Document 254348

Betsi Cadwaladr University Health Board
Board Paper 25.07.13 Item 13/119.3
Urgent & Emergency Care Strategy for North Wales 2013 – 2016
Issues of
The strategy sets out the direction for unscheduled care services
across North Wales within a whole systems approach
encompassing health and social care. The Quality & Safety
Committee received a preliminary draft of the previous unscheduled
care ‘blueprint’ on 3rd January 2013, which was updated and
resubmitted as a Strategy for Urgent and Emergency Care to Q&S
Committee on 2nd May 2013, followed by further iteration received
4th July 2013 where it was approved for submission to the Board for
ratification as a LHB strategy.
The strategy is underpinned by key national and local
documentation and responds to the challenges raised by Welsh
Government and Wales Audit Office regarding existing overburdened unscheduled care services. In addition, the strategy is
informed by health intelligence from Public Health Wales; national
standards identified for emergency care for older people and
children; and baseline requirements for emergency departments as
set out by the College of Emergency Medicine. It is also aligned to
the local BCUHB 3-year strategic plan.
The Chief of Staff for the Primary, Community & Specialist Medicine
CPG led a core local working group, comprising multi-agency
membership from partner organisations, building on the work of the
national programme board for unscheduled care to co-ordinate the
development of a local strategy for the proposed model of care in
North Wales.
The Health Board’s 3-year plan identifies unscheduled care as one
of the priority areas which aims to ensure the delivery of high quality
unscheduled care services through health prevention, promotion
and alternative options to admission with appropriate signposting to
the most relevant services. The strategy reflects the service
changes agreed following the Healthcare In North Wales is
Changing consultation and responds to the concerns raised
regarding ongoing challenges and delays encountered by the
Health Board in improving unscheduled care services.
The Modernising Unscheduled Care Committee, chaired by the
Health Board’s Chief Executive, will oversee the delivery of the
necessary outcomes to improve urgent and emergency care
services in North Wales
Strategic Theme /
Priority / Values /
Francis Report
addressed by this
Making it safe / better / work
legislation or
Standard for Health
The strategy addresses the following standards for health services;
3 – Health Promotion, Protection and Improvements;
7 – Safe and Clinically Effective Care;
8 – Care Planning and Provision;
18 – Communicating Effectively;
24 – Workforce Planning
Evidence base or
other relevant
information to
inform decision
(e.g risk
consultation with
Stakeholder engagement has been undertaken in the development
of the strategy including the following;
• All Wales national steering group comprising all-Wales
• BCU local core working group comprising members from CHC,
WAST, voluntary sector, Local Authorities, GPs, Public Health
• Modernising Unscheduled Care Committee comprising wide
membership with staff and stakeholders
This section is
mandatory due to
legal requirements
The Board and its Committees may reject papers/proposals
that do not appear to satisfy the equality duty. See
Equality Impact
1.Has EqIA screening been undertaken? Yes
(If yes, please supply a copy)
2.Has a full EqIA been undertaken?
(If yes, please supply a copy)
Not required
3.Please state how this paper supports the Strategic Equality Plan
The overall aim of the strategy is to improve access for all
individuals across North Wales to unscheduled care services.
Through a whole systems approach that encompasses self care,
primary care, out of hours and emergency care the patient’s journey
will be seamless, effective and efficient and ultimately result in a
positive experience and outcome.
4.Please include a justification if no EqIA has been carried out:
The overall aim of the strategy is to improve access to unscheduled
care services for the whole population. No negative impacts have
been identified on protected characteristics groups
Recommendations: The Quality & Safety Committee request that the Strategy for
(e.g for Board
Urgent and Emergency Care in North Wales 2013-2016 be
approval or for
submitted to the Health Board for ratification.
Dr Olwen Williams, Chief of Staff, Primary, Community & Specialist
Medicine Clinical Programme Group
Presented by
Jill Newman – Acting Director of Improvement & Business Support
Date of report
10th July 2013
Date of meeting
25th July 2013
BCUHB Coversheet v4 June 2013
Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board
A Strategy for Urgent and Emergency Care in
North Wales 2013 - 2016
Dr Olwen Williams, Chief of Staff
4th July 2013
Page 1 of 28
The aim of this strategy for North Wales urgent and emergency care is to provide effective and
efficient pathways that are responsive to need and readily accessible by the North Wales
Definition of Urgent Care: A condition that requires an assessment and planned intervention
within seven days, or which is likely to lead to an emergency within four weeks.
Definition of Emergency Care: Not always life threatening, but needs prompt assessment and
a planned intervention within 24-hours.
Definition of Unscheduled Care: care that has not been previously planned – may be either
urgent or emergency care
There are a number of services now available to those requiring unscheduled care, within and
across localities and in the acute setting.
We will move the focus from Emergency Departments (EDs) to the whole unscheduled care
pathway, with clarity of what the individual should expect at each step along the pathway. Within
the Annual Quality Framework1, it states that “we must shift the balance towards local services
that tackle problems before they occur or become serious, and that cross traditional boundaries”.
To do this we must ensure that the local population knows and understands their locality, the local
health, social care and voluntary sector services available to them, and how to access the
appropriate service quickly. Should they need hospital or residential care for a short period, then
we must ensure that they know how to access the most appropriate services to enable them to
achieve independence once more, and how to maintain that independence.
The strategy has been drawn up in response to the challenges put forward by the Welsh Audit
Office2 and Setting the Direction3, as well as to try to ease the pressures being experienced by the
Emergency Departments across North Wales. It takes into account the Welsh Government’s 10
High Impact Changes for Unscheduled Care4 and is based on the health intelligence gained from
Public Health Wales documentation5 on unscheduled care 2013 and in correlation with the 1000
Lives Plus programme areas6. It is also aligned to BCUHB 2013-2016 Strategic Plan7.
The strategy will provide the clarity and direction to achieve a whole system’s approach to
unscheduled care that will ease the burden on over stretched services by providing more
appropriate and patient-centred care.
