APPENDIX 1 – BATH LHC A&E 4HR Recovery Plan

Key actions to sustain performance against the Emergency Care 4 Hour Standard RUH & Bath LHC

LAST FINALUPDATEDDRAFT 12.05.08

Actions and lead / Input/area of activity / Timetable and risk status / Achievable % improvement / Comment/Progress
1. Continuation of the Discharge assessment team for a further 3 month period.
Principle: rapid & effective discharge assessment in A&E.
Lead: Malcolm Newton, Divisional Lead, Medicine, Maggie Depledge / Evaluation report for DAT 3 month pilot completed and distributed to PCT leads end April. / Extension to end of July 2008.
The DAT will help reduce admissions and shorten length of stay and hence reduce income to the RUH.
MEDIUM RISK / 0.15% / DAT pilot commenced 25th January in limited form moving to full team (OT and Physio) from Feb’08.
Further data to assess its cost effectiveness and impact will be collated for next 3 month period including any issues relating to community services/ capacity that could have prevented an admission, actual admission avoidance vs LOS reduction.
2. Maintain medical bed capacity in MAU, by moving patients rapidly out of MAU.
Principle: improving patient flow throughout the hospital
Lead: Malcolm Newton, Divisional Lead, Medicine. /
  • Introduction of non verbal handovers from 7th April 08
  • Use of pre-emptive transfers throughout medicine to maintain bed capacity in MAU.
  • Maintain for a further 3 months secondment of a matron to the role of Patient Flow facilitator.
/ Completed & ongoing
Risk increasing in July due to essential planned maintenance leading to closure of MAU.
Plans to re-provide to be confirmed by end of May.
LOW RISK / 0.65% / Intervention has had a significant impact. Site managers’ report increased engagement from wards staff resulting from their sense of control over transfer times, plus ownership of the problem through the principle of shared risk. Time of Day of Discharge has improved across medicine.
A significant internal action, turning discharge planning into a ‘performance’ process. This is now beginning to work even in the absence of the matron, demonstrating a sustainable change in the culture.
3. Review staffing levels to ensure extended senior clinician cover within the MAU and A&E
Principle: improving patient flow & most appropriate person makes the right decision at the earliest point.
Lead: Lead: Malcolm Newton, Divisional Lead, Medicine, / Proposal for Emergency ambulatory care to be expanded and staffed through additional Consultant input.
Quicker access to emergency diagnostics leading to quicker decision making & speedier definitive treatment.
Provide 7 day working by the medical specialties
Scope on back of the is potential for the provision of senior support to the MIU’s within the community / Financial case for additional staff may not be demonstrated
MEDIUM RISK / 0.65% / Pilot in place for a 3 month period.MAU clinicians’ LOS projections are more ambitious than those of in-patient clinicians. More discharges from MAU/MSSU should result, with a further reduction in LOS.
Delivered in Gastroenterology and Cardiology
4. Reduce DToCs to a 1% level or less of the occupied beds.
Principle: rapid & effective discharge assessment
Leads:
BANES PCT : Stella Doble Assistant Director Adult Services/ Tracey Cox, Associate Director Commissioning
Wilts PCT: Dawn Hales, Sally Sandcraft, Director of Nursing.
Somerset PCT: Judith Newman, Director of Commissioning, Annabelle Legg / Individual PCT action plans for BANES & Wiltshire PCTs attached at Annex 1 / HIGH RISK
Trajectory & timeline to be shared at next Local Care Implementation Group / 0.5% / BANES PCT: Funding increased for block beds to provide alternatives to acute care to accommodate CHC patients. Increased presence of discharge liaison nurse on site to reduce response times. To work with RUH to increase time of transfer to community beds to earlier in day.
Wiltshire PCT supporting discharge process with in reach nurse on 3 month basis to look at discharge pathways to community.
Wiltshire whole systems action plan in place.
Somerset PCT has provided an in reach nurse for three days a week to reduce DToCs.
