A&E eCAS Card - The electronic casualty record (#2498)

Idea Description
Supplementary Information
Innovation 'Elevator Pitch':
eCAS Card simplifies recording activity data at point of care in busy A&E Departs. This data is available to all clinical staff with associated patient safety checks. Patient record is more complete accurately reflecting activity & improving coding
Overview of Innovation:
Paperlite - The eCAS Card system is a replacement for the paper Casualty Card used in an Accident & Emergency Department and focuses on simplifying activity recording so the patient record contains rich clinical and nursing content.

Data Collection – The eCAS Card system simplifies and streamlines data collection by reflecting the processes and work flow within A&E Departments whilst integrating with the Trust’s PAS and key IT systems to ensure administrative functions are minimised.

Accessibility - No longer are nurses and clinicians required to search for a single paper record as they will have access to the latest patient information anywhere within the hospital where there is browser access to the network. The same patient record can be viewed with the capability of updating different parts of the record by multiple people simultaneously.

Accessible via multiple devices including Tablets, iPADs and C.O.Ws utilising NHS security protocols.

Monitoring - the system monitors “wait times” and provides simple, visual updates on screen to assist with meeting targets. Utilising the data provided by nursing staff, Sepsis, VTE, Child and adult safeguarding checks are undertaken and appropriate alerts raised if the data meets certain parameters.
  • nursing staff report that their capacity to treat patients and record their activity increases with the use of the eCAS Card service
  • clinicians benefit from having the latest patient information to ensure appropriate and timely treatment.
  • administrative staff note a significant reduction in time spent chasing paper notes, scanning CAS Cards and completing activity data not entered prior to discharge.

Data Sharing – the eCAS Card service ensures accurate and complete activity recording that results in an improved patient record which is then used for;
  • automatic production and e-mailing of GP attendance letters
  • all necessary reports and correspondence
  • A&E data available for Inpatient episode where a patient is admitted
  • simplified coding
Stage of Development:
Market ready and adopted - Fully proven, commercially deployable, market ready and already adopted in some areas (in a different region or sector)
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Overview summary:
NICE recommend Intermittent Pneumatic Compression (IPC) to reduce Venous Thromboembolism (VTE) risk in acute stroke patients. However around 30% of patients cannot be prescribed this modality. To serve this unmet need The Royal Stoke University Hospital has introduced a new VTE pathway which included neuromuscular electrical stimulation of the peroneal nerve using the NICE approved geko™ device (Firstkind Ltd UK). This pathway change also increased patient surveillance of both IPC & the geko™ device so to maximise the anti-stasis intervention.
Challenge identified and actions taken :
VTE prevention strategies available to high risk stroke patients are limited. NICE recommend IPC as the primary method of VTE prevention because the risk of symptomatic intracerebral haemorrhage with routine anticoagulation (including low molecular weight heparin) outweighs any potential benefit. Furthermore anti-embolism stockings are not recommended.

IPC reduces VTE risk by increasing venous return and preventing venous stasis in the veins of the calf. This modality, alongside standard measures of hydration, mobilisation and aspirin represents standard UK VTE prevention for high risk immobile acute stroke patients. The VTE consequence of no IPC intervention in this cohort was recorded in the CLOTS-3 study which showed a high resulting VTE incidence rate of 8.69%.

The geko™ device is an alternative anti-stasis device for use on patients who cannot be prescribed or tolerate IPC. The Royal Stoke University Hospital has recently introduced the device into the stroke pathway for patients who were either contraindicated or became intolerant to IPC and would otherwise have had no anti-stasis intervention.

