www.england.nhs.uk

Discussion slides only

The

importance of

clinical

leadership in

establishing

seven day

services

07 February 2017

www.england.nhs.uk

Agenda

• Welcome Rhuari Pike, Programme Lead - Seven Day Services, London

NHS England Sustainable Improvement Team

• Newcastle upon Tyne Hospitals NHS Foundation Trust how strong clinical leadership enabled the development of an Electronic Review Board on the acute assessment suite

Dr Gibbins Consultant Physician

Annette Richardson Nurse Consultant Critical Care

Newcastle upon Tyne Hospitals NHS Foundation Trust

• Croydon Health Services NHS Trust will present The Edgecombe Unit, a front-end consultant-led, multidisciplinary specialist unit which provides a single-point of access for the wider health economy

Dr Reza Motazed Acute Physician and Nephrologist

Croydon University Hospital NHS Trust

• Questions and Discussion

• Summary

Leadership to Support 7 Day Services

Dr Chris Gibbons

Ms Annette Richardson

What have we done since April 2016?

• Established a 7 Day Services Steering Group membership includes 3 Executive Directors

• Established a 7 Day Services Delivery Group

tasked with identifying solutions to achieve compliance Membership: I/T Director, clinicians, support services…

• Clinical leaders identified and engaged in programme of

work: each Directorate has a lead

Background

• From March 2016 audit – of 280 case notes - over 100 from AS

– Compliance low for twice daily reviews (but not all patients require twice daily reviews!)

• An electronic solution was suggested

– I/T team, with AS consultants designed the system

Why an Electronic Review Board in Assessment Suite?

• Main route of admission for medical patients admitted as an emergency to Newcastle Hospitals

• 50 bedded unit

• 60-80 emergency admissions a day

• Consultant presence 0800-2200 7 days a week with 35 consultants providing input

RVI Acute Admissions Unit

Assessment Suite – Electronic Review Board

• Refocused consultant activity

• Identify which patients need to be reviewed by length of time in hospital

• Ongoing clinical review based on clinical need identified by consultants Purpose of the system?

• Developed July and August 2016

• Implemented 30th August 2016 When was it introduced?

• I/T design

• Chris Gibbons- clinical lead for AS + CD reviewed options and advised on development

• Shown at Clinical Governance meetings , emails, face to face discussions

• Floor walkers on Assessment Suite from I/T for one week

What resource/workforce required for

implementation and support?

• Improved the compliance with 14 hour standard and ongoing reviews

• Consultant feedback- helps to inform where to start ward rounds, a good way of handing over patients, those that require a second review get one

• Likely patient flow improvements

What were the benefits?

Time to Review Column Colour 0 – 1 Hours Red

1 – 2 Hours Amber

2 – 14 Hours Green

Over 14 Hours White

N/A (Review Not Applicable) White

• Another IT system

• “I go where I’m told to”

• Does it matter whether they are seen within 14 hours?

Challenges to Implementation

• Clinical engagement with IT team

• Consultants leading the acute take

• Feeling of control and having a safety net

• You don’t always need evidence that something is better – sometimes it just is!

What worked well

• Roll out I/T solution across Trust • Consultant leads for key specialities to

advise on solution • Include ward areas & critical care

Future Plans

Acute Medical Unit

New Edgecombe Unit

‘The Vision’

Dr Reza Motazed

Consultant Acute Physician/Nephrologist

Clinical Lead for AMU and Edgecombe Unit

7th February 2017

The Acute Medical Unit

• Significant capital investment > £1million

• Brand New Unit in Dec 2012

• Initially 4 consultants – 3 juniors

• 42 beds – 14 monitored

Currently

• Further recruited based on activity

• 9 full time Consultants and 9 juniors

• Consultants have various specialty interests with Acute medicine

• 1 Cardiology • 2 Clinical Pharmacologists • 1 Critical care • 1 Endocrine and Diabetes • 2 Renal • 2 Respiratory Consultants

The Acute Medical Unit (cont)

• Consultants on shop floor (Mon – Fri)

– Twice daily AMU WR – Acute take consultant till 9am - 9pm – Aim to see all acute admissions by a consultant within 12 hours

of admission – 3 AMU Consultant on shop floor (8am – 5pm) – Robust 8am Consultant led handover meeting and MDT

• 6 hour AMU WR- seeing day one patient (Sat/Sun) – A seven day service (new patients in AMU being seen by general and care of the elderly physician) The London Quality Standard in terms of twice a day ward round on weekend in AMU not possible due to number of consultant and the on call duties on the shop floor

New Acute Medical Unit

• Evolution since its launch in Dec 2012

• Increase in number of consultant workforce

• Improved in recruitment and retention of permanent nursing staff

• Consultant delivered service 8 am – 8 pm (morning handover)