We want to be sure that when we make a decision that affects our service users or staff; we do so
in a fair, accountable and transparent way. We need to take into account the needs and rights of
everyone as far as possible. We have looked at equality and human rights considerations using a
method called Equality Impact Assessment Screening. We will continue to build on the work done
so far and think about the overall impact of this strategy as it is implemented to identify any
positive or negative impacts that the Health Board should take into account in the decision making
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North Wales covers approximately 2,500 square miles. According to the 2011 Census8, the
population of Betsi Cadwaladr University Health Board has increased from 664,500 in 2001 to
687,800 in 2011, a rise of 3.5%, and is predicted to reach 750,000 by 2030. In terms of specific age
groups, the percentage of the population in BCU HB aged 65 years and over has increased from
18.3% of the population in 2001 to 20.2% of the population in 2010, reflecting the ageing of the
population; this is a 10.4% growth in this population. There has been a 6.8% increase in the
population aged 75+ in the same period. The population aged 85+ has grown by 12.5%. This is
important, as research has found that people aged over 85 are nearly 10 times more likely to have
an emergency admission than someone in their 20s, 30s or 40s.
According to the Welsh Index of Multiple Deprivation 20119, 11.9% of the population of North
Wales live in the most deprived fifth of Lower Super Output Areas, compared to 19.2% across
Wales, although there are significant pockets of deprivation noted in some locations.
Due to a relatively poorly developed road infrastructure in North Wales travel time to hospitals
can be an issue for remote rural communities. In 2012 there were 135,000 OOH contacts made
and 4million day time GP appointments in North Wales.
In terms of the volume of ED attendance by age and gender, there are three peaks in BCUHB: one
in the 2 year olds, a second in the 20 year old age group and the third in those aged 90+. The
pattern is very similar across Wales.
Diagnosis varies considerably by age group. Injuries and accidents are the most common diagnosis
at EDs overall and are highest in the youngest age groups. Medical diagnoses are also responsible
for a large number of attendances with infections and abdominal complaints being the most
common in this category.
The numbers of individuals requiring admission for unscheduled medical and surgical conditions is
increasing giving rise to increasing demand on unscheduled care.
Strategic Direction
From a national perspective, two key documents have challenged the existing view of unscheduled
care: the Welsh Audit Office Report and Setting the Direction, both of which focus on service
transformation, whole systems thinking, influencing the public to take more responsibility for self
care and self management, working at a local level across statutory, voluntary and independent
sectors strengthening localities to allow them to further direct and develop intermediate and
community services for their populations.
The overall approach to unscheduled care is supported by wider policy development. Our Healthy
Future10 puts a new focus on prevention work. Sustainable Social Services for Wales: A Framework
for Action11 sets out the important role of social services in the unscheduled care system,
particularly in relation to frail elderly people, while The Rural Health Plan12 supports the
development of services in rural areas. Achieving Excellence: The Quality Delivery Plan13 for the
NHS in Wales for 2012-16, describes a journey to ensure delivery of consistent excellence in
service. It outlines actions for quality assurance and improvement. It commits to a quality-driven
NHS that provides services which are safe, effective, accessible, affordable and sustainable and
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come with an excellent user experience. The strategy will also link into Delivering End of Life
The College of Emergency Medicine document Unscheduled Care Facilities15 details the minimum
requirements for units which see the less seriously ill or injured provides the baseline for the
requirements for locality urgent care services as envisaged by this document.
The Way Ahead 2008-201216 also published by the College of Emergency Medicine, provides the
baseline for the requirements for emergency care in the acute setting, defining EDs, their role and
the infrastructure required to enable them to function effectively.
Quality standards for the care of older people with urgent & emergency care needs: The “Silver
Book”17 was published in 2012 and sets the standards of emergency care for the growing number
of elderly & frail accessing services. In the same year Standards for Children and Young People in
Emergency Care Settings18 was developed by the Intercollegiate Committee for Standards for
Children and Young People in Emergency Care Settings. We have taken into consideration the key
college guidance.
The Carers Strategies (Wales) Measure 2010 also places a legal duty on Health Boards to ensure
unpaid carers are a key partner in the delivery of care and supporting their involvement is
considered central to the sustainability of care provision. Unpaid carers are the single largest
provider of care to people with support needs in our local communities (Welsh Government
2012)19; the 2011 census indicates that there are 63,364 carers across North Wales and this
number is likely to be underestimated as many carers do not recognise that they are carers.
Establishment of a Partnership USC Committee for North Wales with representation from Partners
across Health, Local Authority, WAST, Third Sector, Community Health Council.
These collectively establish a strong strategic planning context within which to improve
unscheduled care services in North Wales.
Page 4 of 28
The Patient Journey
By putting the patient at the heart of the strategy and adopting a whole systems approach and
focusing on specific outcomes we aim to improve the patient experience. The colours of the
different areas of the pathway reflect those in the Choose Well literature20.
ACCESS VIA 999/111
CDU / Ambulatory Care
Re-ablement /
Health & Social Care Infrastructure
Public Health Wales
Page 5 of 28
Self Care: for very minor illness and injuries, self management of long term conditions, supported by the Communications
Hub for advice and reassurance.
Citizens to develop confidence in their
ability to manage their own health through
improved information, knowledge and self
Easily accessible systems and processes
that guide people through services, where
individual elements of care are joined-up
and easily navigated
Support and advice from professional staff
to enable citizens to manage their own
conditions and use pre-emptive action to
avoid exacerbation of illness
Development of a health and social care
infrastructure within each locality and
across localities, available 24/7 to the
public and professionals, to provide advice
to citizens about their health concerns.
Information about illnesses and self-care to
be provided to citizens via easily available
media such as internet, iphone apps,
facebook, twitter and other social media.
Ensure the information resources are
available to all who need them, this should
include unpaid carers.
Development of a directory of services
(statutory, voluntary and independent
sector), linked to a website which can be
navigated and interrogated by the public
to provide sources of information and
advice to help them with their self-care.
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Put in place programmes and initiatives to
help patients and their carers with longterm conditions such as the Educating
Patients Programme Wales and X-pert for
patients with Diabetes.
Ensure unpaid carers are offered or
signposted to sources of support to assist
them with their caring role Develop the
role of case management within localities
to work with patients to enable them to
manage their condition.
Mainstream the work of the Chronic
Conditions Management Implementer
sites across North Wales.