Furthermore, nursing practice was amended to increase patient surveillance and maximise compliance for both IPC and the geko™ device. The objective was to maximise the anti-stasis intervention in this population.
Impacts / outcomes: 
Blood clots, or venous thromboembolism (VTE), are a major risk to hospitalised patients. VTE leads to pain, swelling and potential death. While the full scale of the problem is not known, it is estimated that hospital-associated VTE leads to about 40,000 deaths in England per year, 25,000 of which may be preventable through proper risk management and care. This is about five times as many healthcare-associated deaths as from methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile combined. There is a strong quality and financial imperative for hospitals to prioritise VTE prevention.
National Institute for Health and Clinical Excellence (NICE) guidelines set out the preventative measures that should be implemented to reduce this risk. In 2014, new guidelines recommended the use of the geko™ device for use in people who have a high risk of venous thromboembolism and for whom other mechanical and pharmacological methods of prophylaxis are impractical or contraindicated.
The size of a wrist watch and worn at the knee, the easy-to-use geko™ device is a neuromuscular electro-stimulation (NMES) medical device that gently stimulates the common peroneal nerve (a nerve adjacent to the knee) activating the calf and foot muscle pumps. The device creates a painless contraction of these muscles every second resulting in the prevention of “venous stasis” or static blood in the deep veins of the calf.

The risk of venous thromboembolism (VTE) after stroke is increased in patients with restricted mobility and associated increase in venous stasis. The alteration in blood flow in weakened limbs may lead to vessel wall injury, whilst there is also an abnormal tendency for the blood to clot more after stroke. The results from the Royal Stoke University Hospital show that introducing the geko™ device into this pathway lowered the overall incidence rate of symptomatic VTE. The geko™ is as effective as IPC at reducing DVT, the device was well tolerated and offered an alternative prophylaxis strategy to IPC, ensuring that all patients received VTE prophylaxis, where previously no prophylaxis could be given.

A clinical audit reviewed 1,000 patients admitted to the acute stroke unit at Royal Stoke University Hospital between 1st Nov 2016 and 3rd March 2018.

Key impacts:
  • 188 patients were sufficiently mobile and did not require any form of VTE prophylaxis.
  • 125 were assessed and deemed suitable for anti-coagulant drug to reduce VTE risk
  • 687 patients were assessed as immobile and at high risk of VTE, were unsuitable for drug and required an anti-stasis intervention.
  • 21/687 patients refused any kind of anti-stasis VTE preventative treatment
  • Therefore 666 patients received an anti-stasis intervention in addition to standard measures.
  • 544/666 were initially prescribed IPC to reduce their VTE risk
  • 122/666 patients were immediately contraindicated to IPC and were prescribed the geko™ device.
  • 81 patients who were initially prescribed IPC but became intolerant to it and were switched to the geko™ device.
  • Accordingly, 203/687 or 29.5% of patients represented the unmet need as described above and required an alternative anti-stasis and were therefore served by the geko™ device.
  • The geko™ was used for a mean of 9 days/patient.
  • The geko™ device was well tolerated by patients.
Key outcomes:
This audit also reviewed the VTE (DVT or PE) incidence at 90 days post discharge for the 687 patients who needed an anti-stasis intervention.
  • 11 VTE occurred in patients treated with IPC
  • 1 VTE occurred in the group who were initially prescribed IPC but who were switched to the geko™ device.
  • 1 VTE occurred in the group who refused any form of anti-stasis intervention
  • There was no incidence of VTE in patients prescribed the geko™ device.
The above new VTE pathway in acute stroke patients, which increased patient surveillance and included IPC and the geko™ device to maximise the prescribed anti-stasis intervention, resulted in a low overall incidence of symptomatic VTE. The incidence in high risk immobile patients requiring an anti-stasis intervention was 1.9% (13/687), which is lower than the 6.6% in a comparable patient population in the CLOTS-3 study.
Which local or national clinical or policy priorities does this innovation address:
National Institute for Health and Clinical Excellence (NICE) guidelines set out the preventative measures that should be implemented to reduce the risk of blood clots, or venous thromboembolism (VTE). In 2014, new guidelines recommended the use of the geko™ device for use in people who have a high risk of venous thromboembolism and for whom other mechanical and pharmacological methods of prophylaxis are impractical or contraindicated.
Supporting quote for the innovation from key stakeholders:
‘Following the positive results of our clinical audit within our acute stroke unit, the geko™ device is now in routine use and has marked a significant change to our nursing practice. The audit has shown a need to use the geko™ when other VTE prophylaxis strategies are contraindicated or impractical. This pathway enhancement ensures that all acute stroke patients now have another VTE prophylactic intervention option where previously patients would have had no other intervention available to them’.  
Dr. Indira Natarajan FRCP (UK)
Consultant Stroke Physician
Clinical Director Neurosciences
The Royal Stoke University Hospital