• Good area of practice – CQC 2013

• Recruitment of extra junior doctor workforce

• Excellent junior doctor GMC survey (2016)

• Review by ECIST as an efficient unit

• Improved in meeting the ‘London Acute Quality Standards,

• Improved patient experience

2/13/2017

CUH Challenges

• High attendance for a DGH (350- 400/ 24hrs)

• Medical workforce does not match patient flow

• Wrong patients transferring to wrong wards (Increased LOS)

• Very late transfers of patients from AMU to wards:

- Patient safety

- Increased incidents (drug errors, poor hand over)

- Frustration of nursing workforce

2/13/2017

Patient Flow vs Medical Work Force

2/13/2017

Idea for the Edgecombe Unit

• Co- location of existing services to improve use and patient experience

• Expansion of AECU ( Ambulatory emergency Care Unit) – due to increasing number of referrals and pathways

• Development of a new services in the form of

– RAMU – Rapid assessment Medical Unit

– ACE Unit – Acute Care of the Elderly Unit

• Re-location of CRT (Croydon Respiratory Team)

Edgecombe Unit – The Future

• New unit will be nationally innovative/revolutionary, centralising and

crosslinking the:

- Rapid Assessment Medical Unit (RAMU)

- Ambulatory Emergency Care Unit (AECU)

- ACE

- Elderly Frailty Unit (EFU)

- Rapid Response Services

- COPD hot clinic

‘All Under One Umbrella’

2/13/2017

Opened 2nd November 2015

2/13/2017

Ethos for the Edgecombe Unit

• Increased Consultant activity with increased hours to 9am to 9pm to match ED patient attendance

• Direct referrals from clinical streamer in ED for patients referred by GP who attend ED

• Direct GP access to Medical Consultant via mobile to discuss patient admission

Ambulatory Emergency Care Unit -AECU

• Praise from patients, staff and external visitors

• Nationally recognised at HSJ award

• Unit has expanded in terms of innovation and productivity:

- Exponential increase in number of patients (800 patients/month, 10-20%

reduction on call workload)

- Improved communication between GP and acute physician

2/13/2017

How we work for you

GP referral Mobile phone Triage by AEC Consultant

9am – 6 pm (Mon-Fri)

Accepted

Ambulatory patient Medically accepted for

admission/assessment (on

call team)

AEC

• Ambulatory care pathway

• Admission avoidance

Unstable patients

A&E/AMU/HDU/ITU

for on-call team

assessment

RAMU or ACE unit

Advice

AECU at CUH • Ambulatory care pathways:

• Low risk pulmonary embolism

• Deep vein thrombosis

• Lower limb Cellulitis

• General Medical pathway (NOT PATHWAY SPECIFIC – ANY AMBULANT PATIENT CAN COME TO UNIT AFTER DISCUSSION WITH AMBULATORY CONSULTANT)

• Close links with medical specialties • Specialty clinics : ACE / COPD / TIA

• Specialist nurses : Diabetes/ Heart failure/ Oncology/ Palliative care

• Supportive services

• Diagnostics: Pathology and Radiology

Future vision for 7 day service

• Successful recruitment of nurse practitioners to the AECU

• In process of looking at the nursing workforce and staffing to extend AECU service

to Sat/Sun (Weekend Nurse led Service)

• In process of discussion for extra AMU consultant support or existing General and

COE physician to support the AECU for input and support on Sat/Sun

• Patients who are on specific ambulatory pathway already presenting to AECU for

on going treatment at weekends

2/13/2017

RAMU

‘Rapid Assessment Medical Unit’

2/13/2017

Current Situation

• Patient referral to medical team:

• Via ED

• Via GP

• Usually after d/w Ambulatory Care consultant on mobile

• If stable goes to Ambulatory for review

• If unstable /unsuitable for Ambulatory review – comes to ED or AMU

• Via Other

• eg Bethlem, Tertiary referral Centre Repat

Current Problems • Poor patient flow as most patients come up to AMU prior to going to

wards

• In order to create space on AMU inappropriate patients

transferred to wrong wards – leading to increased LOS

• Delay in review of GP patients as they often get seen by ED again

and referred

• Poor use of Ambulatory pathways / processes

• Current working hours of 10am – 8pm lead to a proportion of

patients who are referred late being not post-taked and delaying

discharge till the following morning

2/13/2017

The RAMU • 2 bays in Edgecombe unit

• An assessment area for ALL patients who are referred to the medical

team during the day and night and will include

• Referrals from ED

• ALL patients with a Dear Medical Team Letter who present directly

to ED from GP

• Referrals from GP – not physiologically unstable / requiring urgent

resuscitation

(the appropriateness of this can be gauged by the Ambulatory

Consultant taking the referral from the GP over the phone)

