11.1 - ruh winter planappendicies · ruh surge and escalation (winter plan) 2013/2014 1...

Author: Clare O’Farrell Divisional Manager Sophie Spencer, Speciality Manager. Document Approved by: Francesca Thompson, Chief Operating Officer

Date: 17 October 2013 Version: v4.0

Agenda Item: 11 Page 1 of 83

RUH Surge and Escalation (Winter Plan) 2013/2014 1 Introduction 1.1 The Royal United Hospital Winter Plan sits as part of the Bath Health

Community Winter Plan led by Bath and North East Somerset Clinical Commissioning Group. The Bath Urgent Care Network winter plan for 2013/14 requires all providers to plan to support sustained delivery of the RUH 4hour 95% access target. The RUH winter plan will be monitored internally at the RUH Urgent Care Board and the whole community plan will be monitored at the B&NES Urgent Care Network and Bath Urgent Care Board.

1.2 This paper only covers internal RUH plans and the full community plan will be

completed and shared with Management Board in October 2013, the completion of this integrated plan will be led by the newly appointed Urgent Care Network Programme Lead.

1.3 This paper outlines the additional resource planned over the 2013/14 winter

period to support sustained delivery of the Royal United Hospital (RUH) 4 hour 95% access target. This details the agreed ECIST projects that have been funded by CCGs from 70% threshold monies to the value of £1.9m.

1.4 To support planning in 2013/14 the RUH have developed a capacity model,

identifying the periods of capacity pressure, see appendix 1, this plan has been shared with all community providers and a request made that winter plans identify all providers agreed response.

1.5 The community has now completed bids for the additional £4.4m winter funding and final confirmation is expected by the middle of September, please see appendix 2 for a summary of all funding bids submitted for all providers across the community. Winter funding bids require full community engagement to deliver recovery, and sustained delivery, of the RUH 4 hour performance, demonstrated to NHS England by a co-signed letter confirming all organisations commitment. The RUH Winter plan identifies the risks that remain to delivery in section 9.

2. Surge/Winter Planning Leads

Author : Clare O’Farrell, Divisional Manager Medicine Sophie Spencer Speciality Manager , Document Approved by: Francesca Thompson, Chief Operating Officer



Name Title Contact Details: Executive Lead: Francesca Thompson

Chief Operating Officer

[email protected] 01225 825952

Management Lead: Clare O’Farrell (Urgent Care Network Member)

Divisional Manager Medicine

clare.o'[email protected] 01225 825397

Critical Care Leads: Claire Damen Andrew Georgiou

Anaesthetic Services Manager ITU Clinical Lead

[email protected] [email protected]

The RUH is a member of the Bath Urgent Care Network and the RUH Surge/Winter plan has been peer reviewed by the network to provide assurance of operational readiness. See appendix 11 for 2013/14 Winter Plan Peer Review Preparation from the RUH. This covers the RUH operational readiness for:

• Stroke • Catheter Care • Respiratory conditions • Control of Infection • Frail elderly assessment

3 Capacity Model 3.1 The RUH has projected 4 hour performance over 2013/14 winter based on

activity trends for the last 5 years and 4 hour performance based on the historical ratio of breaches to attendances (outlined in ED Performance delivery – winter 2013 shared with the B&NES Urgent Care Network) see appendix 1.

3.2 This planning identifies some specific periods when it is projected 4 hour

performance will drop below 95%. This modelling also confirms the shortfall in discharges is predominantly on a Sunday or Monday so planning, across the community, will focus attention on weekend capacity as far as possible.

3.3 It is noted that the ratio above 150 attendances is for every extra 10 attendees

there will be on average 2 breaches. Based on this assumption any sustained period of circa 200+ attendances will continue to impact the Trusts ability to sustain 4 hour performance at 95% target.

4 Key areas of focus




4.1 During winter, clinical services within the Trust can experience:

• Increased numbers of patients attending the Emergency department • Increased length of stay due to higher acuity of patients • More complex discharge planning

4.2 Further to this the Trust will often experience over winter:

• Outbreaks of infection within the Trust and community which can both prolong lengths of stay and lead to bed and/or ward restrictions

• Periods of severe weather or flu outbreaks causing increased patient attendances and reductions in staffing numbers

4.3 The Trust also recognises that over the winter period it is not possible to

sustain high levels of elective admissions. In 2013/14 elective work will be reduced in a planned way to create capacity for non-elective patients.

Assessment and Admission (Operational Readiness)

4.4 The RUH has undertaken a number of initiatives to improve the assessment

and admission of emergency patients in the accident and emergency service, Medical Assessment Unit and Surgical Assessment Unit. The operational arrangements within these areas to facilitate the assessment and admissions are detailed below:

4.5 Accident and Emergency Service

• With the appointment to 10 WTE Consultants the ED department will introduce Senior with a team (SWAT) this is based on the recommendation from the ECIST to introduce a Rapid Assessment and Treatment model.

• ED co-ordinators and flow assistants will ensure that the patient pathway experiences minimal delay and that any issues are expedited.

• Patient flow in accident and emergency is monitored and escalation criteria have been incorporated into the new RUH Escalation policy to ensure a Trust wide response to support patient flow out of ED.

• Ambulance arrival screens provide up to date pre-arrival information. The RUH focus on ensuring that ambulance handover processes are efficient and support clear transfer of care maintaining high levels of patient safety and experience.

Graph of RUH time to initial assessment on arrival




(This reflects the point when ambulance handover occurs)

• The rapid chest pain service operates seven days a week on MSSU for patients presenting to the Accident and Emergency Department

• The Emergency Department has access to an adjacent Observation Unit. • Patients requiring admission may be transferred to one of the three

Assessment Units (Medical, Surgical or Paediatric) • The emergency department now have access to primary care records

through TPP 4.6 Hard to Reach and Vulnerable Groups The Mental Health Liaison team for adults of working age and older adults will

continue to support the Emergency Department and Older Persons services over the winter period. Avon and Wiltshire Mental Health Partnership NHS Trust has received additional winter funding monies to extend the hours of the Mental Health liaison team for 8am to 8pm and put in place a member of the intensive team overnight specifically focused on the RUH ED. The Alcohol liaison team will continue to provide a reduced service over the Christmas and New Year holidays.

Both Mental Health and Learning Disabilities patients are supported at the RUH by a corporate role, Sister for Mental Health and Learning Disabilities. This role supports all patients identified prior to admission, particularly elective patients and will start to work with the patient, family and carers prior to admission. The role also provides support to emergency admissions and the post holder can be contacted on admission by acute assessment and/or ward teams to provide specialist support as required.

4.7 Critical Care




• The RUH has an 11 bedded Critical Care Unit which can accommodate up

to 7 level 3 patients and 4 level 2 patients, as well as an 8 bedded Coronary Care Unit.

• The Trust can if necessary access additional capacity by either admitting additional patients to PACU or mobilising PACU staff to admit additional patients to CCU. Every effort is made to avoid transfer of critically ill patients for non-clinical reasons.

• The RUH is not part of a formal Critical Care Network, however good informal networks are in place with local trust. If transfers are made outside of the local clinical networks sign off is required from a member of the executive team.

• The RUH is part of a local major trauma network. The major trauma centre is located at Frenchay Hospital, part of North Bristol Trust. Good relationships already exist between the RUH and the MTC to ensure prompt transferal of patients between these two centres, including processes for appropriate escalation if transfers are delayed.

