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Enhanced Care ModelFinal Report 2019Taskforce on Staffing and Skill Mix

Table of Figures 4Table of Tables 41.0 Foreword by the Minister for Health 52.0 ForewordbytheChiefNursingOfficer 63.0 Introduction 84.0 TaskforceonSafeStaffingandSkillMix 12 5.0 LiteratureandEvidence 145.1 Enhanced Care Model 14 5.1.1EducationandTraining 14 5.1.2SpecificInitiatives 15 5.1.3Availabilityoftherightresource 15 5.1.4Anorganisedapproach 166.0 TheActionsforOrganisingandDeliveringEnhancedCareModel 18 6.1 AimsandObjectivesoftheEnhancedCarePilot 22 7.0 OverviewofPilotTesting 247.1 RationaleforPilotProject 247.2 PilotProjectTesting 26 7.2.1StabilisationoftheNursingandHCAWorkforce 26 7.2.2Organisationalmonitoringofdataregarding 28 demandandsupplyofnursesandHCAs 7.2.3DevelopBespokeDocumentation 30 7.2.4DevelopaTailoredEducationPackage 32 7.2.5Governance 358.0 FurtheroutcomesofthePilot 388.1 PatientandStaffOutcomes 38 8.1.1FamilySatisfaction: 38 8.1.3HealthCareAssociatedInfections 41 8.1.4CareMissed/DelayedEvents 429.0 Recommendations 4410.0 Conclusion 4611.0 AllIrelandEnhancedCareReport 48References 50GlossaryofTerms 52Appendices 53AppendixI EnhancedCareLeaflet 54AppendixII PatientPassport 55AppendixIII PatientBehaviouralChart 57AppendixIV ReferralPathway 58AppendixV RiskAssessment 59AppendixVI ECTObservationAssessment 59AppendixVII GovernanceStructure 60AppendixVIIIAllIslandCollaborativeforEnhancedCare 61

CONTENTS

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Enhanced Care Model Final Report 2019

Table of FiguresFig.1 TheEnhancedCareModel 14Fig.2 ActionAreasfortheOrganisationand 18 DeliveryofEnhancedCare Fig3 ActionofPilotProject 26Fig4 DemandvsAgencySupply2017-2018 28 Fig5 DemandvsAgencySupply2018-2019 29 Fig6 ProjectedSavings 30Fig7 PatientPassport 31Fig8 PatientOutcomes-Documentation 32Fig9 ResultsfromQuestionnaire1 33Fig10 ResultsfromQuestionnaire2 33Fig11 ResultsfromQuestionnaire3 34Fig12 ResultsfromQuestionnaire4 34Fig13 SatisfactionResponse1 38Fig14 SatisfactionResponse2 39Fig15 SatisfactionResponse3 39Fig16 SatisfactionResponse4 40Fig17 SatisfactionResponse5 40Fig18 CareLeftUndoneEventsasReported 42Fig19 AllIslandCollaborativeApproachQuadrupleAim 48 Table of TablesTable1.0 OrganisationsGatherIntelligenceonEnhancedCareDemandandSupply 19Table2.0 TheDevelopmentofEnhancedCareGuideline 19 Table3.0 Education&developmentofStaffInvolvedintheDeliveryofEnhancedCare 21Table4.0 GovernanceofEnhancedCare 21Table5.0 HCAIs2017and2018 41Table6.0 RecommendationsfromthePilotonEnhancedCare 44

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IthasbeenayearsinceIpublishedthe‘FrameworkforSafeNurseStaffingandSkillMix inGeneralandSpecialistMedicalandSurgicalCareSettingsinAdultHospitals in Ireland’andIamdelightedtoprogressthisimportantworkandpublishthisreportonthe‘EnhancedCareModel’.

This is a criticalmilestone in the history of ourhealthservice.Sláintecareprovidesuswithasolidframework and guidance for the developmentof health services over the next decade. Thereis no doubt that considerable change andtransformation is required, and I believe thisEnhancedCareModelisakeypartofthatjourney.

Aswe reform, it is essential our health serviceanticipates, responds and consistently improvesthecarewedeliver.Istronglybelievethe‘EnhancedCareModel’goesalongwaytoachievingouraimsof improving staffing conditions and reformingpatientcare. It isanevidence-based,structuredapproachthatwastestedinOurLadyofLourdesHospital,Drogheda.Thepilotwasunderpinnedbytheprogrammeofresearchforthe‘Frameworkfor Safe Nurse Staffing and Skill Mix’ that hasprovided a significant body of evidence for theIrishcarecontextanddemonstratedasustainednumberofpositivepatient,staffandcostimpacts.

We are now seeking to advance this pilot to anationwide model. I strongly believe this willimprove working conditions for our staff andsignificantlybenefitthecareofourpatients. Iwish to thank theChiefNurse,Dr SiobhanOHalloran, her team and all themembers of thetaskforce steering committee for producingsuch innovative, high-quality evidence-basedandevaluatedpolicyinitiatives.IhavenodoubtthattheirworkandthisFrameworkwillcontinuetodemonstrate themanypositivebenefits thatcan be achieved for both patients and staffthroughthedevelopmentandimplementationofinnovativeapproachestocaredelivery.

1.0 Foreword by the Minister for Health

I would like to pay particular tribute to theDirectorofNursing,MrAdrianCleary,AssistantDirectorofNursing,Ms.EdelKirwan,MsFionaMonaghan-TyerandtheirteamhereinOurLadyofLourdesHospitalwithoutwhosecommitment,leadership andvision this pilotwould not havebeenpossible. ThedevelopmentofthisReportthroughconsultation, testingandevidence, isagreatexampleofsuccessfulpolicydevelopment. In striving to continuously provide safe, highquality care for the patients in our services, Ilookforwardtofurtherroll-outoftheEnhancedCare Model in line with the Framework on anationwidebasis.Thisprojecthasbeenapositivepartnership between the hospital and theDepartment ofHealth and provides a templateforanapproachthatcouldbeusedacrossmanyareasofthehealthserviceforthedeliveryoftheSláintecarestrategy.

IamalsopleasedthatthisprojectispartofanAll-Island collaboration between the offices of theChiefNursingOfficerinmyDepartmentandtheChief Nursing Officer in Northern Ireland. Thework of this collaboration aims to produce keyprinciplesforanAll-IslandapproachtoEnhancedCare.

Simon Harris T.D. Minister for Health

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I am delighted to present this Report on the‘Enhanced Care Model’ as part of the ongoingworkontheFrameworkforSafeNurseStaffingandSkillMix.Theextensivedemandsplacedonthe health services in Ireland and throughoutthe world are constantly changing, increasingandbecomingmorechallenging. Inthiscontext,ourgoaltoprovidehighqualitypatientcareandimproved patient outcomes requires innovativepatientcentredsolutionssuchas theEnhancedCare Model.

The development of the Framework on SafeStaffingandSkillMixwasaninnovativeapproachto addressing workforce planning requirementsand commenced in medical and surgical areasin acute hospitals in Ireland. This approachto determining nurse staffing and skill mix isunderpinned by evidence-based assessment ofindividual patient need while also monitoringpatientoutcomesandmeasuringstaffexperienceto determine the required nursing hours perpatientday.TheFrameworkimplementationdrewattentiontothesignificantchallengeofprovidingenhancedcareor1:1specialling.ThisdemandonnursingtimearisingfromtheneedforEnhancedCare which was regularly supplemented byagencystaffwasdrivinganunstableworkforce.

EnhancedCarereferstotheneedforadditionalorextraordinarycare,beyondwhatisprovidedforwithinaveragedailystaffing level.Theevidencedemonstratesaspecificrequirementforthistypeof care for older persons in the acute hospitalsettingandtheneedtodevelopadistinctmodelfor delivering this type of care that supportsrecovery or healing based on individual patientneed.

Incorporatingevidencedbasedkeyassumptions,the model includes the themes of educationandtraining,theuseofspecificinitiatives,usingthe right resources and an organised approach.The implementation and testing of the modelthrougha structured,hospital-staffedEnhancedCareTeam pilot has demonstrated that it is aneffective and sustainable approach to meetingthe additional care requirements. The pilotprojecthasdemonstratedsomeinitialindicatorsof positive outcomes including evidence of astabilisedandsustainableworkforce,anincrease

2.0 ForewordbytheChiefNursingOfficer

indeliveringaperson-centredapproachtocare,an increase in the involvement of families inEnhancedCareandareduction inagencycostsover time. It is important to me to see policymaderealandachievingtheintendedoutcomes.

Thedevelopmentofthismodelwouldnothavehappened without the expertise, dedicationand vision of the national taskforce steeringcommittee and the research team led byProfessorJ.Drennan. Aspecialwordofthanksto Dr. Phillippa Ryan - Withero, Deputy ChiefNursing Officer Ms Rachel Kenna and Mr RayHealy in my office whose commitment andexpertise continues to drive the developmentof the Framework for Safe Nurse Staffing andSkillMix. Iwould particularly like to thankMrAdrian Cleary Director of Nursing, Ms EdelKirwanAssistantDirectorofNursing,MsFionaMonaghan–Tyer,theEnhancedCareTeamandall the staff involved in the pilot of the modelinOurLadyofLourdesHospitalDrogheda.TheleadershipanddedicationofthewholeteamwasakeysuccessfactorindevelopingandtestingthemodelforthisReport.

Thevaluesofcare,compassionandcommitmentare reflected throughout this reportwhich haspatientsafetyandqualitycareatitscore.Ilookforward to working with all our partners andstakeholdersincludingtheChiefNursingOfficerinNorthernIrelandtofurtherroll-outthismodelofcare.

Dr. Siobhan O Halloran, Chief Nursing Officer.

Introduction

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Care. It also illustrated that the current systemforallocatingEnhancedCarelacksuniformityandassuchhasimplicationsforcontinuity,qualityofcareandcost.

The findings from the Framework on SafeStaffing and Skill Mix (henceforth referred to as the Framework), (Department of Health, 2018)showedthattherequirementforEnhancedCareispresentingasignificantchallengeforservices.TheobjectiveofthisFrameworkwastodevelopa robust mechanism to determine safe nursestaffing and skill mix levels in a range of caresettings and to stabilise the nursing resourcethrough, in part, reducing reliance on the useof agency staff. TheFramework drewattentiontothedemandonnursingtimearisingfromtheneed for Enhanced Care which was regularlysupplemented through the use of agency staff.It also pointed to a specific requirement forEnhanced Care for older persons in the acutehospitalsetting.WhiletheFramework waspilotedin three hospitals the evidence is sufficientlyrobusttoinfernationalscalability. In summary the evidence from piloting theFramework demonstrated the need developa distinct model to underpin the provision ofEnhancedCare.Asetofkeyassumptionsuponwhich tobuildamodelofEnhancedCareweredevelopedfromtheliterature.Theseassumptionsinclude:

• ensuringpatientsafety; • providingasafe,effectiveandefficient levelofcare; • ensuringcarecomplimentsanyplanned treatmentortherapy;and • deliveringcarebasedonguidelines supportedbyclinicaljudgement.

3.0 Introduction

EnhancedCarereferstotheneedforadditionalorextraordinarycare,beyondwhatisprovidedforwithinaveragedailystaffinglevels.EnhancedCareis provided for patients who are disorientated,have altered cognition or behaviour or a non-acutemental illness.TheEnhancedCareModelincludes various levels of care that a patientmay require to support recovery or healing.Enhanced Care involves allocating a specificmemberofstafftoapatientorgroupofpatientswith responsibility for continuous awareness ofthewhereaboutsandcareneeds thepatient (s)through ongoing observation (Dewing, 2013).This can vary from one-to-one care to generalor cohort observation. A variety of titles areusedinterchangeablytodescribeEnhancedCareincluding:constantcare;specialling;one-to-onecare; and direct patient monitoring (Kerr et al.,2013;Wilkeset al.,2010).