Access to locality based community resources
Primary care – GPs, Pharmacists, Dentists, Optometrists
Integrated health, social care and voluntary sector community services for pre-emptive care,
admission avoidance, carers support services and home support
Easily accessible primary care services to
support patients, with prompt and
extended access to the most frequently
required diagnostics
Easily accessible systems and processes
that guide professional staff through
community health, social care and
voluntary sector services
Professional support and advice to provide
pre-emptive care and respond quickly to
prevent needs escalating, operating extended
Reduced variance in access to primary care
services for scheduled and unscheduled
care, progressing the development of
primary care resource centres and a review
of the GMS minor injuries local enhanced
service specification within primary care.
Improved access by primary care
practitioners to specialist clinical advice to
enable decision regarding patient care.
A national telephony system and call
handling software which would enable a
single-point-of-access call handling service
available 24/7. This will be developed at a
locality and / or county level with Local
Authorities in the first instance
Pathways to be developed to include
prompt and extended access to diagnostic
tests and results.
This would act as the channel for signposting and directing members of the
public and professional staff to the correct
service according to need.
The capacity and capability of community
pharmacies, already a significant part of
unscheduled care and advice, to be
developed further.
Care co-ordinators with expert knowledge
of local services will be able to schedule
care according to individual service-user
needs, creating individual care packages.
Page 7 of 28
Review and develop ‘risk stratification’ tool
for primary care and community professionals
to provide early intervention packages of care
to prevent patients health deteriorating and /
or requiring a hospital admission.
Review the provision and role of integrated
health, social care and voluntary sector
intermediate care teams with clear referral
protocols and rapid access, extending roles
for nurses and therapists, and available
beyond 9am – 5pm, and at weekends.
Develop pathways to support case completion
at the earliest point in patient journey. A
broader range of integrated intermediate care
teams / Enhanced Care at Home (in terms of
service scope and operating hours) should be
available, working across localities. This would
include crisis resolution and home treatment
services for those with mental health issues.
Appropriately accessible locality urgent
care services integrated with GP out of
hours with prompt access to diagnostics
Appropriately accessible out of hours
primary care services to support patients,
with prompt and extended access to the
most frequently required diagnostics
Appropriately accessible acute emergency
services at designated centres, with 24/7
access to acute medical service/senior
clinical decision makers, and 24/7 access to
surgical opinion
Urgent care services to be available within
a maximum travel time of 40 minutes (by
car), with prompt and extended access to
diagnostics. Core common opening hours
at the hospital hubs for MIU services with
rapid access to secondary and tertiary care
clinical decision makers.
These services should be supported by
rapid access to professionals for advice and
guidance on a range of conditions
including maternity, palliative care,
substance misuse and mental health.
Common framework of standards and
governance across all urgent care
GP out of hours services to be integrated in
emergency departments and local urgent
care services to enable prompt access to
diagnostics and dispensing.
• Filtering (of immediately life
threatening conditions),
• Triage (when clinically required), and
• Access to ANPs trained in minor illness
and minor injuries
• Signposting / scheduling of patients
attending ED / GP OOH / MIU to match
service users’ need with the
service/practitioners most likely to
provide the best service.
• Use of Telemedicine where appropriate
Transport services with agreed protocols
should be available by WAST and voluntary
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A fast coordinated response with rapid
access to senior clinical decision makers is
The ED needs to have the appropriate staff
and suitable accommodation for the
anticipated throughput of patients.
Clinical Decision Units need to be in place
to avoid admission where unnecessary and
to ensure the patient follows the best
pathway for their condition.
Patients must be made safe and assessed
by ED quickly, with prompt handover from
ambulance crews and speedy handover to
the appropriate place of treatment.
Ensure presence of Acute Intervention
Team on each DGH site.
Patients should be treated by the appropriate specialty and discharged appropriately, with a supporting
package of care if required. Speedy intervention should be provided to ensure effective reablement and
rehabilitation, and patients and their carers supported to maintain their independence
If admitted, patients are transferred to the
appropriate place of treatment speedily
with the minimum amount of time in ED
Easily accessible intermediate and
reablement services to enable patients to
be discharged to a safe and rehabilitative
Easily accessible locally provided services,
statutory and third sector, to enable
patients to maintain their independence
There needs to be sufficient capacity
within the hospital at all times to enable
patients to be transferred from ED to the
appropriate place of treatment.
Senior clinical staff will prioritise ED to
ensure that patients are assessed and
transferred/discharged appropriately to
prevent the build up of pressure within ED.
Discharge dates to be determined as soon
as possible after admission to allow true
discharge planning, with input from the
intermediate care services, carers and
In times of pressure, escalation policies will
be enacted, focusing on patient flow. Local
Authority will prioritise appropriate input
into discharge packages of cares and
WAST/clinical desk will work with the ED
and GPs to manage throughput.
Multi-agency intermediate care services
including district nursing, therapies, local
authority reablement services, generic
health and social care support workers,
CPNs, CAMHS and social workers to
provide packages of care, working with
voluntary sector, to ensure patients/clients
are discharged to a safe and rehabilitative
WAST and third sector to support
discharges by providing patient
Equipment and home loans to be readily
accessible to ensure that patient
discharges are not delayed.
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Community hospital and/or rehabilitation
provision in each locality working with
acute and intermediate care services, to
ensure sufficient capacity to enable
rehabilitation and reablement of patients.
Prompt information to be provided to
primary care and all community parties in
order that they can ensure that the
appropriate support is provided to the
patient and avoid unnecessary readmission.
Voluntary sector involvement at a locality
level to ensure that support is provided to
the patient to help maintain their
Self Care: for very minor illness and injuries, supported by the Communications
Hub for advice and reassurance.
WG 10 High Impact Steps to Transform Unscheduled Care – Transformational Step 1:
“Health and Social Service partners agree a shared vision for unscheduled care services in
their area, based on local assessment of need”. Intended Outcome: “Service planning, redesign, and simplification of access to the USC system, in order to reduce variation of
patient experience and improve the appropriateness of care at the right time in the right
WG 10 High Impact Steps to Transform Unscheduled Care – Transformational Step 6:
“Develop a consistent communications strategy for Service User / Health & Social Care
Worker Engagement”. Intended Outcome: “That patients make informed choices about
the most appropriate service for their needs. The mismatch between clinical need and
place of attendance is reduced”.