4.8 Medical Assessment Unit

• The medical cover for the Medical Assessment Unit is provided predominantly by four acute physicians during in week working hours (Monday – Friday 8am to 6pm) this will increase to 6.7 WTE following pending appointments. Supported by a physician and on-call consultant physician out of hours cover

• Ambulatory care is adjacent to MAU; all GP calls are received by the senior nurses in ambulatory care and signposted to the appropriate service. This service has significantly increased its capacity in 2013/14.

• It is the intention that patients stay a maximum of 12 hours only on the Medical Assessment Unit

4.9 Surgical Assessment Unit

• Consultant cover is provided by the General Surgeon on call and the Emergency Surgery Consultant.

• The new Emergency Surgical Assessment Clinic has been introduced in 2013/14, this is reducing LOS, avoiding ED attendance and reducing admissions.

• All GP calls are received by the Medical Nurse Practitioner and signposted as appropriate.

• As with the medical assessment unit it is the intention that patients stay a maximum of 12 hours only on the Surgical Assessment Unit.

4.10 Emergency Admissions




• Stroke patients should be admitted directly from ED to the Acute Stroke

Unit, normally via CT. In April 2013 two additional Stoke Consultants started in post, providing 7 day ward rounds and opening a 7 day TIA service.

• Fractured necks of femur patients are admitted directly to the Trauma ward (Forrester Brown).

Elective Admissions and Referral to treatment target

4.11 Non-elective pressures over the winter months tend to place significant pressure on elective referral to treatment (RTT) times outlined in the NHS constitution. Competition for available beds leads to delays in bed allocation, and subsequent cancellations. This provides a poor patient experiences and inevitably leads to poor performance in line with managing patients who have breached the 18 week target (‘Backlog’)

4.12 In the past, the Trust has tried to manage both 18 week and 4 hour targets,

while maintaining high standards of patient care. It is recognised that inevitably this can lead to late decision making and a reactive rather than proactive approach to flexing activity up or down.

4.13 Over winter 2013/14 the RUH plans to seek additional elective activity from

other providers, while proactively reducing elective admissions at the RUH during periods of high non-elective demand. A ‘Winter Timetable’ for elective work will be enacted in advance with a shift from inpatient to outpatient activity. A ‘Summer Timetable’ will then be reintroduced once non-elective pressures ease. By combining the planned reduction at the RUH with outsourcing to alternative provides the Trust will continue to manage patients NHS constitutional rights and maintain the backlog at a sustainable level. (See Appendix 10 for full surgical elective plan)

4.14 The RUH plans to move to a winter timetable only if sustained operational

pressure affects the ability for the Trust to operate electively. It is anticipated that specialties can move to the winter timetable in 7-10 days and the Trust will work with alternative providers to ensure elective operating continues if this is enacted. Processes are already in place to transfer patients to these alternative providers if appropriate.

Site Management 4.15 Elective and emergency beds are managed by the Clinical Site Management

and bed management team with support from the clinical divisions. 4.16 In preparation for Winter 2013/14 there had been additional investment into

the bed management team so that a medical and a surgical bed manager is




available on Monday to Friday early and late shifts and a day shift on Saturday and Sunday.

4.17 The Clinical site and bed management team access discharge information

from the RUH Millennium (Patient Administration System) bed board which updates in real time from the patient administration system. This has now been rolled out and is live on all wards. All wards are asked to declare potential discharges via the bed board before 12pm.

4.18 Daily bed planning meetings are held at 0900, 1300 and 1600 chaired by the

clinical site manager with representation from the clinical divisions, discharge liaison and in reach teams.

4.19 On a daily basis there is senior medical and surgical nurse coordinating ward

staffing levels for the divisions. 4.20 The Trusts escalation policy has been reviewed and up-dated. At every

escalation level the Trust has developed and agreed action cards for all key clinical areas, this new policy will be fully implemented from September 2013. The Trusts escalation status is up-dated three times a day and is visible on Millennium and Trust wed site.

4.21 The Clinical Site Team and ED Co-ordinators update the Capacity

Management System (CMS) on a two hourly basis. Holiday Planning - RUH

4.22 Additional operational planning is in place for the October half term period when the RUH has experienced unplanned escalation in previous years. As part of this operational planning staffing will be regularly reviewed to ensure staffing levels are sufficient.

4.23 Operational plans will also be in place for Christmas and New Year which will be communicated in advance, as with half term these plans will specifically review staffing levels. An identified operational manager and executive lead will be available throughout this period to support the Clinical Site Team. Elective activity will be reduced from the 23rd December to 5th January.

5 Transfers and discharge 5.1 As part of the newly introduced ward standards all patients should be aware of

their expected date of discharge and discharge planning is action on admission. This should be further supported by the 7 day ward clerks and discharge coordinators for every ward which has been requested through winter pressure money.

5.2 A list of all patients who are medically and therapeutically fit to leave the hospital is held as the ‘Green to go’ list. This is shared on a daily basis with




community in reach teams and reviewed at the three times a week meetings, including the weekly sit-rep meeting.

5.3 Patients with a length of stay greater than 14 days are reviewed daily by the

Matrons, in line with ECIST guidance. Snap shot reviews of patients at a LOS of 7 days, again following the ECIST guidance can be completed at periods of pressure.

5.4 Wiltshire, Sirona and from 2013/14 Somerset in reach teams are present in

the Trust to work with the discharge liaison team to expedite discharge. Wiltshire and Sirona are piloting 7 day working in 2013/14.

6 Severe Weather Procedures 6.1 The Royal United Hospital NHS Trust’s business continuity plan for severe

weather procedures has been developed to provide guidance when normal business activities have been affected by severe weather which causes difficulties for staff, patients and visitors in attending the hospital or its periphery clinics.

6.2 This guidance is part of the Trust’s Business Continuity Plan and can be used

either as part of the overall plan or in isolation to deal with specific instances of inclement weather; these include flooding, storms causing roads to become blocked and snow and ice.

6.3 The aim of these procedures is to maintain safe staffing levels, to safely

manage a likely increase of trauma patients presenting through the Emergency Department and to rebalance the emergency and elective activity.

6.4 If the plan is activated Command and Control will follow the Major Incident

model and both Bronze and Silver Commands will be established. 6.5 The On-Call Manager, Site Manager and Bed Managers will support the

Incident Coordinator (Bronze) who will be assisted by a second-on Manager. 6.6 A copy of the business continuity plan for severe weather procedures is

included as appendix 3. This plan was last updated in August 2013. 7 Pandemic Flu Planning 7.1 The Royal United Hospital NHS Trusts Pandemic Influenza Contingency Plan

had been prepared with reference to Word Health Organisation and UK Department of Health Pandemic Flu guidance documents (November 2007 and post swine flu guidance 2010).

7.2 A copy of the Trusts Pandemic Influenza Contingency Plan is included as

appendix 4. This plan was last updated in 2009.




Flu Vaccination: 7.3 The flu vaccination will be offered to all staff at the RUH, working to the target

of 75% (3100 staff) of staff to be vaccinated. Staff can attend a central vaccination clinic or a clinic in their local work area. There are 26 agreed vaccination centers around the trust and 60 nurse vaccinators. Vaccination clinics will start from the 14th October. The dates and times of flu vaccination clinics will be communicated to staff through newsletters both printed and via email. The dates will also be cascaded through department meetings.

The vaccination campaign is being coordinated by the Acting Nurse Manager,

Occupational Health and the Business Partner, Surgical Division providing HR support. It is anticipated that inpatients at the RUH will receive the flu vaccination from their GP surgery if appropriate.