ThereasonspatientsrequireEnhancedCarearequite similar throughout the system with fallsandconfusion/agitationbeingthemostfrequentdeterminants. Nursing staff can struggle tomanage unpredictable behaviours where thereare limited specialist resources and a lack oftimetosupervisepatientsexhibitingbehaviours,whichare seenaschallenging (McDonaldet al.,2012). Althoughnursesareskilledinmeetingtheacutehealthneedsofmostpatientstheymaynothavethe expertise required to manage or superviseexpressions of challenging behaviour (Borbasiet al.,2006;McCloskey,2004).WhileEnhancedCarecanbeofbenefittobothpatientandstaffinvolved it can also incur significant financialcosts.Thedatacollected inthedevelopmentofthisreportshowedthatthereisahighrelianceinthesystemonagencystafftodeliverEnhanced

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Thisreportsetsoutto:

• reviewtheavailableevidenceand currentpracticeintheprovisionof EnhancedCare;

• describeamodelandoutlineactions fororganisinganddelivering EnhancedCare;

• outlineandevaluatethe implementationoftheEnhanced Caremodelinapilotsite;

• makerecommendationsforthe implementationofthemodelof EnhancedCareonanational basis;and

• collaborateonanAll-Ireland approachtoEnhancedCare.

Incorporatinganapproachthatincludesleadership,governance,training,andstreamlinedguidancehasthe to potential provide the basis for deliveringEnhancedCareinacosteffectiveandsafemanner.

Taskforce on Safe Staffing and Skill Mix

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Two subsequent research impact evaluationreportshavebeenpublishedwhichdemonstratethe outcome and impact of implementing theFrameworkincludinga:

• substantialreductioninRNand HCAagencyusagerangingfrom 30%to100%;

• stabilisationorreductioninthe proportionofnursinghours providedforone-to-one “specialling”;

• demandforone-to-onecare wasidentifiedacrossallpilotsites;

• generalreductioninstaffsick-leave;

• significantdeclineinnursesensitive outcomeindicators;

• perceptionthattheworking environmenthadbecomeless complex;

• perceptionofthatqualityofcare deliveredasgoodorexcellent increased;and

• reductionintheproportionofcare leftundoneanddelayedevents.

The final report and recommendations by theTaskforce on Safe Staffing and Skill Mix forNursing was published in 2018. (Departmentof Health, 2018). The national implementationbeganin2019andisongoing.

4.0 TaskforceonSafe StaffingandSkillMix

In April 2014, the then Minister for Healthestablished a Taskforce on Safe Staffing andSkillMixundertheauspicesoftheOfficeoftheChief Nurse (see https://health.gov.ie/office-of-the-chief-nursing-officer/our-policies/taskforce-on-staffing-and-skill-mix-for-nursing/. The coreobjective of the Taskforce was to develop aframework to support the determination ofsafe nurse staffing and skill mix in a range ofcare settings. Internationally, there are a largenumberofnursestaffingdecisionsupporttools.The challengewith these tools is thevariabilityof validation and applicability, especially in theIrish healthcare context. The development oftheFrameworkwasbasedonanextensivebodyof literature on safe nurse staffing, evidencereviews, national and international consultationand baseline staffing assessment (Drennan etal., 2018).Once this initialworkwas complete,the Framework was tested in three pilot sitesunderpinnedbyaprogrammeof research.Data(patient,staffandorganisationaloutcomes)fromthreepilotsiteswerecontinuouslymonitoredbylocalimplementationgroupsandaresearchteamfromUniversityCollegeCork(UCC).InFebruary2016, an Interim Report was published whichcontainedanumberofpreliminaryfindingsfromthe implementation of the recommendationsin the pilot testingof theFramework aswell asrecommendations for further roll-out of theFramework(DepartmentofHealth,2016).

Literature and Evidence

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Themodelisbuiltaroundthefollowingthemes:

•educationandtraining; •specificinitiatives; •usingtherightresource;and •takinganorganisedapproach.

5.1EnhancedCareModel

5.1.1EducationandTrainingThe importance and requirement of specifictrainingandeducationareprevalentthroughoutmuchoftheevidencethatwasreviewed(Borbasiet al., 2006; McCloskey, 2004; Rowling, 2012;Yevchaketal.,2012).Theevidencedemonstratesthe need for specific education for health careprofessionalsandhealthcareworkersoncaringfor patients with dementia and/or delirium,the identification of falls’ risk and reasonsfor behavioural disturbances, along with the

• Education andTraining

• Specific Initiatives

• Theavailability oftheright resource

• Takingan organised approach

Figure 1 - The Enhanced Care Model

5.0LiteratureandEvidence

A literature review showed a lack of relevantevidenceinrelationtoEnhancedCareprovisionin acute care setting. The evidence that isavailable in the acute setting predominantlyrefersspecificallytotheolderpersoncarearea;therearealsoseveralstudiesavailableinrelationto mental health settings. This is explained bythefactthatmuchoftheevidenceinthissettingrevolves around challenging behaviours. Theevidencesuggests thatadeliberateapproach isneededwhencaringforpatientwithbehaviouralor cognitive challenges (Chrzescijanski et al., 2007; Kolanowski et al., 2014; Wilkes et al.,2010).

Dewing et al. (2010) noted that there is a lackof structure and no clinical or care centredframeworks for what should happen during aperiodofEnhancedCare.Peopleaged65yearsoroverareatincreasedriskofpooroutcomeswhenadmittedtotheacutecaresettingasaresultofcomorbidityandmismanagementoftheirchronicconfusion(Moyleetal.,2011).

It iscrucial that throughthismodel therapeuticactivities appropriate to the patient areundertaken. The activities which the patientenjoysshouldbeidentifiedeitherbythepatientthemselves or a family member; for example,playing cards, arts and crafts, knitting, readingnewspapers and exercise. Skills are needed inenablingandassistingthepatientinmaintainingtheir safety while promoting independence(Dewing,2013);thiscouldindeedbeappliedtoallpatientsrequiringEnhancedCare.

Themodel developedbelowwas created usingthe evidence and learning arising followingimplementation of the Framework for SafeStaffingandSkillMix.

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management of challenging behaviour (Levy etal., 1999;Menteset al., 1999). Common to alltheevidence, is theapproachtoeducationthatprovidesthehealthcareprofessional/healthcareworkerwiththeskillsandknowledgetomanagepatientswith thesecareneedsmoreeffectivelyand safely. Enhanced Care should involve thepractitioner in some sort of active engagementwith the person they are assigned to observe(Dewing,2013).Educationincludestheskillstoengagethepatientsintherapeuticinterventions,to de-escalate challenging behaviours and tocontribute topatient centred care.Moyle et al.(2008)also recognised theprime importanceofthedevelopmentofstaffexpertiseandeducationin relation to the careof theolderpersonwithchronicconfusion.Dicketal. (2009) foundthatstaff education had a positive impact on theincidenceanddurationof“specialling”.

5.1.2SpecificInitiativesWhilst each of the initiatives differ, havingpatientspecificinitiativesaspartofanEnhanced Caredeliveryisacommonthemethroughouttheliterature.The available evidence demonstratedthepositiveeffectsofinitiativesthatweretailoredtomeettheneedsofpatientsrequiringEnhancedCare. Environmental and social care strategieswork well with older persons with dementiaand/or delirium and as a first-line option non-pharmacologicalinitiativesshouldbeintroduced(Moyle et al., 2008;O’Brien, 2008;Alzheimer’sSociety,2009;DepartmentofHealth(UK),2009;Dewing, 2009). A number of these initiativeshave been described by NHS Improvement(2016)as‘activity’boxes(EastSussexHealthcareNHSTrust,2014), fallsbundles (NHSEastKentHospitalsUniversityNHSFoundationTrust),closeobservation units (Eeles et al., 2013), specificassessment tools such as Patient AttendantAssessment Education Tool (PAAT), AgitatedBehaviour Scale (ABS), and the ‘What Mattersto Me’ initiative (Barry and Edgman-Levitan,2012). Observation and assessment tools needtobedesignedandstructuredefficientlysothatthey accurately reflect the patient’s condition,

behavioural challenges observed, measurestaken to control challenging behaviours andpatient outcomes subsequent to the measuresbeing implemented (Wilkes et al., 2010). It isrecommendedthatthereis:

• acompleteandindividualevidence- basedassessmentofneedstotailorcare toeachpatient;

• acareplanningapproachfocussedon patient-centredmethodsandincludes de-escalationanddiversionaltherapies;

• adedicatedandspecificallyeducatedand trainedresourcetomanagethecareof patientsrequiringEnhancedCare.

5.1.3AvailabilityoftherightresourceAvailability of the right resource is essentialfor the implementation of any improvementinitiative and in relation to the specific careneeds of this patient cohort. Resources in thisinstanceincludematerialsforexampleequipmentrelated to diversional therapies. However,the evidence also points to the availability ofdedicatedsupportcarestaffwhoarespecificallyeducatedandtrainedtodeliverEnhancedCare.InitiativessuchastheEnhancedCareTeam(NHSImprovement,2016),education/trainingsessions(Kolanowski et al., 2014; Yevchak et al., 2012)and CloseObservationUnits require staffwitha variety of skill sets. Prior to the introductionof these initiatives in the UK there was thereliance on agency staff to meet the needs ofthesepatients.Thepurposeofintroducingtheseinitiatives was to move away from this overrelianceonagencystafftoasystemfocussedonensuringthattherighthealthcareworker,withthe right skills and education, and fromwithintheorganisation’sownworkforce,wasdeployedto deliver this care. Notably, improvement incare quality and reductions in costwere someof the outcomes from the introduction of theinitiatives outlined above (NHS Improvement2016).Itisacknowledgedthatinitiativesrelated

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to the introduction of Enhanced Care requireadequateresourcesandfunding(Bradley,2005)withresearchsuggestingthatnursingstaffoftenstruggle tomanagepatientswithunpredictableand challenging behaviours when there arelimitedresourcesandlackoftime(Borbasietal.,2006).

5.1.4 AnorganisedapproachTheevidence frequently refers to thenecessityfor assessment tools to be used to assess therequirement for Enhanced Care and, in somecases,toidentifythelevelofEnhancedCarethatis required (Houghton et al., 2016; Ross Baker,2017;Wilkes et al., 2010).A study undertakenbyDicketal. (2009)foundthatwhenapatientrequired close observation, the most commonresponse and strategy taken by nurses was torequesta“special” withouthavingundertakenan

appropriate assessment of the patient’s actualneeds (for example: RN, diversion therapy, useofalternativestrategies,closeobservationratherthan1:1specialling).Theimportanceofdevelopingspecific policies and guidelines is considered intheliteratureasnecessarytosupportthedeliveryofsafe,qualitycare(Yevchaketal.,2012).Itwasnotable that in some instances, the applicationof thesepolicieswas inconsistentduetoa lackofeducation/trainingontheapproachused.Riskassessmentwas highly recommended as awayofprioritisingtheneedsofboththepatientandtheward.Itisimportantthattheapproachtoriskassessmentisrobustandcansupportthedecisiontoallocateresources(Dewing,2013).Insummarytheevidencesuggeststhatensuringconsistencyinapplication,developingasupportivestructurecombinedwitheducationandtrainingarekeytoorganisingthedeliveryofEnhancedCare.