This is the start of the pathway for most people and it is essential that individuals who feel
they need unscheduled care have access to appropriate advice and information to enable
them to make an informed decision as to whether they can self care in the first instance.
This applies to both public and staff.
More emphasis is required on health promotion and helping people to help themselves. As
stated in the AQF, the aim of NHS Wales is to do more to protect and improve health for all
and within 5 years ‘there must be significant, measurable improvement in reducing health
problems in all the priority areas in Our Healthy Future concentrating efforts on the specific
outcomes identified from the Prevention and Promotion National Programme’.
Where are we now?
Effective chronic conditions management has been a key focus for the Health Board and
there have been effective outcomes regarding this work with a steady decrease in the
number of admissions for a specified group of chronic conditions21.
Information collected between April 2011 and March 2012 showed that there were over
6000 attendances at EDs across North Wales for conditions which could be treated outside
of an ED.
The group of patients who are the greatest users of ED facilities but with the lowest
admissions, i.e. those aged between 15 – 29 are developing patterns of access which will
continue unless we, as health and social care service providers, can educate and empower
them to provide them with more appropriate options. Across North Wales there are six
Children and Young Peoples Partnerships, involving statutory, voluntary and independent
sector organisations, and all have common priorities within their Children’s Plans regarding
healthy lifestyles, community safety and prevention of injuries22.
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North Wales has led the way with the Choose Well approach in Wales. An initiative was
undertaken two years ago which was evaluated, and the findings indicated that this type of
behaviour change could not be effected in one attempt. A national campaign was launched
by WAG on 28th February 201123 but was aimed at four health boards in South Wales who
were experiencing significant pressures. In the winter of 2012/13, BCUHB launched a multidimensional Choose Well Project to increase staff and public understanding of the range of
NHS services available for them to use when they become unwell or injured, and combat
rising demand on emergency care services. This was focussed on young people and used
social media to get the message across. A further campaign was launched in North Wales at
the beginning of November. The media coverage included adverts on S4C, in the cinema and
on local buses. Wide leaflet drops for the public were undertaken and also leaflet and poster
displayed in healthcare settings. A mobile phone and tablet ‘app’ was also designed and a
web page for information.
The Communications Hub concept, as detailed in Setting the Direction, is being addressed as
a multi-agency project in North Wales, reporting to the Primary and Community Services
Implementation Board and led by a regional multi-agency group.
The vision is to provide a health and social care infrastructure (statutory and third sector)
which will contain clear pathways for packages of care provided by multi-disciplinary teams.
This will be supported by an electronic directory of services which will be managed by the
Meeting the Strategy
Choose Well Campaign
- repeat campaign each
year for next three years
and evaluate progress
By whom
Evaluate 2012/13 Choose well Governance &
Winter Project and use
lessons to plan for 2013/14
Information about
illnesses and self-care to
be provided to citizens
via easily available media
such as internet, i-phone
/ android apps,
facebook, twitter etc.
Work with Children and
Young People’s Partnerships
to investigate how this could
be approached
Develop young people’s
communications portfolio as
part of Communications Hub
Communications Hub
- ensure information
resources are
available to all who
need them
SSIA funding received to pilot
community SPoA in
Denbighshire on behalf of
Page 11 of 28
By when
Children and
Young Peoples
Community and
Mental Health
Local Authority /
Leadership Teams
supported by
corporate depts
Winter 2013
By whom
Community &
Medicine CPG
Improvement and
Business Support
By when
develop locality
owned directory of
Evaluate the pilot outcomes,
and if successful roll out
across the Health Board
Communications Hub
- identify current
health and social care
Map health and social care
services by county working
with statutory, voluntary and
independent sector
Put in place programmes
and initiatives to help
patients with long-term
Review patient education
programmes across Health
Board (EPP)
Midwifery and
Patient Services
Develop the role of case
management within
Development of North Wales
model for Advanced
Midwifery and
Patient Services
2013 ongoing
Mainstream the work of
the Chronic Conditions
Implementer sites
Continue to develop locality
Review CCM demonstrator
learning to influence ongoing
CCM priorities
Identification of frequent
callers and/or attenders, with
multi-agency proactive case
management, e.g. use of the
GP/Urgent Care dash board
Primary care &
Leadership Teams
Early 2014
Proactive management
of frequent callers
and/or attenders
Page 12 of 28
Winter 2013
Winter 2013
Access to locality based community resources
Primary care – GPs, Pharmacists, Dentists, Optometrists
Integrated health, social care and voluntary sector community services for preemptive care and home support
WG 10 High Impact Steps to Transform Unscheduled Care – Transformational Step 4
“Local Models of Care are developed and supported to enhance their capacity to meet
core hours demand in order to deliver services aimed at maintaining patients safely in the
community”. Intended outcome: “That when appropriate, patients will access their GP as
a first point of advice and contact, and receive unscheduled care services outside of
secondary care”
The vast majority of health and care needs are met in local communities by primary care and
community services. We all want our care to be local, convenient and of consistently high
quality as stated in Setting the Direction, which aims to establish care pathways to locality
and community based services which are reliable and accessible irrespective of where
people live. These services must be specifically designed to enable individuals to improve
their lives; to enable them to maintain their independence for as long as possible, and to
support them as they become frail and vulnerable to remain safely in their own home. At
the same time, carers need to have confidence in the services that are required.
The evidence would suggest that people who attend EDs with problems that could be
resolved in primary care are often cited as causing long waiting times, poor care and
preventable costs25. Although awareness of NHS Direct, GP out of hours and ED is generally
high, knowledge of how to actually make contact with services tends to be lower,
particularly for NHS Direct, Dental and Pharmacy out of hours services, and a quarter of
contacts were made out of hours, between 6.30pm and 8am, at the weekend or on a bank
One of the key issues would appear to be the inability to easily access locality or community
based services both in and out of hours, by the public, primary care or out of hours services.
Where are we now?
In North Wales we have 14 localities, led or supported by a Locality Lead Clinician working
with a multi-agency core team. This structure is firmly placed within the Primary,
Community and Specialist Medicine Clinical Programme Group, and a management structure
has been devised which is committed to the further development of services within the
localities, and also supported by other relevant CPGs such as Medicines Management and
The needs of the population of the different localities vary and so the strategy is not
prescriptive regarding service delivery, but does require certain elements to be in place to
ensure the needs of individuals are met at different stages in the pathway, focusing on
speedy and easy access to the service that they require.