8 Infection Control 8.1 The Royal United Hospital NHS Trusts Norovirus Management Plan outlines

the actions taken for infection control in the event of a Norovirus outbreak, included as appendix 5. This plan was last updated in August 2013.

8.2 The first priority will be to keep patients safe at all times. In 2013/14 infection

control has been integrated with winter planning to ensure patients are placed into the most appropriate bed to minimise the spread of any infection. New actions to address issues highlighted from previous years include:

• Review of infection issues at site meetings, all direct admit areas to be

visited every morning by the infection control team, with all other wards visited daily.

• In an outbreak decision making regarding cleaning brought forward in the day so that decisions are known for the 1pm Site Meeting.

• Infection control conference call at midday when more than 3 ward areas are affected

• Infection control on-call arrangements at weekends/bank holiday during an outbreak from 1st October until 31st March.

An outbreak occurring in hours would be discussed by the Clinical Site Manager, Ward Manager and Infection Prevention and Control Team to agree a plan of action. A decision whether a ward should be closed to admissions is made by the Infection Control Team or the on call Medical Microbiologist. In the event of an outbreak occurring at the weekend/bank holiday, the on call Medical Microbiologist would be contracted for advice.




8.3 There is a daily review of infection issues at the 0900 site meetings. All direct admit areas are visited every morning by the infection control team. As outlined in the Trusts Norovirus Management Plan when 3-5 whole wards are closed or the outbreak has lasted longer than 2 weeks daily outbreak meetings are instigated.

9 RUH Response to Capacity Model - Planned and Unplanned Escalation

In response to the RUH capacity model (Appendix 1) the Trust has been assessing our ability to respond to the identified periods of predicted pressure. This is described in the section below as planned and un-planned escalation response. This work has necessitated a review of the RUH Bed Model and in October 2013 the RUH has agreed to work collaboratively with the Royal Devon and Exeter Foundation Trust to assess the RUH assumptions using the RD&E bed model. This work will not be fully completed until November 2013. The RUH have no plans to close any beds during 2012/13.

9.1 Planned Escalation: The RUH has identified three responses for planned escalation:

• Swing Ward Capacity (Allocating beds from Surgery to Medicine) • Medical Team for Outlier’s • Efficiencies gained from Urgent Care Improvement Projects

9.1.1 Swing Ward Capacity

The RUH has used the current bed model and winter capacity model to agree to swing capacity from Surgery to Medicine from November 2013. This will transfer 12 in-patient beds on Charlotte Ward (Gynaecology) to Medicine from the 1st November 2013 until 31st March 2014.

9.1.2 Medical Outlier Team

The RUH have identified the need to increase the medical cover for outliers. The impact of high numbers of outliers seen in 2012/2013 was a significant increase LOS for non-elective patients.

The outlier team of two consultants, three SHO’s and allocated therapy (Physiotherapy and Occupational Therapy) will ensure outliers and the swing beds on Charlotte ward will have clear medical support, with morning ward rounds, Monday to Friday.




This will release speciality medical teams to support core wards and provide additional urgent clinic capacity, providing Medical and Surgical assessment units with additional admission avoidance capacity.

9.1.3 Urgent Care Projects

The RUH has a number of Urgent Care Projects, agreed with the ECIST, which will positively impact on RUH 4 hour performance by focusing on the following areas:

• Increasing senior assessment at the front door, rapid assessment and treatment in ED and creating more short stay pathways (Front Door)

• Improving patient flow through the hospital (Flow) • Planning for discharge (Back door)

These projects each have specific KPIs to ensure that the Trust monitor’s their impact monthly; performance is reviewed at the Urgent Care Programme Board. The projects identified within the Winter Funding bids will be managed within the same performance framework.

A summary of the RUH (ECIST) Urgent Care Projects, KPIs and implementation dates are outlined in appendix 6 and the RUH winter funding money urgent care projects are outlined in appendix 7. The full lists of project KPIs and current performance are included within appendix 8.

The Trust wide urgent care Key Performance Indicators (Used as indicators to ensure 4 hour delivery) is included as appendix 9. The September Urgent Care Improvement Board has review and approved the KPIs. The summary for all planned escalation responses is to mitigate the use of unplanned escalation.

9.2 Unplanned Escalation The RUH has identified two responses for unplanned escalation:

• Unplanned escalation bed capacity • Green week escalation response

9.2.1 Unplanned escalation bed capacity

The table below details the escalation capacity that the Trust would use respond to demand surges, support the management of D&V outbreaks and respond to severe weather.




Area: Number of Beds:

Comments:

Charlotte 10 Female only Acute Stroke Unit 2 1 Male and 1 Female, Stroke only. This

will support the national stroke target. Surgical Short Stay Unit

22 Male or Female. This would impact RTT delivery.

Day Rooms 2 Male or Female To be used as the last escalation capacity. Both have been risk assessed for use in escalation.

Total 36 9.2.2 Green week escalation response

The RUH has held two rapid improvement weeks for urgent and emergency care, in May and October 2013. These weeks have encouraged teams to consider piloting different ways of working. A number of these have been incorporated into the RUH escalation action cards; however the weeks have also provided a command and control structure that can be replicated for unplanned escalation. The RUH in extreme escalation would look to rapidly implement the Green week structure and support structures such as:

• Bronze and Silver command • Ward liaison officers deployed • Inpatient diagnostics prioritised • Non-essential meetings cancelled

9.3 Staffing Resource to support Planned and Unplanned escalation

The RUH Urgent Care Improvement Board has been regularly reviewing progress against recruitment of staff to key urgent care projects. This has ensured that plans are robust and will deliver to the agreed implementation dates. This is being monitored weekly at the RUH by the Winter Investment Group, chaired by the Chief Operating Officer. The RUH has continued to closely monitor sickness and vacancies for four key staff groups (These are also the staff groups that will have been impacted by approved winter funding bids):

• Trained Nurses • Untrained Nurses • Medical Staff




• PAMS

The Flu vaccination programme has been accelerated from early October 2013 with the aim of achieving 75% uptake.

The graphs below demonstrate that the RUH improved position for both sickness and vacancies; this will continue to be closely monitored on a monthly basis.

The RUH HR team will continue to ensure sickness is managed efficiently and regularly reviewed. The graph above does not show any significant increase in sickness levels in January to March in previous years.




The performance until August 2013 will have included staffing for all planned escalation. The RUH is continuing to focus on recruitment to Health Care Assistants (HCAs). The Increase in the final quarter for vacancies includes all ECIST and winter funding bids. If required for staffing will be supported by the RUH Staffing Solutions team providing bank and agency options to fill requests for all of the four key staff groups. All unplanned escalation areas have agreed staffing plans to support opening and these plans ensure that each area would be supported by a core of permanent RUH staff to ensure patient safety and quality of care is maintained.

10 Communications

Links with communications teams at the CCGs will be developed to ensure that robust systems are in place for distributing winter messages to GPs, along with publicising correct use of the healthcare system.

A range of communications tools will be used to publicise messages around issues that will affect the health community including:

10.1 Severe weather – in the event of severe weather, existing channels (e.g.

website, social media, media) will be used to publicise messages to staff about how to get in. Advice will also be issued to the public about staying safe in cold weather, and not coming to hospital unless absolutely necessary.




10.2 Infection outbreaks – All existing channels will be used to publicise when infections have caused restrictions on visiting, and the public will be informed via media/website/social media about not visiting if they have been ill in the last 48 hours etc.

10.3 Additional funding – Communication team will report internally and externally about how the additional funding is being used to address normal winter pressures and the difference it is making

10.4 Pressure levels – Messages about high pressure levels will be

communicated internally and externally in accordance with the new Escalation Policy.