The Actions for Organising and Delivering Enhanced Care Model

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Figure 2 - Action Areas of the Organication and Delivery of Enhanced Care

Four action areas emerged from the evidencereview and the recommendations from theimplementation of the Framework (Fig 2 - Action Areas for the Organisation and Delivery of Enhanced Care). Eachactionhasanumberofsteps,asdescribedinTables1-4-StepsineachActionAreafortheOrganisationandDeliveryofEnhanced Care.

ThemodelfortheorganisationanddeliveryofEnhancedCareappliesto:

• allpatientswhoaredisorientated, havealterationincognition,altered behaviouroracutementalillness whileaninpatientinanacutecare setting.

• HealthCareAssistants(HCAs) deliveringEnhancedCare;and

• theleadnurseornurseinchange ofthepatient’scare.

6.0TheActionsforOrganising and Delivering EnhancedCareModel

Enhanced Care does not apply to RegisteredNurses providing one-to-one care or closeobservationtotheacutelyillpatient;forexample,thosepatientswitharaisedEarlyWarningScore(EWS)orwhoareclinicallyunstable.

OrganisationsGatherIntelligenceonEnhanced CareDemandandSupply

EducationandDevelopmentofStaffinvolvedintheDelivery

ofEnhancedCareGovernanceforEnhancedCare

TheDevelopmentof Guidelines/ProtocolsRegarding

EnhancedCare

EnhancedCare

1

3

2

4

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Table1.0OrganisationsGatherIntelligenceonEnhancedCareDemandandSupply

1.1 EachsitewillundertakeanassessmentofthedemandandsupplyofEnhancedCare.

1.2 Datacollectedwillincludethe:• demandforEnhancedCare(i.e.hoursrequired);• supplyforEnhancedCare(i.e.hoursavailable,gradesupplied,supplysource–wardstaff/agency/overtime/bank);and

• reasonsforEnhancedCare.

1.3 ThisdatawillbeusedtoidentifytrendsandpatternsofEnhancedCaredemandandsupply

1.4 AdditionalriskmanagementdatawillbeincorporatedwiththeabovedatasourcestoidentifytheneedforEnhancedCare.

1.5 ThedatawillbeusedtoidentifythecurrentcostofEnhancedCare.

1.6 Collectivelythedatawillbeusedtoinformthesafest,mosteffectiveandefficientapproachtotheorganisationanddeliveryofEnhancedCareonasite-specificbasis.Suchmethodscanincludeorbeacombinationof:1.EnhancedCareTeams;2.CloseObservationsUnits;3.Videomonitoring–similartotelemetryapproaches;4.TherapeuticActivities–e.g.activityboxes,artsandcrafts;5.InvolvementofFamily–structuredapproach;and6.Specifictrainingandeducationprogrammes.

Table 2.0 TheDevelopmentofEnhancedCareGuideline

2.1

EachorganisationwilldevelopaGuidelinetosupportthedecision-makingprocesstodetermineEnhancedCarerequirements.Itshouldbenotedthatthisguidelineshouldworkinconjunctionwithandcomplementotherinitiativessuchas:‘what matters to me’ asanexample(HSE,2018).

2.2 TheguidelinewilloutlinethecategoriesofpatientsthatcanbesafelycaredforbyaHealthCareAssistantwhoisspecificallytrainedfortheroleofEnhancedCare.

2.3 TheguidelinewilloutlinethekeystepstobeundertakentobothassessanddeliverEnhanced Care.

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2.4 Thestepswillinclude;

1.PatientassessmentbyaRegisteredNursetodeterminetheneedfor EnhancedCare–thisstepwillidentifythereasonforEnhancedCarebasedonacomprehensiveclinicalevaluationofthepatient,inclusiveoftailoredtoolsandriskassessmentstotakeaccountoftherisklevelinrelationtosafety,communicationandcognition.Inthisstep,referraltootherHealthcareProfessionals/teamsmaybeidentified;forexample:Fallsteam,MentalHealthteam.TheadviceoftheseteamswillbeusedtoinformtheneedandlevelofEnhancedCare.Additionally,underlyingcauses,suchasinfection,painanddehydrationasexamples,willbeidentifiedandtheirtreatmentincludedinthepatient’soverallplanofcare.

2.EnhancedCarewillbeanintegralpartoftheoveralltherapeuticcareplan;thisistoensurethesensitivemonitoringofthepatient’sbehaviourandmentalwellbeingandidentifyfactorsthatmayexacerbateorinhibitchallengingresponseswhilstatthesametimefosteringapositivetherapeuticrelationshipandusingtheleastrestrictivemeanstomaintainsafety.

3.Continuousreassessmentofpatient’sEnhancedCareneedisrequired;mainlywhereunderlyingcausesarebeingtreated.Thisstepwillalsoincludeanappropriateassessmentbyotherhealthcareprofessionals/teams.

4.Integraltotheinitialandon-goingassessment,istheneedtoidentifyandrecommendthelevelandtypeofEnhancedCare;e.g.closeobservation;constantobservation;cohortEnhancedCare.TheguidelinewillspecifythebroadlevelsofEnhancedCarewiththeoptiontotailorEnhancedCaretoindividualpatients.

2.4.1TheEnhancedCareguidelinewillclearlyidentifytheroleandresponsibilitiesofallstaffengagedinthecareofthepatient.TheroleoftheHCAinEnhancedCareisonethatmustbeincorporatedintothewiderhealthteamontheward.

2.5Ataminimum,theguidelinewilloutlineallnecessarydocumentationtobecompletedbothintheassessment/reassessmentphasesandforon-goingmonitoring.Itisalsorecommendedthatorganisationsdeveloppatient,family,andstaffinformationleafletsonEnhancedCare.Inthecaseofstaff,thisinformationshouldbeparticularlytailoredfortemporarystaffprovidingEnhancedCare.

2.6 TheguidelinewillclearlyoutlinetherequestprocessforEnhancedCarewhichmustincludeanon-goingreviewintandemwithpatientreassessmentasdescribedabove.

2.7 DataonpatientoutcomesandstaffexperienceoftheapproachestoorganisationanddeliveryofEnhancedCarewillbegatheredinadditiontothedatacollectionprocessesinsection1.0.

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Table3.0Education&developmentofstaffInvolvedinthedeliveryofEnhancedCare

3.1

Usingdataintelligence,asoutlinedinsection1,eachsitewillidentifytheirtrainingneedsbasedontheirspecificreasonsforneedingEnhancedCare.Itisrecommendedthattrainingprogrammeswillincludeforexamplefallsassessmentandmanagement,dementiatraining,deliriummanagement,managingbehavioursthatchallengeandmanagingviolenceandaggression.SpecifictrainingandeducationwillbeprovidedtoenableHealthCareAssistantsmanagethesepatientssafelyundersupervisionofaRegisteredNurse.

3.2 Trainingprogrammeswillincorporateinputfromthewiderhealthcareteamtoensureacomprehensiveapproachtoeducation.

3.3 Trainingprogrammeswillbereviewedandamendedwheredemandfortheservicealterse.g.reasonsforrequiringEnhancedCaremaychange.

3.4 Adatabaseoftrainingandeducationcompletedbystaffwillbedevelopedbytheorganisationtoensureappropriateorganisationalcapability.

Table4.0GovernanceofEnhancedCare

4.1 ThegovernancearrangementsforEnhancedCare,takingintoconsiderationlocalprocesses,willbespecifiedintheguideline.

4.2 Overarchinggovernance,inthecontextofsafenursestaffing,fallsundertheLocalImplementationGroupwhichreportstotheHospitalManagementTeamorBoardofManagement.Reportswillincludealllevelsofdatatoassurepatient,staffandorganisationaloutcomesaremonitoredandmaintained.

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6.1AimsandObjectivesof theEnhancedCarePilot

AspartofthePhaseIpilotacollaborativereviewof all the evidence took place between theresearch team, the local implementation groupand the Department of Health to identify theaimsandobjectivesoftheEnhancedCarePilot.Enhanced Care aims to prevent patients fromcomingtoharmbyensuringtheappropriatelevelofobservation is inplacetohelpsafeguardthisvulnerablecohort.TheoverallaimofthepilotistoimplementtheEnhancedCareModelinatestsite.

TheobjectivesoftheEnhancedCarePilotare:

→ ToimproveEnhancedCarespecific initiatives.

→ Initiateandimplementstaffeducation andpracticedevelopmentinitiatives.

→ Standardiseapproachtotheassessment anddeliveryofEnhancedCaretothe appropriatepatients.

→ Developspecificandstandardised guidelines,policiesandproceduretoassure thedeliveryofhigh-qualityEnhancedCare.

Overview of Pilot Testing

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7.0 OverviewofPilotTesting

OurLadyofLourdesHospitalDrogheda (OLOL)was included in theoriginal pilot sites inPhase1 for the Safe Staffing and Skill Mix Framework. Through this process, itwas identified that thehospital had an over-reliance of agency use toaddress a high demand for Enhanced Care. In2017 itwas decided to test the newmodel ofEnhancedCaredeliveryasapilotprojectinOLOL.ThisPilotadheredtotheaimsandobjectivesassetoutinSection4.1above.

7.1RationaleforPilotProject:Prior to the pilot project commencing, OLOLidentifiedtherationaleforwhyanEnhancedCaremodelwasneeded:

• DemographicAgeing:Nationally,the over65-yearagegrouphasincreasedby13%overthelast5years.Thisisexpectedtorisebyafurther3.4%inthenextyear;inaddition,therewillbea3.6%increaseinthepopulationof85yearsandolderagegroup.AretrospectivereviewwasundertakenacrosstheorganisationbetweenJanuary2018–June2018andthisidentifiedthat90%ofpatientsrequiringEnhancedCarewereovertheageof65yearsofage.

• DementiaDiagnosis:TheNationalDementiaStrategyoutlinesthat29%ofallpatientscurrentlyadmittedtoanacutecaresettinghaveadiagnosisofdementia.ManyrequireEnhancedCareduetotheirspecificcareneeds.Thestrategypredictsanincreaseof24%ofpeoplediagnosedwithdementiabytheyear2021.Currently,withintheorganisation,76%ofpatientsrequiringEnhancedCarehaveadiagnosisofadementia.

• DepartmentofHealthSafeStaffingandSkillMixFramework:OLOLwasoneofthreehospitalswhichwerepartofa

pilotprogrammeledbytheDepartmentofHealthtoreviewsafestaffinglevelsacrosstheacutecaresettingfrom2016–2018(DepartmentofHealth,2018).Partoftheresearchidentifiedthattherewasanover-relianceofagencystaffingrequiredtodeliverEnhancedCaretopatients.Italsodemonstratedthatwardstafffelttherewasadditionaltimespentorientatingagencystafftotheward/patienteveryshiftreducingtheamountoftimetheycouldcontributetodirectpatientcare.

• Careeventsmissedordelayed: Theresearchalsoidentifiedarelativelyhighlevelofcareeventsdelayedandmissedeventswhichcouldbeassociatedwiththenumbersandskill-mixofstaffprovidingcare.ThebaselinedatafromtheresearchinOLOLidentified:

o CareUndone:Themeannumberoftasksreportedbynursesasundoneduetolackoftimeontheirlastshiftwas2.75duringPhaseOne.Thisreducedto2.13inphaseTwo(following the introduction of the recommendations in the Framework).

o CareMissed:Themeannumberoftasksdelayedasreportedbynursingstaffwas5.83inPhaseOne.Thisreducedto4.69inphaseTwo(following the introduction of the recommendations in the Framework).