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General practice meet most of the unscheduled care needs of a local population, and we
need to maximise access to primary care services, working jointly with our primary care
providers to ensure timely availability to appointments. Some GP Practices have local
enhanced service agreements such as services for people who have had a minor injury
during the previous 48 hours, which may or may not require sutures. We need to improve
access to primary care by making more appointments available.
Integrated health, social care and voluntary sector intermediate care teams need to be
available to provide pre-emptive care and to respond quickly to prevent needs escalating,
also operating extended hours.
The Enhanced Care at Home service which provides step up and step down health and social
care for individuals with health needs is being rolled out across every locality as both a step
up and step down service. This is supported by GPs and Care of the Elderly Consultants and
reduces average length of stay and hospital admissions.
Other intermediate care services across North Wales were mapped26 to identify service
provision and access/referral criteria. Since that time these services have become
increasingly mainstreamed which has enabled better resource management, but has
complicated access to those services. Setting the Direction requires a single point of access,
and the infrastructure within North Wales is to have a hub and spoke model with a 24/7 hub
and in-hours county based health and social care access points. Following the process
mapping exercise, county based points of access would be established and the hub and
spoke elements would need to be connected using appropriate telephony and IT
We will review and maximise the Community Pharmacy contract to ensure it supports the
health priorities of NHS Wales and local demands and further develop Healthy Living and
Early Years Pharmacies;
Providing access and services for the following:
• Sexual health
• Smoking cessation
• Alcohol and substance misuse
• Weight management
• Screening and vaccination
We will pilot a walk-in service for common ailments with Community Pharmacists providing
advice and support for patients locally (pilot site in Gwynedd.) The pilot will promote self
care and through self referral or signposting enable patients to access the right service at the
right time. Pharmacists have the skills and knowledge to manage common ailments and
through this scheme will be able to offer advice and treatment free at the point of care, thus
removing the barrier that some patients currently have in accessing pharmacies for
treatment. Through the national evaluation we will measure the shift in care from GP
practice and OOH service and the impact on these services with regards to improving access
for patients with more complex needs.
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Meeting the Strategy
By whom
By when
Reduced unnecessary variance Access to Practices is being Primary Care
in access to primary care
audited and lunchtime and Support Unit
half day closures being
Improved access by primary
Direct communication
care to consultant level advice channel between primary
Community and 2013
and secondary care e.g.
Hot clinics; SHINE
Medicine CPG
Pathways to be developed to
Develop following
ECH Project
enable prompt and extended
access to diagnostic tests and End of Life
Chronic Conditions (COPD,
Diabetes, Cardiac);
Frail Elderly
Communications Hub:
− Establish 24/7 hub with WG, LHB and
NHSDW, out of hours
− Development of 24/7 hub
Comms Hub
− Development of six county − Following process
Steering Group
based in hours health and
mapping process,
social care SPoA
establish in hours
county based health
and social care access
Comms Hub
− Easy access to services
− Put in place
Steering Group
technologies between working with
NWIS and
hub and spokes,
national IT
following Welsh
Government guidance groups
re 111
Community Pharmacy
Common ailments scheme
Pilot the WG scheme
promoting self care,
accessing the right service
at the right time,
evaluating service cost,
patient experience and the
shift in service from other
settings such as GP
practice or out of hours
Page 15 of 28
Pharmacy &
and Welsh
June 2013
Access to urgent care services, ranging from locality based urgent care
services to acute assessment at the emergency department (ED),
integrated with GP out of hours services
WG 10 High Impact Steps to Transform Unscheduled Care – Transformational Step 3:
“Develop the clinical model for Welsh Ambulance Service Trust which fits with the LHB
communication hubs, and supports the principle of non-conveyance”. Intended Outcome:
“That patients will receive a timely, co-ordinated clinically appropriate response to their
WG 10 High Impact Steps to Transform Unscheduled Care – Transformational Step 5:
“Local Models of Care are developed and supported to enhance their capacity to meet out
of hours demand in order to deliver services aimed at maintaining patients safely in the
community”. Intended outcome: “That, when appropriate, patients appropriately access
the out of hours service as a first point of advice and contact, and receive unscheduled
care services outside of secondary care
WG 10 High Impact Steps to Transform Unscheduled Care – Transformational Step 8:
“Health Board agree and implement a service model which supports the principle of
treatment of the sickest patient first and provides appropriately accessible acute
emergency services at designated centres, with 24/7 access to acute medical service/
senior clinical decision makers, and 24/7 access to surgical opinion”. Intended Outcome:
“That patients are made safe and assessed by ED quickly, with prompt handover from
ambulance crews and speedy handover to the most appropriate place and clinician for
WG 10 High Impact Steps to Transform Unscheduled Care – Transformational Step 10:
“Local Health Boards have in place pathways, and outcome measures for Stroke,
Myocardial Infarction, Sepsis and Fractured neck of femur as a minimum” Intended
Outcome: “That patients’ experience and outcomes are improved across the whole
Most out of hospital urgent care services are provided in primary care, in hours and out of
hours, and minor injuries services in hospital hubs. The aim is to reinvigorate locality based
urgent care services ensuring that they meet the requirements of the Unscheduled Care
Facilities document published by the College of Emergency Medicine, July 2009, and that
they, along with acute EDs, are integrated with GP out of hours services.
Community Hospital Hubs should not receive patients who are acutely ill, injured or who
require full resuscitation facilities and Welsh Ambulance Services Trust (WAST) processes will
reflect this. Where, in exceptional circumstances, acute patients self-present, staff should
be competent in initial management of these patients and have protocols in place to ensure
rapid transfer to ED. Training needs analysis should be undertaken to ensure that the health
practitioners have the requisite skills and competence. There should be an identified clinical
Page 16 of 28
lead, for both medicine and nursing, which would be responsible for ensuring adherence to
governance standards, and clear guidance within the operational and governance policies
clearly specifying which patient groups or conditions can be treated by the locality service.