10.5 Flu – The Communications team is providing support to the Flu vaccination

programme, publicising availability of vaccines and messages about the benefits of the jab, to ensure that at least 75% take up is achieved.

11 Risks The RUH has assessed the key risk’s to sustained 4 hour performance, these are outlined in the table below:

No. Risk Mitigation Score 1 Recruitment for

Urgent Care Projects

Weekly review of progress at RUH Winter Investment Group. Prompt advertising of posts. Where we are unable to recruit to fixed term posts agency locum will be explored

12

2 Increase in demand for non-elective care off sets the benefits of the additional resource

Urgent Care Working Group to review key community wide daily/weekly metrics. Monitoring of demand by whole health community through Urgent Care Network meeting

12

3 Attendances increase resulting in ED pressure (Impact of NHS 111)

Monitoring of demand by whole health community through the Urgent Care Working Group and Urgent Care Network meetings.

12

4 Community capacity does not sufficiently support back door flow

Robust winter planning by all community providers, with system wide leadership from Urgent Care Board.

16

5 Flu Pandemic threatens business continuity

Flu plan reviewed and in-place for the RUH. Community wide Flu response would be led by Public Health and CCGs. Urgent care network to risk assess all

12




organisations flu plans as part of Community Winter Plan.

6 Reduction of DTOC levels at the RUH is not achieved.

RUH has established a ‘Green to Go’ project, working on a number of areas. (To date improved performance cannot be sustained) Wiltshire has established a DTOC review group to lead on Wiltshire wide plans.

16

12 List of Appendices:

Appendix 1 RUH Winter Capacity Model (Included)

Appendix 2 RUH Business Continuity plan for Severe Weather (Attached)

Appendix 3 RUH Pandemic Influenza Contingency Plan (Attached)

Appendix 4 RUH Nor virus Management Plan (Attached)

Appendix 5 Summary of RUH (ECIST) Urgent Care Projects (Included)

Appendix 6 Summary of RUH (Winter Funding) Urgent Care Projects (Included)

Appendix 7 RUH (ECIST) KPI Performance Report (Included)

Appendix 8 RUH Urgent Care Improvement Board Trust Scorecard (Included)

Appendix 9 RTT Winter Plan (Attached & Not for external circulation)

Appendix 10 2013/14 Winter Plan Urgent Care Network Peer Review Preparation (RUH)

Appendix 11 RUH Winter Funded Urgent Care Projects, KPIs, Funding Summary and Individual Project Cases (Bids)




Appendix 1: RUH Winter Emergency Capacity Modelling Introduction The Bath Urgent Care Network winter plan for 2013/14 will require all providers to plan to support sustained delivery of the RUH 4hour 95% access target. To support organisations in their own capacity planning, the RUH has completed an exercise to predict when the hospital will be experiencing significant operational pressure. All organisations are asked to ensure that their plan identifies these pressure periods and details the actions that they can take:

• Before these periods to prevent 4 hour failure at the RUH • The ability to respond quickly to capacity pressures at the RUH

Key Messages for Planning:

• The variability within hospital admissions and wider external factors such as

weather make it very difficult to predict by day admissions and performance. This model should only be used as a tool to give indicative days or periods of time when the RUH is likely to be experiencing operational pressure.

• The model only uses average attendances and average discharges. Based on some initial investigation the range for these two differs significantly and further work may be required to better understand the variability and thus risk on the Trust.

• Based on the initial modelling which is available by day, the shortfall in discharges is predominantly on a Sunday or Monday. It is therefore important that these extra discharges are timed to peak pressures within the Trust.

• This model does not factor in any of the changes currently being carried out by

the RUH as part of its ECIST recommendations. The RUH will work with this model to confirm its own plans

• If further discussion regarding this model or daily information is required please

contact Michael Oliver, Hd of Business Intelligence at the RUH.




Methodology • The model is by day from the 1st of October 2013 until the 31st March 2014.

Daily data is available if required.

• Activity trends for the last 5 years have been used to under pin the assumptions in the model. These are calculated based on the average admissions and discharges by day of the week and then week of the year.

• 4hr performance is calculated based on the historical ratio of breaches to attendances.

• Elective activity is based on RUH Current winter plan for 2013.14; however this does not differ materially from historical trends when elective activity is reduced. This means that the Trust is currently expecting to see from Nov through until Feb an increase in the RTT backlog to ensure admissions during busy periods are being reduced and mitigate against the likelihood of significant elective cancellations. See appendix 10.

• Additional Discharges required is based on the gap between admissions and discharges during the week. Note that RUH pressure is greatest on Sunday and Monday so responses should support discharges at these times.

• It is not currently possible to model in length of stay although this can be explicitly assumed as part of the admission and discharge assumptions.

• This modelling is not by CCG and given the variability in the data this would be unwise to apply as an assumption. Over the total period a rule of thumb of RUH activity (40/40/20) could be applied.

• Day and Week RAG Rating is based on:

� Net admissions and discharges in day � Cumulative net admissions against discharges over a 7 day period � The week has then been flagged as black if the indicators are triggered on

every day of the week.




Summary Monthly activity and Performance

Oct Nov Dec Jan Feb Mar

Attendances 6344 6083 6193 5958 4804 5566

Admissions 2979 2856 2908 2797 2256 2613

Elective Adm 2708 2559 2233 2566 2292 2473

Breaches 339 351 323 276 152 219

Performance 94.7% 94.2% 94.8% 95.4% 96.8% 96.1%

Assuming Trust performance during 2013.14 YTD is at 95% by the 1st of October this will deliver a performance of 95% for the Year. The assumption in this model is that the Trust will deliver 95.2% performance for the last 6 months of the year. This leaves no allowance for other factors e.g. Snow and Norovirus. Weekly activity and Performance




The following table gives the main summary for providers to use to assess winter plans against:

Triggers: The key assumption to delivery of 4 hour performance is the number of attendances into the ED department. The table below demonstrates the number of attendances at the RUH and the impact this has on breaches. Based on trends over the last 5 years the 95% performance target is maintained at circa 190 attendances. The ratio above 150 attendances is for every extra 10 attendees there will be on average 2 breaches. Based on this assumption any sustained period of circa 200+ attendances will continue to impact the Trusts ability to sustain 4 hour performance at 95% target. During 2013 (highlighted below in red) the number of breaches to attendances was significantly higher with the trigger point around performance at 170-180 attendances.




ED Ambulance Conveyance

Highlighted above is the End of September and whole of October where the ambulance conveyance rates in 2011/12 and 2012/13 were on the increase from the summer period and well above the average for the year. This matches RUH assumptions.

95%




Appendix 5 – Summary of RUH (ECIST) Urgent Care Projects

No. Project Impact Description Start

date

Metric

Front door

1.1 Ambulatory

Care Medicine

- Unplanned admission

avoidance

- Reduced LOS

Ambulatory Care provides a location for

the assessment of less sick patients who

are likely to be able to return home the

same day focusing on admission

avoidance. In May 2013 the elective

work was transferred from Ambulatory

Care to the Medical Therapies Unit.

With the removal of this elective

activity there is significant opportunity

to repatriate non-elective patients

currently treated on MAU which

nationally have been identified as

patients who could be treated through

an ambulatory care pathway.