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• EfficiencyMeasures:TheprovisionofEnhancedCarefrequentlypresentsachallengetoanalreadyoverstretchedbudget,yetmanydeemitessentialfortheprovisionofsafepatientcare(Worleyetal.,2000)(RauschandBjorklund,2010).Thecostofthisserviceisoftenunpredictableandfrequentlynotestimatedwithinanyforecastedbudgetplan(LawsandCrawford,2013).Itwaspartoftheorganisation’sValueForMoneyplantomakecostsavingsacrosstheuseofagencystaffprovidingcare.Thedifferencebetweentheagencydemandandagencysuppliedismanagedlocally,mostusuallyabsorbedbytheward’scarecapacity.ThepurposeoftheEnhancedCarepilotprojectisnottoaddressthegapbetweencaredemandedandsuppliedbutrathertofocusonreducingagencycareusedoverall.

• OrganisationalContext:PatientswhorequireEnhancedCare,oftenduetothenatureoftheircondition(e.g.confusion,agitation,etc.),frequentlyexhibitchallengingbehaviourthatcanbedistressingforthepatient.OLOLallocatedexternalagencyHealthCareAssistants(HCAs),manyofthemhavereceivedlittletraininginprovidingcaretothiscohortofpatients.Traditionally,HCAsaredeployedtolookafteronepatientoragroupofpatientsasacohorttoprovideclosemonitoringandreducetheriskofincidents.Thereisresearchtosuggestthattheirroletendstobeasapassivesitterasopposedtoonewhichisparticipative,therapeutic,active,andcaring.This,togetherwiththelackofcontinuity,leadstodifficultyensuringperson-centredcareisdelivered (Small&Small,2011).

WardD WardE TotalNumberofactivitiesundone,mean(SD)

PhaseI3.50(2.50) 2.00(2.22) 2.75 (2.44)

PhaseII 1.88(2.30) 2.38(1.92) 2.13(2.06)

Shiftswhereatleastoneitemofmissedcarewasobserved,n(%)

PhaseI 11(91.7) 6(50.0) 17(70.8)

Phase2 4(50.0) 6(75.0) 10(62.5)

WardD WardE TotalNumberofactivitiesundone,mean(SD)

PhaseI6.92(3.70) 4.91(3.45) 5.83(3.19)

PhaseII 5.63(2.92) 3.75(2.87) 4.69(2.96)

Shiftswhereatleastoneitemofdelayedcarewasobserved,n(%)

PhaseI 11(91.7) 12(100.0) 23(95.8)

Phase2 8(100.0) 7(87.5) 15(93.8)

CareLeftUndoneEvents

Care Delayed as Reported

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In OLOL the additional time and cost ofEnhancedCarehadpreviouslybeenidentifiedasachallengeandstepshadbeentakenlocallytoaddressthis; forexample, the introductionof new patient behavioural assessments.

Figure 3 - Action of Pilot Project

StabilisingofNursingandHCAWorkforce

CreatingRobustGovernanceStructure

Developing TailoredEducationPackage

Developing BespokeDocumentationforEnhancedCare

Monitoring ofOrganisationalDataRegarding DemandandSupplyofAgency

Use

However, following the evidence fromimplementingtheFramework,anopportunitywas identified to build on the initiativesalreadyinplaceandimplementthemodelforEnhanced Care.

7.2PilotProjectTestingBasedontheactionsfororganisinganddeliveringthe Enhanced Care Model (Section 4.0), OLOLsummarised the steps they required into Fig. 3below. Eachactionwas thenassessed throughasuiteofoutcomeandimpactmeasures.Theseincluded: Each step was assessed throughaction, outcome and impactmeasure to assuresustainablesuccess.

7.2.1 StabilisationoftheNursing andHCAWorkforce

ACTIONAcentralisedanddedicatedEnhancedCareteamwassetup.Thecalculationmethodincorporatedin the Safe Staffing and Skill Mix Frameworkwas used determine the number ofwhole-time

equivalent (WTE) HCAs needed to deliver thequantumofEnhancedCarerequired.Thisresultedin a requirement for 16HCAs and oneCNM3.AnEnhancedCareCoordinatorwasappointedatCNM3gradetooverseeandmanagetheday-to-dayoperationsoftheEnhancedCareteam.

OUTCOMEAstabilisedandmanagedworkforcewasinplaceto deliver Enhanced Care as evidenced by thereduction in the use of agency staff to providethiscare.

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IMPACTTheroleoftheEnhancedCareCoordinatorwasfundamentaltotheroll-outandmeasurementoftheimpactofthepilotproject.TheEnhancedCareCoordinatordescribedtheimpactoftheputtinginplacethemodelfordeliveryofEnhancedCare.:

“The main role and responsibilities of the CNM3 Enhanced Care is to support the ward staff to ensure that the appropriate level of observation and support is in place to manage the patients deemed to require an increased level of observation to maintain patient safety. I meet with patients, families and nursing staff to assess and determine how best to meet the patients’ needs using the Enhanced Care team. The introduction of the Enhanced Care team has improved the delivery of patient centred care. The stability of the team ensures that there is continuity of care for the patient. The Enhanced Care team can identify changes in the patient’s condition and report this to relevant nursing staff. The introduction of the Enhanced Care team also decreases the amount of time required to orient agency HCA’s

The most common reason for patients requiring Enhanced Care is because of the risk of falls. Many of the referrals come after the patient has had an in-hospital fall. To date, there has only been one occasion when a patient had an assisted fall, with no injury, while the Enhanced Care team was in place.

The feedback from the staff to date is very positive in relation to how the Enhanced Care team has led to better patient interaction, the staff acknowledge that the traditional 12-hour shifts sitting beside a patient may not be the best way to care for patients. Also, the rotation of the HCAs is beneficial ensuring positive therapeutic interaction. The Enhanced Care team has stated that they feel like part of the team even though they rotate to different wards. This suggests that they are now merging into the ward culture and are accepted as part of the team.

On reflection I feel that this is a very positive change in how we care for our patients and feeds into our ethos of care, compassion and commitment to delivering quality care to the patients.”

Members of the Enhanced Care Team in OLOL – L-R Petra Weldon, Fiona Monaghan-Tyer, Ken Obama, Edel Kirwan, Sharon Burns, Michelle Reilly and Sabu Matthews

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between August 2017 and May 2018 acrossall eleven-general medical/surgical wards. Onaverage,therewasarequirementfor188HCAsper month to meet the demand for EnhancedCare.TheaverageagencyHCAsupplywas124HCAspermonth.Whilethedemandforagencywasnotalwaysmet,othermeasureswereputinplacetoprovidethepatientsrequiringEnhancedCare with safe environment. These measuresincluded, cohorting of patients who requiredEnhancedCare together in oneward,with oneHCA to supervise or placing patients in a highobservation area on theward.Additionally, thewards had access to special assistive devicessuch as motion/bed leaving alarms that wouldalertthestaffshouldaselectedpatientattempttomobilisewithoutsupervision.

EnhancedCareReportDraft21|P a g e

Pre-Pilot:

AretrospectivereviewwasundertakentoanalysedemandandagencysupplyforEnhancedCare.Thedemandwasextrapolatedfromthesafestaffingtaskforcesoftware(Trendcare©)betweenAugust2017andMay2018acrossalleleven-generalmedical/surgicalwards.Onaverage,therewasarequirementfor188HCAspermonthtomeetthedemandforEnhancedCare.TheaverageagencyHCAsupplywas124HCAspermonth.Whilethedemandforagencywasnotalwaysmet,othermeasureswereputinplacetoprovidethepatientsrequiringEnhancedCarewithsafeenvironment.Thesemeasuresincluded,cohortingofpatientswhorequiredEnhancedCaretogetherinoneward,withoneHCAtosuperviseorplacingpatientsinahighobservationareaontheward.Additionally,thewardshadaccesstospecialassistivedevicessuchasmotion/bedleavingalarmsthatwouldalertthestaffshouldaselectedpatientattempttomobilisewithoutsupervision.

Figure5-DemandvsAgencySupply2017-2018

Post-implementation:

Aseven-monthevaluationfollowingtheintroductionoftheEnhancedCarepilotwasundertaken.ThedaterangeswereSeptember2017toApril2018andSeptember2018toApril2019.TheevaluationshowedthedemandforEnhancedCareincreasedby20.4%postimplementationoftheEnhancedCarepilot.Onaverage,therewasarequirementfor236HCAsrequiredpermonthtomeetthedemandforEnhancedCarepost-implementation.TheaveragenumberofagencyHCAssupplieddroppedto88WTEpermonth.ThisreductioninagencyusedemonstratesthatOLOLisachievingstabilisationofthenursingandHCAworkforceovertime;thisstabilisationisassociatedwithlowerorganisationalcostsandbetterpatientoutcomes(DepartmentofHealth,2018)

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Figure 4 - Demand vs Agency Supply 2017 - 2018

DemandvsAgencySupplyAug2017-May2018

7.2.2 Organisationalmonitoring ofdataregardingdemandand supplyofnursesandHCAs

As part of the Safe Staffing and Skill MixFramework,OLOLhadbegun streamlining theirdata collection process to provide accuratemonitoringofpatientandstaffoutcomes.

ACTIONPre-Pilot:A retrospective review was undertaken toanalysedemandandagencysupplyforEnhancedCare. The demand was extrapolated from thesafe staffing taskforce software (Trendcare©)

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Post-implementation:A seven-month evaluation following theintroduction of the Enhanced Care pilot wasundertaken.ThedaterangeswereSeptember2017toApril2018andSeptember2018toApril2019.TheevaluationshowedthedemandforEnhancedCare increasedby20.4%post implementationofthe Enhanced Care pilot.On average, therewasa requirement for236HCAsrequiredpermonthto meet the demand for Enhanced Care post-


Figure6-DemandvsAgencySupply2018-2019

OUTCOME

Thereductioninagencyusageandspendingovertheperiodofthepilotdemonstratesthetransitiontoamorestabilisedworkforce.Thisinturnindicatesthatcareisbeingprovidedmoreconsistentlytothosewithadditionalcareneeds.TheintroductionofthededicatedEnhancedCareteamhasdemonstratedachangeinthewaythatagencyuseisbeingdeployed,leadingtoasustainableandconsistentworkforcecaringforpatientsrequiringadditionalcare.

TherehasalsobeenareducednumberofagencystaffdeliveringEnhancedCare,despitetheincreaseindemandoverthetimeofthepilotperiod.

IMPACT

050

100150200250300350

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DemandvsAgencySupply2018-2019

Demand

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DemandvsAgencySupply2018-2019

Figure 5 - Demand vs Agency Supply 2018 - 2019

implementation.TheaveragenumberofagencyHCAssupplieddroppedto88WTEpermonth.ThisreductioninagencyusedemonstratesthatOLOL is achieving stabilisation of the nursingandHCAworkforceovertime;thisstabilisationisassociatedwithlowerorganisationalcostsandbetterpatientoutcomes(DepartmentofHealth,2018)

toasustainableandconsistentworkforcecaringforpatientsrequiringadditionalcare.

Therehasalsobeenareducednumberofagencystaff delivering Enhanced Care, despite theincrease in demand over the time of the pilotperiod.

OUTCOMEThe reduction in agency usage and spendingover the period of the pilot demonstrates thetransitiontoamorestabilisedworkforce.Thisinturn indicatesthatcare isbeingprovidedmoreconsistentlytothosewithadditionalcareneeds.The introduction of the dedicated EnhancedCare team has demonstrated a change in thewaythatagencyuseisbeingdeployed, leading

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Figure 6 - Projected Savings

combinedwith thecostsof theEnhancedCarerecruitmentandongoingminimalagencyrequiredtosupplementvacancies.

