The document provides an overview of the SAFER patient flow bundle and Red2Green days tools. It summarizes: - The SAFER bundle focuses on senior review, all patients having clear plans/criteria for discharge, early flow of patients from assessment units before 10am, earlier discharges with 1/3 before midday, and reviewing long stay patients. - Red2Green days classify patient days as red (not ready for discharge) or green (ready). It aims to have no red days by addressing delays and barriers. - Evidence shows increased mortality with emergency department overcrowding and delays. Early mobility and discharge can reduce length of stay and improve outcomes while hospitalization risks deconditioning

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SAFER patient flow bundle & Red2Green days overview slides (P Gordon Feb 2020)

2. 2 |
Red2Green days and the SAFER patient
flow bundle are only tools
Health warning – do not try and performance management them

3. 3 |
bottleneck
bottleneck
bottleneck
bottleneck
DemandDemand DemandDemand
Ambulance
Full assessment
unit
Full emergency
department
Full specialty
wards
Demand
Discharge
delays
Handover
delays,
queues
Exit block.
ED crowding
Late transfers
‘Outliers’
Late discharges,
long stay
patients
What problem are we trying to help improve?

4. 4 |
bottleneck
bottleneck
bottleneck
bottleneck
DemandDemand DemandDemand
Ambulance
Full assessment
unit
Full emergency
department
Demand
Specialty
wards
Discharge
Handover
delays, queues
Exit block. ED
crowding
Late transfers
‘Outliers’
Late discharges,
stranded patients
Patients wait the longest here
What problem are we trying to help improve?

5. 5 |
Start with a compelling story

6. 6 |6 |
SAFER patient flow bundle & Red2Green days overview slides (P Gordon Feb
2020)
“Patients’ time is the most important currency in
health and social care” - Prof Brian Dolan

7. 7 |
Risks of Hospital based De-conditioning Habitual Inactivity
#EndPJparalysis
Impact of Bed Rest in Older People in first 24 hours
• Muscle power – 2-5%
• Circulating volume by up to 5%
In first 7 days
• Circulating volume by up to 20%
• VO2 Max by 8-15%
• Muscle strength – 5-10%
• FRC – 15-30%
• Skin integrity
SAFER patient flow bundle & Red2Green days
overview slides (P Gordon Feb 2020)

8. 8 |8 |
Last 1000 days videos
SAFER patient flow bundle & Red2Green days overview slides (P Gordon Feb
2020)

9. 9 |9 |
Useful evidence & reference
slides – link here
SAFER patient flow bundle & Red2Green days overview slides (P Gordon Feb
2020)

10. 10 |10 | SAFER patient flow bundle & Red2Green days overview slides (P Gordon Feb 2020)

11. 11 |11 |
Simple rules work better in a
complex system
Harvard Business Review - Creating Simple Rules for Complex Decisions

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#Red2Green days - Keep it as simple as possible

13. 13 |13 | SAFER patient flow bundle & Red2Green days overview slides
(P Gordon Feb 2020)

14. 14 |
1. Do I know what is wrong with me or
what is being excluded?
2. What is going to happen now, later
today and tomorrow to get me sorted
out?
3. What do I need to achieve to get
home? ‘Back to baseline’ is rarely a
useful phrase.
4. If my recovery is ideal and there is no
unnecessary waiting, when should I
expect to go home?
Questions patients and their loved ones should know the
answer to – is it a Red day if they can’t answer the
questions?

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Practical #Red2Green tips
• Start the daily, morning multi-disciplinary board round
with all patients marked as RED – don’t turn them
green until all planned actions are completed
• Really challenge and ask – does this patient need to
be in hospital?
• Develop a local list of reasons for red days e.g. no
senior review, patient not dressed, the 4 questions,
complex patient awaiting external support, diagnostic
delayed or not reported
• Red days aren’t bad – they highlight the constraints /
the areas to focus improvement efforts
• Have a routine afternoon huddle
• Keep it as simple as possible and don’t
performance manage the number of red
days

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Measurement for improvement – not judgement
• Have a ‘knowing how we are doing board’ on every ward so everyone can see
• Make it a central team’s weekly job – don’t add it as another job for busy ward staff
to do

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is a widespread disease

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#Red2Green days videos
https://www.youtube.com/playlist?list=PL6rrXMWFEqXLdOzCnuMP9oH6WU
_OOeoWt

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S
A
F
E
R
SAFER
patient flow
bundle
Senior review
All patients have a plan including an expected date of
discharge and clinical criteria for discharge (enabling
criteria led discharge)
Flow – all wards that routinely have patients
from assessment units pull the first patient
before 10am
Earlier discharge – a third before
midday
Review – stranded / long stay patients
The SAFER patient flow bundle
SAFER patient flow bundle videos

