Date post: | 05-Dec-2014 |
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Health & Medicine |
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Length of Stay Dr Derek Thomson GP & Medical Director
To Cover
• What is Northumbria Healthcare FT? • Organisational Integration reducing LOS • Reducing Surgical LOS • What effect are we having ? • What about the future - Northumbria
Specialist Emergency Care Hospital (NSECH)
Northumbria Healthcare Foundation Trust – Integrated Care Provider
• Secondary Care – 9 Hospitals, 3 DGH, 6 Community Hospitals – Soon to be 10 hospitals, then 12 hospitals.
• Community Service – The coming together of; – Nth Tyneside community services, – Northumberland Community services and Northumberland Social care – To create BU (£70million health and £140million social care)
• Social Care - Partnership agreement maintained between the county council and Northumbria
• Population of 500k, spread over c2,500 sq miles and c 9,000 staff
Organisational Structure • Northumbria Formed in 1998, Foundation Trust since
2006 • Many examples of ‘Copy and Paste’
• Leadership and development programs, recruitment process, driven by patient experience and QI
• Built upon strong, accountable Clinical Business Units, – Med and Emergency Care, Emergency and Planned Care,
Paeds, Clinical Support, Community • Paired Clinical and Managerial Leaders • Stable senior management team • Long and strong relationship with Primary Care
Reducing LOS through Integration – What is possible?
• Reducing Hospital Bed usage – Community/Pre-admission, Front of House, Back
of House, Transfer of Care (discharge), Community/re-admission prevention
• Speeding up flow through the Hospital • Reducing Admissions to Nursing and
Residential Care
Community Admission avoidance
Front of House Reducing Length of Hospital stay
Supported Discharge
Community Re-admission avoidance
Ambulatory Care NGH, WGH
Surgical assessment units
Phone Help lines IBD, TIA, Rheum
Admission avoidance program A&E
Facilitated Discharge Team FDT
COPD Program
LTC Management EDD AND Ticket Home
Nurse led early discharge
Discharge Lounge WGH+,NGH
Alcohol Project
Frail Elderly Care Pathway
Hospital Frail Elderly Care
LINS LINS
Short Term Support Team N’land
Specialist FDT in Orthogeriatric,Stroke
Community Hospital Utilisation
Nursing & Care Home Initiatives- matrons
DAART & ENP-NT Pharmacy Incentive
Integrated End of Life incl Community & CS
Consultant Telephone call
Primary Care Incentive Scheme
Matron supporting nursing homes
LTC Annual Rv
OOH D/Nurse
^ Clinic Capacity
Telehealth
JELS
Early Discharge
Pharmacy
(Safeguarding)
(Podiatric waiting list)
(Sexual Health)
Community Investment
Health and social care integration
Pulm Rehab-Nth Tyne
Pulm Rehab N’land
Lung Improvement Program
CGA in hospital, Follow up in Community, 1 wk
Single Point of Access
Hospital to Home Team
Elderly Assessment Unit
Improving Length of Stay
Estimated Discharge
Dates
Nurse led discharge
Complex discharge
Speeding up the pathways
• At Admission - Identification of complex discharge (Mayo risk stratification tool)
• Estimated Day of Discharge and Ticket Home – Visual controls for patient and staff
• Hospital to home team- Community based MDT • Pits stop approach to discharge • Nurse led Discharge • CGA in hospital, seen by D/Nurse within 7 days • Single Point of access to Community Services • Community based Short term Support Service
Complex discharge
• Using the Mayo Tool to identify complex
discharges
• More visual displays for patients
Further improvement cycles
Ticket Home postcard
EDD: Visual display for patients
Ticket Home leaflet
Nurse led discharge Aim to smooth out variation in discharges over 7 days
0
10
20
30
40
50
60
WG D/C
NT D/C
Since starting nurse led discharges, we have average of 2 extra discharges per ward at a weekend, that would have stayed in hospital
Hospital 2 Home Team Northumberland
• Northumberland Team Live from November 2013
• Community Matron Team Lead • Social Work, OT, care management, STSS,
mental health specialist. • Work into Front of House – A&E and MAU • Back of House through the MDT’s • Smaller team in North Tyneside
Ambulatory Care and Elderly Assessment Units
• Ambulatory Care – 31,000 cases through ambulatory care in past 12m – Rate now >3,000 per month – 85% medical cases
• Elderly Assessment – Preparation for NSECH – Opening on 3rd site soon – 50% go home, 20% direct to rehab facility and
30% still get admitted
Reducing LOS in Surgery
• Gynae – Laparoscopic Hysterectomy since 2008 now 90% done this way – 70% now as Day cases and 90% <24hr stay – Previously average LOS was 3.5 days – ½ complication rates
• Colo-rectal – Laparoscopic plus enhanced recovery= 1.5 day reduction
• Orthopaedics – Hip and Knee replacement – Fast Track Surgery and enhanced recovery
programs and day zero mobilisation. median LOS = 3.0 days , Mean LOS = 3.8 in 12-13. National LOS was 5.3 days in 11-12.