IMPACTTheestimatedoverallsavingsof€400kisbasedon the costs including the projected increaseof demand (estimated at 24% year-on-year)

7.2.3 DevelopBespoke Documentation

ACTIONWorking groups were established to designand develop documentation to support theimplementation of the Enhanced Care process.The documentation was created using a co-design approach and reviewed using multiplePlanDo StudyAct (PDSA) change cycles and aprojectprocess.AsuiteofdocumentsrequiredtoimplementEnhancedCarewasdeveloped.Underthefirst assumptionof theFramework for SafeStaffingandSkillMix,eachpatient’scareneedsare unique, it can be assumed that not everypatientwill requireeachdocument torecordorsupportthenecessarylevelofcare.Eachpatientshouldbeassessedindividuallyandcontinuously;these documents will assist in the assessment,care planning and communication of EnhancedCare.Thedocumentsdevelopedinclude:

• EnhancedCareLeaflet(appendixI)• PatientPassport(appendixII)• PatientBehaviouralChart(appendixIII)• ReferralSOP(appendixIV)• RiskAssessment(appendixV)• EnhancedCareTeamObservation• Assessment(appendixVI)

OUTCOMEPatientPassportPatient passports were developed to aid theimplementation of person-centred care, byproviding staff with ready access to clinicaland non-clinical information that is importantto the patient. This includes information suchas; preferred name, name of carer, likes anddislikes. The staff caring for this patient can usethis informationto tailor interventiontobemoreperson-centred. Aspotauditwasundertakentoassure theuseof thepatientpassport.A totalof30of62patientswereauditedFebruary2019withafurther30of62patientsreviewedMarch2019.

CostsofAgency2017-2018

€1.2M

ProjectedCost2018-2019

€1.5M

Includingprojectedincreasedindemandat24%

IncludingincreaseandrecruitmentofECT

IncludingprojectedsavingsfromareductioninNSO

ActualCosts2018-2019

€1.1M

OverallSavings€400K

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100%ofpatientsverifiedinFebandMarchhada patient passport by their bed-sidewith theirname above their bed reflective of the nametheywantedtobeknownby.However,followingthe audit in February, only 46% of passportshadevidencethattherewasfamilyengagement

duringitsdevelopment.FollowingaPDSAcyclereview,itwasdecidedtoaddafamilysignatureon the form to note their involvement in thedevelopmentofthepassport.Duringtherepeatspot audit inMarch, this compliance increasedfrom46%to93%.


PatientPassportPatientpassportsweredevelopedtoaidtheimplementationofperson-centredcare,byprovidingstaffwithreadyaccesstoclinicalandnon-clinicalinformationthatisimportanttothepatient.Thisincludesinformationsuchas;preferredname,nameofcarer,likesanddislikes.Thestaffcaringforthispatientcanusethisinformationtotailorinterventiontobemoreperson-centred.

Aspotauditwasundertakentoassuretheuseofthepatientpassport.Atotalof30of62patientswereauditedFebruary2019withafurther30of62patientsreviewedMarch2019.

Table3-Pre-ImplementationAudit

100%ofpatientsverifiedinFebandMarchhadapatientpassportbytheirbed-sidewiththeirnameabovetheirbedreflectiveofthenametheywantedtobeknownby.However,followingtheauditinFebruary, only 46% of passports had evidence that there was family engagement during itsdevelopment.FollowingaPDSAcyclereview,itwasdecidedtoaddafamilysignatureontheformtonotetheirinvolvementinthedevelopmentofthepassport.DuringtherepeatspotauditinMarch,thiscomplianceincreasedfrom46%to93%.

Table4-Post-ImplementationAudit

Figure8-PatientPassport

AuditDateRange NoofPatientsAudited TotalNumberofpatientsreceivingEnhancedCareSpotAuditOne 11th-17thFebruary2019 30 62SpotAuditTwo 18th-24thMarch2019 30 61


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Figure 7 - Patient Passport

AuditDateRange No.ofPatients Audited

TotalNumberofpatients receivingEnhancedCare

SpotAuditOne 11th-17thFebruary201 30 62

SpotAuditTwo 18th-24thMarch2019 30 61

AuditDateRange No.ofPatients Audited

TotalNumberofpatients receivingEnhancedCare

SpotAuditOne 11th-17thFebruary201 30 62

SpotAuditTwo 18th-24thMarch2019 30 61


PatientPassportPatientpassportsweredevelopedtoaidtheimplementationofperson-centredcare,byprovidingstaffwithreadyaccesstoclinicalandnon-clinicalinformationthatisimportanttothepatient.Thisincludesinformationsuchas;preferredname,nameofcarer,likesanddislikes.Thestaffcaringforthispatientcanusethisinformationtotailorinterventiontobemoreperson-centred.

Aspotauditwasundertakentoassuretheuseofthepatientpassport.Atotalof30of62patientswereauditedFebruary2019withafurther30of62patientsreviewedMarch2019.

Table3-Pre-ImplementationAudit

100%ofpatientsverifiedinFebandMarchhadapatientpassportbytheirbed-sidewiththeirnameabovetheirbedreflectiveofthenametheywantedtobeknownby.However,followingtheauditinFebruary, only 46% of passports had evidence that there was family engagement during itsdevelopment.FollowingaPDSAcyclereview,itwasdecidedtoaddafamilysignatureontheformtonotetheirinvolvementinthedevelopmentofthepassport.DuringtherepeatspotauditinMarch,thiscomplianceincreasedfrom46%to93%.

Table4-Post-ImplementationAudit

Figure8-PatientPassport



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Post-ImplementationAudit

Table 3 - Pre- Implementation Audit

Table 4 - Post- Implementation Audit

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BehaviouralChartA spot audit was also undertaken to examinethe compliance of the behavioural and riskassessment.Atotalof30patientswereauditedon February 2019 with a further 30 patientsauditedonMarch2019.All of patients audited(100%)hadapatientpassportfullycompleted;ariskassessmentfullycompletedwithariskratingscoringidentified.Themajority(90%)ofpatientsinFebruaryhadanidentifyingpatientstickeronthepatientpassport.Thisincreasedto93%inthe


BehaviouralChart

Aspotauditwasalsoundertakentoexaminethecomplianceofthebehaviouralandriskassessment.Atotalof30patientswereauditedonFebruary2019withafurther30patientsauditedonMarch2019.Allofpatientsaudited(100%)hadapatientpassportfullycompleted;ariskassessmentfullycompletedwith a risk rating scoring identified. Themajority (90%)of patients in Februaryhadanidentifyingpatient stickeron thepatientpassport. This increased to93% in the followingaudit inMarch.Itisrecommendedthattheauditsarecontinuedonaregularbasisandfindingsreportedtothelocalimplementationgroup.IMPACT

Acknowledgingtheincreaseinuseandawarenessofthebespokedocumentsdemonstratesearlysignofthemodelofcarebecomingembeddedwithintheorganisation’spractices.

Figure9-PatientOutcomes-Documentation

7.2.4 DevelopaTailoredEducationPackageACTIONA bespoke specialist training programme was developed for all members of the Enhanced Careteam. The research revieweddemonstrated the importance ofmatching education to the patientandstaffneeds(Schoenfischetal.,2015;Evans,2008).Initially, a retrospective reviewwas undertaken over a six-week period in April andMay 2018 toanalyse why patients required Enhanced Care. A four-day education programme was then

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BehaviouralChart

Aspotauditwasalsoundertakentoexaminethecomplianceofthebehaviouralandriskassessment.Atotalof30patientswereauditedonFebruary2019withafurther30patientsauditedonMarch2019.Allofpatientsaudited(100%)hadapatientpassportfullycompleted;ariskassessmentfullycompletedwith a risk rating scoring identified. Themajority (90%)of patients in Februaryhadanidentifyingpatient stickeron thepatientpassport. This increased to93% in the followingaudit inMarch.Itisrecommendedthattheauditsarecontinuedonaregularbasisandfindingsreportedtothelocalimplementationgroup.IMPACT

Acknowledgingtheincreaseinuseandawarenessofthebespokedocumentsdemonstratesearlysignofthemodelofcarebecomingembeddedwithintheorganisation’spractices.

Figure9-PatientOutcomes-Documentation

7.2.4 DevelopaTailoredEducationPackageACTIONA bespoke specialist training programme was developed for all members of the Enhanced Careteam. The research revieweddemonstrated the importance ofmatching education to the patientandstaffneeds(Schoenfischetal.,2015;Evans,2008).Initially, a retrospective reviewwas undertaken over a six-week period in April andMay 2018 toanalyse why patients required Enhanced Care. A four-day education programme was then

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Feb-19 Mar-19Figure 8 - Patient Outcomes - Documentation

Behavioural Chart

followingauditinMarch.Itisrecommendedthattheauditsarecontinuedona regularbasisandfindings reported to the local implementationgroup.

IMPACTAcknowledgingtheincreaseinuseandawarenessof the bespoke documents demonstrates earlysign of themodel of care becoming embeddedwithintheorganisation’spractices.

7.2.4 DevelopaTailored EducationPackage

ACTIONA bespoke specialist training programme was developedforallmembersoftheEnhancedCareteam. The research reviewed demonstrated theimportanceofmatchingeducationtothepatientandstaffneeds (Schoenfischetal.,2015;Evans,2008).

Initially, a retrospective review was undertakenoverasix-weekperiodinAprilandMay2018toanalyse why patients required Enhanced Care.A four-day education programme was thendeveloped around the care needs identified

fromthis review.Variousmembersof themulti-disciplinaryteamtogetherwithspecialistexternalspeakers were involved in the delivery of theprogramme.All16EnhancedCareteammembersattendedthetraininginDecember2018.

OUTCOMEIn total over200 staff, fromboth theEnhancedCareteamandwardstaff,enrolledonthespecialisttrainingprogramme.

Aquestionnairewascirculated toall16staffontheEnhancedCare teamat the commencementandagainuponcompletionofthebespoketrainingprogramme.A100%responseratewasachieved.

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QuestionOne:31.5%oftheparticipantsfelttheyhadsufficientskillstocompleteandusethepatientpassportpre-trainingincomparisonto100%ofstaffposttraining

QuestionTwo:31.5%oftheparticipantsfelttheyhadsufficientskillstomanageapatientwithdementiapriortothiseducationprogramme.However,100%ofparticipantsfeltthatafterthetrainingtheyfelttheyhadenoughskillstocareforapatientwithadementia.


developed around the care needs identified from this review. Various members of the multi-disciplinary team together with specialist external speakers were involved in the delivery of theprogramme.All16EnhancedCareteammembersattendedthetraininginDecember2018.OUTCOMEIntotalover200staff,fromboththeEnhancedCareteamandwardstaff,enrolledonthespecialisttrainingprogramme.Aquestionnairewascirculatedtoall16staffontheEnhancedCareteamatthecommencementandagainuponcompletionofthebespoketrainingprogramme.A100%responseratewasachieved.

Questionone:

31.5%oftheparticipantsfelttheyhadsufficientskillstocompleteandusethepatientpassportpre-trainingincomparisonto100%ofstaffposttraining

Figure10-ResultsfromQuestionnaire1

QuestionTwo:

31.5%oftheparticipantsfelttheyhadsufficientskillstomanageapatientwithdementiapriortothiseducationprogramme.However,100%ofparticipantsfeltthatafterthetrainingtheyfelttheyhadenoughskillstocareforapatientwithadementia.