May

2013

- Number of non-elective patients

seen in

ambulatory care,

per month

- Number of patients

discharged from

MSSU with 0-3

days

In July 2013 140 non-

elective patients

were treated

through Ambulatory

Care equating to 16

beds saved

1.2 Surgical

Emergency

Pathway


avoidance

- Reduced LOS

The aim of this project is to improve the

emergency surgical pathway for

category C/D (see NCEPOD

classification) patients, thus reducing

length of stay by;

• Providing consultant led ring fenced emergency theatre lists

• Providing consultant led daily urgent GP access clinic, with access

to diagnostics, within the Surgical

Assessment Unit (SAU)

All patients are assessed, admitted and

treated in this fast track pathway

minimising length of stay and risks

associated with that. Those already an

inpatient will have the risk of being

cancelled on the theatre 1 list

significantly reduced, again reducing

LOS and increasing speed of post-

operative recovery. Those seen in the

emergency clinic will have a senior

review and decision made as to their

management- sent home and listed for

next day, or admitted for theatre that

afternoon. These will both reduce LOS.

May

2013

- Number of patients seen in

urgent clinics

- Pre-op length of stay for cat C/D

theatre list


deteriorating

from C/D lists to

A/B due to

theatre 1

capacity

In first three months

reduction in pre-

operative length of

stay from 5 to 0 days

1.3 Acute Oncology - Unplanned admission

The Acute Oncology service supports

patients who either have acute

April

2013

- Review by Acute Oncology Team




avoidance

- Reduced LOS

complications of non-surgical cancer

treatment or an emergency caused by

the disease process, whether the

primary site is known, unknown or

presumed. The aim is to avoid

admission non-electively or to support

patients to directly access appropriate

services (e.g. day care).

To support these patients the acute

oncology service has introduced;

• An acute oncology nurse specialist working out of ED

• 24 hour support helpline • 5 day a week opening for day care

unit

• Availability of acute oncology outpatient slots as a direct

alternative to admission.

• Transfer of most oncology chemotherapy regimens previously

given as an in-patient.

within 24 hours

of admission

- Number of patients whose

admission was

avoided through

consultant lead

intervention

In the first four

months the team

have avoided 324

admissions through

Consultant

intervention

1.4 ED

Implementation

of SWAT (Senior

with a team)


avoidance

- Reduced LOS

SWAT Additional Consultant and

nursing staffing within ED to provide

early senior assessment and team

management of undifferentiated

‘majors’ patients. Major’s patients will

receive initial assessment by a

consultant within 30 minutes of arrival;

this will define a care plan and make a

decision whether the patient requires

admission or referral to an in-taking

specialist team. The Consultants team

will then take over the patients care

plan.

Oct

2013

- % of patients with time to

treatment ≤60

minutes

- % of patients admitted

1.4% reduction in

admissions planned

for 2013/14

1.5 FOCUS

(Frail Older

people’s

comprehensive

care unit for

short stay)

- Reduction in OPU LOS

FOCUS Based on the Poole model for

RACE (Rapid Assessment Consultant

Evaluation) this is a consultant driven

care pathway with intensive nursing

and therapy input. The aim is to

significantly increase the number of

patient’s discharged with a LOS of less

than two days. A number of other

benefits were identified by Poole

including accelerated initiation of

appropriate treatment, reduction in the

number of admissions to inpatients

beds, more appropriate placement of

patients and a reduction of patients

Oct

2013

- % of FOCUS patient group

with LOS ≤2 days

- FOCUS patient group average

LOS (days)

10% increase in

number of patients

discharged LOS ≤2

days planned in 12

months




admitted to other clinical speciality

beds.

1.6 Urology Nurse

Practitioners


avoidance

The project will support the recruitment

of two specialities nurses to improve

the management of urethral and

suprapubic catheters across the Trust.

The Urology nurse practitioners aim to

avoid admissions to the Trust and will

support ED in the following ways;

• Be available on mobile phone to respond to all inpatient and primary

care requests for advice. Divert

patients from ED/SAU to Urology

OPD where possible

• Visit ED daily, and be first port of call to deal with

catheter/nephrostomy problems

(approximately 30-50 attendances

per month)

Jan

2013

- Number of catheter patients

seen within the

Emergency

Department

- Number of catheter patients

diverted from

the Emergency

Department to

Urology

Outpatients.

Avoidance of

between 30-50

admissions per

month

1.7 Implement

Internal

Professional

Standards for

response to

ED/MAU/SAU


avoidance

Internal professional standards for all

hospital specialties outlining standard

responses to the hospital front door

areas – ED/MAU/SAU. Project is

working on establishing audit process

for KPI.

Nov

2013 –

to be

fully

implem

ented

- Time to doctor review in ED (30

minutes)

Maximum of 30

minutes to specialty

review in ED

Flow

2.1 Ward standards - Reduction in LOS

Implementation of ward standards

across all Medical and Surgical wards.

These standards have been developed

and include expectations for wards

around discharge planning (e.g.

declaration of all discharges before

1pm, all patients to have EDD on white

board). All hospital wards will use an

electronic bed board. All ward white

boards are being upgraded.

Sept

2013

Under

review

by DON

- % of non-elective adult discharges

before 1pm

- % EDDs on Millennium

Help facilitate 10%

increase in number

of patients

discharged before

1pm in 2013/14

2.2 Access times to

Cath Lab

- Reduction in cardiac LOS

Ensuring Inpatients do not wait

inappropriately long for Cath Lab

procedures. This in turn will reduce LOS.

March

2103

- No of patients waiting over 96

hours weekly

Planned reduction in

2013/14 from a

baseline of 20 to 0.

2.3 Escalation

Policy

- Reduction in LOS

Agreed Escalation policy for

management of surge in demand.

October

2013

- Average number of escalation




Action cards for all key staff members. beds one

(midnight

snapshots)

- Maximum number of

escalation beds

open (midnight

snapshot)


escalation beds open

from 2012/13

baseline of 35

2.4 Hip Fracture

Pathway

- Reduction in LOS for hip

fracture

patients

Focus on NICE guidelines and Best

Practice guidance for hip fracture

patients to ensure appropriate

management of this patient group and

reduce LOS. This includes additional

therapy investment.

Sept

2013

- % of Hip Fracture patients

discharged to

their usual place

of residence.

- Average LOS for Hip Fracture

patients.


LOS from 16 days to

10 days

2.5 Dementia

Challenge

Initiative

- Reduction in OPU LOS

The aim of the project is to make sure

patients with dementia receive the right

care at the right time. This will be

achieved through ensuring patients will

Dementia receive integrated, well

managed care in hospital and that

patients are well supported on

discharge.

April

2013

- LOS for patients admitted with

dementia

- Reduce falls for dementia

patients


LOS from 12 to 9

days

2.6 Medical

Therapies Unit

- Reduction in LOS


avoidance.

Established medical therapies unit for

medical elective work to ensure this

work does not default to ambulatory

care.

May

2013

- Number of cardiac elective

patients through

MTU per month

- Number of non-cardiac electives

through MTU

per month

In July 145 cardiac

electives where

treated on MTU

compared to

2012/13 baseline of




82

2.7 Outlier team - Reduction in LOS

Consultant lead team specifically to

review all medical outliers on surgical

wards to ensure clear patient pathway

management for those patients not on

specialty wards to reduce LOS.

Oct

2013

- Average number of medical

outliers

Reduction to ≤15

from 2012/13

baseline of 28

2.8 Phlebotomy - Reduction in LOS

Extended phlebotomy services to seven

mornings each week in order to reduce

the amount of time junior doctors

spend collecting routine blood samples,

and to promote more timely blood

testing that facilitates patient’s

treatment, discharge and bed

availability.

