 UPPER 5 3,717 409 12 UPPER 254 28 46 Mid

13 na 51 MID 8 4,431 405 13 UPPER 438 40 12 Upper

14 na 6 UPPER 3 2,715 403 14 UPPER 271 40 10 Upper

15 na 44 MID 3 1,872 397 15 UPPER 113 24 65 Mid

16 na 5 UPPER 1 823 396 16 UPPER 38 18 90 Lower

17 na 28 MID 6 1,523 394 17 UPPER 155 40 11 Upper

18 na 7 UPPER 11 7,028 387 18 UPPER 558 31 35 Mid

PRACTICE PROFILE SUMMARY

RATES UPPER/ LOWER

QUARTILE

ALL A&E ATTs

CRUDE RATE PER

1,000 POPN

RATES RANKING

RATES UPPER/ LOWER

QUARTILE

GP A&E ATTs

CRUDE RATE PER

1,000 POPN

RATES RANKING

NHSL GP PRACTICE

ALL A&E ATTs DIRECT GP A&E ATTs

GP PRACTICE A&E ATTENDANCE RATES PER 1,000 PRACTICE POPULATION

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1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 61 64 67 70 73 76 79 82 85 88 91 94 97

2005/06 2006/07 2007/08 2008/09

INCREASING YEAR ON YEAR FOR THE MAJORITY OF PRACTICES

PRACTICE NUMBER 63616 = 316

RATES OVER 4 YEARS2008/09 = 3162007/08 = 3182006/07 = 3022005/06 = 283

INCREASING OVER 3 YEARS FOR THIS PRACTICE

A&E ATTENDANCE RATES BY GP PRACTICE - 2008/09BY LOCALITY & THEN NUMERICAL PRACTICE CODE ORDER

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AIRDRIE BELLSHILL CLYDESDALE COATBRIDGE

RURAL AVERAGE 17 MILES TO NEAREST A&E

CUMBERNAULD

UPPER/MID RANGEDEPRIVATION

MID RANGE DEPRIVATION

EAST KILBRIDE

BEST ACCESS TO ALL 3 SITES

HIGH DEPRIVATION

HAMILTON MOTHERWEL WISHAW

MEAN

MID/LOWER RANGE

DEPRIVATION

LOW RANGE DEPRIVATION

CLOSE PROXIMITY TO LOCAL A&E

MID RANGE DEPIRVATION

MID RANGE DEPRIVATION

6 PRACTICES ONLY 1 MILE FROM LOCAL A&E

PRACTICE NUMBER 63616 = 316

OOH CONTACT RATES BY GP PRACTICE - 2007/08BY LOCALITY & THEN NUMERICAL PRACTICE CODE ORDER

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MEAN

AIRDRIE BELLSHILL CLYDESDA COATBRIDGECUMBERNAULD EAST KILBRIDE HAMILTON MOTHERWEL

LWISHAW

PRACTICE NUMBER 63616 = 211

GP Information Pack 1 - A&E Presentations

GP Practice profile 1 - demography & deprivation

GP Practice profile 2 - Age & deprivation GP Practice - QOF prevalence

benchmarking GP Practice benchmarking GP Practice ranking GP Practice referral source & flow group Charts comparing trends over time

GP Information Pack 1 - Emergency Admissions

6 year trends - “Navigator” generated Admission numbers and rates Bed day numbers & rates Elective shown for completeness CHI population change Each GP Practice benchmarked against:

NHS LanarkshireNHS ScotlandNorth CHPSouth CHP