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QuestionOne:Doyouhavesufficientskillstocompleteanduseapatientpassport

QuestionTwo:DoyouhavesufficientskillstomanagepatientswithDementia

Figure 9 - Results from Questionnaire 1




QuestionThree:

31.5%oftheparticipantsfelttheyhadenoughskillstomanageapatientwithahighriskoffallspriortothiseducationprogrammeincomparisonto100%ofparticipantsposttraining.


QuestionFour:

TheliteraturereviewstronglysupportedtheimportanceofincludingviolenceandaggressiontrainingforEnhancedCarestaff(Wilkesetal.,2010).Thiswasinthepiloteducationcurriculumbutnotdeliveredbecauseoftheunavailabilityofspecialistfacilitatorsintheshorttimeperiod.Despite

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QuestionThree:31.5%oftheparticipantsfelttheyhadenoughskillstomanageapatientwithahighriskoffallspriortothiseducationprogrammeincomparisonto100%ofparticipantsposttraining.

QuestionFour:TheliteraturereviewstronglysupportedtheimportanceofincludingviolenceandaggressiontrainingforEnhancedCarestaff(Wilkesetal.,2010).Thiswasinthepiloteducationcurriculumbutnotdeliveredbecauseoftheunavailabilityofspecialistfacilitatorsintheshorttimeperiod.Despite not receiving training, the staffbecamemore aware to their own skills deficit andidentifiedthisisanareatheywouldseekassistancefromnursingstaffifrequired.Whilst25%ofparticipantsfelttheyhadsufficientskillsortrainingsurroundingmanagementofviolenceandaggressionpre-training,50%ofparticipantsnotedtheydidnothaveadequatetrainingorskillsinthemanagementofviolenceandaggressionposttraining.



QuestionThree:

31.5%oftheparticipantsfelttheyhadenoughskillstomanageapatientwithahighriskoffallspriortothiseducationprogrammeincomparisonto100%ofparticipantsposttraining.


QuestionFour:

TheliteraturereviewstronglysupportedtheimportanceofincludingviolenceandaggressiontrainingforEnhancedCarestaff(Wilkesetal.,2010).Thiswasinthepiloteducationcurriculumbutnotdeliveredbecauseoftheunavailabilityofspecialistfacilitatorsintheshorttimeperiod.Despite

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Question4:Doyouhavesufficientskillstomanagepatientswithhighriskofviolence and /or aggression




notreceivingtraining,thestaffbecamemoreawaretotheirownskillsdeficitandidentifiedthisisanareatheywouldseekassistancefromnursingstaffifrequired.Whilst25%ofparticipantsfelttheyhadsufficientskillsortrainingsurroundingmanagementofviolenceandaggressionpre-training,50%ofparticipantsnotedtheydidnothaveadequatetrainingorskillsinthemanagementofviolenceandaggressionposttraining.


IMPACT

Overall the results showtheparticipantshaveamarked increase inknowledgeandskills requiredsurrounding the use of patient passports, dementia care, and falls awareness and therefore areequippedtodeliverEnhancedCare.WardStaffwerealsoprovidedwithtrainingregardingEnhancedCare to support the implementation. The test of changewill be in the sustained improvement ofpatientoutcomesovertime.

7.2.5 GovernanceACTIONTheCNM3facilitatedtheoperationalmanagementsurroundingtheimplementationandpilotingofthe project. This role was supported by the Assistant Director of Nursing with responsibility forresourcing and project management. The existing governance structure from phase 1 of theFrameworkforSafeNurseStaffingandSkillMixwasexpandedtoincludetheEnhancedCareproject(AppendixVII).OUTCOMETwoseparatebutparallelgovernancestructureswereputinplacetoensuretheimplementationofthe recommendations in the Framework and the Enhanced Care pilot; these are the LocalImplementation Group and Enhanced Care Operational Group. Representatives of key roles or

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violenceand/oraggression

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affecting patients and the organisation. TheLocal ImplementationGroup (LIG) is chairedbytheDirectorofNursingandsupportedbydirectreports of the information as set out in Phase1 of the Framework (Appendix VII) i.e. patientoutcomes, staff measure and organisationmeasures. This information is used to overseeboth the Framework and the Enhanced Carepilot. The Enhanced Care Operational GroupreportsintotheLocalImplementationGroupbyproviding systematic and triangulated reportsof activity and outcomes to inform the LIG’soversight.

Thereasontwoparallelstructuresexistwasduethe Framework implementation structure wasalready inplace inOLOL.Once theFrameworkimplementation is complete the LIG will bemaintainedastheSafeStaffingOversightGroup.ThisstructurewillstillreflectthegovernanceandoversightasoutlinedinAppendixVII.

IMPACTThe governance framework oversaw theimplementation of the Enhanced Care modelacross OLOL and sought assurances ofeffectiveness and efficiency improvementswithoutcompromisinganypatientoutcome.TheLIG reports regularly to theHospital ExecutiveManagement Group through the Director ofNursing.Asapilotsite,theLIGalsofurnishedtheDepartmentofHealthwithregularupdatesandreports.

IMPACTOveralltheresultsshowtheparticipantshaveamarkedincreaseinknowledgeandskillsrequiredsurrounding the use of patient passports,dementiacare,andfallsawarenessandthereforeare equipped to deliver Enhanced Care. WardStaffwerealsoprovidedwithtrainingregardingEnhancedCare to support the implementation.The test of change will be in the sustainedimprovementofpatientoutcomesovertime.

7.2.5 GovernanceACTIONThe CNM 3 facilitated the operationalmanagement surrounding the implementationand piloting of the project. This role wassupported by theAssistantDirector ofNursingwith responsibility for resourcing and projectmanagement.Theexistinggovernancestructurefromphase1of theFramework forSafeNurseStaffing and SkillMixwas expanded to includetheEnhancedCareproject(AppendixVII).

OUTCOMETwoseparatebutparallelgovernancestructureswereputinplacetoensuretheimplementationof the recommendations in theFrameworkandthe Enhanced Care pilot; these are the LocalImplementation Group and Enhanced CareOperationalGroup.RepresentativesofkeyrolesordepartmentsthroughoutOLOLweremembersof the LIG so that oversight was conclusiveand all-encompassing of the various factors

Further outcomes of the Pilot

8

38


8.0 Furtheroutcomesof thePilot

8.1 PatientandStaffOutcomes

8.1.1 FamilySatisfaction:A family questionnaire was designed anddelivered to all familymembers inMarch 2018(prior to the implementation of the EnhancedCare project) and March 2019 (following theimplementationoftheEnhancedCareproject)toassess the effectiveness of the implementation

QuestionOne:InMarch2018,40%offamiliesreportedthathadbeenengagedwithinthedevelopmentofa one-to-one careplan for their relatives; following implementationof theEnhancedCareinitiative,100%offamiliesquestionedinMarch2019reportedthattheywereinvolvedinthedevelopmentofaone-to-onecareplan.


8.0 FurtheroutcomesofthePilot

8.1 PatientandStaffOutcomes

8.1.1 FamilySatisfaction:AfamilyquestionnairewasdesignedanddeliveredtoallfamilymembersinMarch2018(priortotheimplementation of the Enhanced Care project) andMarch 2019 (following the implementation oftheEnhancedCareproject)toassesstheeffectivenessoftheimplementationofEnhancedCare.Thefamily questionnairewas distributed to 35 families: 29 questionnaireswere returned fromMarch2018survey(82%responserate)with31returnedinMarch2019survey(88.5%responserate).

QuestionOne:

InMarch2018,40%offamiliesreportedthathadbeenengagedwithinthedevelopmentofaone-to-onecareplanfortheirrelatives;followingimplementationoftheEnhancedCareinitiative,100%offamiliesquestionedinMarch2019reportedthattheywereinvolvedinthedevelopmentofaone-to-onecareplan.

Figure14-SatisfactionResponse1

QuestionTwo:

PriortotheimplementationoftheEnhancedCareinitiative,9%offamilyrespondentsreportedthattheywereawareof theavailabilityof activityequipment their relative; following implementation,75% of families reported awareness. The is a critical indicator of the increased awareness ofalternativetherapiesandactivesavailabletopatientthatrequireEnhancedCare.

40%

100%

0%

20%

40%

60%

80%

100%

March March

March2018vsMarch2019

Wereyouincludedinthedevelopmentofyourfamilymembers1:1planWereyouincludedinthedevelopementofyourfamilymembers1:1plan

Figure 13 - Satisfaction Response 1

ofEnhancedCare.Thefamilyquestionnairewasdistributed to 35 families: 29 questionnaireswere returned from March 2018 survey (82%responserate)with31returned inMarch2019survey(88.5%responserate).

39


QuestionTwo:Prior to the implementation of the Enhanced Care initiative, 9% of family respondentsreportedthattheywereawareoftheavailabilityofactivityequipmenttheirrelative;followingimplementation,75%offamiliesreportedawareness.TheisacriticalindicatoroftheincreasedawarenessofalternativetherapiesandactivesavailabletopatientthatrequireEnhancedCare.

QuestionThreeandQuestionFour:AllfamilieswhohadafamilymembersupportedbytheEnhancedCareteamwerefullyawareofwhatapatientpassportwasincomparisonto52%priortoits introduction,with90%ofrespondentsstatingthefamilypassportwasinuseduringthisadmission.ThisdemonstratestheincreasedprovisiononindividualisedcarewhichiscoretoboththeEnhancedCaremodelandtheFrameworkforSafeNurseStaffingandSkillMix.

Isthereanyactivityequipmentinuse



Question3andQuestion4:

AllfamilieswhohadafamilymembersupportedbytheEnhancedCareteamwerefullyawareofwhatapatientpassportwasincomparisonto52%priortoitsintroduction,with90%ofrespondentsstatingthefamilypassportwasinuseduringthisadmission.ThisdemonstratestheincreasedprovisiononindividualisedcarewhichiscoretoboththeEnhancedCaremodelandtheFrameworkforSafeNurseStaffingandSkillMix.


9%

75%

0%

10%

20%

30%

40%

50%

60%

70%

80%

March March



52%

100%

0%

20%

40%

60%

80%

100%

March March


AreyoufamiliarwiththetermPatientPassport



Question3andQuestion4:

AllfamilieswhohadafamilymembersupportedbytheEnhancedCareteamwerefullyawareofwhatapatientpassportwasincomparisonto52%priortoitsintroduction,with90%ofrespondentsstatingthefamilypassportwasinuseduringthisadmission.ThisdemonstratestheincreasedprovisiononindividualisedcarewhichiscoretoboththeEnhancedCaremodelandtheFrameworkforSafeNurseStaffingandSkillMix.


9%

75%

0%

10%

20%

30%

40%

50%

60%

70%

80%

March March



52%

100%

0%

20%

40%

60%

80%

100%

March March


AreyoufamiliarwiththetermPatientPassport



AreyoufamiliarwiththetermPatientPassport?

40




Question5:

Prior to the implementation of the Enhanced Care team, 31% of respondents reported that theEnhancedCareservicewaseitherhelpfulorveryhelpful; this iscomparedto87%ofrespondents,who following the implementation of the Enhanced Care team found the service helpful or veryhelpful.


8%

90%

0%

20%

40%

60%

80%

100%

March March


If'Yes'isitbeingusedduringthisadmission

0%

10%

20%

30%

40%

50%

60%

VeryHelpful Helpful NeitherHelfulorUnhelpful

Unhelpful VeryUnhelpful

%R

espo

nse


FamilySatisfactionSurvey

Mar-18 Mar-19



Question5:



8%

90%

0%

20%

40%

60%

80%

100%

March March



0%

10%

20%

30%

40%

50%

60%



%R

espo

nse



Mar-18 Mar-19



Question5:



8%

90%

0%

20%

40%

60%

80%

100%

March March



0%

10%

20%

30%

40%

50%

60%



%R

espo

nse



Mar-18 Mar-19

If‘Yes’isitbeingusedduringthisadmission?