20. 20 |
Based on a
clinical care
bundle
Based on the same principle as care bundles which help
reduce variation e.g. the ventilator acquired pneumonia
bundle (my first experience)

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Senior review
before
midday
Senior review before midday
Board round video
Ward round conference videos
Dr Caldwell – the importance of ward rounds video

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Board
rounds

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Royal College of Physicians - Ward rounds in medicine: principles for best practice
Updated guidance due to be published March / April 2020

24. 24 |
https://www.bmj.com/content/365/bmj.l4367

25. 25 |
All patients have a clear plan that they and their loved
ones know. The plan should include an expected discharge
date, clinical criteria for discharge and a decision made if the
patient is suitable for criteria led discharge
Clinical criteria for discharge and criteria led discharge slides

26. 26 |
1. Do I know what is wrong with me or
what is being excluded?
2. What is going to happen now, later
today and tomorrow to get me sorted
out?
3. What do I need to achieve to get
home? ‘Back to baseline’ is rarely a
useful phrase.
4. If my recovery is ideal and there is no
unnecessary waiting, when should I
expect to go home?
The 4 Questions all patients and / or their loved
ones should be able to answer

27. 27 |
• “Home when stable”
• “Home when mobile”
• “Start discharge planning”
• “Home after weekend”
• “Medically for discharge when
back to baseline”
• “Recheck bloods tomorrow”
Common – but not really clear

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Example acute kidney injury (AKI)

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Example: GI bleed

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Example - pneumonia

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• Mobility e.g. walk up to 10 metres
#EndPJparalysis
• Eating and drinking
• Toilet
• What does the person really want
and have the risks been explained
to them and / or their family?
• Plan to assess at home wherever
possible #homefirst
Functional and emotional criteria are
also important

32. 32 |
A clear plan

33. 33 |
Flow– early pull, first patient
arrives on the ward (from the
assessment unit or emergency
department before 10am). Note – this
is for wards that routinely have
patients transferred from assessment
units / the emergency department
Let the wards choose – site teams,
monitor and trust ward teams
Measure it, make it visual everyday

34. 34 |

35. 35 |
A third of discharges before midday

36. https://www.ncbi.nlm.nih.gov/pubmed/26845068

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Admissions
Discharges
No beds!
Week day
Early flow is needed to drive early discharges
12.00 17.00
SAFER patient flow bundle & Red2Green days overview slides (P Gordon Feb
2020)

38. 38 |
Admissions
Discharges
Left shifting the discharge curve
Week day
12.00 17.00
Discharges 2-3 hours earlier

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Review long stay patients
• Daily (board / ward rounds
• A weekly process (don’t pull
clinical teams off the wards)

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Think #homefirst

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What matters to ‘me’
Tell me the risks of staying in hospital
or going #homefirst

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https://www.rcot.co.uk/file/2022/download?token=wWxjCFTa

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SAFER patient flow bundle & Red2Green days overview slides (P Gordon Feb
2020)

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#longstaywednesday results
• Reducing the number of long stay patients in the Trust’s beds, up to 100 less patients who
have been in hospital for 21 days or more.
Long stay Wednesday
Long stay Wednesday406
277
198
107
Reducing long hospital stays videos

45. NHS Futures long length of stay website
(you can register with an NHS email account)
Useful on-line resources

46. https://endpjparalysis.org/
#EndPJparalysis

47. 47 |
Average Length of Stay (Individual Ward LOS)
Northern Care Alliance – All Hospital Sites
Northern Care Alliance Average LOS (Individual Ward LOS)
UCL
Mean
LCL
UCL
Mean
LCL
End PJ Paralysis Launch
Event 10th July 2017
01/01/2017
05/02/2017
12/03/2017
16/04/2017
21/05/2017
25/06/2017
30/07/2017
03/09/2017
08/10/2017
12/11/2017
17/12/2017
21/01/2018
25/02/2018
01/04/2018
06/05/2018
10/06/2018
15/07/2018
19/08/2018
3
4
5
6
7
8
9
Learning
Session
Reduction in
Average LOS
from 6 to 5.1
Days (16%)

48. 48 |

49. 49 |
Link them all together

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Perfect is the enemy of getting things done

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Useful evidence & reference slides
SAFER patient flow bundle & Red2Green days overview slides (P Gordon Feb
2020)

52. 52 |
ED mortality rate within 30 days = 1% (of 15 million) = 150,000 deaths
Assuming most are
in the admitted
cohort = 5 million
ED admissions
150k/ 5m= 3% mortality for admitted patients
4.34% = 217,000
Data indicates an XS
mortality of 1.35% if
TiD > 4hrs
= 67000 XS
= 1 per day per ED
180 EDs
365 days
67000/180/365 = 1
‘We have used linked hospital and ONS mortality
data and undertaken a comprehensive analysis,
adjusting for a wide range of potentially
confounding variables to ensure we are not just
seeing the effect of things like comorbidities,
deprivation etc and still find that if you stay more
than 4 hours in ED then at 30 days your mortality
rate is 1.34% higher than if you stay a shorter
period.’