Out of Hours Service
The Out of Hours medical services are established to receive calls from patients or carers
during the period between 6.30pm and 8.00am on weekdays and over the weekend and
bank holidays, where there is a medical problem or a perceived medical problem that cannot
wait until the next available ‘in hours’ availability. The service triages the contact
appropriately and arranges for advice, a face to face contact at either a centre or patient’s
home. The service works alongside WAST to facilitate transportation to hospital in the case
of an Emergency. The service will deliver to the performance standards for GP out of hours
services (Wales). It is acknowledged that there are medical workforce issues that need to be
addressed for OOH services to be sustainable.
Minor Injury Units
Sustainable minor injury units are being established at locality hubs. Minor injury services
will be provided by minor injury practitioners (eventually emergency nurse practitioners and
advanced nurse practitioners) working in full partnership with the other services provided at
the locality hub. Where attendances are low, but the service is vital because of geographical
considerations, the practitioners will undertake joint roles with other services. Once
autonomous minor injury unit practitioners have been recruited, enhanced training will be
delivered to increase the case mix of injury cases that can be treated in localities. It is
envisaged that locality minor injury practitioners will work in partnership with local general
practices in some localities and also be supported from a minor injuries hub initially based in
Llandudno General Hospital using videoconferencing to provide remote decision-making to
expedite local care and to reduce unnecessary transfers to secondary care. Once
competences are established 999 stand down procedures for minor injury presentations will
be established with WAST to prevent long unnecessary transfers and treatment delays. A
dialogue is in place with GP OOH managers to establish joint working arrangements between
minor injury unit practitioners and GP OOH doctors and advanced nurse practitioners. It is
envisaged that in some sites GP OOH services will be delivered by minor conditions trained
advanced nurse practitioners with additional minor injury competences. Although daytime
unscheduled minor conditions care is not part of the remit MIU services it is envisaged that
developing local agreements with primary care may help to manage seasonal fluctuations of
demand in rural areas subject to local service level agreements.
Welsh Ambulance Services Trust (WAST)
WAST will review practices and processes for Paramedics accessing existing Alternative Care
Pathways, or providing information to patients’ own GP. In particular, referrals for non-injury
fallers, resolved epilepsy and resolved hypoglycaemia.
An enhanced system has been developed, in partnership with LHB clinical colleagues across
Wales, to deliver a more robust yet streamlined process for Paramedics to use 24/7. This, in
turn, has increased the numbers of suitable patients accessing Alternative Care Pathways
enabling them to remain safely at home.
Page 17 of 28
In keeping with current improvement techniques, this change was piloted within the ABMU
area on the existing pathway for falls and information sharing for Resolved Hypoglycaemia
and Resolved Epilepsy prior to the phased roll out across Wales. An operational ‘field guide’
has been developed for clinicians to use, following a full clinical assessment, to initiate an
appropriate referral via a dedicated coordination point which is available 24/7.
The coordination point has access to a directory of services that allows the user to identify
service provision within the patient’s area, identify frequent service users, and feedback to
the Paramedic when the referral has been made. Dedicated referral agents then make the
referral on the Paramedics behalf to the identified Community Teams for falls screening or
inform the patient’s own GP when the patient is left at home following a Resolved
Hypoglycaemic or Resolved Epileptic episode.
Emergency Departments
ED overcrowding remains a major challenge to providing high quality clinical care.
Overcrowding is often due to ill patients awaiting admission, not ambulatory care patients.
Hospitals should have enough capacity to ensure that patients are not kept waiting for
admission to a hospital bed. These delays may result in increased mortality and morbidity27,
both within28 and externally to the hospital e.g. ambulance crews can wait for a considerable
length of time before ED staff are in a position to accept the patients which reduces the
numbers of ambulance crews available to respond to 999 calls.
The ED core service, as described by the College of Emergency Medicine (The Way Ahead
2008-12), would comprise medical staffing (ST4 or above) trained and experienced in
emergency medicine, 24 hours a day supported by a multi-disciplinary team including
nursing, therapists. The facilities available should be up to date for resuscitation, emergency
care and ambulatory care and as a minimum an emergency hospital must have an ED,
Critical Care, Acute Medicine, laboratory services and diagnostic imaging with 24/7 access to
x-rays, ultrasound and computed tomography (CT). The ED will receive timely support from
inpatient teams and efficient procedures for admission to hospital.
Clinical Decision Units
Each ED will have a Clinical Decision Unit (CDU) / observation ward. The purpose of a CDU is
to provide a facility where patients can spend a period of time (up to 12-hours) undergoing
observation, diagnostic tests and assessment rather than being admitted to inpatient
facilities. The guidelines for CDU specify their role in the management of 9 specific
conditions and should not be confused with Ambulatory Care Units which deal with 38
medical conditions. Up-to-date information technology (IT) and records system linked to the
hospital and community care records will be available.
Ambulatory care patients should be triaged to assess the appropriateness of their care by a
primary or intermediate (Health and/ or Social) care team. Where patients are triaged as
suitable for primary care type services in hours, these patients could potentially be
scheduled, as they would be for out of hours services. Ambulatory care areas should be
developed and utilized to their full potential.
Page 18 of 28
ED will be assessed for their trauma status and will work with North Wales Critical Care
Network and the major trauma emergency providers (University Hospital North Staffordshire
(UHNS) in Stoke.
Acute Medicine Unit
There will be a robust Acute Medicine Team who provide care within the first 72 hours of
admission, deliver Ambulatory Care Services, frail elderly assessment with the CoTE team
and co-ordinate hot clinics for rapid assessment of specific conditions. The acute medicine
team will adopt 7 day working to complement the Emergency Medicine Consultants. They
will be in the AMU for more than 4 hours, 7 days per week, have no other fixed clinical
commitments, perform twice daily consultant reviews of all AMU patients and undertake
acute cover in blocks of days.
GP admissions
A robust mechanism for assessing and admitting GP admissions will be put in place which
includes timely assessment by the appropriate clinician and once admitted, GPs to be
informed of discharge in a timely manner.
Where are we now?
MIU opening hours have been standardised within our hospital hubs, (8am-8pm, 7-days per
week) and are standard operating policies for the units are being developed.
As a result, local urgent care / MIUs have been subject to review and were agreed by the
Health Board in January 2013 as detailed in Health Care in North Wales is Changing
documentation29. The aim is to ensure that local urgent care is provided within each locality
or within 40 minute travel time (by car). The local urgent care could be provided by an MIU
/ GP OOH in a community hospital, or a DGH ED.