QuestionFive:PriortotheimplementationoftheEnhancedCareteam,31%ofrespondentsreportedthatthe EnhancedCare servicewas either helpful or very helpful; this is compared to 87%ofrespondents,whofollowingtheimplementationoftheEnhancedCareteamfoundtheservicehelpfulorveryhelpful.

41


FamilyTestimonial:AnexampleofapositiveexperienceofEnhancedCarefromafamilymemberisoutlinedinthequotationbelow:

“The difference in the care with Mam when your team are with her, they don’t just sit there. It is lovely to see her enjoying herself and having her hair done & nails painted and looking so well. We can’t

thank you enough for the care you have given Mam.

We couldn’t have done it without you. It means so much to us as a family. Thank you”

8.1.2 FallsData from the hospital databasewas collectedbetween January 2017 and December 2018andanalysedtoreviewfallsper1000beddays.This informationmustbe taken incontextwiththe implementation of the Framework, andthe outcomes cannot be based solely on theimplementation of the Enhanced Care pilotproject.

• 2017:421fallsoccurred (rate: 3.53 falls / 1000 bed days) • 2018:493fallsoccurred (rate: 3.57 falls / 1000 bed days)

ThesefallsratesarewellbelowtheNHSI(NHSImprovement, 2017) benchmark for acutehospitals:(6.1falls/1000beddays).Internationalresearchwould suggest fall rates may increasewith the development of an Enhanced Careprocess, noting a rise in falls is generallyassociatedwithassistedfalls(Tzeng&Yin,2007);in addition, there may be an increase in the

HospitalAcquiredStaph. AureusBloodstreamInfection

Number of Cases 2017

5 3 0.04 0.02

19 17 0.15 0.12

Number of Cases2018

Rate per1000 beddays 2017

Rate per1000 beddays2018

HospitalAcquiredNew CasesC.Difficile

reportingof falls.YetSpivaetal (2012)&Laws&Crawford(2013)bothsuggestfallsmayreduceifmembersofaspecialistteamarepresentandappropriate guidelines and assessments are inuse.

In line with the above, only one patient whoreceived care from the Enhanced Care teamduring the eight-month trial sustained a fall;thisfallwasclassifiedasanassistedfallwithnoreportedinjury.

8.1.3 HealthCareAssociatedInfectionsData from the hospital databasewas collectedand analysed to review Healthcare AssociatedInfections(HCAIs)inrelationtohospitalacquiredStaph.Aureus and hospital acquired C.Difficile.HCAIsreducedper1,000beddayfrom2017to2018.Thisinformationmustbetakenincontextwiththe implementationoftheFrameworkandshouldnotbebasedsolelyontheEnhancedCarepilotproject.

Table 5 - HCAIs 2017 and 2018

5.0HCAIs2017and2018

42


8.1.4 CareMissed/DelayedEventsData to measure care events delayed or careleft undone were captured across two dateranges: September 2017 to April 2018 (priorto the implementation of Enhanced Care) andSeptember 2018 to April 2019 (following theimplementationofEnhancedCare).

CareMissedEvents:Therewasa79%reductionnoted in care missed events with the meanreducing from 1.88% to 0.44% across the twodate ranges. This information must be takenin context with the implementation of theFramework, not based solely on the EnhancedCarepilotproject.


NumberofCases2017

NumberofCases2018

Rateper1000beddays2017

Rateper1000beddays2018

HospitalAcquiredStaph.AureusBloodstreamInfection 5 3 0.04 0.02HospitalAcquiredNewCasesC.Difficile 19 17 0.15 0.12

Table5-IncidenceofCDIFF2018-2018

8.1.4 CareMissed/DelayedEventsData tomeasure care events delayedor care left undonewere captured across twodate ranges:September2017toApril2018(priortotheimplementationofEnhancedCare)andSeptember2018toApril2019(followingtheimplementationofEnhancedCare).

CareMissedEvents:Therewasa79%reductionnotedincaremissedeventswiththemeanreducingfrom1.88%to0.44%acrossthetwodateranges.ThisinformationmustbetakenincontextwiththeimplementationoftheFramework,notbasedsolelyontheEnhancedCarepilotproject.

Figure19-CareLeftUndoneEventsasReported

0123456789

%of

pat

ient

s


% ofeventsmissedSept2017-April2018

% ofeventsmissedSept2018-April2019


Figure 18 - Care Left Undone Events as Reported

Recommendations

9

44


9.0 RecommendationsLearnings from the pilot site have provided several recommendations for any organisation undertakingtheimplementationoftheEnhancedCaremodel.

the above recommendations for localdevelopmentofchangetodelivercaredifferentlyare in linewiththeSláintecarevisiontochange

Recommendation1 Beforeimplementation,baselinedataonpatient,staffandorganisational outcomesareidentifiedandcollected.Thisallowstheorganisationto identifythechallengesthatmayimpactupontheimplementation ofEnhancedCare.

Recommendation2 ProvidedocumentationrelevanttotheprovisionofEnhancedCare. Continuouslyreviewandassessthedatabeingcollected.Ongoingaudits ofdata,documentsandpatientoutcomesareessentialtoensuring thesuccessoftheprojectbutalsothesafetyofthepatientsinvolved.

Recommendation3 Includeviolenceandaggressionmanagementinbespokeeducationforthe EnhancedCareteam.Thecurriculumshouldbereviewedannually andupdatedbasedonthefeedbackfromthepatients,familiesand staffinvolved.Thistrainingshouldbeupdatedeverytwoyears,in linewithothermandatorytraining.

Recommendation4 Adoptarobustgovernancestructurebeforecommencingimplementation. Thisstructurecanprovideoperationalandstrategicoversightwhile alsoassistingwithanydecisionsinthedeliveryofEnhancedCare

Table6.0RecommendationsfromthePilotonEnhancedCare

howwedelivercare,provideinnovative,effective,efficientandpatientcentredsolutions.

Conclusion

10

46


10.0 Conclusion

Akeypriority for theHSE is toensurethecareprovided anticipates, responds and consistentlyseeks to improve how patient care is delivered(HSE, 2018). This is taken in the context ofincreasing demands on the health servicenot least the growing complexity in patientpresentationsandtheneedtoprovidesafequalitycare to older people presenting to the acutecare setting. Tomeet thepriorityofenhancingthe care delivered to patients, especially thosewithcomplexneeds, there isaneedtodevelopand implement innovative approaches to caredelivery.Oneinnovativeapproach,asoutlinedinthisreport,istheimplementationofanevidence-basedinitiativetoprovidesafeandeffectivecaretopatientswhorequireinterventionsaboveandbeyond routine care. The implementation of astructured,hospital-staffedEnhancedCareteamhasdemonstrated in thispilot that it canbeaneffectiveand sustainable approach toprovidingsafecaretoavulnerablecohortofpatient

Acknowledging that further research is needed,the pilot project has demonstrated some initialindicatorsofpositiveoutcomes:

•Amorestabilisedandsustainable workforce •Increasedindividualisedandperson -centredapproachtocare •Increasedinvolvementoffamilies inEnhancedCare • Indicationofthemodelbecoming embeddedinroutinepractice •Reductioninagencycostsovertime

The development of a bespoke educationprogramme helped to deliver appropriatetraining to staff, ensuring the care needs ofthe patients could bemet.The use ofmultiplestrategies, including referral pathways, riskassessments, behavioural charts, and patientpassportsprovidedthestaffwiththenecessarytoolsrequiredforthesuccessfulimplementationof this initiative. On-going measurement,evaluation, and dissemination of findings havefacilitated staff engagement,whereby staff feeltheyhavebeencollectivelyinvolvedthroughoutthe process. This pilot project has improvedthewayEnhancedCare is provided topatientsthroughouttheorganisation.

All Ireland Enhanced Care Report

11

48


11.0 AllIrelandEnhanced Care Report

An All Island Collaborative Task Group hasbeen set up between the offices of the ChiefNursing Officer (CNO) in Northern Ireland (NI)and Republic of Ireland (ROI), to develop keyprinciplesforEnhancedCarethatwillbeappliedinbothjurisdictions.

Thiswork has been developed in linewith theprinciplesofQuadrupleAim (Figure 15). InitiallyatripleAimwasdevelopedin2008toguidethedesignofhealthcaresystemswithinapopulationhealth patient experience of care and reducingcosts. In recognition that the backboneof anyeffective healthcare system is engaged andproductive in terms of workforce, a fourth(quadruple) aim was introduced improving theexperience of providing care. The fourth aimholds particular importance within nursingworkforce planning arrangements. Nurses areoften central to the teams of health and socialcareprofessionalschargedwithdeliveringhealthand service improvements. Effective workforceplanningisvital,notonlyinensuringtheavailabilityofenoughnumberofskilledstaffareavailablebutalso inprovidingstructuresandsupportsothateachmemberofthenursingworkforceteamcanrealise a sense of accomplishment and successthatresultsfrommeaningfulwork.AQuadrupleAimapproachwill be applied to thedeliveryofthisproject.

Thiscollaborationaimsto:

• Ensurethatthereisguidanceand aframeworktosupportdecisions fortherequirementsfornursestaffing forEnhancedCareinhospitalsettings.

• Reviewtheavailableevidenceand currentpracticeineacharea.

• Proposeasetofkeyprinciples regardingEnhancedCaretakinginto accounttheappropriateprofessional/ skillsettodelivercaretothepatient.

• Testtheexperienceoftheapplication ofasetofprinciplesforEnhancedCare provisionineachareathroughthe initiationoftestpilotsitesinNIand ROI.

• Produceanall-islandrecommendation andguidingprinciplesforEnhanced Careforthenursingworkforceinacute hospitalsettings.

• Ensurethedevelopmentofguidance andstandardisationofassessmentof therequirementsofEnhancedCareand implementaprocessformonitoringand reviewineacharea.

Thedriverdiagram(AppendixVIII)describesthekey aims and objectives and change ideas thatneed to be considered as part of this project.Dueconsiderationwill begiven to theongoingwork progressing through workforce policyframeworksineacharea.

The learning from this pilot project has beensharedwith theNI approach to their provisionof Enhanced Care. The NI group are trialling adifferentadaptationofEnhancedCare,usingthesameprinciples.ThistrialinongoingandareportisduetobepublishedinSeptember2019.

Figure 19 - All Island Collaborative Approach - Quadruple Aim

Improvingthe health ofour people

Supportingand

empoweringstaff

Improvingthequality

andexperience ofcare

Ensuringsustainability

of ourservice

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50


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Laws,D.andCrawford,C.L.(2013)Alternativestrategiestoconstantpatientobservationandsitters:Aproactiveapproach,Journal of Nursing Administration,43(10),pp.497–501.DOI:10.1097/NNA.0b013e3182a3e83e.

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Schoenfisch,A.L.,Pompeii,L.A.,Lipscomb,H.J.,Smith,C.D.,Upadhyaya,M.andDement,J.M.(2015)Anurgentneedtounderstandandaddressthesafetyandwell-beingofhospital‘sitters’,American Journal of Industrial Medicine, 58(12),pp.1278–1287.DOI:10.1002/ajim.22529.

Wilkes,L.,Jackson,D.,Mohan,S.andWallis,M.(2010)Closeobservationby‘specials’topromotethesafetyoftheolderpersonwithbehaviouraldisturbancesintheacutecaresetting,Contemporary Nurse,36(1–2),pp.131–142.DOI:10.5172/conu.2010.36.1-2.131.