Plans for the future:
Whilst the above data has proven sufficient for the geko™ device to be adopted specifically to meet this unmet need, this audit will be extended as will the ongoing collation of associated quantitative & qualitative data.
Further support will be given to multiple trusts to further validate the use of the geko™ device to serve this large and meaningful unmet need in acute stroke patients
A publication strategy will also be formulated with the aim to present this data as appropriate.
Tips for adoption:
Firstkind are determined to remove any administration obstacles to accelerate the adoption process whilst fully respecting due process. We can assist the adoption process by offering the following:
  • The team at Royal Stoke Hospital are receptive to assist where possible in terms of process and sharing of experience
  • The sharing of all the relevant “committee” forms that allow for a new device to be considered and used within a trust. This common approach has created efficiency.
  • In terms of any device audit that has been conducted to quantify the size of any unmet need the audit collection forms have been shared between trusts to the reduce administrative burden.
  • Created a cross trust partnership approach to delivering patient benefit.
Adopting this approach has fast-tracked the implementation of this new technology into the stroke pathway in several centres across the U.K.

Contact for further information:
Firstkind Ltd
Hawk House
Peregrine Business Park
Gomm Road
High Wycombe
HP13 7DL

E: geko.support@firstkindmedical.com
W: www.gekodevices.com

T: +44 (0)845 2222 920 (Orders)
T: +44 (0)845 2222 921 (Enquiries)
F: +44 (0)845 2222 820
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Innovation 'Elevator Pitch':
WaitLess is an app for patients, combining A&E & MIU real-time waiting times, numbers waiting, traffic & routing helping patients make better decisions about where to go for minor emergencies. In east Kent, it reduced minor A&E attenders by 11%.
Overview of Innovation:
WaitLess is an innovative new app for patients. This reduces A&E attendances during busiy times by showing patients the quickest place to be seen, simply. It proves patients can be treated faster and closer to home by highlighting alternative services, driving activity away from busy A&Es. It's free for patients to download and was designed by patients for patients, funded by CCGs and STPs. Our charging model is 25,000 per CCG, or 3p per person based on population.

It's priced delibarately low to make WaitLess accessable to all, and can be deployed in less than two weeks. WaitLess was independently evaluated by the University of Greenwich and the Behavioural Insights Team and found to achieve an 11% reduction in minor attendances. 

Various studies undertaken since 2009 have found A&E attendance reduction schemes to be difficult to achieve. This is thought to be due to a number of factors incuding that patients find urgent care pathways confusing and hard to navigate. Various studies have identified that patients make a relatively quick decision about where to access treatment minor injuries. Once patients have arrived in A&E, evidence shows that they are committed to waiting to be seen and often reluctant to move. WaitLess applies an effective three second nudge to patients, by showing the quickest place to go and using real time routing options to help avoid traffic and overcrowding busy units during peak times. 