Acute Emergency Services
YGC and YG ED capital projects have been approved and dates for commencing have been
identified with both expected to be completed by 2015. The three units will have integrated
OOH services and CDUs. An ED system IT pathway is being procured for all 3 ED sites.
Innovate work within acute medicine is ongoing with ambulatory care being delivered on all
Meeting the Strategy
OOH workforce
Ensure GP / ANP staffing
OOH integration with ED /
Develop operational policy
Page 19 of 28
By whom
Community &
Medicine CPG
Community &
Medicine CPG
By when
Implement the MIU
reconfiguration of services (as
approved by the Board in
January 2013 in relation to
Ensure hospital hubs
develop a core service
provision, and are open 7
days per week, 8am – 8pm
WAST alternative care
Include this improved
service in a
communications strategy
for USC
Implement pathways for,
Resolved hypoglycaemia;
Resolved epilepsy
Identify frequent service
users through directory of
By whom
Minor injuries
(reporting to the
Project team
responsible for
Community &
Medicine CPG
Community &
Medicine CPG
By when
ED Capital Development
– YGC & YG new build
Emergency Quarters
– Integrate OOH services
and CDUs within the 3
– Implement ED IT
ED Medical Staff recruitment
Recruit to full complement
of ED consultants on each
Community &
Medicine CPG
Clinical Decision Unit /
Observation Unit
Implement protocol driven
CDU / Observation units
on each site
Community &
Medicine CPG
Acute Medical Unit
Implement 7-day working
for consultant body.
Establish workforce that
can deliver 12 hour cover,
7-days a week for the unit
through workforce
redesign, job planning and
Community &
Medicine CPG
Page 20 of 28
Ambulatory Care
Establish robust
ambulatory care services
on all three DGHs
Acute Intervention Team /
Hospital at Night
Ensure Acute Intervention
Team available on each
ED Pathways
Implement following
Myocardial infarction
Fracture Neck of Femur
Trauma unit status
Assessment of DGH
NW Critical Care
regarding specifications for Network
‘Trauma Unit’ status to be
GP admissions
Ensure appropriate
assessment and flow of GP
Page 21 of 28
By whom
Community &
Medicine CPG
By when
Community &
Medicine CPG
Once admitted, patients should be treated by the appropriate
specialty and discharged appropriately, with a supporting package
of care if required. Speedy intervention should be provided to
ensure effective re-ablement and rehabilitation, and patients and
their carers supported to maintain their independence
WG 10 High Impact Steps to Transform Unscheduled Care – Transformational Step 7:
“Health and social care partners agree a co-ordinated model to identify and support those
groups of patients with high USC use, or who have the potential to be high USC users”.
Intended Outcome: “The reduction of USC attendances, admissions and re-admissions for
this group of patients”
WG 10 High Impact Steps to Transform Unscheduled Care – Transformational Step 9:
“Health and Social service partners agree and implement processes which facilitate early
safe discharge following unscheduled admissions”. Intended Outcome: “That patients
have an appropriate length of stay, and are discharged in a planned co-ordinated way
with suitable support services”
It is imperative that, once admitted, patients have access to prompt diagnostics and
therapeutic interventions and daily decision making by a senior clinician occurs. To
maximise this, 7-day working across a range of services may be required. A comprehensive
geriatric assessment should be carried out when appropriate. Patient flow is key as
described in Setting the Direction as a system which actively pulls patients towards high
quality organised services closer to home. When the hospital’s capacity becomes saturated,
the pressure is most keenly felt in ED. In order to maximise the patient outcome, once the
patient has been assessed and the decision made to admit, the patient needs to be treated
and discharged without any delays within the hospital setting. There are a number of areas
which need to be addressed to maximise patient flow through the hospital system, such as
bed and staffing capacity, patient length of stay and frequency of ward rounds, predicted
date of discharge, the time of day the discharge takes place, delayed transfers of care,
continuing health care agreements, availability of step down facilities, social services input
etc. Transport arrangements for discharge should be readily accessible, whether provided
by WAST, or the voluntary sector.
Good discharge information provided to all community agencies involved in patient’s
discharge and ensures that the GP is aware of the patient’s requirements and can deal with
them accordingly; poor or inadequate discharge information can result in re-admission.
Rehabilitative and re-enablement packages of care, developed by intermediate care teams
(including ECH) working with the voluntary sector and delivered in the locality are essential
in ensuring that patients can regain their independence. This type of locality based, quality
organised service delivered close to the patient’s home is the foundation of successful
patient flow through the hospital system.
Page 22 of 28
Where are we now?
Discharge from Hospital
A BCU-wide discharge planning protocol was implemented during 2012 and continuous
education is delivered to healthcare staff to support this.
Predicted Date of Discharge (PDD) is implemented across all medical and COTE wards. The
current model is under review with some variation in how the process is applied. PDD is
communicated via patient white boards, on PAS Occupancy Screens, at Bed Meetings etc.
Delayed Transfers of Care (DTOC) are monitored on a weekly basis and an action plan
developed with locality matrons across BCU focusing on Length of Stay and DTOCs. Matrons
are kept informed of any delays over 20 days and actively involved in resolving issues.
Choice Protocol is implemented to assist individuals going into care homes. Within the East,
USC funding is being used to discharge patients earlier into care homes where patients and
families have chosen placement rather than wait for MDT and funding decision for patients
transferred to care homes with CHC monies. Assessments are then undertaken by the CHC
team within the care home.
Enhanced Care at Home (ECH) is a primary care based model of care, with GPs supported by
a multi-agency, multi-disciplinary team to provide a short period of rapid and intense ‘step
up’ and ‘step down’ care for the patients from their own practices. The team, working with
local GPs comprises an Advanced Nurse Practitioner, District Nursing, 24/7 Health Care
Support Workers, Social Workers, support from a Care of the Elderly Consultant, a voluntary
sector co-ordinator, community equipment and Community Pharmacy.
Psychiatric Liaison Services
There is consistent evidence that modern resourced liaison services reduce hospital use by
at least 10%. Current services are predominantly reactive within a limited resource base.
Leadership is required to promote a consistent cultural change to whole person care.