• All unstable/ physiologically compromised patients will still be advised to go

to A&E initially

2/13/2017

RAMU Staffing/Support

• On call Consultant – (regular reviews 9am – 9pm)

• Medical on call team – further supported by x 2 Physicians

Associates (day and night)

• Additional Band 5 nurses x2

• Band 3 Staff x2

• Porters

• Extended AMU X-Ray hours

• Urgent processing of bloods from laboratory

• Urgent investigation – Consultant to Consultant discussion to

organise

2/13/2017

RAMU Model

• NOT extension of AMU

• NOT a medical ward

• Requires senior consultant presence for assessment and

management from 9am to 9pm (SpR support over night)

2/13/2017

Functionality

• All patients will be seen by the medical team and be post-taked by the on

call Consultants within 4 hours of arriving on the RAMU (KPI – 4 hours stay)

• Decisions following post-take could be:

• Discharge home

• Discharge home with f/up (GP)

• Refer to Ambulatory pathway/process – following liaison with AECU

Consultant

• Admit to AMU – short stay / for specialty review then home

• Admit to the emergency Frailty Unit following d/w ACE Team

• Admit to Specialty ward

2/13/2017

RAMU Vision

• The vision is that rapid review and decision making will

• Ensure early decision about outcome and hence appropriate ward

destination

• Early discharge with appropriate specialty f/up

• Increased use of ambulatory processes to reduce in-patient bed needs

• Reduced LOS in the medium/ long term

• Improved patient experience

• For 7 day service in RAMU the unit will need extra one AMU physician

for early input into RAMU on Sat/Sun.

2/13/2017

Frailty Unit (Acute Care of

Elderly – ACE unit)

• Increasing ageing population

• The elderly have:

• Higher ED conversion rate

• Longer length of stay

• Increased morbidity and mortality in hospital

• Avoidable harms: catheters, ward transfers, delirium, pressure

ulcers

• Tendency to work in ‘silo’ pathways – primary/secondary care/

social

Frailty Unit (ACE unit) – 7 day Consultant

led Service • 14 bedded unit

• Daily consultant ward round including weekends

• MDT includes dedicated nurse, PT/OT/care manager, SHO, pharmacist (on

weekends access to PT/OT and care manager who are on call)

•

• 3 board rounds a day Mon-Fri

• ACE clinic runs Mon-Fri for rapid access appointments, consultant run but

still full access to the MDT members as needed.

• Rapid diagnostics for both the unit and the clinic

2/13/2017

Criteria

• >70 yrs old for the ACE unit

• Frailty syndrome – falls, confusion, new

incontinence, mobility/functional decline

• Predicted LOS of <48hrs

• Not suitable for ACE:

• Need for a cardiac monitor/NIV

• Where primary problem would better managed by

another speciality e.g. surgery

• Clinically unstable needing longer length of stay

Outcomes at CUH

• Improved early Comprehensive Geriatric Assessment

• Higher patient and carer satisfaction – 100% satisfaction on

friends and family test

• Average in length of stay reduced by 5 days across elderly

care since Nov 2012

• Improved links with primary care

• Cohesive working with rehab team (CICS bed/home),

community services and rapid response , access to step up

beds

• Faster, safe discharges

Since the opening of the Edgecombe unit

So to the success!!!

Since Opening

• Over 26000 patients have presented to the unit

•50% of patients that attend the unit complete their pathway within the unit

•Circa 20% reduction in the number of medical admissions (10-15 per day)

•The unit has been commended by the latest ECIP report (2016)

•Improved ED performance

Length of Stay

• Trustwide LoS

• 5.4 days 2014/15

• 4.5 days 2015/16

• Medical LoS

• 6.7 days 2014/15

• 5.4 days 2015/16

• Care of the Elderly Los

• 4.6 day reduction within 9 months

‘What will Edgecombe Unit Deliver’

• Reduce LOS

• Improve patient journey and experience

• Improve relations between GP/ED/AMU/Specialties

• Lead to improved morale

• Better use of existing services

• Reduce need for current bed base/escalation beds

• Deliver a sustainable model of care to effectively deliver ED performance targets

• Act as a gate keeper to the admission profile of the organisation and preventing

unnecessary admissions

• Future Goal – To aim and implement 7 day service in AECU and a more

robust Service in RAMU on Sat/Sun

2/13/2017

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Discussion & Summary

• Let us know if you have any work you would like to

share

• or if there are other topics you are interested in

Email: england.si-7ds-support@nhs.net

www.england.nhs.uk

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7 Day Services: Top Tips to Engage Your

Stakeholders

• Tuesday 7th March 2017

• 13.00-14.00hrs

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