A reiew undertaken by encompass MCP found the following observations, which were confirmed as statistically significiant by the behavioural insights team and the University of Greenwich:
  1. Improved patient experience as patients are signposted to units with the lowest wiaiting times
  2. Reduction in A&E minors attendances by 11%
  3. An overall reduction of 5% in attendances across A&E and minors as more patients choose primary care.
  4. Quick and responsive, nudging patientstowards facilities with lowest waiting times.
  5. Takes pressure away from A&E and flattens activity
  6. Quick to deploy
Business cases for WaitLess are currently being considered across a broad range of regions, inclduing the South West, Greater Manchester, Yorkshire and the Humber, Surrey and Sussex. Given the benefits to the NHS, we are seeking to significantly accelerate this rollout across the NHS and to explore alternative uses for WaitLess (such as Primary Care). As a proven autonomous decision aid, WaitLess is a key pillar to any urgent care strategy.
Stage of Development:
Market ready and adopted - Fully proven, commercially deployable, market ready and already adopted in some areas (in a different region or sector)
WMAHSN priorities and themes addressed: 
Wealth creation / Digital health / Innovation and adoption / Person centred care
Benefit to NHS:
WaitLess has been independently evaluated by the University of Greenwich and the Behavioural Insights Team and found to deliver reduced activity, waiting times and save money for the NHS. The headline benefits are:
  1. Reduced minor injury attendance profile across the whole health economy. The total number ofcases (including A&E and MIU) shows a significant decrease (5% less, p=0.024).
  2. The total number of A&E cases shows a significant decrease (11% decrease, p<0.001).
  3. The proportion of cases (MIU out of (MIU+A&E) shows a significant decrease (the effect size varies by day of the week, but is approximately 3-4%, p<0.001)
  4. Reduction in A&E minors attendances by 11% within six months against an end of year target of 5%.
On days where there is significiant pressure on majors, it is  common for waiting times in minors to increase. As waiting times increase in one facility, patients choose alternative locations where waiting times are improved.  This has the net effect of spreading activity across A&E and UTC settings much more effectively.

As patients choose A&E because they are unaware of level 3 & 4  A&E units (UTC), nationally Hospitals are facing an increase of circa 5% year on year in A&E attendances. Peak attendances are predictable, occuring in the early evening and at weekends. WaitLess acts as an autonomous patient decision aid, helping to reduce pressure without impacting on surrounding UTCs. In addition to the benefits to patients, operational and performance benefits, WaitLess also saves money for Commissioners.

It is common for Urgent Care Centres to have much ower waiting times than A&E departments. By using real time data, WaitLess influences patients to choose the facility that willsee them fastest, giving improved overallexperiencefor patients and encouraging more competition among providers of urgent treatment services.

With many UTCs commissioned on block arrangements, overheads are already paid for. In these scenarios, each A&E attendance saved is equivalent to 85.00 per episode saved. Where UTCs are commissioned on PbR, the standard tariff is 65.00 per episode. in thesecases, WaitLess saves 20.00 per episode. The PbR savings alone equate to 100,000.00 per CCG. 
Initial Review Rating
5.00 (1 ratings)
Benefit to WM population:
Activity analysis has highlighted over the years that A&E is seen as a  trust brand by patients. Commissioning of alternative facilities with different names, such as MIU / UTC / Minor Injury Cinic / MIIU has created a significant confusion among patients about which services are  available and what they offer. A number of self help apps have been developed to support patients, however these have nationally had a limited impact on emergency attendances to A&E. Since 2004, the UK has seen A&E attendances grow by 5% year on year. A&E Departments are now widely reported to suffer from overcrowding, leading to sub-optimal conditions both for clinicians and patients. The majority of A&E attendances are from patients who choose to self present to Hospital, most with Ambulatory and more minor conditions. As an ex Urgent Care Commisisoner and General Manager for A&E and Acute Medicine, I knew prior to the build of an app that patients make a quick decision about where to access urgent care services, which was recognised by the behavioural insights team in 2015. In many other parts of healthcare planning, autonomous patient decision aids have been found to be highly effective in terms of both influencing behaviour and flattening demand. This can be seen in the NHS rightcare guides. WaitLess provides this for Urgent Care services. It helps the local population in the following ways:
  1. Encouraging people to access care services closer to home
  2. Reducing avoidable A&E attendances
  3. Improving the patient experience
  4. Empowering patients to mae a better decision about where to go to be seen
  5. Reducing pressure on overstretched A&E departments
  6. Savng money for the local health economy to re-invest in pathway changes that are sorely needed to improve urgent care flow.
Current and planned activity: 
We are currently enagaged in discussions around WaitLess with Nene and Corby CCGs, Yorkshire and the Humber and Greater Manachester. As part of the National Innovation Accelerator, we have ensured WaitLess is built on a platform that is simply scaled. Patient feedback has highlighted a need to provide WaitLess at scaleas patients commute for work and leisure and come to rely on the information. Our diffusion plan is outlined in a 12 week programme per CCG which can run in parralel with up to 26 CCGs per cycle. As WaitLess technology is bespoke, it has been built with scaling in mind. Our 12 week programme can be accelerated to 2 weeks, depending on each health economies informtion capabilities and appetite.
What is the intellectual property status of your innovation?:
As a developed and deployed product, we have IP rights  to our innovation
Return on Investment (£ Value): 
Very high
Return on Investment (Timescale): 
0-6 mon
Ease of scalability: 
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Innovation 'Elevator Pitch':
We work to reduce unplanned hospital admissions. Proactive Health Coaching helps patients to better control their health and thus reducing non-elective care. Engaged patients seek care at the right place, helping the NHS use its resources efficiently
Overview of Innovation:
Health Navigator is dedicated to improving patients’ lives through digitally supported health coaching at scale which is underpinned by robust scientific evidence.
Our forward strategy includes delivering an effortless patient experience and a focus on the development of a range of digitised services. To enable this, we are transforming the ways in which we deliver our services.