Psychiatric liaison services currently operate mainly between the hours of 9am–5pm, 5-days
per week on each site. It is proposed, as part of the Out of Hours developments within the
Mental Health CPG, that this service will expand to formally cover 24 hours, 7-days a week
with predominately a band 6 nurse service supported by Consultant Psychiatrists.
Re-ablement services, provided by Local Authorities, are available free for up to 6 weeks for
anyone over the age of 18 who needs assistance and support after a period of illness, or the
onset of a disability, where a range of flexible support is offered that best meets the
patient’s needs and can support their carers and families. Individuals requiring longer-term
support after the initial 6-week period will have their needs assessed and further support
plans put in place where necessary. Occupational Therapy and Physiotherapy staff within
the Health Board, provide intermediate care to prevent hospital admission and expedite /
support hospital discharge and transfer patients to re-ablement services if appropriate
Page 23 of 28
The range of short term, rehabilitation care services are provided by statutory, independent
and voluntary organisations often working together. Re-ablement services aim to prevent
unnecessary hospital admission, promote and facilitate a safe and timely hospital discharge,
prevent premature or unnecessary care home admissions and enable people to live as
independently as possible.
Meeting the Strategy
Complete in line with funding
allocation and ECH roll out
Roll out to all localities
Improve discharge planning
processes focusing on
identifying PDD and 11am
– PDD / Morning
Discharge Task & Finish
Group established
– Review of PDD
processes with a view
to introduce PDD
based on key clinical
Community &
Medicine CPG
A joint 3-month pilot currently
ongoing between BCU and
Conwy Social Services
involving the use of PDD on
PAS referral to Social Workers
to reduce journey time from
referral to assessment
Outcomes of pilot to be
reviewed and processes
strengthened to support
earlier discharge and
improve patient flow
Improvement & Summer
Support / Conwy
Social Services
Drive improvements to
increase the number of 11am
discharges as part of
Unscheduled Care Actions.
Development of Driver
Diagrams and
commencement of the
‘Transitions of Care
Community &
Medicine CPG /
Improvement &
Psychiatric Liaison
Developing an Integrated 24
hour Liaison Response Service
linked to the Mental Health
Out of Hours Provision
Agree over all model
Confirm resources
Link to Out of Hours
Mental Health Plan
Page 24 of 28
By whom
By when
April 2014
Mental Health & Spring
Disability CPG
Re-ablement Service Pathway
Third Sector input re Red
Cross / Home from Hospital
By whom
By when
Develop clear pathways for Therapies CPG
access to re-ablement
services that ensure
prompt access
Included within ECH
Robust Information Gathering and Progress Monitoring
BCU currently has a plethora of mechanisms for collecting core information around the
unscheduled care pathway which need to be reviewed and streamlined to ensure consistent,
timely and robust data is collected reported through a single reporting mechanism which
links with the quality improvement and mortality agenda.
Working with informatics we will develop a mechanism to monitor the strategy on a
quarterly basis and provide a written report to the Unscheduled Care Modernisation
Committee. Each area unscheduled care committees will feed into the monitoring process.
Next Steps
This urgent and emergency care strategy has significant implications and challenges in
delivering a co-ordinated joined up whole systems approach to delivering a high quality, safe
patient journey. It requires cooperation and shared vision across health, social care and
WAST. Resources, man-power and financial implications need to be worked through with all
Page 25 of 28
Glossary of Terms
Accident and Emergency
Chronic obstructive pulmonary disease
Care of The Elderly
Clinical Decision Unit
Clinical Programme Group
Community Response Teams
Delayed Transfers of Care
Enhanced Care at Home
Emergency Department
General Practitioner
Health Care in North Wales is Changing
Information Technology
Local Health Board
Myocardial Infarction
National Health Service
NHS Direct Wales
Neck of Femur
Out of Hours
Patient Administration System
Primary, Community and Specialist Medicine
Predicted Date of Discharge
Quality and Outcomes Framework
Unscheduled Care
Welsh Ambulance Services NHS Trust
Wales Audit Office
Page 26 of 28
NHS Wales Annual Quality Framework 2011-12. Welsh Government
Transforming Unscheduled Care and Chronic Conditions Management: Betsi Cadwaladr
University Health Board (December 2012). Wales Audit Office
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Ten High Impact Steps to Transform Unscheduled Care (June 2011). Unscheduled Care
Atenstaedt R & Jones C. 2013. Unscheduled Care Data Profile for BCUHB. Public Health
1000 Lives Plus Campaign. National Leadership for Innovation & Healthcare [available at:
Our 3 Year Plan 2013-2016. (2013). BCUHB
Office of National Statistics, Census 2011, [available at:
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Our Healthy Future (2009). Welsh Assembly Government.
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Delivering End of Life Care Plan. (2013). Welsh Government.
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Emergency Medicine
Banerjee; J. and Conroy; S. et al. (2012). Quality Care for Older People with Urgent and
Emergency Care Needs: The Silver Book
Standards for Children & Young People in Emergency Care Settings (2012). Developed by
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Welsh Government (2012) “Carers Strategies (Wales) Measure 2010: Guidance issue to
Local Health Boards and Local authorities”
Choose Well Campaign Wales (2011). Welsh Government [available at:
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Implementation Board
North Wales Clinical Strategy for Children Report, Appendix 6 – North Wales Children and
Young People’s Strategic Plans – Common Health Related Themes and Priorities, to the NHS
Reform Board, September 2009
Choose Well Report for National Programme for Unscheduled Care Board Meeting, (11th
May 2011)
BCUHB Community Nursing Strategy Framework for Implementing Recommendations,
March 2011
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Rajpar SF, Smith MA, Cooke MW. Study of choice between accident and emergency
departments and general practice centres for out of hours primary care problems. Emerg
Med J 2000; 17:18-21
BCUHB Intermediate Care Review across North Wales
McInerney JJ, Breslin TM, Cogan L, Stedman W, Kyne L, Power K. Prolonged boarding in an
overcrowded ED in Ireland and its impact on morbidity among elderly patients. Emerg Med J
2008: 25 (Suppl1) A8
Richardson DB The access block effect: relationship between delay in reaching an inpatient
bed and inpatient length of stay. Med J Aust 2002; 177:492-5
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Page 28 of 28