Worley,L.L.M.,Kunkel,E.J.S.,Gitlin,D.F.,Menefee,L.A.andConway,G.(2000)Constant Observation Practices in the General Hospital Setting: A National Survey, Psychosomatics.Vol.41.DOI:10.1176/appi.psy.41.4.301.

Yevchak,A.,Steis,M.,Diehl,T.,Hill,N.,Kolanowski,A.andFick,D.(2012)Managingdeliriumintheacutecaresetting:Apilotfocusgroupstudy,International Journal of Older People Nursing,7(2),pp.152–162.DOI:10.1111/j.1748-3743.2012.00324.x.

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GlossaryofTermsBedOccupancy Thenumberofbedsthatareoccupiedovera24-hourperiod

EnhancedCare Theallocatingofadedicatedmemberofthehealthcareteamto apatientwhorequiresadditionalcareorsupervisionbeyondthe usualwardcomplement.

HCA HealthCareAssistantisanunregisteredhealthcareworker, (Health Care providingpatientcareunderthedirectguidanceandsupervision Assistant) ofaregisterednurse. SkillMix Themixofeducation,training,skillsandexperiencewithinthe nursingcareteamthatincludesbothregisterednursesandhealth careassistants.

PersonCentredCare PersonCentredCaresupportspeopletomakeaninformeddecisionabout, andsuccessfullymanage,theirhealthandcare (TheHealthFoundation,2014)

Registered Nurse ARegisteredNurseisanursewhosenameisenteredinthenursedivision oftheregisterofNurseandMidwivesbytheNursingandMidwiferyBoard ofIreland(NMBI,2014)

WTE WholeTimeEquivalent–calculationofamemberofstaffdelivering 39hrsperweek.

Appendices

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EnhancedCareReportDraft44|Page

EnhancedCareReportDraft45|Pa

ge

AppendixIEnhancedCareLeaflet

55



AppendixIIPatientPassport

AppendixIIPatientPassport




56





57


AppendixIIIPatientBehaviouralChart


ge

AppendixIIIPatientBehaviouralChart


ge

58


AppendixIVReferralPathway


AppendixIVReferralPathwayOurLadyofLourdesHospital

SOPforReferraltoEnhancedCareTeam

1. HowtomakeareferraltoEnhancedCareTeam:

WardteamtoinstigateRisk:multiplefalls/walkingaboutRisk:significant

Localmanagementplan,

MayrequestaidsfromEnhancedCareTeam

eg.Arts&craftmaterials.

Unlessclinicalindicate

StartbehaviouralChartStartbehaviouralChart

DiscusswithCNM3EnhanceCareTeam

1. fallsRiskAssessment:Carebundle,aidstominimiserisk2. Considerco-hort/highvisibilitybay(nurse/HCAinbay)3. Completepostfallsreview(ifpatienthasfallen)4. Reviewmedication/Behaviouralchartsconsidermedicalreiew5. IfpatientremainsatriskdiscusswithCNM2/3and

PatientassessedtoestablishlevelofRisk

NurseinChargetoassesspatient’slevelofriskusingtheEnhancedCareRiskAssessment&DecisionAlgorithmforacuteinpatientAreas

GreenAMBERAMBER

REDAMBER


Reassess.ConsiderescalationtoHIGHRISKRED

ContactEnhancecareCNM3/oroutofhoursADONtoreviewpatient,actions:

• ReviewRiskAssessment• CheckPlaninplacetoinvestigatecauseof

distress• Looktodeploystafffromward/EnhancedCare

Teamtoprovideobservation

PatientrequiresEnhancedCare,

CNM3/OutofhoursADON-patientwillbeallocatedappropriateresources

WhereEnhancedCareTeamcan’tprovideresourceCNM3willreviewwithADoNRE:needforagency

(Patientswhohaveadiagnosisofdementiadonotde-escalateafter72hrswillbereferredtothecareoftheolderpersonCNSteamforexpertsupport)

• OutofHours–EnhanceCareTeammembersareallocatedtopatientsrequiringcloseobservation.AllrequestsforassessmentshouldbecompletedwithCNM3EnhancedCareTeam(i.e.8am-4pm,Mon-Fri).Outsideofthesehours/weekends/bankholidays,anyrequestsshouldbediscussedwiththeADONoutofhours(Bleep157).

2. RolesandResponsibilitieswhenapatientisreceivingCarefromEnhancedCareTeam2.1CNM3ECTisresponsiblefor:

• AdheringtoandimplementingtheSafeandSupportiveObservationGuidance• Overseeingthemanagementandco-ordinationofcareplansofpatientswithintheirareaswho

requireEnhancedCareonadailybasis.• AssessandreviewdailywithCNM’s/Nurseincharge,theneedforEnhanceCareTeamandthe

useofadditionalresourcestosupportenhancedobservatione.g.aids,stafftoensureefficientutilisationofEnhancedCareTeam.

• Ensuringappropriateescalationofpatientswhorequirementalhealthassessment–werepatientsaredisplayingbehaviourswhichcannotbedeterminedbyaclinicalcause,thenwardteamsshouldconsidertheneedtorefertomentalhealthservices.Wherethesebehavioursareassessedandareconsideredtobeputtingthepatients/staffathighriskofharm–thisshouldbeescalatedandconsiderationshouldbegivenfortheneedtodeployaregisteredpsychiatricnurseandexpediteurgentreferraltopsychiatricteam.ThisriskisflaggedtothedivisionalCNM3/ADON/Consultant,sothatasafeenvironmentcanbemaintainedforpatientsandstaff.

2.2Wardteamsareresponsiblefor:

• TheimplementationoftheSpecialObservationRiskassessment• Reviewingandagreeingriskassessmentsforenhancedobservationandensuringde-escalation

managementplansinplace


• Ensuringappropriatecaremanagementandtreatmentplansareinplaceandprogressedinatimelymanner

• WorkinpartnershipwiththeEnhancedCareTeamtoensureappropriatelevelofcare/observationandsupportisprovidedthroughouttheshift

• Responsibleforensuringstaffareawareandcanadheretotheprocesswhenapatientrequiresasafeguardingassessment.

• Actionsforde-escalationofdistressshouldbedocumentedandreviewedaspartofthenursing/clinicaltreatmentplan.

• Undertakeareviewof“SpecialObservationriskAssessment”withinamax.72hoursanddailythereafter.

• AnypatientrequiringEnhancedCareTeaminputforlongerthana21dayperiodmustbereferredtotheDirectorofNursingfordiscussionrelatingtothecontinuationofcare.

• Ongoingneedforsupportiveorreduced/de-escalationshouldbedocumentedinthepatient’snursing/medicalnotes.

• EnsureEnhancedCareTeammembersareallocatedbreaks,andprovidedwithrestandchangingfacilitiesinlinewiththoseprovidedforthewardteam

• WhereWardteam/EnhancedCareTeamwith-drawobservationfromapatientanyongoing/furtherconcernsregardingrisktothepatientshouldbeimmediatelyescalatedtotheCNMforreview.De-escalationbyEnhancedCareTeam/wardteamshouldbedocumentedinthepatient’srecordandcounter-signedbyaregisterednursecaringforthepatientfollowingdiscussionwithCNM/Nurseincharge.

Thepatientremainstheresponsibilityofthewardteamthereforeifapatient’sbehaviourescalatestoalevelwherethesafetyoftheindividualpatient,staffmembersorotherpatient’s/visitorsiscompromisedthenthenurseinchargeofthewardmustensurethatappropriateactionsareundertakenandwardstaffaredeployedtosupportEnhancedCareTeamstaffmembersuntilatimewherethesituationcanbede-escalatedorcontained.

WorkinginPartnership:

• RegisteredNursesareaccountableformaintainingthepatient’ssafety;theyretainresponsibilityforanyactivitiestheydelegatetotheEnhancedCareTeamHealthCareAssistantincludingundertakingenhancedobservation.

• RegisteredNursesmustensureanypatientthatrequiresenhancedobservationshavealltheirnursingcareneedsmetandthatallstaffinvolvedintheprocessreceivesufficienthandover(ISBAR)todelivercare.

• EnhancedCareTeamHealthCareAssistantwillactivelyparticipateinprovidingcareandengageintherapeuticinteractionswiththepatient/documentinteractionsandinterventions/escalateconcernsorchangesinbehaviourtotheregisterednurse.

• EnhancedHealthCareAssistantwillworkwithwardstafftoensurethepatient’scareneedsareappropriatelyassessed,planned,implementedandevaluated.

• EnhancedCareTeamwillnotprovide2HCA:1patientcare;howeverwherepatientslevelofriskisfelttoexceedthe1:1observationthiswillbeescalatedtotheappropriatenursemanager.

• EnhancedCareTeamwillnotprovidecaretochildrenoradolescentsunderthecareofchildrenadolescentsmentalservices

• WhereapatientrequiresaSecurityOfficerforreasonsofpatient/staffsafety,localpolicytoapply.

Feb2019VERSION3FMT

59


AppendixVRiskAssessment


AppendixVRiskAssessment


AppendixVIECTObservationAssessment


AppendixVIECTObservationAssessment

EnhanceCareTeamLevelobservationassessment

ConsidertheRisk

LOW

Safety:CanMobiliseunaided.Canusecallbell.Mayrequireassistancewithpersonalcare

Safety:CanMobilisewithaidsorsupervision.Canusecallbellintermittently.Mayrequireassistancewithpersonalcarebutmayshowreluctance

Safety:MayattempttomobiliseUnaidedbutunabletodoso.Unable/won’tusecallbell.Refusestoacceptassistancewithpersonalcare.Hasahistoryoffalls,Alteredsleeppattern.Riskofselfharm

Communication:Ensuretheifthepatientwearsglassesorahearingaidhassame.Nocommunicationissues

Communication:EnsuretheifthepatientwearsglassesorahearingaidhassameCancommunicateneeds.Hassomeevidenceofexpressiveandreceptivedysphasia

Communication:EnsuretheifthepatientwearsglassesorahearingaidhassameLimitedornoeffectivecommunication.Confusedandoragitated.Constantreassurance&reiterationrequired.Mayormaynotbede-escalated

Cognition:Comprehends,Awareoflimitations/hasinsight

Cognition:HaslimitedcomprehensionPoorsafetyawareness

Cognition:Nosafetyawareness.UnabletomaintaintheirowndignityDemonstrateslevelsofanxiety,aggression.Nosafetyawareness.Displayofsociallyinappropriatebehaviour

Procedural:Compliantwithtreatmentsandtherapy

Procedural:Somecompliancewithtreatmentsandtherapy

Procedural:Non-compliantwithtreatmentsandtherapy.

MODERATE HIGH

60


AppendixVIIGovernanceStructure


DaytoDayMonitoringandReviewofEnhancedCare

OperationalGroup

CNM3andADONmaintainoperationaloversightofrequirementandsupply

Triangulation Systematic ProfessionalJudgement

LocalImplementationGroup

ChairedbyDirectorofNursing

Outcomes

Falls

Pressureulcers

Activities/distraction

PatientExperience

Workforce

ECrequired

EDsupplied

Staffeducation/training

Organisational

Agencyused

Agencycosts

Clinicalleadership

Adverseoccurrences

HospitalExecutiveManagementTeam

Hospital / Group Board

War

dto

Boa

rdA

ccou

ntab

ility

HRandFinanceinput Quality and Safety input

AppendixVIIGovernanceStructure

61


AppendixVIIIAllIslandCollaborativeforEnhancedCare


AppendixVII

Department of Health, Hawkins Street, Dublin 2, D02 VW90, Ireland.

Ph: +353 1 6354000

www.health.gov.ie

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