Dec

2012

- % non-elective adult discharges

before 1pm (ex

A&E)

- Reduction in number of blood

collected by

junior doctors

(audit)

Help facilitate 10%

increase in number

of patients

discharged before

1pm in 2013/14

Backdoor

3.1 Review of

section 2/5 &

CHC process

(supported by

ECIST)

- Reduction in LOS

Standardise and improve discharge

processes for patients requiring referral

to social services or continuing health

care.

Oct

2013

- Reduction in LOS for flow bundle

pilot area –

Victoria

- Audit of time from admission

to completion of

section 2

Baseline to be

developed in

September 2013

3.2 Rehabilitation

to home

- Reduction in LOS

Additional therapy staff will be

incorporated in the current OPU

therapy team, with the specific aims to

increase discharges home and decrease

LOS for OPU patients. The team will

work with the OPU consultant team to

identify patients on admission, who will

receive focused rehabilitation. The team

will work over 7 days, and will manage

the ‘virtual ward’ of patients across the

RUH. It has been estimated the team

May

2013

- Decrease in referrals to

community

hospitals

- Reduction of NEL adult inpatients

>14 day LOS


% of patients with

>14 day LOS from

14% to 6%




will be able to see 20-30 patients daily.

3.3 Green to go - Reduction in LOS

To achieve a smooth, timely and

proactive discharge process for all adult

patients at the RUH.

Oct

2013

- Delayed Transfers of Care

at 1%

Planned reduction of

DTOC’s from 4.3%

baseline to 1%

3.4 Implement

Community

Wide Choice

Policy

- Reduction in LOS

Agree community wide choice policy for

all patients who require discharge to

nursing or residential homes.

Oct

2013

- Bi-monthly audit of whether

patients have

received ‘When

can I go home?’

discharge

leaflets on target

wards

Increased awareness

amongst patients of

discharge process.




Appendix 6: Summary of RUH (Winter Funding) Urgent Care Projects Baselines are currently being assessed for each project to be available at the Urgent Care Board meeting on the 12th September. All projects need to confirm start dates; those included have firm staffing plans in-place. Funding has been requested from October 2013.

No. Project Impact Description Start

date

Metric

Front Door Staffing

1.1 Emergency

Department

- unplanned admission

avoidance

ECIST have advised RUH that to ensure

ED can manage peaks in demand,

staffing should be more robustly

matched to activity. The additional

staffing will also allow the RUH to

provide a minors service for a longer

period into the night if required on peak

days e.g. Sunday. The staffing will

ensure that the RUH ED department will

have sufficient resource to maintain

Ambulance Handovers.

- Reduced ED 4hr Breaches.

Delivery of

National ED

Quality

Indicators

1.2 Front Door - Reduction in LOS

Additional senior pharmacist, pharmacy

technician and pharmacy porter to

support ED, MAU and SAU to ensure

focused pharmacy input to these areas

and help facilitate earlier patient

discharge

- Increased Number of

pharmacy

reviews on

MAU/SAU and

ED on Saturday

and Sunday

1.3 Cardiac

Technician for

the front door

- Reduction in LOS

Cardiac technician dedicated to MAU

patients to expedite cardiac diagnostics

to facilitate earlier discharge.

- Number of patients waiting

for inpatient

echo

1.4 MAU staffing - Unplanned admission

avoidance

- Reduction in LOS

Additional MAU registrars and MNPs to

support 7 day ambulatory care and

release senior medical time to focus on

earlier discharge of the most complex

patients.

- Number of non-elective patients

seen in

ambulatory care,

per month

1.5 SAU Nurse

Practitioners


avoidance

Additional SAU nurse practitioners to

support the current nurse practitioner

with GP liaison 7 days a week. This will

help support admission avoidance and

increased numbers in the ESAC clinics at

weekends.

- No of patients seen in

emergency

surgery clinics on

Saturday/

Sunday

7 day working

2.1 ESAC Service 7

days

Unplanned

admission

avoidance

Additional consultant support to the

ESAC service to allow this service to be

provided 7 days a week.

- No of patients in emergency

surgery clinics on




Saturday/

Sunday

- 2.2 Ward clerks &

discharge

coordinators

- Reduction in LOS

Additional ward clerks and discharge

coordinators to support a 7 day service

across every ward to help facilitate

timely discharge.

- Increase in numbers of

patients

discharged on

Saturday/Sunday

- 2.3 7 day acute

oncology

- Reduction in LOS

Additional nursing support to provide

the acute oncology service on MAU,

SAU and ED at weekends.

- Review by Acute Oncology Team

within 24 hours

of admission on

Saturdays &

Sundays

- 2.4 7 day therapies Reduction in

LOS

Additional weekend service,

complementing existing weekend

services to improve patient flow and

alleviate winter pressures.

Respiratory – ward cover 7 days to

facilitate weekend discharges

Orthopaedics – Doubling orthopaedic

support to ensure mobilising occurs on

a 7 day basis.

OPU – Rehab to home 7 day service to

support earlier discharge for the most

complex patients.


assessed at

weekends by

therapists in

respiratory,

orthopaedics

and OPU.

Support services

3.1 Additional

transport

December to

March

- Reduction in LOS

Additional transport services from

December to March supporting

discharge and ensuring no patients

discharge is delayed waiting for

transport.


discharged on

hospital

transport.

3.2 Cardiac

Technician to

support the

wards

Reduction in

LOS

Increased cardiac technician support to

the wards to facilitate earlier

diagnostics and therefore earlier

discharge

- Number of patients waiting

for inpatient

echo

3.3 S&LT for Stoke - Reduction in LOS

Increased capacity to the ASU therapy

team, adding enhanced cover for

speech and language therapy in

particular access to dysphagia

assessment on a 7 day basis. Rationale

includes, management of risk for

swallow assessments (dysphagia),

Sept

2013

- Time from admission to

assessment by

S&LT for stroke

patients




enhancing patient flow with increased

therapy aiming to decrease LOS, and

improved quality of therapy input for

the Stroke Pathway.

3.4 Radiology - Reduction in LOS

- Admission avoidance.

Additional radiologists and

radiographers to support earlier

diagnostics for front door services to

facilitate earlier discharge or avoid

admission

- Increase in radiology

inpatient

requests cleared

on a daily basis

3.5 Primary Care

Clinical assistant

- Admission avoidance

GP working at the front door and as

part of the outlier team to liaise with

GPs. This role would further develop

our GP liaison processes, ensure GPs are

notified of all patients LOS >14 days and

support ambulatory care during peak

periods

Oct

2013

- GP notification of all patients

LOS >14 days




Appendix 7: RUH (ECIST) Project KPIs – performance report

Work Stream Project Index Metric Baseline Target Trend Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13

1.1.1Number of non elective patients seen in ambulatory

care, per month107 Trajectory � 115 135 140 138 131 120

1.1.2Number of adult non elective patients discharged from

MSSU with 0-3 days LOS71 90 � 48 93 90 93 82 70

Surgical Emergency Pathway 1.2.1 Number of patients seen in urgent clinics 0 160 � 0 86 95 131 115 137

1.3.1Review by an Acute Oncology Team within 24 hours of

admission (CQUIN)0% 90% � 100% 100% 100% 100% 100% 94%

1.3.2Number of patients whose admission was avoided

through consultant lead intervention. 0 68 � 80 81 82 81 78 81

1.4.1% of non GP referred patients time to treatment ≤60

minutes46.7% 55.0% � 46.3% 56.6% 52.6% 49.7% 54.4% 50.5%

1.4.2 Non GP referred admission rate 34.8% 33.0% � 31.6% 32.6% 35.1% 34.0% 35.0% 34.3%

Implement Internal Professional

Standards for response to

ED/MAU/SAU

1.5.1 Time to doctor review in ED (30 minutes) 30 �

1.6.1 % of ACE OPU patient group with LOS ≤2 days 25.1% 35.0% � 18.8% 26.0% 27.2% 27.8% 26.9% 26.3%