– Top 5% – All surgeons receive their performance monthly – #NOF
Pre-assessment
• Ensure the pre-assessment screening pathway is a safe and timely assessment
• Optimisation - allow enough time for further investigations or interventions to be put in place prior to surgery
• Identify complex patients early and pre-planned to the H2H team
• Collaborative working between GP’s, Surgeons and Pre-assessment
• Early pre-assessment generates a pool of patients who can fill gaps on operating lists
SO WHAT ?
• Recent CHKS Comparisons • Northumbria average LOS is 3.6 days
compared to National rate of 4.2 days • Mixed across different specialities AND • All targets achieved • Financial Surplus
NORTHUMBRIA HEALTHCARE NHS FOUNDATION TRUSTMidnight bed occupancy 2012/13 and 2013/14NTGH, Wansbeck, Hexham
1800018500190001950020000205002100021500220002250023000Monthly occupied bed days Monthly total OBD OBD reduction trajectory (seasonal)
N.B. Excludes paediatrics beds,well babies, SCBU, obstetrics, critical care,
NORTHUMBRIA HEALTHCARE NHS FOUNDATION TRUSTMean length of spell 2012/13 and 2013/14NTGH, Wansbeck, Hexham
*Mean length of spell (proxy) - occupied bed days in the month divided by total admissions in the month
5.0
5.2
5.4
5.6
5.8
6.0
6.2
6.4
6.6
6.8
7.0
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Mean length of spell*(days)
mean length of stay 11/12 mean length of stay 12/13 mean length of stay 13/14
N.B. Excludes paediatrics beds,well babies, SCBU, obstetrics, critical care,
988.
6
988.
4
916.
2
911.
1
889.
1
862.
6
857.
8
856.
8
831.
4
809.
7
781.
8
766.
7
756
697.
2
670.
3
659.
8
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Permanent admissions to care homes, per 100,000 population - 2012/13
Northumbria Specialist Emergency Care Hospital - NSECH
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Specialist Emergency Hospital
Outpatients Diagnostics Day cases Elective Surgery
Sub acute in-patients
A&E Emergency Admissions
Acute in-patients
Minor injuries
Acute in-patients
A&E Emergency admissions
“hot” diagnostics
Outpatients Diagnostics Day cases Elective Surgery
Sub acute in-patients
A&E Emergency Admissions
Acute in-patients
Minor injuries
Focussed around 3 major sites
1 major “emergency site”
Outpatients Diagnostics Day cases Elective Surgery
Sub acute in-patients
A&E Emergency Admissions
Acute in-patients
Minor injuries
Northumbria Specialist Emergency Care Hospital - NSECH
• Services – All ambulance and GP referrals – Major A&E / Specialist ED in the new world, 24/7
emergency Care Consultant delivered service – Acute medicine, GI, Cardio, Resp, Elderly (incl ambl
function), Stroke, Trauma, Maternity, Paeds and Surgery specialist wards with 7 day consultant working
– Critical care – Some high risk elective surgery – Ambulatory care – medically led – Surgical assessment unit
• 24/7 consultant presence – early senior decision making
• Backed up by 8 til late specialist consultants, 7 day working. Quicker specialist decision making,
• Dedicated 7 day Diagnostics • 7 day working for Endoscopy • No longer wait in MAU/ECU – patients will go
directly to speciality ward from A&E
Effect on Length of Stay
• All the business units and specialities working towards reducing LOS
• Working within and across BU and specialities, via integration board
• Working at these for a long time and been able to close wards in the past 3 years
• There is no single silver bullet • Future major reconfiguration to create the next
step-wise change
Summary
Any Questions?