Position monitored via :-
Weekly DTOC group
RUH CommissioningCollege
Wiltshire Whole Systems Group
5. Increase the number of discharges per day that occur in the morning
Principle: reducing peaks & troughs in demand
Lead: Jude French, Patient Flow Facilitator / Medical and surgical wards / MEDIUM RISK
Ongoing / 0.05% / Assessed as already having an effect. Work is ongoing to ensure this becomes part of routine practice.
6. Increase the number of weekend discharges
Principle :- 7 day working and reducing peaks & troughs in demand
Lead: Dr Hubbard, Chair of Medical Division and Jude French, Patient Flow Facilitator / Weekend plans completed by Friday lunchtime with all potential discharges having both discharge summaries complete and TTO’s written and supplied to the ward. / MEDIUM RISK / 0.05% / Clinicians are discharging well at weekends from the short-stay streamis feeding through to prompt discharges on Monday. Next steps should include discharge planning 7/7 in the other in-patient areas. Patient transport arrangements to be reviewed to support change.
7. To treat and discharge all minors within 2 hours.
Principle: rapid & effective discharge assessment in A&E.
Lead: Mandy Rumble, Clinical Services Manager / Plan to be developed by ED department / Plan to be agreed by end of June 08.
High risk / 0.25% / To assess best practice from elsewhere.
8. Increase overall capacity through the reduction of LOS for all specialties with particular attention to those currently above the national ALOS.
Principle: Treating patients in a timely manner
Lead: Tracey Cox, associate Director, Commissioning (as lead Commissioner) Dr W.Hubbard, Chair Medical Division / Key work streams in Falls, Stroke and COPD linked to commissioning intentions for 2008/09. / MEDIUM RISK
Ongoing / 0.15% / Individual PCT service development groups in place.
Joint PCTs and RUH meeting to be arranged for June 08 to share plans for 2008/09 and assess potential for further joint working.
9.Reduce the incidence of orthopaedic injury breaches through the establishment of an assured trauma pathway.
Principle:-Treating patients in a timely manner
Lead: Steve Hart, Divisional lead Surgery / Pathway in place by beginning of June 08Mr S Hart / MEDIUM RISK / 0.15% / Joint working group of A& E staff and Trauma team to be established.
10. Reduce Ambulance Conveyance rates to the RUH
Principle: peaks and troughs in demand tobe reduced and most appropriate useof whole system resources
Lead: Corinne Edwards, Urgent Care & LTC lead, BANES PCT , Sally Sandcraft, Director of Nursing, Wiltshire PCT / RUH has the highest number of ambulance conveyed patients compared to nearby hospitals. / HIGH RISK / 0.25 / Implementation of CMS programme to allow ambulance crews, GPs, community teams and other providers to access up to date information about all services and capacity availability.
To reassess potential for clinical desk to provide a hub for ambulances to seek advice using CMS and access further clinical advice.
Wiltshire PCT Urgent care GP targeting GWAS calls to prevent admissions. Service to commence May 08
Individual; PCT trajectories for a reduction in conveyance rates to be agreed.
12. Reduce and then eliminate Ambulance off load waits, by the use of pre-emptive transfers from ED to MAU and MAU to the general/specialist wards.
Principle: Reduce peaks and troughs in demand
Lead: Mandy Rumble , Clinical Services Manager / New pre-emptive transfer protocol produced. / MEDIUM RISK
Eradicate . 45 min breaches by July 31st 2008. / Ambulance waits reducing. Monitored at weekly taskforce meeting
13. Reduce and then eliminate delays for mental Health assessment in A&E and on wards and ensure timely transfer on
Lead: Diane Fuller, Director of Patient Care Delivery, RUH
Tracey Cox, Associate Director of Commissioning B&NES PCT / Obtain faster mental health liaison response for inpatients. / HIGH RISK / Mapping of provision and funding of existing adult and older people’s liaison services underway.
Urgent Care Implementation Group to carry out themed review at June 08 meeting.

Trust Board

16 June 2008