One of our services is Proactive Health Coaching (PHC). PHC is a telephone-based health management service that improves patient health and quality of life, while ensuring that healthcare resources are spent as efficiently as possible.
PHC provides non-medical patient support to help patients understand their chronic conditions, plan their care and navigate an often-complex healthcare system.
By identifying those likely to see future avoidable unplanned care, a coach is able to proactively support the patient. Support including helping to stabilise their condition, feel more confident in managing their conditions and navigating the often-complex health care system, thus reducing the risk of unplanned care.

Our model is evidence-based and grounded in scientific research, supported by several successful randomised trials. In summary PHC uses a patented combined approach of:

1) a complex risk predicting algorithm to forward predict on a daily basis, patients which are at high risk of a non-elective admissions
2) to then provide a programme of individualised care to those at high risk using our nurse led case management programme.

The unique combination of the two provides the outcomes summarised below.

The end goals are:

1) To improve patient outcomes and reduce healthcare utilisation
2) To deliver operational efficiencies across the whole health system by reducing demand and avoidable admissions
3) To deliver a significant cost saving

Our company has successfully delivered this service to over 33000 patients in Sweden where we also conducted a randomised control trial with 12000 patients which statistically showed a reduction in healthcare utilisation by 30-50%. These results were published in the EJEM in 2013 and 2015.

We are now conducting another RCT in the UK with The Nuffield Trust as the principal investigator to replicate the Swedish results. We have over 7 CCGS already working with us and two years’ worth of data is showing statistically significant reductions of 30% in non-elective admissions and 36% in A&E attendances in the intervention groups.
Stage of Development:
Market ready and adopted - Fully proven, commercially deployable, market ready and already adopted in some areas (in a different region or sector)
WMAHSN priorities and themes addressed: 
Wellness and prevention of illness / Innovation and adoption
Benefit to NHS:

The intervention is co-created and patient goal focused.
First we get to know the patient during a face-to-face meeting with a health coach where we review the challenges the patient faces, agree on some shared goals and make a plan for the future.
Over the next 6-9 months, the coach and patient have regular contact as the patient continues to make progress. Over time, the patient becomes more confident about managing their own condition and seeking the right care, at the right time.
By the end of their coaching program most patients feel confident to continue independently. By this time, the risk of seeking avoidable unplanned medical care has decreased significantly.
Proactive Health Coaching is being delivered together with various CCG partners in England and will be evaluated by the Nuffield Trust on a yearly basis.
By supporting patients with weekly coaching calls, the randomised control trial with NHS Vale and York CCG is already showing high levels of improved patient experience, a reduction in attendances at A&E and fewer admissions to hospital. Patients being supported by their health coaching intervention are also reporting more confidence in the management of their conditions.
From a recent NHS Confed case study (June 2017), results collated by NHS Vale of York CCG are currently being evaluated and published by the Nuffield Trust, an independent health charity. In this early assessment of the trial, this case study covers 183 patients, of which 121 patients have had the support of a health coach, has yielded savings per patient in the first year of the intervention of £1,034 less than the control group. This means that the service is already close to break-even in its first year, as it costs £1,200 per person for a two-year intervention.
Moreover, there are the associated operational benefits from taking activity out of the system. In particular, the intervention group has had 63% fewer non-elective admissions and 60% fewer A&E attendances. The number of bed days was 17% less than the control group. The results also provide evidence of relevance, spread and replicability, with the initiative being easy to replicate, even in financially challenged care economies.
Recent results show a statistical reduction of 30% and 36% in non-electives and A&E attendances respectively. Since 2010 the Proactive Health Coaching service has helped over 15,000 patients to achieve better health, with 90% reporting that their health coach has improved their quality of life.
Initial Review Rating
5.00 (1 ratings)
Benefit to WM population:
Proactive Health Coaching helps increasingly stressed health care systems.
We know that receiving the right care, at the right time is crucial to effective care, but navigating a highly complex health care system can often leave patients feeling overwhelmed or under treated, leading to repeated unplanned hospital visits or admissions. The stress on the system is apparent within emergency departments in the UK that are under increasing pressure as visitor numbers continue to rise.
But reports show that a lot of the health care we provide is avoidable. What’s more, the vast majority of resources end up funnelling to a small number of people. Health Navigator provides an evidence-based solution through non-medical, intensive, short-term coaching for patients with diverse and often complex health needs. Coaching results in reduced costs for this care heavy group and frees up much needed acute resources.
At Health Navigator, we have experienced nurses and AHPS working as health coaches who provide the support needed to understand health conditions, plan care, and enable patients to become more confident in managing their individual health needs.

The intervention is delivered in four phases.
Patient Identification: Identification through a predictive model to ensure the right intervention, to the right patients, at the right time.
Intervention: Non-clinical telephone-based intervention to empower the patient and improve ordinary care – so that avoidable care can be proactively prevented.
Evaluation / Monitoring: Continuous monitoring to ensure resource-efficient effort per patient.
Discharge: When patient is no longer in need of support a decision is jointly taken by patient and health coach to end contact.
Personal Health Coaching has the ability to significantly reduce avoidable healthcare consumption in the West Midlands, reducing costs and freeing up much needed acute resources. Latest results show a statistical reduction of 30% and 36% in non-electives and A&E attendances respectively. If scaled up across the West Midlands this could significantly reduce health inequalities, improve patient outcomes, reduce operational pressures whilst delivering a financial saving.
We are currently working with 3 CCG’s in the region and are seeking additional sites in the West Midlands to join our randomised control trial.

Current and planned activity: 
This is an exciting time for Health Navigator UK. We are encouraged by the progress we are making and are delighted to have secured a number of significant contracts to deliver new and innovative healthcare services in the UK.
Proactive Health Coaching is being delivered together with seven CCG partners in England and will be evaluated by the Nuffield Trust on a yearly basis. We are currently showing statistically significant reductions in the intervention group compared to the control of 30% in non electives and 36% in A&E attendances.
We are at the start of a significant growth phase but acknowledge we cannot do it alone and we are seeking additional sites in the West Midlands to work with.
If you would like to explore this opportunity please get in touch.
What is the intellectual property status of your innovation?:
Held by Health Navigator UK Ltd
Return on Investment (£ Value): 
Return on Investment (Timescale): 
1 year
Ease of scalability: 
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