1.6.2 ACE OPU patient group average LOS (days) 11.2 8.0 � 14.2 12.1 10.7 10.1 10.6 11.4

1.6.3Daily pharmacy review and TTAs are completed daily

before 1pmAudit 95.0% � Baseline

1.7.1Number of catheter patients seen within the

Emergency Department0 10 �

1.7.2Number of catheter patients diverted from the

Emergency Department to Urology Outpatients.0 6 �

Orthopaedic weekend Registrar

cover1.7.3 Number of Orthopaedic doctor breaches at weekends 2.3 0 � 3 1 3 5 1 1

2.1.1% non elective adult discharges declared before 1200

(ex A&E)36.5% 70% � 32.2% 38.6% 39.1% 37.7% 36.10% 31.00%

2.1.2 % of NEL adult discharges ≥2 LOS with EDD 90.8% 100% � 90.4% 94.2% 93.7% 91.9% 90.4% 93.4%

Access times to Cath Lab 2.2.1No patients waiting over 96 hours (stretch target of 72

hours) weekly 20 0 � 10 8 3 0 0 15

2.3.1 Average number of medical outliers (snapshot) 35 0 � 41 4 7 7 15 33

2.3.2 Maximum number of medical outliers (snapshot) 98 0 � 64 28 22 26 26 46

2.4.1% of Hip Fracture patients discharged to their usual

place of residence39.1% 45.0% � 35.3% 32.3% 32.1% 44.4% 27.9% 61.9%

2.4.2 Average LOS for Hip Fracture patients 15.6 Trajectory � 18.2 15.3 15 12.3 12.3 13.1

2.5.1 LOS for patients admitted with dementia 12.0 9.0 � 15.0 15.1 9.2 11.4 13.6 11.6

2.5.2 Reduce falls for dementia patients 58 46 �

2.6.1Number of cardiac elective patients through MTU per

month82 Trajectory � 0 77 125 146 95 122

2.6.2Number of non-cardiac electives through MTU per

month36 Trajectory � 0 37 94 119 153 164

2.7.1 Pre-op length of stay for cat C/D theatre list 5 Trajectory � 0 0.7 0 0 0

2.7.2Number of patients detioriating from C/D lists to A/B

due to theatre 1 capacity5 0 � 0 0 0 0 0

2.8.1 % non elective adult discharges before 1pm (ex A&E) 21.0% 35.0% � 20.7% 19.9% 21.6% 19.4% 20.1% 19.9%

2.8.2Reduction in number of blood collected by junior

doctors (audit)Audit � Baseline

2.9.1Surgery - overnight discharges seen before 1000 and

post op before 1600Audit � Baseline

2.9.2Respiratory - all acute respiratory patients on MAU

seen before 1200Audit � Baseline

2.9.3OPU - see all post 48 hr LOS patients daily to review

pathway and optimise chance of discharge homeAudit � Baseline

Green to Go 3.1.1 DTOC at 1% 4.3% 1.0% � 3.6% 5.5% 3.4% 5.0% 4.3% 4.1%

3.2.1Non elective adult average LOS of discharges from

Victoria ward.13.8 12 � 14.2 16.1 14.9 11.3 12.7 10.9

3.2.2Audit of time from admission to completion of section

2Audit � Baseline

Implement Community Wide Choice

Policy3.3.1

Bi-monthly audit of whether patients have received

'When can I go home?' discharge leaflets on target

wards (3 each audit)

0 � Baseline

3.4.1 Decrease in referrals to community hospitals Audit �

3.4.2Reduction of geriatric medicine NEL adult inpatients

>14 day LOS40.2% 39.2% � 60.3% 55.8% 56.2% 44.1% 56.6% 47.6%

Front Door

Therapies projects

Flow

Back door

Therapies pilot – Rehabilitation to

Home

Review of Section 2/5 & CHC

process (Supported by ECIST)

Extended Phlebotomy service

Ambulatory Care Medicine (MAU

Area B)

Acute Oncology

ED Implementation of SWAT

Hip Fracture Pathway

Dementia Challenge Initiatives

Medical Therapies Unit (MTU)

Urology Specialist Nurses

Outlier Team

Ward Standards

ACE OPU

Surgical Emergency Pathway

Author: Clare O’Farrell Divisional Manager Sophie Spencer, Speciality Manager. Document Approved by: Francesca Thompson, Chief Operating Officer






Appendix 10: 2013/14 Winter Plan Peer Review Preparation Winter plans submitted to the CCG need to be tested for system wide resilience. The intention is to undertake some of the testing by looking at how well our respective plans join up for the 5 conditions that are likely to form a major part of the demand pattern. Please complete the form below to assist with this process. All forms received by Monday 23rd September will be shared with all providers so that we can identify in advance of the Peer to Peer review on Wednesday 25th whether there are areas of our respective plans that need to be strengthened. Stroke Outline briefly the pathway you expect service users to follow while in your care

Patients admitted to the RUH with Stroke should be directly admitted from the Emergency Department to the Acute Stroke Unit. The Acute Stroke Unit (ward B6) is a 26 bedded ward located in RUH Central on the ground floor. Research has shown that patients with stroke who receive rapid and specialist treatment on an acute stroke unit have a better chance of survival and are more likely to regain independence and have less long-term disability.

What assumptions have you been able to make about demand this year vs last year

• Assumptions re changes in the stage in the pathway at which people present to your service

• Assumptions re changes in overall volume

No anticipated volume or significant pathway changes.

Capacity 2012/13 vs 2013/14 • What additional resources are in place • What impact do you expect this to have on throughput

Two additional Stroke consultants have been appointed. This has supported 7 day working, increased in week consultant presence on ASU and additional capacity to support stroke patients which are outlying on other wards. It is anticipated that increased senior decision making will reduce length of stay.




Therapy support to the acute stroke unit has increased both at weekends and in week. At weekends there is now a Speech and Language therapist and Occupational Therapist present on the ward both Saturday and Sunday. Physiotherapy will also continue to be provided at the weekends. In the week there has been increased weekday Occupational Therapy (1WTE) and Speech and Language Therapy (0.6WTE) input to ASU has also increased. Increased therapy will reduce length of stay for stroke patients on ASU enabling increased capacity on the unit. It will also support increased number of patients being able to return straight home from hospital.

System / process changes that you have implemented since last winter and the impact you anticipate these having on your service

The stroke unit has introduced 7 day ward rounds, following the appointment of two additional consultants. This supports increased numbers of weekend discharges.

Increased therapy support, as outlined above, both in week and at the weekends will support a reduction in length of stay on the stroke unit.

What assumptions are you making about other providers doing anything differently as a result of your plans Wiltshire CCG are planning to review community Neurology provision

which might bring benefits to stroke patients through the early support discharge programme. Community providers are able to support discharge at the weekend by mirroring 7 day service provision.




Catheter Care Outline briefly the pathway you expect service users to follow while in your care

Patients attending the RUH for catheter care (either through ED or SAU Emergency clinic) would be referred to the Urology Specialty team would review the patient and if possible provide care in ED/Clinic to avoid admitting the patient to hospital. Patients might also be booked to attend Urology outpatients.