53. 53 |53 |

54. 54 |
Poor emergency department performance
(waiting) correlates with increased mortality

55. 55 |
• Retrospective analysis of
694 patients with
community acquired
pneumonia
• Delayed delivery of
antibiotics in 4 hours
• ED not crowded – 31%
• ED overcrowded – 72%
Pines JM et al. The impact of emergency
department crowding measures on time
to antibiotics for patients with
community acquired pneumonia. Annals
of Emergency Medicine, 2005,
50(5):510-516
Crowded emergency departments
• Dangerous
• Correlates with increased length of stay
Patients waiting over 12 hours for a
bed have a 2.35 increase in their
hospital length of stay.
Essential drugs are delayed
when an emergency
department is crowded

56. 56 |
https://onlinelibrary.wiley.com/doi/epdf/10.1111/j.1553-2712.2011.01236.x

57. 57 |
Monday Tuesday Weds Thursday Friday Saturday SundayMidnight
Midnight
Midnight
Midnight
Midnight
Midnight
Midday
Midday
Midday
Midday
Midday
Midday
3-day LOS difference between 9am and 9pm admissions (four days for >75 year cohort)
https://www.hsj.co.uk/commissioning/senior-staff-cover-means-earlier-
discharges/5071139.article
Early versus late admission

58. 58 |
https://bmjopen.bmj.com/content/bmjopen/7/5/e015676.full.pdf

59. 59 |59 |
• Mean medical bed occupancy decreased significantly from 93.7% to 90.2% ( p=0.02)
• Mean reduction in all markers of mortality (range 4.5–4.8%). SHMI (p=0.02) and crude
mortality (p=0.018) showed significant trend changes after intervention
• Improved 95% performance

60. https://www.ncbi.nlm.nih.gov/pubmed/26845068

61. 61 |
Conclusion
A loss in home time is associated with decline in several
patient‐centered outcome measures. These results provide
empirical evidence to promote adoption of home time and its
clinical interpretation for database studies of medical
interventions.
Results
The risk of mobility impairment, depression, and difficulty in
self‐care increased steeply after home time loss of 15 days or
greater.
https://onlinelibrary.wiley.com/doi/abs/10.1111/jgs.15705

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https://discover.dc.nihr.ac.uk/content/signal-000759/getting-hospital-patients-up-and-moving-shortens-stay-and-
improves-fitness#.XL-Hq6LOfgw.twitter

63. 63 |
https://www.bmj.com/content/360/bmj.k433

64. 64 |
https://www.tandfonline.com/doi/full/10.1080/07853890.2018.1511918#.XBKKCdEdVY4.twitter

65. 65 |
Results
• The exercise intervention program provided significant benefits over usual care.
• At discharge, the exercise group showed a mean increase of 2.2 points (95% CI, 1.7-2.6
points) on the SPPB (Short Physical Performance Battery) scale and 6.9 points (95% CI,
4.4-9.5 points) on the Barthel Index over the usual-care group.
• Hospitalization led to an impairment in functional capacity in the Barthel Index of −5.0
points (95% CI, −6.8 to −3.2 points) in the usual-care group, whereas the exercise
intervention reversed this trend (1.9 points; 95% CI, 0.2-3.7 points).
• The intervention also improved the SPPB score (2.4 points; 95% CI, 2.1-2.7 points) vs
0.2 points; 95% CI, −0.1 to 0.5 points in controls).
• Significant intervention benefits were also found at the cognitive level of 1.8 points
(95% CI, 1.3-2.3 points) over the usual-care group.
https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2714300

66. 66 |
https://www.nursingtimes.net/clinical-archive/cardiovascular/effects-of-bedrest-1-introduction-and-the-cardiovascular-system/7026883.article

67. 67 |
https://academic.oup.com/abm/article-abstract/52/1/88/4683158

68. 68 |
• https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2729744

69. 69 |69 |
https://academic.oup.com/ageing/article-abstract/47/4/512/4951828?redirectedFrom=fulltext

70. https://www.slideshare.net/hattersley4/deconditioning

71. https://www.bmj.com/content/366/bmj.l4949?utm_source=twitter&utm_medium=hootsuit
e&utm_term=&utm_content=SME&utm_campaign=editors