No anticipated significant volume or pathway changes. In time it is anticipated that increased patient information and education will decrease the amount of patients` admitted to the RUH for catheter care.


Two additional senior nurse practitioners are currently being recruited; part of their role will be to improve the management of urethral and suprapubic catheters across the Trust. These nurses will work as part of the multidisciplinary team at the RUH, with the aim of reducing catheter use and complications, resulting in improved quality of care, along with reduced LOS, morbidity and inappropriate emergency admissions. The posts outline is as follows;

• Be available on mobile phone to respond to all inpatient and primary care requests for advice. Divert patients from ED/SAU to Urology OPD where possible

• Attend the Urology ward round daily to troubleshoot and anticipate problems. Review all “problem” patients prior to




a weekend to ensure catheter management plan in place

• Visit ED daily, and be first port of call to deal with catheter/nephrostomy problems (approximately 30-50 attendances per month)

• Manage and run TWOC clinics to deal with current demand (offering an extra 300 appointments per year)

• Provide urological education for RUH staff, district nurses and GPs

• Manage and develop the RUH “Continence Ambassadors” project

It is planned that these specialist nurses will be in post from January 2013.


Part of the Nurse Practitioner role will be to provide education to RUH staff, district nurses and GPs. Patients will be better informed and educated about catheter care on discharge and therefore it is anticipated that less patients will attend the RUH ED department or be admitted to the RUH for catheter care.

What assumptions are you making about other providers doing anything differently as a result of your plans

Improvements in patient information and communication with GPs and community teams will facilitate management of patients with catheters in the normal place of residence and avoid admission to the RUH.




Respiratory Outline briefly the pathway you expect service users to follow while in your care

Patients admitted to the RUH with respiratory conditions are admitted via ED to MAU, and then on to the Respiratory Unit. The MAU department has an Acute Physician with an interest in Respiratory who acts as the main point of liaison between Respiratory and MAU, and takes a lead for patients on non-invasive ventilation. The Respiratory Unit (B47) is a 33 bedded mixed sex ward situated in Zone B (B47) on the second floor. It is set out as four six-bedded bays, a High Care Unit containing 4 beds, and 5 single side rooms with en-suite facilities. The Unit runs a Pulmonary Rehabilitation service for patients with complex needs who can been discharged with planned early rehabilitation. The Unit also works closely with the BaNES IMPACT service, which provides supported care for people with COPD.




No anticipated volume or significant pathway changes.


Two additional respiratory consultants have been appointed, and are expected to start in January 2014. This will support seven-day consultant-led ward rounds and additional capacity to support respiratory patients which are outlying on other wards. It is anticipated that increased senior decision making will reduce length of stay.




Therapy support to the ward has been increased as part of the winter funding allocation; this will support reduced length of stay.


The Unit will introduce 7 day ward rounds, following the appointment of two additional consultants. This supports increased numbers of weekend discharges. Increased therapy support, as outlined above, both in week and at the weekends will support a reduction in length of stay on the unit

What assumptions are you making about other providers doing anything differently as a result of your plans Community providers are key to facilitating earlier discharge from the

Unit. The role of the IMPACT team in Sirona is important in ensuring that patients with COPD have appropriate admission avoidance and early discharge intervention in place. Community providers are able to support discharge at the weekend by mirroring 7 day service provision.




Control of infection Outline briefly the pathway you expect service users to follow while in your care

Patients will follow the appropriate clinical pathway through the RUH for their condition. All patients will be cared for using standard universal precautions to prevent infection e.g. hand washing, PPE etc. The Trust has an Infection Prevention and Control Team. Policies exist to support the prevention and management of infection including,

• Outbreak Control Policy • Decontamination Policy • Cleaning Policy • Isolation Policy • Universal Precautions Policy

Policies are also in place to specific outbreaks such as the Management of Diahorrea and Vomiting Policy.




Norovirus The Trust has not experienced summer outbreaks of Norovirus which may indicate that this winter will not be a bad outbreak year. No predictions around Norovirus have been received yet from Public Health, there are expected in October 2013. The Trust monitors GP results and nursing home outbreaks of Norovirus which are seen to precede hospital outbreak. Flu The Infection Prevention and Control Team monitor the HPA Syndromic Surveillance bulletin which gives weekly predictors and updates around flu outbreaks to support local planning and prediction.

Capacity 2012/13 vs 2013/14 From 1st October to 31st March the Infection Prevention and




• What additional resources are in place • What impact do you expect this to have on throughput

Control Team provide an on call service over weekends in order to offer support to clinical areas, particularly at times of outbreak. There is also a 24/7 Microbiologist Consultant on call.


Staff awareness campaigns within the RUH; infection matters and hand hygiene have already launched and will continue over the winter months. The Infection Prevention and Control Team have changed the way they support inpatient areas prior to winter 2013. Previously they would visit all admission areas on a daily basis. They now visit all inpatient ward areas on a daily basis to raise awareness and provide education to staff.


The Infection Prevention and Control Team attend a monthly meeting with public health, B&NEs and Wiltshire Infection Control teams to share best practice particularly in relation to Norovirus and Flu planning.




Frail elderly assessment Outline briefly the pathway you expect service users to follow while in your care

From October 2013 the RUH will be opening ACE OPU (Assessment and Comprehensive Evaluation – Older Persons’ Unit). The primary aim of this new unit is to facilitate rapid clinical assessment, investigation and interventions to support early discharge for older people, reducing the length of their hospital stay. Patients will be assessed by a multi-disciplinary team including; Consultant, Nurse, Physiotherapist, Occupational Therapist, Pharmacist, Discharge Liaison Nurse, Social Services and Community teams.




This service is aimed at patients who would already normally access secondary care services through the RUH Emergency Department or via direct GP admission. However through intensive multi-disciplinary support it is anticipated that the number of older patients who are able to go home within 48 hours will be significantly increased.


In order to support ACE OPU the Trust has invested in additional medical, nursing, therapies and pharmacy support for the Unit.


GPs and community staff can contact the Geriatrician of the day to discuss patients who may need admission .The Geriatrician may recommend the patient is assessed in ACE OPU if this is appropriate.


Community providers are key to facilitating earlier discharge from ACE OPU. A daily white board round will be held on the Unit this will only support rapid discharge if all local health, social care and voluntary sector organisations are represented on a daily basis as well as the RUH multidisciplinary team.




Winter Plan Project Key Performance Indicators

Author : Clare O’Farrell, Divisional Manager Medicine & Sophie Spencer Speciality Manager , Document Approved by: Francesca Thompson, Chief Operating Officer

Date: 11/10/2013 Version: v4.0

Agenda Item: Page 47 of 83

RUH Winter Plan Project Proposals

Title of Proposed Scheme 1.1 Front Door Staffing – Emergency Department

Provider Royal United Hospital Bath

Responsible Manager including title, email address & contact number

Mandy Rumble, Matron Emergency and Acute Medicine

[email protected]

01224 821076

Brief Description of Proposed Scheme including rationale for the investment

Investment WTE

Flow Assistants in ED 2.0 WTE B2

HCAs in ED 5.5 WTE B3

HCAs in ED 3.5 WTE B4

Resus High care Nurses 5.5 WTE B5

ED Nursing at Night 2.5 WTE B6

SAU/ED/MAU porters 15.1 WTE B2

Cleaner in ED 1 WTE B1

ECIST have advised the RUH that to ensure the Emergency Department can manage peaks in demand, staffing should be more robustly

11.1 - ruh winter planappendicies · ruh surge and escalation (winter plan) 2013/2014 1...

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