72. 72 |72 |
• Office for National Statistics. Excess winter mortality in England and Wales: 2015/16 (provisional) and 2014/15 (final). Access 12/11/2017:
https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/excesswintermortalityinenglandandwales/2015to2016provi
sionaland2014to2015final
• Richardson DR. Increase in patient mortality at 10 days associated with emergency department overcrowding. Med J Aust. 2006; 184:213–6.
• Sprivulis PC, Da Silva JA, Jacobs IG, Frazer AR, Jelinek GA. The association between hospital overcrowding and mortality among patients admitted via
Western Australian emergency departments. Med J Aust. 2006; 184:208–12.
• Chalfin DB, Trzeciak S, Likourezos A, Baumann BM, Dellinger RP. Impact of delayed transfer of critically ill patients from the emergency department to the
intensive care unit. Crit Care Med. 2007; 35:1477–83.
• Carter EJ, Pouch SM, Larson EL (2014) The relationship between emergency department crowding and patient outcomes: a systematic review
www.ncbi.nlm.nih.gov/pmc/articles/PMC4033834/
• Hoot NR, Aronsky D (2008) Systematic review of emergency department crowding: Causes, effects, and solutions www.annemergmed.com/article/S0196-0644(08)00606-
9/fulltext
• Boyle, A., Higginson, I., Smith, S. et al. Crowding in Emergency Departments. College of Emergency Medicine, London, England. 2014
• Asplin, B.R., Magid, D.J., Rhodes, K.V. et al. A conceptual model of emergency department crowding. Annals of Emergency Medicine (2003); 42: 173-180
• Krochmal P, Riley TA. Increased health care costs associated with ED overcrowding. Am J Emerg Med. 1994; 12:265–6.
• Liew D, Liew D, Kennedy MP. Emergency department length of stay independently predicts excess inpatient length of stay. Med J Aust. 2003; 179:524–6.
• Bernstein SL, Yadav K, Wall S, et al. Association between ED crowding and inpatient length of stay [abstract]. Acad Emerg Med. 2008; 15:S201.
• Beckett D (2014) Boarding: Impact on patients, hospitals and healthcare systems www.acutemedicine.org.uk/wp-content/uploads/2014/11/Plenary-5-1030-Wrong-Place-
Anytime-Why-Boarding-is-Bad-for-Patients-Hospitals-and-Healthcare-Systems.pdf
• Campbell CS Deconditioning: The consequence of bed rest: http://aging.ufl.edu/files/2011/01/deconditioning_campbell.pdf
• Imminence of death among hospital inpatients: Prevalent cohort study. David Clark, Matthew Armstrong, Ananda Allan, Fiona Graham, Andrew Carnon and
Christopher Isles, published online 17 March 2014, Palliative Medicine
• Gill et al. The Deleterious Effects of Bed Rest Among Community-Living Older Persons. Journal of Gerontology (2004), Vol. 59A, 7: 755–761
References

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• An acute hospital admission greatly increases one year mortality – Getting sick and ending up in hospital is
bad for you: A multicentre retrospective cohort study. Marianne Fløjstrup, Daniel Pilsgaard Henriksen, Mikkel
Brabrand. November 2017Volume 45, Pages 5–7. European Journal of internal medicine
• Likelihood of Death Within One Year Among a National Cohort of Hospital Inpatients in Scotland. Clark,
DavidSchofield, LaurenGraham, Fiona M.Gott, MerrynJarlbaek, Lene et al. Journal of Pain and Symptom
Management , Volume 52 , Issue 2 , e2 - e4
• Death within 1 year among emergency medical admissions to Scottish hospitals: incident cohort study.
Moore E, Munoz-Arroyo R, Schofield L, et al., BMJ Open 2018;8:e021432. doi: 10.1136/bmjopen-2017-
021432
• Senior staff cover means earlier discharges.HSJ. 2014. https://www.hsj.co.uk/commissioning/senior-staff-
cover-means-earlier-discharges/5071139.article
• Factors Associated With Delayed Discharge on General Medicine Service at an Academic Medical Center.
Rohatgi N , Kane M , Winget M , Haji-Sheikhi F , Ahuja N. Journal for Healthcare Quality : Official Publication
of the National Association for Healthcare Quality [08 Jan 2018]
• Pines JM et al. The impact of emergency department crowding measures on time to antibiotics for
patients with community acquired pneumonia. Annals of Emergency Medicine, 2005, 50(5):510-516
• NICE Guidance. Emergency and acute medical care in over 16s. Quality standard [QS174] Published date:
September 2018. https://www.nice.org.uk/guidance/qs174
• Other relevant NICE information:
• https://www.nice.org.uk/guidance/ng94/resources/emergency-and-acute-medical-care-in-over-16s-
service-delivery-and-organisation-pdf-1837755160261
• https://www.nice.org.uk/guidance/ng94/evidence/26.frequency-of-consultant-review-pdf-
172397464639
References